Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0112, written 7 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 | 7 Mar 2019 |
|---|---|
| Reference | 2019-0112 |
| Deceased | Matthew Bilby |
| Coroner | Timothy Brennard |
| Coroner area | Lincolnshire |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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.
Timothy W Brennand HM Senior Coroner County of Lincolnshire REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Secretary of State for Transport, Department for Transport, Great Minster House, 33 Horseferry Road, London SW1P 4DR 2. Head of Highways, Lincolnshire County Council, Newland, Lincoln LN1 1YA CORONER | am Timothy W Brennand, HM Senior Coroner for the County of Lincolnshire, 4 Lindum Road, Lincoln, Lincolnshire, LN2 1NN. 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 INVESTIGATION and INQUEST On 18 September 2018 | commenced an investigation into the death of Matthew Bilby, aged 48 years. The investigation concluded at the end of the inquest on 7 March 2019. The medical cause of death was determined to be: ta. Traumatic Injuries There was a short form conclusion of road traffic collision. CIRCUMSTANCES OF THE DEATH On the 6th September 2018, the deceased was riding ME casas Duke motorcycle along the B1166 on the eastern side of the junction with the A1 e, Crowland, Lincolnshire. The deceased drove past on the nearside of standing traffic queuing at the junction and onto the southbound carriageway of the A16 into the path of a DAF Tipper Heavy Goods Vehicle travelling on the A16 where the vehicles were to collide. The deceased was knocked into the air and sustained extensive internal injuries. He remained conscious for a period following the impact, before suffering a cardiac arrest. Despite attempts at resuscitation, he was pronounced dead at the scene. 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. — te The court heard evidence from a number of current regular road users describing the 1 layout of the A16/B1166 junction as "dangerous", "horrendous", "confusing" and "difficult"; 2. In evidence the Lincolnshire Police confirmed that this was the fourth fatality at this junction; 3. The junction was created as a "staggered" junction in August 2010. Following one of the previous fatalities at the junction further work had been undertaken with red thermoplastic laid in hatched areas; 4. Expert evidence received from the East Midlands Operational Support Service Serious Collision Investigation Unit confirmed the junction to be an "accident blackspot" and that the staggered junction created an on-going risk to future road users in that: a. This junction should be reconfigured as a roundabout; b. Alternatively there should be the deployment of considered traffic calming measures (cameras, traffic lights, speed restrictions). ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | 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, namely by 28 May 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 (a) The next of kin (b) Lincolnshire Police (c) East Midlands Operational Support Service | 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. TIMOTHY W BRENNAND HM SENIOR CORONER
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.
Department for Transport Timothy W Brennand HM Senior Coroner County of Lincolnshire 4 Lindum Road From the Secretary of State The Rt. Hon. Chris Grayling Great Minster House 33 Horseferry Road London SW1P 4DR Tel: 0300330 3000 E-Mail: Web site: www.gov.uk/dft Our Ref: MC/253924 Your ref: 02310-2018 Lincoln, Lincolnshire LN2 1NN W May 2019 Ce MA Bren D Thank you for your letter of 3 April 2019 and the accompanying report into the fatal accident on the A16/B1166 junction, Crowland, Lincolnshire. | was very saddened to learn of the tragic circumstances of the death of Mr Bilby. You raised a number of concerns in your letter, including the following: “Expert evidence received from the East Midlands Operational Support Service Serious Collision Investigation Unit confirmed the junction created an on-going risk to future road users in that: a. This junction should be reconfigured as a roundabout; b. Alternatively, there should be the deployment of considered traffic calming measures (cameras, traffic lights, speed restrictions).” The responsibility for traffic management on local roads rests with the relevant local highway authority, as they are best placed to consider how to use traffic management measures so that local needs can be effectively met. My Department's role is to provide the overarching strategy and policy context, as well as guidance to help them in managing their roads. Local authorities are responsible for setting their own design standards. For roads of this type, Lincolnshire County Council may have chosen to adopt the guidance provided by Highways England in the Design Manual for Roads and Bridges (DMRB). This is provided for the