Prevention of Future Deaths reports · 2019

Saeid Hedayat

Regulation 28 report to prevent future deaths, reference 2019-0327, written 2 Oct 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report2 Oct 2019
Reference2019-0327
DeceasedSaeid Hedayat
CoronerRobert Simpson
Coroner areaWest Sussex
CategoryRoad (Highways Safety) related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

Regulation 28: REPORT TO PREVENT FUTURE DEATHS

NOTE: This from is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT DEATHS

THIS REPORT IS BEING SENT TO:

, Director of Highways, Transport and Planning, West Sussex County Council, County Hall,

Chichester PO19 1RQ

1 CORONER

I am ROBERT SIMPSON, Assistant Coroner, for the coroner area of WEST SUSSEX

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 the 18th February 2019 an investigation was opened into the death of Saeid Hedayat, aged 55. The
investigation concluded at the end of the inquest on 1st October 2019. The conclusion of the inquest was that
‘Saeid Hedayat lost control of the vehicle he was driving on the B2112 which overturned. As a result of this he
suffered a hypoxic brain injury and died’.

4 CIRCUMSTANCES OF THE DEATH

On the 8th February 2019 Saeid was involved in a single vehicle road traffic collision. Following heavy rain the
B2112 was flooded across the westbound carriageway. This flooding resulted from the blockage of drain
number B9913 with debris and silt. The blockage occurred on top of the drain grating in zone 1. Nothing in
the other zones of the drain impeded the drainage of water.
When the police collision investigator attended the scene 2 hours and 50 minutes after the collision the water
was receding but still measured up to 7cm in depth. I found that the depth of the flood at the time of the
incident was likely to be greater than this.
There is no lighting at the location and the road is subject to the national speed limit.
No conclusions could be drawn from the evidence available about the speed at which Saeid was driving.
Saeid either lost control after swerving to avoid the floodwaters or as a result of aquaplaning having hit the
floodwaters. After losing control his vehicle flipped and landed on its roof causing multiple injuries.

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 will occur unless action is taken. In the circumstances it is my statutory duty to report to
you.

The MATTERS OF CONCERNS are as follows: -

(1) West Sussex County Council’s risk assessment which was carried out to determine drain clearance
frequency did not take any account of zone 1 blockages and I heard evidence that there is no time
period set for reviewing the risk assessments. I heard evidence that the risk levels have not been
reviewed since 2011 despite more recent data being available.
I also heard evidence that neither anomalous silt level reports nor reports from members of the
public of road flooding would trigger a review of the risk assessments.

(2)

 (4)

(3) The highways authority representative at the inquest was not able to inform me of what plans West
Sussex County Council has to reassess the drain risk levels in light of the increased severity of winter
storms.
I found that that drain numbered B9913 was blocked on a regular basis due to debris and silt
collecting in zone 1. There are no warning signs (temporary or permanent) drawing drivers’ attention
to the flood risk despite this. I heard evidence that signs would not normally be installed unless the
highways authority were not able to immediately resolve the flooding if they attended. This approach
does not appear to adequately deal with the risks posed where road flooding occurs regularly due to a
zone 1 blockage.

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 28th November 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 Person namely

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

Robert SIMPSON
Assistant Coroner for
West Sussex Coroner's Service

Dated: 2nd October 2019

Responses

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 from West Sussex County Council (PDF)
Matt Davey
Director of Highways, Transport & Planning

www.westsussex.gov.uk

29 NOV 2019

County Hall

West Street west

West Sussex sussex

PO19 1RQ county
council

27 November 2019

Private and Confidential
Mr Robert Simpson
Assistant Coroner
Coroner’s Service

County Record Office
Orchard Street
CHICHESTER

West Sussex

PO19 1DD

Dear Mr Simpson

Re: Inquest into the death of Saeid HEDAYAT

Thank you for your letter of 2"4 October 2019 (ref 00442-2019) regarding the
inquest into the death of Saeid HEDAYAT. I have been through the points raised
and tried to address them in turn below.

Addressing each of MATTERS OF CONCERNS are as follows: -

(1) West Sussex County Council's risk assessment which was carried
out to determine drain clearance frequency did not take any account of
zone 1 blockages and I heard evidence that there is no time period set
for reviewing the risk assessments. I heard evidence that the risk levels
have not been reviewed since 2011 despite more recent data being
available.

On the first point, whilst it is recognised that we did not provide evidence that
there was no time period for reviewing the risk assessment, we would like to
assure the Coroner that we have reviewed the risk and that that our current and
future operations take account of changes in risk level.

At the start of our current Term Maintenance Contract (which commenced 1*
July 2011) we worked with our contractor to develop an annual, county wide
gully cleansing programme, To do this historical WSCC information regarding
gully cleansing, silt levels and treatment intervals were assessed and an
optimised cleansing programme developed. This approach involved looking at
where flood events have occurred and, where silt levels in gullies have
historically been high, arranging for these gullies to be cleansed more regularly
than those in areas not prone to flooding and with historically low levels of silt.

Cont...

The treatment intervals for each gully were reviewed on a regular basis to
ensure that the most appropriate level of service is delivered. At the end of a
two-year cleansing cycle, an optimised cleansing regime was agreed and this
took into account any changes in silt levels and priority based on levels of risk
determined by the assessment of need.

