Prevention of Future Deaths reports · 2019

Christopher Gibbs

Regulation 28 report to prevent future deaths, reference 2019-0100, written 25 Mar 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report25 Mar 2019
Reference2019-0100
DeceasedChristopher Gibbs
CoronerRichard Middleton
Coroner areaDorset
CategoryRoad (Highways Safety) related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

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.

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)

NOTE: This form is to be used after an inquest.

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO:

1. RE highways Department, Bournemouth Borough

Council.
2. Dorset County Council, Highways Department, County Hall,
Colliton Park, Dorchester, Dorset, DT1 1XJ

1 | CORONER

Iam Richard Middleton Assistant Coroner, for the Coroner Area of Dorset

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.

3 | INVESTIGATION and INQUEST

On the 12 October 2017, an investigation was commenced into the death of
Christopher William Gibbs, born on the 9‘ January 1987.

The investigation concluded at the end of the Inquest on the 22" March 2019.

The Medical Cause of Death was:

1a Head and Chest Injury

The conclusion of the Inquest was Road Traffic Collision.

CIRCUMSTANCES OF THE DEATH

On the 3" October 2017 Christopher Gibbs was cycling home from work along
the A338. At approximately 10.15pm he was struck from the rear by a courier
van travelling in the same direction and died at the scene from the injuries he
sustained in the collision

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. During the inquest evidence was heard that:

I. That the A338 road is a main arterial route linking Ringwood to
Bournemouth and Poole and is the main route taken by traffic
entering from the east of the county to Bournemouth. The road
stretches for approximately 10 miles and consists of long straight
sections and open sweeping bends. There is no change in the
speed limit and no exits off the 10 mile stretch of road.

IL. The A338 is a dual carriageway. The eastbound and westbound
traffic is separated by a solid concrete barrier. There is a
maximum speed limit of 7Omph. Cyclist are allowed on the
carriageway. There is vegetation on either side. There is no
highway lighting.

Ill. The driver of the courier van stated that he did not see Mr Gibbs.
Mr Gibbs was riding with correct lighting on the front and rear of
his bike. Mr Gibbs was correctly positioned in the road as was the
driver.

IV. Witnesses expressed surprise that in light of such a fast, busy
and unlit road there appeared to be little protection to vulnerable
road users particularly cyclists.

Vv. The space between the rumble strip marking the edge of the
inside lane of the carriageway and the adjoining grass verge
contains debris from the road and is an unsafe space to cycle.

2. Ihave concerns with regard to the following:

I. There is no cycle lane on either side of the carriage way.

II. There are no warning signs to drivers making them aware of the
potential presence of cyclists. Warning signs at the east bound
carriageway near the Blackwater junction and westbound
carriageway soon after the Ashley Heath roundabout would prompt
such consideration by drivers in what would then be an
unremarkable 10 mile drive. Such information would hopefully be at
the fore front of drivers minds as they commenced this 10 mile
section of his/her journey.

ACTION SHOULD BE TAKEN

In my opinion urgent action should be taken to prevent future deaths and I
believe you and/or 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, 20 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.

COPIES and PUBLICATION

I have sent a copy of my report to the Chief Coroner and to the following
Interested Persons:

7
:
7 _|

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.

Dated Signed ve <

25 March 2019 Richard Middleton

Responses

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.

Response from Dorset County Council (PDF)
Environment Infrastructure and Economy

4 County Hall, Dorchester, DT1 1XJ
= Dorset ® 01305 221000

Council 4% www.dorsetcouncil.gov.uk
Mr R T Middleton Date: 8 May 2019
H M Assistant Coroner for Dorset Ref: RTM/02866-2017/LJ

The Coroner’s Officer Officer:
Town Hall, Bournemouth )) po
=— See

Dear Mr Middleton
RE: Regulation 28 Report — Inquest touching the death of Christopher Williams Gibbs

| have been asked to respond to your letter addressed to the Head of Highway Department
dated 26 March 2019 which included a Regulation 28 Report raising concerns with regards to
cyclist safety on the A338.

The request to install cycling warning signing on the A338, whilst understandable is not
something that we are able or willing to support as it is not the prescribed use of such signs as
per the Traffic Signs Regulations and General Directions (TSRGD) 2016. TSRGD 2016 states
that cycle warning signs ‘... may be used to warn traffic of a place where a cycle route crosses
or joins a road and is not controlled by traffic signals.’ Such signs are therefore not to be used
to warning of the possible presence of cyclists.

An additional reason for not being supportive of the request to install cycle warning signs on the
A338 is that it could generate a false sense of security and encourage more people to choose
to cycle on the A338.

The A338 is not part of a recognised cycle network and is not promoted as such. Whilst there
are no regulations that prevent a cyclist from using dual carriageways such as the A338 it is not
something that Dorset Council actively encourage.

The A338 route is not identified as a key cycle route and facilities for cyclists on or alongside
the A338 route are not being considered at this time.

Cycling infrastructure schemes are prioritised to areas where there is already notable levels of
cycling for leisure and/or commuting or where there is real potential to increase the level of
cycling as a preferred choice of transport to/from work — many cycle infrastructure schemes
provide inks to/from residential and commercial hubs.

| hope that it is recognised that we have considered your concerns and recommendations
having provided reasonable reasons for why we have not agreed on this occasion.

