Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0238, written 12 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 | 12 Jul 2019 |
|---|---|
| Reference | 2019-0238 |
| Deceased | Jason Imi |
| Coroner | Alison McCormick |
| Coroner area | Berkshire |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Berkshire Coroner’s Office Reading Town Hall, Blagrave Street, Reading, RG1 1QH Tel. 01189372300 coroner@reading.gov.uk 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: The Highways Authority 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 August 2018 I commenced investigations into the deaths of Jason Robert Imi (aged 48 years) and John Carl Shackley (aged 61 years). The investigations concluded at the end of the inquests on 8th July 2019. The conclusions of the inquests into the deaths of both men were: Road Traffic Collision 4 CIRCUMSTANCES OF THE DEATH On 2nd August 2018 Jason Imi and John Shackley were on a corporate day with their work team. They were staying at the Royal Berkshire Hotel on the A329 London Road, Sunninghill, Berkshire. That evening the group went for dinner at a restaurant just up the road from the hotel. The group walked back from the restaurant to the hotel shortly before 11.30pm. There is no pavement on the side of the road where the Royal Berkshire Hotel is located. Mr. Imi and Mr. Shackley walked together at the back of the group along the pavement on the opposite side of the road to the hotel. As they crossed the road back to the hotel they were hit by a motor car being driven in an easterly direction along the A329. As a result of the collision both men sustained fatal injuries and died at the scene. The A329 is subject to a 50mph speed limit at the locus of the accident. 5 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 could occur unless action is taken. In the circumstances it is my statutory duty to report to you. I am concerned that there is no footpath on the A329 on the side of the road where the Royal Berkshire Hotel is located, meaning that any pedestrians walking into or out of the hotel entrance have to cross the A329 to get from or to a footpath, and that there is no street lighting in the vicinity of the hotel. Street lights end 100 metres west of the hotel entrance. This means that pedestrians entering or leaving the hotel during the hours of darkness have to cross the road in a place where there is no illumination, and so they are Berkshire Coroner’s Office Reading Town Hall, Blagrave Street, Reading, RG1 1QH Tel. 01189372300 coroner@reading.gov.uk not easily visible to motorists driving along the A329. There is also a tree canopy in the summer, further shading the road, and a dip in the road surface on the eastbound approach to the hotel which adversely affects forward visibility towards the hotel for motorists. I consider that unless some action is taken there is a continuing risk of pedestrians entering or leaving the Royal Berkshire Hotel being run over as they cross the A329 at night. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has 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 13th September 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 family of Jason Imi The family of John Shackley The insurers of the vehicle involved in the road traffic collision on 2nd August 2018 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. 12th July 2019 Alison McCormick Assistant Coroner for Berkshire
Berkshire Coroner’s Office Reading Town Hall, Blagrave Street, Reading, RG1 1QH Tel. 01189372300 coroner@reading.gov.uk 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: The Highways Authority 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 August 2018 I commenced investigations into the deaths of Jason Robert Imi (aged 48 years) and John Carl Shackley (aged 61 years). The investigations concluded at the end of the inquests on 8th July 2019. The conclusions of the inquests into the deaths of both men were: Road Traffic Collision 4 CIRCUMSTANCES OF THE DEATH On 2nd August 2018 Jason Imi and John Shackley were on a corporate day with their work team. They were staying at the Royal Berkshire Hotel on the A329 London Road, Sunninghill, Berkshire. That evening the group went for dinner at a restaurant just up the road from the hotel. The group walked back from the restaurant to the hotel shortly before 11.30pm. There is no pavement on the side of the road where the Royal Berkshire Hotel is located. Mr. Imi and Mr. Shackley walked together at the back of the group along the pavement on the opposite side of the road to the hotel. As they crossed the road back to the hotel they were hit by a motor car being driven in an easterly direction along the A329. As a result of the collision both men sustained fatal injuries and died at the scene. The A329 is subject to a 50mph speed limit at the locus of the accident. 5 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 could occur unless action is taken. In the circumstances it is my statutory duty to report to you. I am concerned that there is no footpath on the A329 on the side of the road where the Royal Berkshire Hotel is located, meaning that any pedestrians walking into or out of the hotel entrance have to cross the A329 to get from or to a footpath, and that there is no street lighting in the vicinity of the hotel. Street lights end 100 metres west of the hotel entrance. This means that pedestrians entering or leaving the hotel during the hours of darkness have to cross the road in a place where there is no illumination, and so they are Berkshire Coroner’s Office Reading Town Hall, Blagrave Street, Reading, RG1 1QH Tel. 01189372300 coroner@reading.gov.uk not easily visible to motorists driving along the A329. There is also a tree canopy in the summer, further shading the road, and a dip in the road surface on the eastbound approach to the hotel which adversely affects forward visibility towards the hotel for motorists. I consider that unless some action is taken there is a continuing risk of pedestrians entering or leaving the Royal Berkshire Hotel being run over as they cross the A329 at night. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has 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 13th September 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 family of Jason Imi The family of John Shackley The insurers of the vehicle involved in the road traffic collision on 2nd August 2018 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. 12th July 2019 Alison McCormick Assistant Coroner for Berkshire
2 responses 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.
