Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0290, written 10 Sep 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Sep 2018 |
|---|---|
| Reference | 2018-0290 |
| Deceased | Elijah Shotade |
| Coroner | Dewi Pritchard-Jones |
| Coroner area | North West Wales |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
D. Pritchard Jones Senior Coroner for North West Wales _ . vss ee REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: (1) Director, North & Mid Wales Trunk Road Agency, Unit 5 Llys Britannia, Parc Menai, Bangor, Gwynedd, LL57 4BN 1, | CORONER | am Dewi Pritchard Jones, Senior Coroner for the coroner area of North West Wales 2 CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 03/09/2018 | commenced an investigation into the death of Elijah Oluwagbenga Shotade, who was born on 7" February 1987. The investigation has not yet been concluded and the inquest has not yet been heard. 4 CIRCUMSTANCES OF THE DEATH On 31* August 2018 Elijah Oluwagbenga Shotade was driving a motor vehicle over the Britannia Bridge in a westerly direction. He overtook two vehicles but did not return to his nearside lane. He continued in the east bound carriageway and collided with an east bound heavy goods vehicle suffering injuries that led to his death. My investigation, to date, shows that there have been numerous, almost identical, collisions and incidents. My investigation, to date, would suggest that motorists driving in a west bound direction, having been used to driving along the dual carriageway of the A55, enter onto the Britannia Bridge (which is not a dual carriageway) but seem to behave as if the east bound lane is the offside lane of a dual carriageway. The result of this is that they find themselves in the east bound carriageway of the bridge and on leaving the bridge they are unable to turn to their nearside lane due to the presence of barriers. The situation is made worse by many sat navs directing the motorists to “bear right’ on leaving the Britannia Bridge. 5 CORONER’S CONCERNS During the course of the investigation the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. — (1) That the layout of the road is such that motorists driving in a west bound direction will remain the east bound lane after overtaking and are unable to return to their nearside lane. (2) That many sat.navs direct a west bound motorist to bear right thereby encouraging them to enter onto the east bound lane 37 Castle Square, Caernarfon, Gwynedd, LL55 2NN Tel 01286 672804 | Fax 01286 675217 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe that your organisation has the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 13" November 2018 . |, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons Director of Highways, Isle of Anglesey County Council, Council Offices, Llangefni, Anglesey, LL77 7TW | am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. ©] =| Dated 10 4 a Signature |~_J) ae Senior Coroner for North West Wales 37 Castle Square, Caernarfon, Gwynedd, LL55 2NN Tel 01286 672804 | Fax 01286 675217
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Adran Yr Economi a Seilwaith Department for Economy and Infrastructure AG Llywodraeth Cymru Welsh Government Her Majesty’s Senior Coroner North West Wales 37 Y Maes Caernarfon Gwynedd LL55 2NN For the attention of: Dewi Pritchard Jones Our Ref: OC-01011-18 Your Ref: DJP/AWH20920 Date 7th November 2018 Dear Sir RE REGULATION 28 REPORT — ELIJAH OLUWAGBENGA SHOTADE DECEASED Thank you for your letter of 18" September. | was very sorry to hear of the death of Mr Shotade on 31% August 2018. | note that you have raised concerns with regard to two issues detailed in Section 5 of your Regulation 28 Report: “The MATTERS OF CONCERN are as follows. - (1) That the layout of the road is such that motorists driving in a west bound direction will remain in the east bound lane after overtaking and are unable to return to their nearside lane. (2) That many sat.navs direct a west bound motorist to bear right thereby encouraging them to enter onto the east bound lane.” | have set out below details of the action that has been taken or will be taken in response to the concerns outlined in your report and your investigation into the death of Mr Shotade. North Wales Police first drew the Welsh Government's attention to a potential issue at this location in January 2018. This followed two incidents that occurred at the end of 2017. ™ BUDDSODDWYR INVESTORS Parc Cathars ‘ Cathays Park Ffén_» Tel 0300 025 255526 \. # MEWN PoBL IN PEOPLE SN xeon - The first was on 30" November 2017 and resulted in serious injuries when a van travelling westbound crossed the centreline and collided with a car travelling in the opposite direction. The van driver, who was inexperienced at driving on the left and had had little sleep in the previous 48 hours, later admitted dangerous driving and was given a 16 month prison sentence and was banned from driving in the UK for 32 months. The second was on 23 December 2017 and involved a westbound vehicle entering the eastbound carriageway purportedly as a result of a satellite navigation system instruction. Thankfully, no collision occurred. Following discussions with North Wales Police in February 2018, the Welsh Government inspected the road layout and signing and reviewed the collision records to establish whether there was an historical pattern of similar incidents at the location. The traffic signs and road markings were in compliance with the required standard ~ the Traffic Sign Regulations and General Directions (TSRGD) 2016. The collision records for the previous 5 years (1% January 2013 to 31° December 2017) did not highlight any pattern of previous collisions similar in nature to those outlined above. Notwithstanding the outcome of these investigations the Welsh Government decided to carryout a review of the traffic signing and road markings across the A55 Britannia Bridge and implement any recommended improvements as soon as possible in the 2017/18 financial year. The review concluded that although the relevant traffic signs and road markings complied with standards, they could be reinforced to further reduce the risk of westbound vehicles crossing over into the eastbound carriageway. The works were programmed to commence in September 2018, when the fatal collision that is the subject of your letter occurred on 31% August 2018. The final report on the incident from North Wales Police is awaited, pending completion of their investigations, which | will consider in addition to the inquest conclusion. The extension of the double white lines prohibiting overtaking over the whole length of Britannia Bridge and lane arrows to reinforce the direction of travel has now been completed. Improvements to the signing, which will affirm that vehicles should keep left, will follow before the end of the financial year. The design of all improvements has been subject to Stage 1 and 2 Road Safety Audits. A Stage 3 Road Safety Audit will be carried out following the implementation of all the improvements. The safety of the site will continue to be monitored as part of the Stage 4 Road Safety Audit process. While satellite navigation systems are navigational tool for drivers, it remains the driver’s responsibility to observe and obey road markings and signs. If a satellite navigation system instruction is likely to lead to a manoeuvre that endangers other road users, the driver of a vehicle should not comply with it. Drivers must not follow any satellite navigation system instructions which would be to the detriment of road safety. The works outlined above seek to reinforce the driver’s understanding of the road layout at this location, however, ultimately drivers remain responsible for ensuring that they do not fall below the standard expected of a competent and careful driver. If you wish to discuss this letter, then please contact me on P| Yours faithfully, Deputy Director Network Management Division Welsh Government
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