Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0180, written 30 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 | 30 May 2019 |
|---|---|
| Reference | 2019-0180 |
| Deceased | Barbara Henderson |
| Coroner | Tom Osborne |
| Coroner area | Milton Keynes |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This from is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: Jim O’Sullivan, Chief Executive of Highways England 1 CORONER I am Tom OSBORNE, Senior Coroner for the area of Milton Keynes 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 3rd September 2018 I commenced an investigation into the deaths of Susan Barbara HENDERSON aged 36 years and Margaret Louise SHAW aged 53 years. The investigation concluded at the end of the inquest on 5th April 2019. The conclusion of the inquest was that the drivers had died from multiple injuries and part of the narrative conclusion was that: The standing water had accumulated due to blocked gullies on the side of the road that had not previously been identified on routine inspection. 4 CIRCUMSTANCES OF THE DEATH Susan and Margaret died on the A5, Milton Keynes when one car aquaplaned across the road into the path of an oncoming vehicle. Both drivers died at the scene as a result of their injuries. 5 CORONER’S CONCERNS The MATTERS OF CONCERNS are as follows: During the course of the evidence I heard how the roads are examined and monitored on a regular basis but that such inspections are conducted at speed and that the process failed to identify the problem with this particular drain on the A5. I believe that the process for inspection should be reviewed. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) 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 24th 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: The families of both Ms Henderson and Ms Shaw Kier Highways Thames Valley Police 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. 9 Tom OSBORNE Senior Coroner for Milton Keynes Dated: 30 May 2019
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.
highways england Mr Tom Osborne, HM Coroner's Office, Civic Offices, 1 Saxon Gate East, Central Milton Keynes MK9 3EJ Safety, Engineering and Standards Executive Director, Temple Quay House 2 The Square Temple Quay Bristol BS1 6HA 23 July 2019 Dear Mr Osborne, Regulation 28 Report into the death of Susan HENDERSON and Margaret SHAW On behalf of of Highways England Company Limited, please find attached the Highways England response to the Regulation 28 Report dated 30 May 2019 following the deaths of Susan Henderson and Margaret Shaw. We will also post a hard copy to the Milton Keynes Coroner’s Office in Saxon Gate East, Milton Keynes. Yours sincerely Safety, Engineering and Standards Executive Director cc: Registered office Bridge House 1 Walnut Tree Close. Guildford GU1 4LZ Highways England Company Limited registered in England and Wales number 09346363 Q Q disability B S confident — COMMITTED ------- REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS RESPONSE IS BEING SENT TO: 1. The Senior Coroner for the area of Milton Keynes, Mr Tom Osborne of Civic Offices, 1 Saxon Gate East, Central Milton Keynes MK9 3EJ in response to a ‘Regulation 28 Report to Prevent Future Deaths’ received following an inquest hearing into the deaths of Ms Susan Henderson and Ms Margaret Shaw, that concluded on 05 April 2019. 1 HIGHWAYS ENGLAND I am on behalf of Bridge House, 1 Walnut Tree Close, Guildford, SURREY, GUi 4LZ. , Safety, Engineering and Standards Executive Director , responding , Chief Executive of Highways England Company Limited of 2 CORONER’S MATTERS OF CONCERN The MATTERS OF CONCERN are as follows: - “During the course of the evidence I heard how the roads are examined and monitored on a regular basis but that such inspections are conducted at speed and that the process failed to identify the problem with this particular drain on the A5. 1 believe that the process for inspection should be reviewed.” 3 DETAILS OF ACTION TAKEN At the request of the Senior Coroner, Highways England has undertaken a thorough review of our inspection requirements and processes across the whole of the Strategic Road Network (SRN) including the speed at which driven inspections are carried out. Each maintenance contract type (as listed below) is underpinned by specific maintenance and inspection requirements: (cid:127) Asset Delivery Asset Management Requirements (ADAMr) for Asset Delivery (AD). (cid:127) Asset Maintenance and Operational Requirements (AMOR) for Asset Support Contracts. [As in the case of the A5 Trunk Road on Area 8 with our Service Provider, Kier Highways Limited.] (cid:127) A modified AMOR for Progressive Asset Delivery contracts. (cid:127) Routine and Winter Service Code/Network Management Manual (RWSC/NMM) for