Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0231, written 5 Jul 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Jul 2019 |
|---|---|
| Reference | 2019-0231 |
| Deceased | Keith Battman |
| Coroner | Karen Harrold |
| Coroner area | West Sussex |
| 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) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Nathan Elvery, Chief Executive, West Sussex County Council, County Hall, West St, Chichester PO19 1RG 2: HE County Road Safety Group Manager, West Sussex County Council, County Hall, West St, Chichester PO19 1RG CORONER | am Karen Harrold, Assistant Coroner for the coroner area of West Sussex. 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. htto:/Awww.legislation.gov.uk/ukpga/2009/25/schedule/5 hittp://www.legislation.gov.uk/uksi/2013/1629/made INVESTIGATION and INQUEST On 13 November 2018, the Senior Coroner, Penelope Schofield, commenced an investigation into the death of Keith Winston Battman aged 74 years old. The investigation concluded at the end of the inquest on 25 June 2019. | recorded a conclusion of Road Traffic Collision. The medical cause of death was recorded as: 1a) Multiple traumatic injuries and clostridium difficile colitis (treated with colectomy October 2018) 2) Cardiomegaly CIRCUMSTANCES OF THE DEATH At around 16:30 hours on Wednesday 10 October 2018, a Peugeot Boxer minibus was being driven north along the A285, returning from a university football match in Chichester to Uxbridge. In the front passenger seat of the minibus one of the team was assisting the driver with navigation. At the same time, Keith Battman was travelling south on the A285 riding a Triumph Tiger motorcycle. A witness travelling in the same direction as Mr Battman told police that she had been held temporarily by traffic lights which had been placed at roadworks on the approach to the village of Duncton at its northern end. Whilst at the traffic lights she became aware of Mr Battman’s motorcycle which travelled to the front of the queue and stopped. When the lights turned green she described the motorcycle as having “shot off. Meanwhile, on approach to the right hand bend in front of Seaford College, the driver of the minibus had slowed, ready for the bend. As he was coming out of the bend he was confronted by Mr Battman’s motorcycle travelling towards him in a straight line and on his side of the road. This is corroborated by the front seat passenger of the minibus; bike tyre makings found on the road; and one tyre mark from the minibus. Tyre markings left by the motorcycle suggest that Mr Battman was travelling in a straight line and that he may have mistook the drive leading to the school as the A285. As the minibus and Mr Battman travelled towards the bend neither road user would have been able to see each other approaching due to a high hedge that blocked the view of any approaching traffic. Whilst approaching the left hand bend Mr Battman passed: A 30 mph speed sign; Ared triangle warning sign showing a left hand bend & instruction to slow Two painted SLOW signs on the road surface; A white map type direction sign showing the direction of the main road to the left and a No Through Road straight ahead. The colour of the road surface also changes on The Drive. However, the main road dips immediately in front of the entrance to the college and that cannot be seen until very close to the bend. The motorcycle was upright when it collided with the front offside wing of the minibus and the front wheel of the motorcycle pushed the front offside wheel of the minibus back into the wheel arch. As the motorcycle continued forward into the front of the minibus, Mr Battman, was thrown forward and his head impacted on the lower offside corner of the windscreen. His visor detached from his helmet and there were scratches to the helmet consistent with catching the wing of the minibus. The driver of the minibus confirmed that he saw the rider hit the window before he fell to the side of the minibus. The motorcycle then rotated clockwise before falling onto its offside. The motorcycle then slid back north along the southbound lane. The motorcycle was reported to have caught fire almost immediately after the collision. The damage to the motorcycle was such that there may have been a fuel leak from the tank or engine and almost certainly igniting having come into contact with hot components. On the day of the collision it was a bright sunny day, the sun would have been directly ahead of Keith Battman as he approached the bend. It is possible that glare from the sun may have obscured the view he had of the bend. However, the witness behind Mr Battman made no mention of the sun although it is not clear if she was asked. Mr Battman received serious injuries as a result of the collision and he was airlifted to St George's Hospital in Tooting where he remained until his death on 28 October 2018. CORONER’S CONCERNS During the course of the inquest I heard evidence ro a forensic collision investigation and reconstruction officer with Surrey police. He attended the scene on 10 October approximately 1 hour 20 minutes after the collision. After speaking to West Sussex officers, he surveyed the scene and took photographs. He returned to the scene some 5 months later and took a further set of photograpghs showing the bend and road signage. The evidence revealed that Mr Battman may have mistaken the entrance to Seaford College (The Drive) as the continuance of the A285 and as a result of travelling on a straight trajectory rather than taking the left hand bend he collided with a minibus on the other side of the road which was travelling in the opposite direction. In light of this finding, | studied the photgraphs taken at the time of the accident (10 October 2018) and more taken at the scene on the 19 March 2019 and discussed them in detail with At the time of the accident, there were no black and white chevrons road signs to warn road users of their approach to a tight bend. | was dismayed to learn that the chevron warning sign facng southbound traffic on the approach to Seaford College bend was removed between October 2010 and July 2011. However, the Sussex County Council Road Safety Group records de not show whether this was as part of the road safety scheme or was not replaced following a maintenance incident. No clear reason has been provided by the Road Safety Group. The evidence supplemented by extensive analysis of the photographs concerns me greatly. There have been 7 collisions on this stretch of road in the last ten years: 3 slight, 3 serious and one fatality (Mr Battman). 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 which are as follows:- 1. lam concerned that the number of black and white chevrons installed immediately outside of the entrance to Seaford College are insufficient. There are now two small raised chevrons to allow for the dip in the road but they do not appear to adequately draw the attention of drivers approaching the bend to the fact that there is a sharp hand bend ahead. Consideration must be given to how many are needed and their location taking into account the topograghy and sight lines. There is a speed limit sign approximately 350 metres back from the bend as you travel south. | am concerned this does not in itself give sufficient warning and perhaps a vehicle activated flashing warning sign should be installed to detect the speed of approaching traffic and alert drivers to slow down. There are two “Slow” markings on the road but | am concerned that these are faded and may not be sufficiently prominent. Overall, consideration should be given to whether this stretch of road in both directions needs further improvement. 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 30 August 2019. 1, 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: 1) The family of Keith Winston Battman; | have also sent it to: 4) ee... collision investigation unit, Surrey police and Sussex police — operations command, Haywards Heath police station, Bolnore Road, Haywards Heath, West Sussex, RH16 4BA 2) EE Surrey Police, Roads Policing Forensic Collision Investigation Unit | 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. Date: 5 July 2019 Karen Harrold Assistant Coroner West Sussex
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.
