Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0168, written 25 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 | 25 May 2019 |
|---|---|
| Reference | 2019-0168 |
| Deceased | Ahmed Motala |
| Coroner | Caroline Saunders |
| Coroner area | Gloucestershire |
| 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.
H M Assistant Coroner for Gloucestershire
Dr Simon Fox QC
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Local Highways Manager
Gloucestershire county Council
Floor 5
Block 5
Shire Hall
Westgate Street
Gloucester GL1 2TG
CORONER
| am Caroline Saunders, H M Assistant Coroner for Gloucestershire.
CORONER'S LEGAL POWERS
t 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.
-
INVESTIGATION and INQUEST
On 14 December 2018 | commenced an investigation into the death of Ahmed Hassam Motala
The investigation conciuded at the end of the inquest on 21° May 2019
The conclusion of the inquest was: Road Traffic Collision.
The medical cause of death was 1a) Multiple Injuries
4 CIRCUMSTANCES OF THE DEATH
On 29th November 2018, Ahmed Motala was cycling to work along the A38 at Cole Avenue in
Gloucester. He was cycling in a westbound direction in cycle lane. After the junction with Epney
Road, Mr Motala was in collision with a lorry. It appears that Mr Motala swerved or was blown by
the wind into the lorry. The injuries he sustained resulted in his death.
8 | CORONER’S CONCERNS 7
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. -
The evidence of the Police Collision Investigator and the evidence of witnesses who were
motorists on the day (one who regularly used the cycle lane himself) describe the state of the
cycle lane as being in very poor condition and cyclists have to swerve in the cycle lane to avoid
ihe defects. Moreover | heard that to avoid the defects they cycle very close to the while line
separating the lane with the traffic. This is obviously very dangerous.
At the time of the impact, Mr Motala was not ina cycle lane, what is more the weather on that
day was described as “diabolical” . Therefore | do not consider that the state of the cycle lane
itself contributed to his death.
However, | am concerned that lives of cyclists in the future may be put at risk if the cycle lane
stays in the current state of repair.
Gloucestershire Coroner's Court, Corinium Avenue, Barnwoed, Gloucester, Gt4 30
Tel 01452 305661 | Fax 01452 412618
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you have the power
to take such action.
i YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely by
4pm 19" July 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.
a)
COPIES and PUBLICATION
| have sent a copy of my report to the Chief Coroner and to the following Interested Persons
(1) The family of Mr Motala
2)
(3)
{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 compiete or redacted or summary form. He
may send a copy of this report to any perscn 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 —_ 24/519
Signature. Coe hee
Caroline Saunders
H M Assistant Coroner for Gloucestershire
Gloucestershire Coroner's Court, Corinium Avenue, Barnwood, Gloucester, GL4 3D)
Tel 01452 305661 | Fax 01452412618
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.
agamstershisc Highways Highways Commissioning Block 5, 5th Floor Shire Hall Gloucester GL1 2TH 08000 514 514 highways@gloucestershire.gov.uk Gloucestershire Coroner's Court Corinium Avenue Barnwood Gloucester Our Ref: 11225598 Date: Wednesday, 12 June 2019 Mr Ahmed Hassam Motala deceased Thank you for your letter dated 24th May 2019 regarding the cycle lane in Cole Avenue. Our Safety Inspection Team have been out and assessed the site using our Safety Defect Criteria. At present there are no actionable safety defects, however the red surfacing that is sometimes used in cycle lanes to highlight their presence is starting to strip away. There is no quick fix for this issue and the lanes have to be planed out and fully resurfaced. Cole Avenue is currently in our resurfacing programme for the next financial year 20/21, this will involve the tarmac surface and cycle lanes being planed out and new tarmac put in its place. Until this time, Cole Avenue will continue to be inspected as part of our key route inspections once a month and any defects that are present will be attended to. I have stressed the importance of picking any issues up in this location and the inspectors will now pick up any defects that meet the criteria for a footpath defect within the cycle lanes. This criteria is different to that of a carriageway and will highlight smaller defects. I trust this is acceptable to you, should you have any further queries please do not hesitate to contact me. Local Highway Manager (Gloucester) Area Highways - Southern :ollow us on Social Media for updates. W ono — f GR our highways investurni n inaucesterne s Gads
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