M25 and M40 Design, Build, Finance and Operate (DBFO) roads. (cid:127) RWSC/NMM or Trunk Road Maintenance Manual (TRMM) for other DBFO roads. (cid:127) TRMM for the Severn Bridge Crossing. Highways England is satisfied there is consistency between the different sets of inspections requirements and processes including the requirement to drive at the safe prevailing traffic speed of the road for the driven inspections. For Asset Support Contracts a risk based approach is used to determine the frequency of 1 inspections. For Asset Delivery Areas and Regions, where inspections are undertaken by Highways England the frequency of inspections is dependent on the risk categorisation of the route. For other contract types such as Design, Build, Finance and Operate inspections a risk based approach is also used to determine the frequency of inspections. Inspections are undertaken by safety patrols to identify defects and are carried out at safe prevailing traffic speed with a driver and an observer. Sometimes a video survey is also used. If appropriate, inspections can also be undertaken on foot. Gully gratings are also inspected as part of the long stop condition survey inspections which should be undertaken annually for Asset Support Contract areas and at least every two years for Asset Delivery areas. Identification of a blocked gully grating would be recorded as a defect. Recessed gullies can be swept with a normal sweeper if the entrance and exit splays are tapered appropriately. If a sweeper cannot be used these are cleared by hand. As Milton Keynes Inspectors in the area have been made aware of the locations of recessed gullies, and have been instructed to pay particular attention to them as part of the inspections. Kier Highways Limited have written to Milton Keynes Council, as the designated Litter Authority, to highlight issues with litter and detritus build up on the A5 and will continue to do so when they consider the condition has dropped below an acceptable condition. 4 DETAILS OF FURTHER ACTION PROPOSED From the 1st October 2019 Area 8 will be moving from the current Asset Support Contract arrangements to the new Asset Delivery approach. Asset Delivery inspections will be undertaken in-house by Highways England staff. The Asset Delivery inspection methodology is considered appropriate for Highway England’s network and gives flexibility to allow increased inspection frequencies at locations where a specific risk has been identified. The methodology for undertaking inspections can be varied dependent upon the network characteristics, its accessibility and the safety of inspecting. For some locations and asset types it may be necessary or appropriate for the inspection to be undertaken on foot. From July 2022 all Asset Support Contract areas will have moved over to Asset Delivery. Following the review of inspection requirements and processes Highways England has decided to issue a memorandum to all our Areas to highlight the importance of: (cid:127) Understanding the location of recessed gullies, particularly on All Purpose Trunk Roads; (cid:127) Using an appropriate methodology for recording defects and condition of recessed gullies, for example undertaking a walked inspection if the condition of the gully grating is not clear from a safety patrol carried out at the prevailing traffic speed or video survey; (cid:127) Consideration of renewing recessed gullies that do not conform to standard to enable 2 them to be cleaned mechanically; and (cid:127) Communicating defects to Local Authorities as the body responsible for the sweeping and cleaning of All Purpose Trunk Roads. 5 TIMETABLE FOR ACTION Date Action 15th August 2019 Issue memorandum to all Highways England Areas to highlight the importance of inspection and defect rectification for recessed gullies. 1st October 2019 Area 8 to move from the current Asset Support Contract arrangements to the new Asset Delivery approach. 6 EXPLANATION AS TO WHY NO ACTION IS PROPOSED Highways England’s review of the inspection requirements and processes used by Highways England’s Areas and Regions, and our supply chain, concluded they had a common risk based approach, and were understood by inspectors and applied consistently. Therefore, there are no proposals to change the requirements and processes. 7 SAFETY OF ROAD USERS The safety of our road users is an imperative for our business in what we set out to achieve, and a core value of our organisation in how we go about it. Highways England’s renew of the inspection procedure has not identified any further action beyond the move to the new Asset Delivery system for the A5 Milton Keynes on 1st October 2019. 22 July 2019 , Safety, Engineering and Standards Executive Director on behalf of 3
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