strategic road network, but can be applied to roads such as the B1166 and A16 at the authority’s discretion. With regard to traffic calming, the Department provides best practice guidance for local authorities in Local Transport Note 1/07: Traffic Calming which can be found at: https://assets. publishing.service.gov.uk/government/uploads/system/up loads/attachment_data/file/329454/Itn-1-07_Traffic-calming.pdf This guidance includes a section on rural areas, and advises that some speed reduction can be achieved by introducing local 30 mph speed limits on higher speed limit roads. Generally, a specific set of measures will be required at each individual site. The guidance also covers roundabouts, highlighting that new roundabouts in rural areas have reduced injury accidents, on average, by 54 per cent. Advice on the use of speed cameras is also provided. Additionally, the guidance covers the use of rumble devices on rural roads. Rumble devices are small raised areas across the carriageway with a vibratory audible and visual effect. They are used to alert drivers to take greater care in advance of a hazard such as a bend or junction. From the above, | trust you will accept that no action is necessary from the Department with regard to your specific concerns. Rt Hon Chris Grayling MP SECRETARY OF STATE FOR TRANSPORT
Lincolnshire COUNTY COUNCIL Our Ref: PR/31072019 Date: 31 July 2019 Place Directorate Highway Network Management Private & Confidential 36 Orchard Street Mr T Brennand Lincoln HM Senior Coroner LN1 1XX G2 Aus 2019 County of Lincolnshire Email: ; ray 4 Lindum Road cschighways@lincolnshire.gov.uk Lincoln Tel: 01522 782070 LN2 1NN c/o: LincsCoroner@lincolnshire.gov.uk Dear Mr Brennand Inquest touching the death of the late Matthew BILBY Thank you for your letter dated 18 June 2019 with attached copy of the Secretary of State for Transport's response to the Regulation 28 Report. | have noted the comments made by the Secretary of State, specifically that ‘the responsibility for traffic management on local roads rests with the relevant local highway authority." However, as set out in the Council's response dated 11 June 2019 to the Regulation 28 Report, there is currently no funding available for the Council to proceed with a project to construct a four-arm roundabout at this location. In our response of 11 June 2019, we therefore confirmed the following:- de We would continue to monitor funding opportunities for the roundabout and 2 We are currently assessing the impact the traffic calming measures have had on collision rates. | take this opportunity to update you regarding the above actions as summarised below. e Lincolnshire Road Safety Partnership (LRSP) monitor road safety data for all locations across the County and promote appropriate measures where required depending on the available funding. LRSP's Accident Investigation Team re-assess the collision history of all sites on an annual basis and use that assessment to rank the sites in order of priority to ensure that resources can be directed accordingly. * The Average Speed Camera System along the A16 was installed in December 2016. Since then in terms of the overall section, the numbers of speeding offences have gone down. The actual numbers are 6649 in 2017, 4209 in 2018 and 1532 during first 6 months of this year. This reduction in speed offences numbers evidences that the average speed cameras have been successful in reducing vehicle speeds along the A16. * Following the reduction in vehicle speeds at this location, the junction has recently been re-assessed on 31 December 2018, taking into account the collision history at the location, with a priority ranking assessment in the low 70s. In the previous assessment undertaken in July 2017, the A16/B1166 junction was ranked at number 46. In summary, following the installation of red surfacing and average speed camera system, the evidence suggests the traffic calming measures have resulted in a reduction of vehicle speeds at this location. The location has recently been re-assessed taking into account the collision data history for the site, which has produced a priority ranking in the low 70s. Having regard to the position of the junction in the priority ranking list, further improvements led by Lincolnshire Road Safety Partnership would prove difficult in terms of funding in the absence of a specific funding opportunity. There are currently no funding opportunities available to deliver the roundabout at this location. The roundabout's construction cost of over 2 million pounds was estimated about 2 years ago and is likely to exceed that now. Therefore, we would look to update this estimate in readiness for any funding opportunity that may become available in the future. | trust that the above update is useful and please let us know if you have any further queries. Yours sincerely ce Head of Highways Services
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