Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0170, written 24 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 | 24 May 2019 |
|---|---|
| Reference | 2019-0170 |
| Deceased | Barry Clow |
| 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
IS BEING SENT TO:
Local Highways Manager
Gloucestershire county Council
Floor 5
Block 5
Shire Hall
Westgate Street
j. leucester GL1 2TG
CORONER
! am Caroline Saunders, H M Assistant Coroner for Gloucestershire.
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.
INVESTIGATION and INQUEST
On 17th December 2018 | commenced an investigation into the death of Ray Ronald
Westlake.
On 14" December 2018 | commenced an investigation intot he death of Barry Malcolm Clow
The investigations concluded at the end of the 2 inquests on 21° May 2019
The conclusion of both inquests were: Road Traffic Collision.
The medical cause of death in both circumstances was ta) Multiple Injuries
4 CIRCUMSTANCES OF THE DEATH
On 9" December 2018 Mr Clow was driving along the A424 towards Stow in the Wold. In the
vicinity of Upper Rissingion he lost control of his car and collided with a vehicle coming in the
opposite direction. Mr Westlake was a passenger in the second vehicle. Both Mr Clow and Mr
Westlake died at the scene from their injuries
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. —
The evidence that | heard was that it had been raining on that day and there were large areas of
standing water and running water throughout this stretch of the A424. | am told that there are
features in the side of the road (grips) which are dug out to encourage the water to run away but
these are regularly overwhelmed. The evidence from other motorists and local residents is that
this is a significant problem for motorists, especially those who do not know this stretch of road.
Whilst it may not be possible to ensure that the water runs away | was surprised as was the
Police Collision investigator that there were no signs warning motorists for the potential for this
area to flood.
_| am concerned that if this situation continues, future lives will be put at risk in the same way.
Gloucestershire Coroner's Court, Corinium Avenue, Barnwood, Gloucester, GL4 3D2
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.
7 | 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.
8 COPIES and PUBLICATION
i have sent a copy of my report to the Chief Coroner and to the following Interested Persons
(1) The family of Barry Maicolm Clow
(2) The family of Ray Ronald Westlake
(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 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,
9 Dated 24/5119
Signature Cov. ole.
Caroline Saunders
H M Assistant Coroner for Gloucestershire
Gloucestershire Coroner's Court, Corinium Avenue, Barnwood, Gloucester, G14 3D)
Tel 02452 305661 [| Fax 01452 412618
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.
· ~,.9.~fJ~~t~,rshire CO UN fY COUNCIL Highways Highways Commissioning Block 5, 5th Floor Shire Hall Gloucester Gll 2TH 08000 514 514 highways@gloucestershire.gov.uk Caroline Saunders Gloucestershire Coroner's Court Corinium Avenue Barnwood Gloucester GL4 3DJ Your Ref: TRO/je Our Ref: GCC/HC/BS/RG/01 Date: Monday, 3 August 2020 A424 Incident on 9 1h December 2018 Dear Caroline, I refer to your report of the 24 May 2019. Please accept our sincere apologies for not replying and confirming our actions following the recommendations in the Coroner's Regulation 28 Report . This was due to an administrative oversight although we can confirm that your report itself was considered and actioned at the time. Our response is now enclosed. Regulation 28 Response Letter: Mr Barry Clow Deceased Mr Ray Westlake Deceased Regulation 28 Report to Prevent Future Deaths We write in response to your Regulation 28 report dated 24 individuals. th May 2019 following inquests into the deaths of the above named Although Gloucestershire County Council were not an Interested Party at the inquests and were not required to attend to give any evidence we understand from your report that the inquests received some evidence that the relevant stretch of the A424 had been noted to flood on occasion. Prior to receipt of your report, Gloucestershire County Council was not aware that flooding was as an issue at that location which was already furnished with roadside 'grips' to aid drainage. We had not been informed of any incidents of flooding at that location by motorists or residents and have not received any reports of flooding since. In the 10 years prior to 9/12/18, Gloucestershire County Council had received only one report of a "slight" road traffic accident on 28 July 2018 that involved some surface water in the general vicinity of where the 9/12/18 incident took place. This incident followed what was described as a "dramatic rain storm" that led to the temporary presence of surface water on the highway. Save for this single incident, Gloucestershire County Council are unaware of any traffic collisions involving surface water at this December 2018. The contents of your Regulation 28 Report were the first and only site prior to or following the incident on 9 December 2018 incident suggestion we have received as to flooding or drainage being an issue. Our records relating to the 9 record that this took place in heavy rain and high winds in very wet conditions with surface water on the highway. th th Follow us on Social Media for updates. - r:o.GlosRoads f GlosRoads A' 9,.Q~f-~~t~rshire (O Ul'll'Y CO UNCIL Highways Notwithstanding that the sad circumstances leading to the deaths of Mr Clow and Mr Westlake appears to have arisen following the presence of surface water on the highway following a period of very heavy rainfall, the Council elected to exercise a statutory power to erect flood warning signs at the site on the 29 July 2019 in response to the information provided to us in your Regulation 28 Report. th I trust the above is of assistance to you. Should you have any further queries please do not hesitate to contact me. Yours faithfully, Local Highway Manager Follow us on Social Media for updates. - @GlosRoads f GlosRoads
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