Prevention of Future Deaths reports · 2019
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 report | 2 Oct 2019 |
|---|---|
| Reference | 2019-0327 |
| Deceased | Saeid Hedayat |
| Coroner | Robert Simpson |
| Coroner area | West Sussex |
| 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 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
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.
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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