Should you want more information please do not hesitate to get in touch.
Yours sincerely
4 J
Z

Michael Potter
Road Safety Manager

Growth and Infrastructure

Town Hall Annexe BCP
St Stephen’s Road
Bournemouth/ BH2 6EA

Council

Mr RT Middleton

H M Assistant Coroner for Dorset

The Coroner's Officer - pth

Town Hall Date: 8" May 2019
Bournemouth

BH2 6éDY

Our Ref:
Contact:

Dear Mr Middleton

Re: Inquest into the Death of Christopher William Gibbs (Cyclist) - 3° Oct 2017

Thank you for your letter dated 26'" March 2019, including a Regulation 28 Report, raising concerns in
regard to cycle safety on the A338, following a fatal road traffic incident.

| thought it would be helpful to clarify the location of the incident in respect to the boundaries of the
jurisdictions at the time of the incident and also at the present time. At the time of the incident the
location was approximately 6.4km beyond the boundary of Bournemouth Borough Council's
jurisdiction. It occurred within the section of the A338 that Dorset County Council then had
responsibility for.

As you may be aware, effective from 1* April 2019, there has been a re-organisation of local
government in Dorset and under this re-organisation, Bournemouth, Christchurch and Poole have been
amalgamated to form a unitary council called BCP Council and Dorset County Council has also
become a unitary council called Dorset Council. Under this new arrangement the boundary has moved
relative to this incident, which still occurred beyond the new BCP Council boundary, but by a reduced
distance of approximately 1.6km. Whilst the incident occurred outside our jurisdiction, we do recognise
the part this authority has to play in reducing the future risk to cyclist and to improve road safety.

Generally speaking, in regard to modifications to the layout of roads to improve safety, such as signing
and lighting or measures to reduce speed, BCP Council receive large numbers of requests and far
more than we can afford to implement. In order to reduce the maximum number of casualties with the
finite funding available we prioritise road safety requests on the basis of actual casualty evidence.

To put this into context it may help to explain that there are more than 100 locations around the BCP
area where there is a significant casualty accident record over the last 5 years (7 or more casualty
accidents within 50m radius = cluster site) and current levels of funding will only allow us to treat a
smail number of these locations each year. The work we do in refation to Bournemouth is explained in
more detail in our road safety report that can be found here:

http:/Avww. bournemouth.gov.uk/travelandtransport/RoadSafety/RoadSafetyInBournemouth.aspx

bepcouncil.gov.uk

‘BCP Council’ is the operational name for Bournemouth, Christchurch and Poole Council.

2

We have investigated the casualty accident history in the section of road over a length of 2km before
BCP Council’s boundary. There have been 7 collisions here over the last 5 years that resulted in
casualties. These included 9 minor injuries and 1 serious injury. These incidents do not form a cluster
site and none of these incidents involved cyclists. Therefore, unfortunately, this location is not
sufficiently highly ranking to justify any engineering intervention, purely on the grounds of road safety.

Although the incident occurred outside our new boundary, in terms of the rest of the A338 within BCP
Council's area, it is worth noting that significant sections have ‘hard strips’ that can be used by cyclists
to keep them out of the main traffic flow. In addition, the Council has previously introduced reduced
speed limits of 50mph and 40mph along the more urban sections of the A338 and it has installed
facilities to allow cyclists to safely negotiate slip roads. We do not currently have plans to introduce
additional cycle facilities, signing or additional lighting on this route as the casualty record does not
warrant such action and the route is not one we plan to actively promote for cyclists.

As part of a major highway programme and the development at Wessex Fields, the Council has taken
the opportunity to install average speed cameras between Cooper Dean Roundabout and Blackwater
junction and it is anticipated that once active, along with existing speed camera sites, these will help
moderate traffic flows and speeds and improve safety along the route. In addition, once both phases of
the Wessex Fields highway development have been introduced, this will offer an improved alternative
route for cyclist travelling from Bournemouth up to Holdenhurst Village and towards the Airport.

As noted in your report cyclists are permitted to use dual carriageways. However, the speed differential
between cyclists and other vehicles can be high and it may be prudent for cyclists to consider
alternative routes. For this reason, the Council has taken steps to introduce parallel safer routes along
some sections of the A338 and does not propose to promote or encourage cycling on the A338 itself.

BCP Council is currently working on plans to install cycle facilities along sections of Wallisdown Rd that
are well used by cyclists and it is also working to secure substantial additional funding through the
Transforming Cities Fund to allow more cycle schemes to be brought forward along key cycling routes.
These will hopefully link the outer areas of the conurbation, such as Ferndown and Ringwood,
providing an alternative safe route for cyclist to commute into Bournemouth, Christchurch and Poole.

In regard to wider transport policy, BCP Council is promoting the use of cycling and other sustainable
travel modes in general, as these help alleviate congestion and bring wider health and environmental
benefits. To support and encourage this growth, the Council has introduced a significant number of
facilities designed to make cycling easier, safer and more direct. For example, in Bournemouth, these
include investment of more than £7.5m over the last 10 yrs to fund the delivery of over 100 schemes. It
also regularly undertakes media campaigns advising drivers to look out for cyclists and give them
space, and for cyclists to use helmets, lights, bright or hi viz clothing to make themselves as
conspicuous and safe as possible.

Whilst this response is not supportive of remedial action in relation to the sad and tragic death of this
cyclist, | hope | have adequately set out how the Council priorities it’s road safety interventions as well
as outlining some of our previous, current and future plans to improve safety.

Yours sincerely

‘A i Daud o~

Head of Highways and Transportation (Bournemouth)

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