Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0037A, written 6 Mar 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Mar 2019 |
|---|---|
| Reference | 2019-0037A |
| Deceased | Michael Henderson |
| Coroner | Kirsty Gomersal |
| Coroner area | Cumbria |
| Category | Road (Highways Safety) related deaths · Alcohol, drug and medication related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
MISS KALLY CHEEMA LLB HER MAJESTY’S SENIOR CORONER COUNTY OF CUMBRIA REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: CUMBRIA COUNTY COUNCIL (HIGHWAYS DEPARTMENT) 1 CORONER I am Miss Kirsty Gomersal Area Coroner for County of Cumbria 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: https://www.legislation.gov.uk/ukpga/2009/25/contents http://www.legislation.gov.uk/uksi/2013/1629/contents 3 INVESTIGATION and INQUEST On 21 May 2018, Ms Kally Cheema (Senior Coroner) commenced an investigation into the death of Michael Andrew HENDERSON to whom I shall refer as Mikey. On 7 June 2018, Mr Robert Chapman (Assistant Coroner) commenced an investigation into the death of Stephen Brian CHAMBERS to whom I shall refer as Stephen. The investigations into Mikey’s and Stephen’s deaths concluded at the end of their inquests on 28 February 2019. The conclusion of Mikey’s inquest was Road Traffic Collision. The medical cause of death of Mikey’s death was multiple injuries inconsistent with life. The conclusion of Stephen’s inquest was Road Traffic Collision. The medical cause of death of Stephen’s death was multiple injuries inconsistent with life. 4 CIRCUMSTANCES OF THE DEATH On 1 May 2018 at 21:30, Mikey was the driver of a car in which Stephen was the front seat passenger. It was raining heavily. Mikey was driving in a southerly direction along the A5094 New Road towards Whitehaven. Mikey lost control of the vehicle at speed. The vehicle skidded sideways into a concrete lamp‐post. The force of the collision was such that the car was split in two horizontally. Both Mikey and Stephen were declared dead at the scene. Mikey’s blood alcohol level was 166 mg per 100 ml of blood. During the course of the inquest, I heard evidence from an experienced Collision Investigator with Cumbria Constabulary. The Collision Investigator could not tell exactly at what speed Mikey’s car had hit the lamppost. His opinion was that the car must have travelling greatly in excess of the speed limit of 40 mph. The Collision Investigator advised me that he had never seen a car damaged to the extent that Mikey’s car was damaged. Fairfield, Station Road, Cockermouth, Cumbria, CA13 9PT hmcoroner@cumbria.gov.uk Tel 0300 303 3180 Fax 01900 706915 The Collision Investigator concluded the collision occurred as a resultof,or a combination of, alcohol, excess speed and poorly maintained rear tyres. My findings of fact incorporated the Collision Investigator’s conclusions. 5 CORONER’S CONCERNS 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: During the course of the inquest, I read evidence from a police constable who attended the scene. He advised me that in his 24 years’ service, he was aware of a number of multiple fatal road traffic collisions on this road, mainly involving excess speed. The Collision Investigator gave evidence in person. He has 22 years’ police service, the majority of which have been in the roads policing unit. He has been an expert collision investigator since 2011. The Collision Investigator advised me that the speed limit of 40 mph on New Road was appropriate and that relevant signage was appropriate. He was also aware of a number of fatal and serious collisions on New Road. Mikey and Stephen were the third and fourth deaths of which he was personally aware. The Collision Investigator advised me that it is feasible to considerably exceed the speed limit on New Road to 60 or 70 mph or even greater. He advised me that the road has a number of unusual features – it is very wide with embankments and woodland on each side. It is not in a built up area. This may give the impression (despite signage) that the speed limit is much greater than 40 mph. The road travels downhill towards Whitehaven and has a number of bends. The Collision Investigator was concerned that there could be further future deaths on this road because of the speeds that can be attained. His considered opinion was that there were measures that could be taken to reinforce and encourage compliance with the speed limit. I fully appreciate that speed was not the only factor in Mikey’s and Stephen’s deaths. I also appreciate that it is not possible to “force” drivers to adhere to the speed limit. However, it may be that due to the unusual features of New Road that “traffic calming measures” may reduce the risk of future serious collisions and I recommend that that you give consideration to taking such action. Fairfield, Station Road, Cockermouth, Cumbria, CA13 9PT hmcoroner@cumbria.gov.uk Tel 0300 303 3180 Fax 01900 706915 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you, Cumbria County Council, 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 1 May 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: , Mikey’s father. , Mikey’s mother. , Stephen’s father. I have also sent it to the following who may find it useful or of interest: Cumbria Constabulary (for the attention of ). Cumbria Constabulary (for the attention of ). 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 6 March 2019 Miss Kirsty J Gomersal Area Coroner County of Cumbria Fairfield, Station Road, Cockermouth, Cumbria, CA13 9PT hmcoroner@cumbria.gov.uk Tel 0300 303 3180 Fax 01900 706915
2 responses 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.
