Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0295, written 21 Jan 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Jan 2019 |
|---|---|
| Reference | 2019-0295 |
| Deceased | Robert Norton |
| Coroner | Martin Fleming |
| Coroner area | West Yorkshire (West) |
| 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.
IN THE WEST YORKSHIRE WESTERN CORONER’S COURT IN. THE MATTER OF: , The Inquest Touching the Death of Robert Irwin Norton A Regulation Report — Action to Prevent Future Deaths THIS REPORT IS BEING SENT TO: | - Director for Regeneration and Strategy _Calderdale Council Northgate House | Northgate Halifax HX11UN 1 | CORONER Martin Fleming HM Senior Coroner for West Yorkshire Western CORONER'S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the coroners and 7 Justice Act 2009 and regulations 28 and 20 of the Coroners ' | Unvestigations) Regulations 2013 INVESTIGATION and INQUEST 3 On.30/8/17 I opened an inquest into the death of Robert Irwin Norton © who, at the date of his death was aged 74 years old. The inquest was © resumed:and concluded on 14% January 20019 ‘I found that the cause of death to be: - la Traumatic fractures of thoracic spine arrived ata conclusion of Road Traffic Collision. 4 | CIRCUMSTANCES OF THE DEATH At approximately 11.45am on 5% April 2018, Mr Norton was riding his | motor cycle on the roundabout of the A644 Wakefield Road having approached the roundabout along Wakefield Road from the Cooper RT3589. 1 [-- Bridge direction. Mr Norton was.travelling around the roundabout in the offside lane with the intention of joining the M62 eastbound. At t5is time the driver of a Volvo motor vehicle entered the roundabout in the =: nearside lane, travelling from the Brighouse direction with the intension. of travelling straight ahead_ towards Cooper Bridge. The driver of the motor vehicle was travelling around the roundabout with Mr Norton _ driving his motorcycle alongside. Once at the entry to the slip road-Mr Norton moved from his offside lane into the path of the Volvo resulting - in a collision with the off side front wing of the Volvo and causing Mr. Norton to fall from his motor cycle and collide with a wooden fence adjacent to the slip road, tragically causing him to sustain fatal injuries. During the inquest I heard evidence to suggest that the road markings painted on the road surface were worn and difficult to read with the potential for causing motorists to be in the incorrect lane to exit the roundabout onto the entry slip to the M62. Given two lanes on the © _| roundabout and two lanes on the slip road, I heard evidence that this could give the impression that the exiting the roundabout onto the slip * , uals ‘is possible from either lane. . . , CORONER’S CONCERNS The MATTER OF CONCERN is as follows: - e To consider the existing legibility of the painted road markings e To review the existing road lay out in order to prevent potential ‘confusion by motorists ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that has the power to take such action. In the circumstances iti is my statutory duty to report to you. YOUR RESPONSE You are under a duty to respond to this renert within 56 days of its date; I may extend that period on request. Your response must contain details of action taken or proposed to be taken, setting out the timetable for such action. orate you must explain why no action is proposed. : RT3589 2 COPIES T have sent a copy of this report to: E- daughter ee Wye ee ye HE irector for Regeneration and Stratgey-— Calderdale Council e Chief Coroner DATED this 21/1/19: 'D ler RT3589 - 3
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.
Csku'-TUcdt Council g i f ' ' ‘ U N A R M l i ifi Regeneration and Strategy Strategic Infrastructure Ainleys Depot Huddersfield Road Eiland HX5 9JR 15 th March 2019 Mr M D Fleming HM Senior Coroner City Courts The Tyrls BRADFORD BD1 1LA Dear Mr Fleming Robert Norton deceased - Inquest 14th January 2018 Thank you for your recent report, dated 22nd January 2019, regarding the unfortunate death of Mr Robert Norton. I can confirm that following receipt of your report, and upon further investigation, I propose the following actions: 1. White Lining I have now studied photographs of the white lining which were taken by one of my engineers shortly after the accident took place. As you can see from the photograph below, the lining itself is clearly legible which is supported by his overall assessment of the general condition (also included for completeness) r . /*- -aftr ( y bert tcrrpany . 2 0 1 7 , I n c l u s i v e E m p l o y e r s \ f 2/ 15th March 2019 FEATURE COHDITIOH ROAD SURFACE Asphalt Generally satisfactory apart from some minor cracking in the road surface as can be seen In the photographs In Appendix B DRAINAGE Good No visible defects STREET LIGHTING System of street lights present ROAD MARKINGS Acceptable condition SIGNING Good CONTAINMENT (barriers etc.) Good The accident took place at 11.45 so street lighting would not have been in operation. All road markings visible with some signs of wear, which would be expected on a heavily trafficked road such as this AU existing signing is in an acceptable condition Steel crash barriers are provided at the back of the footway and these appear to be In good condition I will therefore continue to inspect the lining on a regular basis and renew as required. 2. Overall layout of roundabout and dual entry exits Calderdale MBC carry out accident studies on all fatal accidents as a matter of course, we are also notified of all other personal injury accidents. Although the roundabout layout and exit lane detail is not uncommon, in light of your concerns I will commission a study of any similar accidents so that any remediation can be applied as necessary. Yours sincerely Assistant Director - Strategic Infrastructure
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