Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0165, written 20 May 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 May 2019 |
|---|---|
| Reference | 2019-0165 |
| Deceased | Richard Phillips |
| Coroner | Richard Middleton |
| Coroner area | Dorset |
| 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 (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. Dorset Council, Highways Department, County Hall, Colliton Park, Dorchester, Dorset, DT1 1XJ 1 | CORONER I am 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 2™ January 2018, an investigation was commenced into the death of Richard Geoffrey Phillips, born on the 3 April 1982. The investigation concluded at the end of the Inquest on the 14" May 2019. The Medical Cause of Death was: 1a Multiple Injuries The conclusion of the Inquest was Road Traffic Collision. CIRCUMSTANCES OF THE DEATH On the 19/12/17 at approximately 8.30am Mr Phillips was riding his motorcycle along the B3091 in a north easterly direction from Sturminster Newton to Shaftesbury. He had passed Guys Marsh and was approaching the area locally known as St James’ Common. The weather conditions were cold and icy. A car was approaching from the opposite direction along the single carriageway. The direction of travel of the car involved a descent. The vehicle has moved into the opposite carriageway and struck Mr Phillips broadside knocking him from his motorcycle with force. Mr Phillips was pronounced dead at the scene by paramedics. 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: a) There was water running down the descent which had frozen over. b) The direction of travel of the running water was down the nearside of the south westerly side of the B3091, across both sides of the carriageway then down the nearside of the north easterly side of the carriageway. c) Drivers of motor vehicles who use this route regularly reported the existence of standing/hanging water in this area being present for months prior to the accident. Those who attended the scene reported finding it difficult to remain upright when walking over the frozen stretch of road. d) Dorset Police provided a Collision Investigation Report which concluded that the driver of the motor car lost control of the car due to the presence of the ice on the road surface. Mr Phillips was positioned correctly in the road; was driving in a manner appropriate for the road conditions; was wearing a helmet and appropriate clothing. There were no mechanical defects to either vehicle. e) Dorset Police reported that there had been 2 road traffic collisions reported at this location in January 2015 (i.e. a similar time of the year to this incident) 2. Ihave concerns with regard to the following: a) The collision investigation officer from Dorset Police expressed concern in relation to the poor drainage of surface water on this particular stretch of road. My attention was drawn to four drainage gullies within 150 metres of the scene, two on each side of the road. As the water flows down the southbound side of the road it does not flow into the gulley but due to the camber of the road the water crosses over the centre of the road and flows down the centre of the road before flowing on to the opposite carriageway. On the nearside of the opposite carriageway is another drainage gulley which contains a gridded metal drain which was (at the time) largely obscured and overgrown by grass. The water once again bypasses this gulley. It is this surface water which has frozen at the time of the accident. At least 2 of the gullies which could drain the water away from the carriageway appear redundant. The positioning of these gullies are questionable. b) Maintenance of the road and its verges. 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, 15" July 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: 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. Dated Signed he S| 20" May 2019 Richard Middleton
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.
[ae Dorset Highways Wanchard Lane, =@ Dorset seers il Dorchester. Co Unite DT2 9RP 01305 2281020 ae www.dorsetcouncil.gov.uk Mr R T Middleton Date: 18/11/19 The Coroner's Office for the Ref: RTM/03611-2017/LJ County of Dorset Officer: Town Hail [J BH2eDy Se BH2 6DY Ke Dear Mr Middleton Re: Regulation 28 Report - Inquest touching the death of Richard Geoffrey Phillips Since our last letter of the 11" September we have investigated the site further and have had confirmation regarding the location of the accident. The accident took place on the section of the B3091 that has subsequently been resurfaced. During this resurfacing the camber of the road was adjusted to improve the ride quality and to ensure that surface water enters the existing drainage system in an efficient manner. This was done as part of our normal construction process, rather than a reaction to reports of problems in the area. The highway in question is affected by run off from neighbouring properties and springs. As a result of these issues there will always be some surface water on the carriageway but the improvements we have made will reduce it as much as is reasonably possible. We believe that this resurfacing work has already greatly improved the situation and, as such, we have no plans to carry out any further work in this location for the time being. We will continue to inspect the section regularly and monitor the surface water situation over the winter period. The drainage system has been cleaned recently but we will react to any blockages that are reported to us by the public or staff locally. Your Sincerely Community Highways Manager Dorset Council
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