Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0399, written 21 Dec 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Dec 2018 |
|---|---|
| Reference | 2018-0399 |
| Deceased | Paul Fairey |
| Coroner | Philip Barlow |
| Coroner area | London Inner (South) |
| 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.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. London Borough of Lewisham 1 | CORONER | am Philip Barlow, assistant coroner, for the coroner area of Inner South London 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 28 September 2017 | commenced an investigation into the death of Paul Fairey, age 44, The investigation conciuded at the end of the inquest on 20 December 2018. The conclusion of the inquest was Road Traffic Collision. The Medical Cause of Death was 1a) Brainstem herniation 1b) Head injury. 4 | CIRCUMSTANCES OF THE DEATH 1. Paul Fairey was a pedestrian on Mayow Rd, SE26. At about 00.40 on 23 September 2017 he walked into the northbound carriageway and was hit by a car travelling north. Mr Fairey suffered a severe head injury from which he later died. 2. The collision occurred 500m south of Perry Vale between the junctions of Adamsrill Rd and De Frene Rd, near a pedestrian crossing point and to the entrance of Mayow Park. 3. The evidence at the inquest was that Mr Fairey would have been difficult to see. He was wearing dark clothing but also the collision occurred in an area of poor visibility. 4. The speed limit on the road is 20mph. The evidence was that the car was travelling in excess of this. 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 street lamp nearest to the collision site (8m south of De Frene Rd, on the east side of Mayow Rd) was shrouded by tree foliage causing a large shadow across Mayow Rd. This shadow encompassed the site of the collision and the nearby pedestrian crossing point. (2) There is a painted “SLOW” on the north bound lane near to the collision site. The evidence was that this sign has faded and may not be clearly visible to a motorist. (3) There is a speed cushion close to the pedestrian crossing point. The evidence was that a car can straddle this speed cushion without needing to slow down. Also the speed cushion is beginning to break up. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you or your organisation has 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 18 February 2019. |, 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 1. a. Fairey’s mother) c/o Slater & Gordon solicitors | have ‘ 2. erious Incident Investigation Unit) 3. who may find it useful or of interest. | 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. 21.12.18 Philip Barlow 2, . PR l ae c
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.
RECEIVED Lewisham Mr Philip Barlow Deputy Coroner for London Inner South Coroner for Inner South District Greater London Southwark Coroner’s Court, 1 Tennis Street, Southwark. SE1 1YD Interim Chief Executive London Borough of Lewisham Laurence House Catford, London SE6 4RU 12 February 2019 Dear Mr Barlow Re: Prevent Future Deaths Report for Paul Fairey (deceased) (date of death: 23/09/17 On behalf of the Council I can confirm receipt of your letter dated the 21 st December 2018 containing the Prevent Future Death Report touching the death of Mr Paul Fairey. I set out below our response to the matters of concern raised in your letter. The MATTERS OF CONCERN raised are as follows. - The street lamp nearest to the collision site (8m south of De Frene Rd, on the east (1) side of Mayow Rd) was shrouded by tree foliage causing a large shadow across Mayow Rd. This shadow encompassed the site of the collision and the nearby pedestrian crossing point. Response - The trees under consideration are privately owned. Letters were sent to the adjacent property owners in May 2018 requiring that they cut back the tree foliage to the highway boundary. As no action has been taken the Council is arranging for the foliage to be cut back. The work is expected to be completed by the end of February 2019. There is a painted "SLOW" on the north bound lane near to the collision site. The (2) evidence was that this sign has faded and may not be clearly visible to a motorist. Response - The northbound "SLOW" marking approaching the crossing point was remarked in December 2017. The southbound slow marking approaching the crossing point was also remarked. There is a speed cushion close to the pedestrian crossing point. The evidence was (3) that a car can straddle this speed cushion without needing to slow down. Response - The speed cushions in Mayow Road have been in place for a number of years and may be less effective due to long term wear. Financial constraints generally mean that widespread renewal of worn traffic calming features is not feasible. However it is proposed to reconstruct the speed cushions in close proximity of the two pedestrian refuge crossing points adjacent to Mayow Park to ensure that they are as effective as possible. This work is programmed to be completed by the end of April 2019.
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