John Carl SHAKLEY Reg 28 Response (logged on Dear Sirs, I refer to your letter regarding the deaths of Mr Jason Imi and Mr John Shackley following the unfortunate road crash on A329 London Road, Sunninghill on 2nd August 2018. I have been asked to respond to you on behalf of the Royal Borough of Windsor and Maidenhead, who are the Highway Authority responsible for this section of road. I apologise for the delay in responding to you. As with all fatal road crashes on roads across the Borough, we arrange to meet the Police as soon as possible after any crash. This allows us to review the circumstances around the crash, identify possible contributory highway issues and if necessary put in place any remedial measures as soon as possible. In this case, a meeting was held on site with the Police on 7th August 2018. No tra(cid:431)ic management issues were identified during this site visit that may have contributed to this collision. Our information is that there have been no reported injury crashes on London Road within 200m of the Hotel entrance over the five year period 1st May 2013 to 30th April 2018 and that there have been no reported pedestrian casualties in the area since 1st January 1990. I do however note that you have raised concerns about a number of issues where you consider that there is a danger that future deaths could occur unless action is taken. With regards to these points that you raise: Whilst it is acknowledged that there is no footway on the north side of London 1. Road in the immediate vicinity of the Royal Berkshire Hotel, the likely number of users of a possible new footway is very low as there are only a small number of properties on the north side of the road and very few of the Hotel guests walk along this section of road. The lack of a footway is not unusual in a rural setting such as this, although there is a continuous footway along the south side of the road. We will nevertheless monitor and review pedestrian activity in the area. 2. small settlement to the west of the hotel, which commences at a point approximately 100 metres west of the Royal Berkshire Hotel. Whilst it is not usual practice to install street lighting for an individual access such as this, subject to budget prioritisation, the Council will look to introduce additional street lighting on the section of London Road up to the Hotel entrance. 3. but have not identified any specific road safety issues associated with tree cover. Colleagues have reviewed the tree canopy surrounding the road in this rural area There is existing street lighting on the road corresponding with the edge of the Although there is a slight dip in the road in the vicinity of the Hotel entrance, 4. there is advance signing to advise of the Hotel entrance as well as signing immediately opposite the Hotel entrance. Further signing or tra(cid:431)ic measures are not considered necessary to alert approaching drivers to the presence of the Hotel entrance. I trust that this response addresses the concerns that you have raised. Yours sincerely, BSc (Hons) MSc CMILT MCIHT Principal Engineer Reply
John Carl SHAKLEY Reg 28 Response (logged on Dear Sirs, I refer to your letter regarding the deaths of Mr Jason Imi and Mr John Shackley following the unfortunate road crash on A329 London Road, Sunninghill on 2nd August 2018. I have been asked to respond to you on behalf of the Royal Borough of Windsor and Maidenhead, who are the Highway Authority responsible for this section of road. I apologise for the delay in responding to you. As with all fatal road crashes on roads across the Borough, we arrange to meet the Police as soon as possible after any crash. This allows us to review the circumstances around the crash, identify possible contributory highway issues and if necessary put in place any remedial measures as soon as possible. In this case, a meeting was held on site with the Police on 7th August 2018. No tra(cid:431)ic management issues were identified during this site visit that may have contributed to this collision. Our information is that there have been no reported injury crashes on London Road within 200m of the Hotel entrance over the five year period 1st May 2013 to 30th April 2018 and that there have been no reported pedestrian casualties in the area since 1st January 1990. I do however note that you have raised concerns about a number of issues where you consider that there is a danger that future deaths could occur unless action is taken. With regards to these points that you raise: Whilst it is acknowledged that there is no footway on the north side of London 1. Road in the immediate vicinity of the Royal Berkshire Hotel, the likely number of users of a possible new footway is very low as there are only a small number of properties on the north side of the road and very few of the Hotel guests walk along this section of road. The lack of a footway is not unusual in a rural setting such as this, although there is a continuous footway along the south side of the road. We will nevertheless monitor and review pedestrian activity in the area. 2. small settlement to the west of the hotel, which commences at a point approximately 100 metres west of the Royal Berkshire Hotel. Whilst it is not usual practice to install street lighting for an individual access such as this, subject to budget prioritisation, the Council will look to introduce additional street lighting on the section of London Road up to the Hotel entrance. 3. but have not identified any specific road safety issues associated with tree cover. Colleagues have reviewed the tree canopy surrounding the road in this rural area There is existing street lighting on the road corresponding with the edge of the Although there is a slight dip in the road in the vicinity of the Hotel entrance, 4. there is advance signing to advise of the Hotel entrance as well as signing immediately opposite the Hotel entrance. Further signing or tra(cid:431)ic measures are not considered necessary to alert approaching drivers to the presence of the Hotel entrance. I trust that this response addresses the concerns that you have raised. Yours sincerely, BSc (Hons) MSc CMILT MCIHT Principal Engineer Reply
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