Cumbria County Council Phil Greenup Economy & Infrastructure Cumbria House 117 Botchergate Carlisle Cumbria CA1 1RD T: 01228 221062 E: philip.greenup@cumbria.gov.uk 22 August 2019 Miss Kirsty Gomersal Area Coroner for County of Cumbria Fairfield, Station Street Cockermouth Cumbria, CA13 9PT Email: hmcoronor@cumbria.gov.uk Dear Ms Gomersal An item was raised at the Casualty Reduction and Safer Highways (CRASH) partnership group meeting on May 14th 2019 following the Regulation 28 Report submitted to Cumbria County Council resulting from the fatal collision on New Road, Whitehaven on 1 May 2018. The CRASH group actioned that all available collision and traffic data be collated and that Cumbria Constabulary’s Collision Reduction Officer and Cumbria County Council’s Traffic Management Officer for the area meet to discuss all records and conduct a site visit to consider options. The collision data gathered covered a period between 2009 and 2019 highlighting 17 collisions – 14 of which were slight, 2 serious and 1 fatal. The causation factors that were listed for the serious and fatal collisions were: One serious - tyres illegal, defective or under inflated, exceeding speed limit, impaired by alcohol. One serious - exceeding speed limit, following too close, poor turn or manoeuvre, failed to look properly, swerved, loss of control. One fatal - slippery road, tyres illegal, defective or under inflated, exceeding speed limit, loss of control. In addition to the above, following the Collision Investigation being carried out for the fatal collision, it is apparent in this case that there were additional causation factors, most notably the driver being under the influence of alcohol and possibly drugs. At the site visit, it was noted that the road is constructed to a high standard, acting as a key route into the town. Discussion took place considering the available engineering measures along the stretch of highway, concluding that there are very few traffic calming options that would effectively reduce driver speeds without having an adverse impact on traffic flow in and around Whitehaven. Given the overall compliance with the posted speed limit, and collision causation factors attributed to driver error, it is not recommended to pursue any direct traffic calming measures at this time. It is worth noting however, that Cumbria County Council have a proposed scheme planned for implementation this financial year to replace the concrete lighting columns which currently sit at the edge of the footway (closest to the carriageway) with new modern installations to the rear. Additionally, Cumbria County Council is about to start work improving the junction of Bransty Row and North Shore Road, Whitehaven as part of a major development project in the town. As part of these works, it is planned to significantly enhance the gateway on New Road and this should positively impact driver behaviour in this area. Yours sincerely Assistant Director Highways & Transport Serving the people of Cumbria cumbria.gov.uk
Cumbria County Council Economy & Infrastructure 107-117 Botchergate Carlisle Cumbria CA1 1RD T: 01228 226015 E: 7 June 2019 Miss Kirsty Gomersal Area Coroner for County of Cumbria Fairfield Station Street Cockermouth Cumbria CA13 9PT Your reference: 33761 Dear Miss Gomersal Re: Michael Andrew Henderson (Deceased) and Stephen Chamber (deceased) Inquest: 28/02/2019 at The Coroner's Court, Cockermouth I am writing in response to your letter dated 14 March 2019 to which was attached a copy of the Regulation 28 letter regarding the above inquest. Please accept my sincere apologies for delay in sending you this response. The recommendations stated in the Regulation 28 letter that “traffic calming measures” on New Road may reduce the risk of future serious collisions were discussed and considered at the Casualty Reduction and Safer Highways Group (CRASH) on Tuesday 14 May where it was agreed that a traffic speed survey be undertaken along with further investigations to determine what, if any, measures are required. The CRASH group consists of the County Council, (Highway Authority), Cumbria Constabulary and other interested parties, some of whom will have attended past collisions on this road and will have experience of travelling on this road. Yours sincerely Angela Jones Acting Executive Director of Economy & Infrastructure Serving the people of Cumbria cumbria.gov.uk
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