Prevention of Future Deaths reports · 2019

Evie Wright

Regulation 28 report to prevent future deaths, reference 2019-0063, written 21 Feb 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report21 Feb 2019
Reference2019-0063
DeceasedEvie Wright
CoronerMaria Voisin
Coroner areaAvon
CategoryOther related deaths
Sourcejudiciary.uk record · original PDF
Responses published2

The report

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.

aM SE)
M. E. Voisin
Her Majesty’s Senior Coroner
Area of Avon

15th February 2019 REF: 10027

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
=
echnical Director
Persimmon Homes Severn Valley

e . North Somerset Council

1 CORONER

1am M E Voisin Senior Coroner for Area of Avon

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.

http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www legislation.gov.uk/uksi/2013/1629/part/7/made

3 INVESTIGATION and INQUEST

On 28/03/2018 | commenced an investigation into the death of Evie Alicia WRIGHT. The investigation
concluded at.the end of the inquest.

Box 3 on the Record of inquest read: “Evie Wright died on 6th March 2018, 100 yards north of Corondale
Crossing, Weston Super Mare. She had walked onto the railway line and into the path of a train which
struck her causing her to suffer multiple injuries and her immediate death. “

4 CIRCUMSTANCES OF THE DEATH

The conclusion in Box 4 read: “Evie Wright died when she was struck by a train her intention when she
walked onto the train line is unknown.”

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. —

Telephone 01275 461920
Email AvonCoronersTeam @bristol.gcsx.gov.uk Website www.avon-coroner.com
The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL

In this case | heard evidence from Network Rail and North Somerset District Council.

That evidence confirmed that the level crossing used by Evie at the time was risk assessed as complying
with the standards set.

However | also heard that in the vicinity of the crossing there was planning permission in place to build a
footbridge. | have been told that such had been the position since 1991; that it was an obligation on the
builder at the time to build a footbridge; that planning permission had been granted in 2000.

| heard a number of reasons and explanations for why this has not happened.

| was told that there are now plans in relation to a new footbridge which is different in construction and
that its location has moved hence it requires a fresh planning application and permission.

| have heard that a footbridge would enhance safety and eliminate risk, that network rail supports the
closure of any crossing but has no power or responsibility — that rests with the North Somerset District
Council and the developer — now Persimmon, who it should be noted were not the original developer.

Telephone 01275 461920
Email AvonCoronersTeam@bristol.gcsx.gov.uk Website www.avon-coroner.com
The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe you and 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
Thursday 18" April 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

| have sent a copy of my report to the chief coroner and to the following interested persons — the family
of the deceased and to the LOCAL SAFEGUARDING BOARD. | have also sent it to Network Rail 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.

21/02/2019

Signature
ME Voisin Sehior Coroner Area of Avon

Telephone 01275 461920
Email AvonCoronersTeam@bristol.gcsx.gov.uk Website www.avon-coroner.com
The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL

Responses

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.

Response from North Somerset Council (PDF)
l5ApriI2Ol9
JW/pk/Coronerl 50419
10027

Date:
My ref:
Your ref:
Contact:
Telephone:
Email:

M E Voisin
Her Majesty’s Senior Coroner
Area of Avon
The Coroner’s Court
Old Weston Rd
Flax Bourton
BS48 1UL

(3-North
\ Sonlerset

COUNCIL

a unitary authority

Chief Executive
Corporate Services
North Somerset Council
Town Hall
Walliscote Grove Road
Weston-super-Mare
BS23 4EJ

DX 744990 Clevedon

Dear Ms Voisin

Regulation 28 report: Corondale Crossing, Weston-super-Mare

Thank you for sending us your report dated 21 February requesting details of the action
Persimmon Homes and ourselves propose to take to prevent future deaths.

We will arrange to meet with Persimmon Homes to explore the issues in detail but I can
confirm that I have already met with their regional Managing Director,
, and
Technical Director,
maffer of urgency.

, on 26 March to discuss how to progress a response as a

We are also firmly of the view that Network Rail has an essential role to play in resolving
this issue and will seek its engagement in delivering a solution, and hope you agree.
the importance attached by Network Rail on its website to closing such crossings and its
statement that it has delivered closure of 1100 level crossings between 2009 and 2017. I
trust that Network Rail will work positively with us on this particular crossing and am
pleased that you have sent a copy of your report to Network Rail.

I note

In this respect, the first action to prevent future deaths will be for us to consider with
Network Rail what further measures can be put in place to improve the safety of the
crossing. We will also ask Network Rail to review its risk assessments to determine
whether improvements, alterations or other mechanisms can be introduced

In terms of other actions, you will be aware from the inquest of the problems that have
prevented the bridge being built in the past. These include disposal of land required for
construction of the bridge by the British Rail Property Board; the subsequent bankruptcy of
the acquiring company before the land was registered; changes made to rail infrastructure
company structures and associated staffing changes; changes to the structural standards

( )

INVESTORINI’EOPLE

Clear leadership, quality services, affordable council tax
www.n-somerset.gov.uk
Town Hall, ‘Neston-super-Mare BS23 1UJ

SA’

 for such bridges required by Network Rail; and the need to establish future responsibility
for liabilities for repair, maintenance and claims relating to the bridge.

You will also be aware of the challenges that we face in going forward. These include
meeting Network Rail’s updated design requirements and standards; ensuring future
liabilities for repair, maintenance and claims relating to the bridge and its use are
appropriately addressed; the need to establish whether a bridge to current design
standards can be sited in the previously approved location or whether alternative sites
need to be considered; the need to pursue the submission of a fresh planning application
by the appropriate body for a new bridge; acquisition of the land on which a bridge would
be sited; securing the funding for a new bridge from the appropriate body; and recognition
that closure of either of the public rights of way at Wells and Corondale crossings must
follow a separate statutory process and is likely to require current users to divert to less
convenient routes.