The programme ensures that no gullies, chambers or catchpits are above a 50%
silt level at any time.

The average silt level from the cleansing data would adjust the cleansing
frequency based on a re-assessment of risk.

A full review of all gully cleansing data on our current term maintenance contract
was undertaken at the start of this year (2019) and our programme was again
prioritised and optimised prior to the start of this current financial year (1 April
2019),

Moving forward, WSCC has now adopted the approach of recording Zone 1
blockages when the contractor Is undertaking the cleansing programme. It will
be logged as the asset being “obstructed prior to cleanse” and will be reported
back with all other cleansing data and defects. This data, in addition to any
recorded customer enquiries, will give enhanced data which will help identify
areas where we might have ongoing zone 1 blockages and thus help address the
Coroner's concern.

On the second point, as stated above, at the end of each two year cleansing
cycle we undertook a review of the programme. The average silt level from the
cleansing data would adjust the cleasing frequency based on a reassessment of
risk level. This information was not however included in the Witness Statement
of Richard Speller as we have limited paperwork detailing the methodology and
Officers involved in the past contract management have left the Authority.
However we do have some annual plans from the contractor which cite this
working practice which could be provided if required by the Coroner or we could
ask for statements from the contractor to confirm this.

As stated above, under our current Term Maintenance contract, we undertook a
full review of the programme at the start of this year and and a new optimised
programme commenced on 1 April 2019. We are currently undertaking a
procurement exercise for a new contract starting April 1%t 2020 and there will be
a review of the programme again and we will consider risk levels again. Award of
the contract is likely to be made in December 2019 after which the specifications
for drainage cleansing frequency within the new contract can be disclosed.

Cont..

(2) I also heard evidence that neither anomalous silt level reports nor
reports from members of the
public of road flooding would trigger a review of the risk assessments.

Flooding incidents are not necessarily caused by blocked gullies. When we
receive a report of a flooding incident where water is slow to drain, then an
officer will attend site and assess the likely cause. There may not be any
evidence of an issue and in this case the contractor may not be asked to attend.
For example , where there has been an exceptional severe weather event and
the gully and drainage system did not have the capacity to cope with the deluge.
If an officer visits the site and the gully is silted they will arrange for our
contractor to attend site and undertake an adhoc cleanse. Whenever our
contractor attends site for cleansing or jetting outside of the cleansing
programme (i.e. when data is recorded as ‘Ad-Hoc ’) if the level of silt recorded
is above 50% then this would factor into the optmisation of the frequency of
cleansing going forward. This information is recorded in our record management
system.

As stated above, we have put in place new processes to capture areas where
there are zone 1 blockages (1.e. frequently occuring substantial detritus sitting
over the top of the gully). This can then be taken into account through
performance reporting and when we undertake annual reviews produce our
optimised programme in our new contract.

We also monitor a drainage ‘heat map’ which shows customer reports on
drainage issues and this highlights areas reported and affected following rain
events. We use this information when we are considering remedial work.

(3) The highways authority representative at the inquest was not able
to inform me of what plans West Sussex County Council has to reassess
the drain risk levels in light of the increased severity of winter storms.

WSCC was part of the team who prepared the Guidance for Climate Change
document (see attached). This document outlines the key areas that a local
authority needs to consider in relation to climate change risk assessment and
the adaptation of corporate plans, policies and performance and infrastructure.
The document also considers our approach to land use, planning and the built
environment which includes devolopments and drainage requirements and
specifications for surface water drainage plans.

As Highway Authority we will be considering the climate change impacts and

how to future proof our network. This will include understanding and reacting to
drain risk levels in light of any increased severity of winter storms.

Cont

(4) I found that that drain numbered B9913 was blocked on a regular
basis due to debris and silt

collecting in zone 1. There are no warning signs (temporary or
permanent) drawing drivers’ attention

to the flood risk despite this. I heard evidence that signs would not
normally be installed unless the

highways authority were not able to immediately resolve the flooding if
they attended. This approach does not appear to adequately deal with
the risks posed where road flooding occurs regularly due to a zone 1
blockage.

It would set a very difficult precident for the highway authority if we adopted a
policy of signing occassional laying water as a result of Zone 1 restrictions which
only ocurred as a result of infrequent events (storms). In inclement weather rain
intensity may cause any catchment area to become temporarily blocked by
detritus.

As a Highyway Authority, we use the Traffic Signs Manual (Chapter 8 and 4)
which gives guidance on how to use of Flood warning signs.

The Traffic Signs Manual states that Flood Signs (dia.554) can be used when
conditions become dangerous and used for as long as as the hazard continues to
exist or expected to occur in the near future.

If we attend site and are unable to resolve a flooding issue immediately and this
is impacting safe passage of the highway, our normal practice is to place
temporary Flood Signs to warn motorists until we can resolve the issue.

In terms of the subject location, we were not aware of an ongoing issue with
zone 1 blockage (only one customer report) and as such would not have deemed
it necessary to install signage.

If we had been aware of an ongoing issue then we would have either signed as
appropriate or invesitigated remedial measures.

If you feel there are any matters that you were concerned about that have not
been adequately covered in this response please do not hesitate to contact me.

Yours sincerely

Director of Highways, Transport & Planning

Enc. Good Practice Guide ADEPT 2019

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