Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0009, written 15 Apr 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Apr 2019 |
|---|---|
| Reference | 2019-0009 |
| Deceased | Shaun Neal |
| Coroner | James Thompson |
| Coroner area | County Durham and Darlington |
| 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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Traffic Section, Durham County Council, County Hall, Durham CORONER lam JAMES E THOMPSON, Assistant Coroner, for the Coroner area of County Durham and Darlington 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. (see attached sheet) INVESTIGATION and INQUEST On 7'* September 2017 | commenced an investigation into the death of Shaun David Neal, 46 years. The investigation concluded at the end of the inquest on 15'* April 2019. The conclusion of the Inquest was Shaun David Neal died as a result of a road traffic collision whilst riding his motorcycle on A68 near Tow Law, Co. Durham on 2" September 2017. He collided with an on-coming motor vehicle and as a result suffered fatal injuries and died at the scene of the collision. CIRCUMSTANCES OF THE DEATH Mr Neal was killed when a vehicle in the opposing lane overtook a vehicle and in doing so struck Mr Neal and caused him a fatal injur 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. Evidence heard at inquest confirms only ‘broken’ white line hazard road markings were present on the road surface at the location of the collision 2. Durham County Council Traffic Section have surveyed the scene and found no requirement to change the road markings from broken hazard white lines to double solid white lines as it was thought a short section of double white lines may confuse drivers. Expert evidence from a police collision investigator believed the presence of double white solid line markings would, in a driver obeying the restriction prevent such a manoeuvre that led to the collision, by removing the option to overtake on that section of road. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you, your organisation 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 10" June 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. COPIES and PUBLICATION !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
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.
Contact, Direct Tel: email: Your ref: JET/AB/2005 /17 Our ref: OC 1488 By email hmcoroner@durham.gov.uk Mr James E Thompson HM Assistant Coroner for County Durham and Darlington PO Box 282 Bishop Auckland County Durham DL14 4FY 7th June 2019 Dear Mr Thompson Regulation 28 — Mr Shaun David Neal (Inquest 15 April 2019) Thank you for your letter and Regulation 28 Report dated 15" April 2019 which Terry Collins, Chief Executive, has asked me to respond to. This was a tragic accident and the Council wishes to express its sincere condolences to the family and friends of Mr Neal. In accordance with Regulation 28 we have considered whether any improvements should be made to the section of A68 road to prevent future accidents and this letter is our response pursuant to Regulation 29. Site Investigation Following Fatal Accident Report The Council has an Accident Investigation and Prevention team and one of their roles is to investigate every fatal accident in conjunction with Durham Constabulary’s Traffic Management Unit. Please find attached a copy of the report at Appendix 1. These reports are undertaken to help identify any defects or improvements to the highway infrastructure. The report made the following observations / recommendations although it noted that they were not considered contributory factors in the accident. ___| Observation / Recommendation Action As part of the general maintenance | An order was placed for the programme, at the earliest recovery of road markings in the vicinity of Hermitage Bridge. Regeneration and Local Services Durham County Council, County Hall, Durham DH1 5UF Main Telephone 03000 26 0000 Text Messaging Service 07860 093 073 www.durham.gov.uk Page 2 of 4 convenience, refurbish the road ] markings showing signs of wear. 1/2 Review the existing hazard marker | Hazard marker posts were | provision with regard to level of checked, and a works order deterioration and maintained placed to replace any defective conspicuousness during periods of | posts. vegetation growth. Replace posts, if required, and address any visibility concerns as part of the general | maintenance programme. 3 Given the observations made in the | A visibility survey was visibility at junctions and bends undertaken to determine whether section, determine the requirement | a system of double white lines for additional highway infrastructure | was required. Such a system such as supplementary road was not identified as being markings and upright signing. justified. A full review of the Council's accident report including further survey work has been undertaken. Accordingly, in responding to the ‘Matters of Concern’ that you raise in your report, we would comment as follows: e It is acknowledged that in cases where a traffic accident has arisen from a vehicle overtaking another vehicle and, in so doing entering the opposing carriageway and colliding with an oncoming vehicle, the suggestion of a restriction to prevent overtaking at that location may have prevented the incident. This statement could be said for any location where an accident occurs arising from an