Whilst I fully understand why much focus has been placed on the absence of a bridge, we
feel it is important to emphasise that building the bridge in the previously approved location
would not necessarily have led to the closure of the Corondale Crossing. As you will be
aware, the bridge which received planning permission was some distance from the
crossing. Building a bridge in an alternative location may also not necessarily lead to the
closure of the crossing given the separate statutory process which must be followed.
therefore believe it is essential that Network Rail is requested to review the safety
arrangements at the existing crossing and this is the first action we will take.

I

Recognising that the Council does not have the authority or power to build the bridge itself,
we will therefore take the following actions:

•

•

•

•

•

By 301h April we will seek Network Rail’s comments on what further measures can be
put in place to improve the safety of the crossing and request Network Rail reviews its
risk assessments to determine whether improvements, alterations or other
mechanisms can be introduced.
By 30th April we will meet with Persimmon Homes in connection with their obligations to
construct the bridge under the section 52 agreement
By 30th May we will meet with Network Rail to seek agreement to funding from Network
Rail towards construction of a bridge and commitment in the meantime to make any
identified improvements to the safety of the existing crossing;
By 30th May we will seek Network Rail’s confirmation of the appropriate current design
requirements for the bridge and convey those standards to Persimmon Homes (and/or
whichever body it is agreed will submit a fresh planning application to current
standards);
By 3O July, we will seek agreement with Network Rail and Persimmon Homes to a
draft project plan identifying the steps to be taken to deliver a new bridge.

• Within 13 weeks of its submission we will use our best endeavours to determine any
planning application submitted to the Council for a new bridge and will provide advice
prior to any application being submitted to identify any issues which may arise.
If and when planning permission for a bridge is granted, we will request Network Rail to
use its Compulsory Purchase Powers to acquire land needed to construct the bridge.
• After the bridge is constructed, and subject to the appropriate statutory process, we will

•

use the appropriate powers to seek to divert the Public Right of Way from the
Corondale crossing to the new bridge.

 I hope this letter makes clear the action the Council proposes to take in response to your
findings.

Yoirs sincerely

J0 Walker
Chief Executive

This letter can be made available in large print, audio, easy read and other formats.

Documents on our website can also be emailed to you as plain text files.

Help is also available for people who require council information in languages other than

English. For more information contact the sender of this letter.

The content of this communication is meant for disclosure to the intended recipient(s) only.

If you have received this in

error, please notify the sender and destroy the communication without copying it or forwarding it.

You should be aware that all communications received and sent by this council are subject to the

Freedom of Information Act 2000
Response from Persimmon Homes (PDF)
PERSIMMON ° PERSIMMON HOMES SEVERN VALLEY

Davidson House

106 Newfoundland Way
Portishead

Bristol

BS20 7QE

Our Ref: PM/JE Tel: 01275 396000
Main Fax: 01275 845486
wivw.persimmonhomes.com

15" April 2019

Ms ME Voisin

Her Majesty's Senior Coroner — Area of Avon
The Coroner’s Court

Old Weston Road

Flax Bourton

BS48 1UL

Dear Ms Voisin

Regulation 28 Report Corondale Crossing Weston Super Mare

Thank you for providing Persimmon Homes Ltd (Persimmon), a copy of your report dated 15%
February 2019 (Ref:10027).

You have considered the obligation to construct a footbridge over the railway line which was
part of a planning agreement dated 23 March 1999, to which the British Railways Board
(now Network Rail), Woodspring District Council, the County Council of Avon (now North
Somerset District Council) and three other developers known as Locking Castle Limited (since
acquired by Persimmon) were parties. .

Whilst the developers submitted an approved application to fulfil this obligation, any
construction commencement was prevented by British Railways Board’s disposal of the land
to Drawdale Ltd on which part the footbridge was to be constructed. Drawdale Ltd then
proceeded to refuse to grant rights to develop the footbridge without a ransom payment.
No party had the ability to force Drawdale Ltd to grant sald rights frustrating the ability to
proceed.

Your finding in your report, final section. paragraph 5;

" aathat network rail supports the closure of any crossing, but has no power or
responsibility...”

Is respectfully not fully accurate. Network Rail is intrinsic and responsible along with North
Somerset District Council to ensure that an acceptable solution can be found to prevent any
future deaths as the applicable landowners and the only relevant parties capable of carrying
out the actual construction over an active railway line.

Persimmon Horngs Severn Valley is a trading division vf Persimmon Homes Linited
Registered Office: Persinunon House, Fulford, York YOI9 4FE.

Registered in England No. 4108747. A subsidiary of Persimmon pic

Since receiving your report, Persimmon has attended two meetings on the 26" March and the
3" April with North Somerset District Council which have been productive. We understand
that North Somerset are now seeking to arrange a further meeting with Network Rail before
the 30" May which Persimmon have agreed to attend to explore an acceptable resolution
which includes a significant financial contribution to North Somerset District Council &
Network Rail in order for the construction to take place.

Yours sincerely

Director in Charge

Related reports

Other reports by Maria Voisin

See all →

More reports categorised “Other related deaths”

See all →

Track Maria Voisin

See every Prevention of Future Deaths report matching Maria Voisin, and how often a new one appears.

What would an alert for this have sent me? Search the full text

Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.

These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.