Response of West Sussex County Council to the Regulation 28 Report to Prevent Future Deaths issued by Karen Harrold, Assistant Coroner dated 5th July 2019 following the inquest into the death of Keith Winston Battman. Keith Winston Battman died on the 28th October 2018 as a result of a road traffic collision that occurred on the 10th October 2018 at the Seaford College bend on the A285, Duncton, West Sussex. Following the letter received from Karen Harrold, Assistant Coroner to the coroner area of West Sussex, dated 5th July 2019 (ref 02751-2018) enclosing the Regulation 28: Report to Prevent Future Deaths, the County Council responds with the comments and actions detailed below. Firstly I should clarify that the chevron was removed around the time the 2010/11 road safety scheme was installed, this scheme lowered the speed limit to 30mph and removed many of the warning signs through the village - a concept known as self-explaining roads. With regard to the Matters of Concern raised: 1. Following the police notification of Mr Battman’s collision the authority began its own now well established investigation procedure and acting on additional information from the police that Mr Battman may have mistook the school drive for the main road it was decided that further signage should be added. Two small stock chevrons were temporarily erected while a larger yellow bordered chevron was being manufactured; the new larger chevron was erected on the 2nd May 2019. We consider that this new signage, which reinforces the existing bend warning and map type direction sign, along with the measures detailed in paragraphs 2 and 3 below will overcome the topography issues and provide additional warning of the nature of the bend to southbound motorists. In addition the authority is in discussion with local landowners and the Duncton Parish Council with regard to removing some of the hedge on the inside of the bend to improve sight lines. While the removal of the hedge is not within the authority’s control, all of the parties involved have responded positively to the proposal. We are also in dialogue with Seaford College regarding the potential to interrupt the “straight on” view for southbound drivers by installing a banner type sign over their gateway. Again this measure is not within our control, but again I can advise that Seaford College have responded positively to the proposal. 2. There is a double side 30mph repeater sign 210m to the north of the bend, this upright sign is supplemented and reinforced with two 30mph road marking roundels (one in each lane). Drivers travelling south through the village of Duncton will have been travelling in a posted 30mph speed limit for over half a mile and will have passed four 30 mph repeater signs with associated 30mph roundels and a vehicle activated flashing 30mph speed limit reminder sign before reaching the bend. It is considered that these signs and road markings are sufficient to alert drivers to the 30mph speed limit. Analysis of the recorded injury collision history, as part of our investigation, has identified an emerging trend of southbound motorcyclists failing to negotiate the bend. It is anticipated that the installation of the larger chevron warning sign will, in combination with the other warning signs, help address this issue, however, we are cognisant that some drivers and riders who use a route on a regular basis do not notice standard warning signs and road markings as they may believe they are familiar with the conditions they are likely to encounter. To mitigate this risk it is our intention to install a vehicle activated flashing bend warning sign for southbound traffic at an appropriate distance to the north of the bend. A technical appraisal is currently being undertaken to ensure that this device can be installed at a safe location and to determine the appropriate trigger speed at which it activates. 3. One of the recommendations arising from our investigation following the collision was to refresh the give way lining at the Seaford College junction. Following receipt of your report the two painted SLOWs have been added to this programme of works. We anticipate that this work will be completed by the end of this August. In your report you suggested that consideration should be given to whether this stretch of road needs further improvement and I wanted to assure you that this section of road and the A285 as a whole have been the subject of a significant amount of study in recent years and have received many road safety intervention treatments. Previous works for this bend include an additional bend warning sign with a “Reduce speed now” sub plate; resurfacing with a high quality high skid resistant road surface; a reduction of the speed limit from 40mph to 30mph including Vehicle Activated Sign installed close to the village school to warn drivers and riders if they exceed the speed limit. To summarise, the two small chevrons highlighting the bend for southbound traffic have already been replaced with a larger more prominent yellow bordered two bar chevron. A vehicle activated bend warning sign for southbound traffic will be installed this financial year. The two SLOW markings to the north of the bend along with the junction markings at the college entrance will be remarked this August. County Road Safety Group Manager 26 July 2019
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