overtaking manoeuvre and if restrictions were introduced because of such accidents, there would be a proliferation of restrictive measures throughout the highway network. It is therefore necessary to ensure that restrictions are only used where they are fully justified by an adherence to the national standards which have been developed to ensure the credibility of the restrictions, a consistent and appropriate usage; e There is no mandatory requirement to introduce double white line systems on the road network therefore this discretionary decision rests with the Traffic Authority to make, who in turn would consult with the Police due to contravention of the fining system being an endorsable offence as per Section 36 of the Road Traffic Regulation Act 1988; e The criteria for the use and design of double white line systems is given in Chapter 5 of the Traffic Signs Manual issued by the Department for Transport. This document was revised and reissued in 2019 and consideration of the request for the introduction of double white lines has been reviewed in accordance with the latest version of this document. e Where double white lines are to be considered, the road should be surveyed in accordance with the procedure detailed in Chapter 5 Section 3.9. Page 3 of 4 e The road has been surveyed as detailed in the procedure. The survey of the location identified only a short length where visibility was impaired although this was below the criteria for the provision of a system of double white lines. e - Chapter 5, paragraph 3.1.2 states that where visibility is just above the minimum standard, but overtaking may nevertheless present a danger, the warning line to Diagram 1004 (hazard line) should be used. e Chapter 5, paragraph 3.1.5 indicates that where forward visibility is less than the desirable minimum it does not automatically follow that double white lines should always be installed and that regard to the route should be part of the consideration. It goes on to suggest that it is important not to use the marking where the appropriate criteria are not satisfied, otherwise it will be brought into disrepute and eventuaily lose the respect of drivers. e Chapter 5 paragraph 3.1.6 states that the emphasis should always be on not using double white lines except where they are clearly justified by the criteria on both the length in question and as part of the route as a whole. e The A68 is a principal road through the County which is primarily rural in nature and follows the topography of the land through which it passes. Along the route there are sections of the road which have systems of double white lines provided although these are generally associated with the vertical profile of the road (hidden dips and long crests). Notwithstanding this, there are other locations along the route where forward visibility is impaired due to either or both the horizontal and vertical alignment which currently are not subject to double white line systems and where a hazard line is provided. The introduction of double white lines, particularly over short distances at sporadic locations along the A68 where visibility is slightly impaired is likely to lead to increased confusion amongst motorists as to where it is safe and where it is not safe to overtake. Provision at this location would be inconsistent with the rest of the route. e An integral part of the assessment process is the consideration of the previous accident history along the section of road and the circumstances relating to any accidents which have occurred. There are no previous accidents over the last 10 years (the extent of available detailed data) relating to overtaking where visibility is impaired. e Consideration has also been made regarding other guidance for motorists and, in particular Rule 127 of the Highway Code which describes a hazard line, stating do not cross it unless you can see the road is clear and wish to overtake or turn off. In addition, Rule 166 of the Highway Code indicates that a motorist must not overtake if there is any doubt, or where you cannot see far enough ahead to be sure it is safe. It goes on to give examples of a corner or bend, a hump bridge and the brow of a hill. e tis concluded that the criteria for the provision of a system of double white lines has not been met and there is no previous history of overtaking accidents associated with impaired forward visibility at this location. Therefore, there is no Page 4 of 4 justification for the introduction of double white lines and the current provision of a hazard marking is considered appropriate and consistent with the rest of the A68 route. Whilst it was not considered appropriate to introduce a system of double white lines at this location, it was noted during the survey that a number of hawthorn bushes contributed to * the reduced visibility. An order for the removal of these bushes was subsequently made and they have since been removed. We have consulted with the Police Traffic Management Officer who is supportive of this decision. Our condolences go to Mr Neal's family and friends on their tragic loss. | hope the above goes some way towards offering a considered response to your correspondence. If you would like to discuss this matter further please contact Traffic Asset Senior —_— on a number EEE OF by email at Your sincerely oo Strategic Highways Manager Enc Appendix 1
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