Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0373, written 29 Nov 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 Nov 2018 |
|---|---|
| Reference | 2018-0373 |
| Deceased | Luke Saxton |
| Coroner | Robert Turnbull |
| Coroner area | North Yorkshire |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Robert Turnbull Senior Coroner for Western Area of North Yorkshire REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1) Richard Flinton, Chief Executive, North Yorkshire County Council 2) Chief Coroner 3) CORONER I am Robert Turnbull, Senior Coroner for Western Area of North Yorkshire 2 CORONER’S LEGAL POWERS I 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. hhp://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/201 3/1 629/parU7/made 3 INVESTIGATION and INQUEST On 261h September, 2018, I commenced an investigation into the death of Luke John Saxton. The investigation concluded at the end of the inquest on 26 November2018. The conclusion of the inquest was Luke John Saxton died of multiple injuries as a result of an accident. 4 CIRCUMSTANCES OF THE DEATH At about 23:10 hours, 23 June, 2018, Luke John Saxton was walking along the A59 at a point near to the Bull at Broughton public house. lighting at that location. Mr Saxton was struck by a motor car travelling in the direction of Bamoldswick. The driver of the motor car, although displaying dipped headlights, had been unable to see him until too late to avoid the collision. Mr Saxton died at the scene from injuries sustained. It was dark at the time and there was no street 5 CORONER’S CONCERNS During the course of the inquest 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) The collision occurred in darkness in an area where there was no street lighting; 2) Mr Saxton had been attending a wedding at nearby Broughton Hall, a popular wedding venue; 3) There are bus stops in the area where the collision occurred which were also in darkness; 4) Consideration should be given to erecting street lighting to cover the area where the collision occurred up to the bus stops at either side of the Bull at Broughton public house. 21 Grummar School Lane, Nortliallerlon, Norlh Yorkshire. 1)11. 11W I Fax 01609 780 793 id 01609 533 805 6 7 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 25 January 2019. I, 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 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons, I 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. 9 Dated 29 November2018 Signature_______________________ Senior Coroner for Western Area of North Yorkshire 21 Grammar School Lane, Noriliullerton, North Yorkshire, 1)1.6 IDE Tel 01609 533 805 I Ea 016(19 780 793
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.
North Yorkshire County Council rN. V. I 23JAN2019 Richard Flinton Chief Executive County Hall Northallerton North Yorkshire DL7 BAD Tel: 01609 532444 Email: Our Ref: RF/AF/LJ190121 Your Re!: 00420-2018 AM 22 January 2019 Mr Robert Tumbull Senior Coroner for the Western Area of North Yorkshire 21 Grammar School Lane NORTHALLERTON North Yorkshire DL6 1DF Dear MrTumbuli RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS I refer to your Regulation 28 Report dated 30 November 2018, concerning the fatal collision on the A59 at Broughton, resulting in the death of Luke John Sexton. Having considered thoroughly the detail of your report In conjunction with the County Council’s oWn Fatal Collision Inspection Report and advice from the relevant NYCC officers, I have arrived at the following conclusions: Regulation 28 Report, Recommended Action - Street Lighting When assessing the need for street lighting a range of factors are considered, one of the most significant being the long term collision record. Collision records are studied as part of the County Councils, Fatal Collision Inspections Report to understand the comparative detail of any past occurrences and identify trends. As part of this inspection, records indicated there were 8 personal Injury collisions on this section of the A59 In the latest 5 year period, prior to this incident (3 years is the standard study period). Only one of which occurred during the hours of darkness involving two vehicles, none were pedestrian related. Typically the County Council would not consider installing street lighting where the daylnlght ratio was greater than 3:1 as this would tend to indicate other factors were at play. Given the nature of the road and speed limit, there would be a requirement for passively safe columns with associated disconnection system. in addition to this, the installation of a system of streetlights alone would default the speed limit to 30mph. Therefore it would also be necessary to make a speed limit Traffic Regulation Order (TRO) applying the national speed limit and installing the necessary signs. Consideration must also be given to precedent, over 80% of the County’s roads are currently unlit and to take this course of action at this location and collision history, would likely lead to numerous other locations in the county beig equally of merit. At present there are no footpaths linking Broughton Hall and the bus stop on the south side of the A59, nearest to the Bull Public House, where the collision occurred for the reason there is a nearer bus stop located to the west of the side road junction, with a footpath link. It would not be expected for people to be walking that route specifically, even if the hall is a popular wedding venue. Pedestrian flows on this section of the A59 are likely to be very low and similarly traffic flows on the A59 during the night time is also considered to be relatively low. Therefore, there is no direct justification to install a footway. A review of the bus services in this area also shows that there were no bus services operating during the hours of darkness and any specific street lighting at the bus stops would likely be switched off after the last scheduled bus as an energy saving measure. A costing exercise for the provision of street lighting returned a figure in the region of £66,000 and the associated legal procedure for the making of a TRO and signing would be in the region of £5,000. Having given due consideration to the erection of street lighting and through that objective assessment, I have been Informed that on balance this section of the A59 falls below the required level for such intervention. Proposed Action Notwithstanding the above, we may be able to introduce another measure to support any pedestrian movement In this area with the aim of reducing their potential conflict with live traffic, subject to further review. The Traffic Signs Regulations and General Directions 2016 (TSRGD) does prescribe a pedestrian in the road warning sign (TSRGD Diagram 544.1). However, it is specified that it can only be installed at locations where the road does not have a footway(s) and with no verge or metre hard strip. This section of the A59 In question does in part have footways on the south side extending between the Bull Public House and the bus stop. The carriageway also has a metre wide hard strip and grass verge for its remaining length between the bus stop and its junction with the side wad leading to Broughton Hall, from where it is understood Mr Saxton travelled from. This section of carriageway is also relatively flat and affords satisfactory inter-visibility between drivers and pedestrians. On that basis, this section of the A59 does not merit the installation of these signs. However, it is noted that work has been done to use the metre hard strip as an unofficial cycle lane with measures installed to guide cyclists from the west bound traffic lane to this strip. Furthermore, it is wholly feasible that a pedestrian may not wish to walk on the grass verge and chose to walk on the surfaced carriageway. Combined this may offer some mitigating circumstance. Further consideration will need to be given to this as the installation of none prescribed signs on the highway would result in the County Council being held accountable should a future collision occur in which this sign(s) was struck or in some way involved. Nevertheless a pragmatic approach must be taken and this will be looked at in more detail by the relevant officers. Additional Action Although not directly associated with this collision, further road safety works are being introduced at the nearby A59/Gargrave Road junction which has been identified a high risks site for vehicles Improvements to the existing signing and wad marking will be making turning movements. introduced at the very earliest opportunity, (subject to weather conditions for lining works) and will contribute towards improving overall road safety in this area. Whilst this may not be the recommended outcome, I trust the reasoning set out demonstrates that NYCC has respectfully given this matter the due consideratIon it deserves given the tragic circumstances Involved and that the further mitigation goes some way to addressing your concerns. Please advise if you would like me to forward a copy of this letter to Mr Saxton’s family direct. Yours Sincerely Richard Flinton Chief Executive
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