Prevention of Future Deaths reports · 2019

Steffan Evans

Regulation 28 report to prevent future deaths, reference 2019-0339, written 8 Oct 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report8 Oct 2019
Reference2019-0339
DeceasedSteffan Evans
CoronerAndrew Haigh
Coroner areaStaffordshire (South)
CategoryRoad (Highways Safety) related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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
THIS REPORT IS BEING SENT TO:

aso for Highways and the Built County
ighways artment
Staffordshire County Council

1 Staffordshire Place
Stafford

ST16 2LP
1 | CORONER

| am Mr Andrew Haigh senior coroner for the coroner area of Staffordshire South

2 | 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.

3 | INVESTIGATION and INQUEST

On 17" January 2019 | commenced an investigation into the death of Steffan
Gareth EVANS, 28 years.

The investigation concluded at the end of the inquest on 25" September 2019. The
conclusion of the inquest was accident with the Cause of Death being Multiple
Injuries.

4 | CIRCUMSTANCES OF THE DEATH

Steffan Evans died at the scene of a road traffic collision on 15!" January 2019 near
Burton when a car he was driving collided with another car that had just emerged
from a driveway and then crashed into a van that was travelling in the opposite
direction. A major causative factor was the speed that Steffan was driving at. The
road is the B5017 (between Needwood and Burton).

[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 CONCERN are as follows. —
| am aware that following this collision you did make some enquiries concerning this

stretch of road (B5017 between Needwood and Burton). However there does
appear to be a genuine continuing concern about the volume and speed of traffic on

this road, bearing in mind the various junctions that there are. | would not ask you
to repeat work you have already done, but | wonder if there should be a further
review of this stretch of road to see if any steps should be taken to improve its
safety.

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.
na RESPONSE a

You are under a duty to respond to this report within 56 days of the date of this
report, namely by 14" December 2019. |, 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 A ari),

Virgin Media and Clyde & Co

| 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.

8" October 2019

Andrew A Haigh
HM Senior Coroner
Staffordshire (South)

Coroner's Office

No 1 Staffordshire Place
Stafford

ST16 2LP

Tel No: 01785 276127
Fax No: 01785 276128

www.staffordshire.gov.uk
sscor@staffordshire.gov.uk

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 Staffordshire County Council (PDF)
Staffordshire

County Council

Mr Andrew A Haigh

Senior HM Coroner for Staffordshire South
Coroner's Office

No 1 Staffordshire Place

Stafford

ST16 2LP

tS, O'% >}

Communities and Road Safety
Staffordshire County Council
1 Staffordshire Place
Tipping Street
Stafford
‘eST16:2LEP

Telephone: 01785 278160
E- nai

12'" December 2019
Our ref: RR/B5017BurtonRdCallingwood
Your ref:

Dear Mr Haigh,
Re: Steffan Gareth Evans (Deceased)

| refer to your Regulation 28 Report regarding the ‘Inquest into the death of Steffan Gareth
Evans and your comments concerning the B5017 Burton Road between Needwood and
Burton. This letter is in response to your matters of concern recorded in section 5 of your
report.

Some of the information that will be outlined below, has been included within email exchanges
with that | believe you have been copied into. Therefore, | apologise for
the duplication, though | feel it is necessary to reiterate the actions undertaken.

Following the collision in January, as is the process following all fatal road traffic collisions; the
collision history at this location was examined. The search concluded that no personal injury
collisions had been recorded within 300m of where the fatal collision took place within the
latest three years of complete data that we had available at the time. When the search area
was widened, two slight personal injury collisions have been recorded on the stretch of B5017
between Five Ways Island, Needwood and the change of speed limit east of The Acorn Inn.

This collision history does not indicate a requirement for speed reducing features. If patterns of
treatable collisions are identified, remedial measures proportionate to the accident problem,
will be proposed and prioritised against other locations across Staffordshire. As the budget for
road safety improvements is finite, it is the sites with the greatest proven need which are
treated first, and these will have a cluster of incidents with a discernible trend or pattern in the
cause of each.

CO

the knot unites

Staffordshire

County Council

On the 14! February, a Hazard Report Card was received from [requesting
we ‘assess the need for a reduction on the speed limit and the addition of signage to indicate
the presence of hidden entrances’. A speed and volume survey to ascertain vehicle speeds
was undertaken during the 10th and 19 July and 85!" percentile speeds of 56mph in both
directions over a 24-hour period were recorded. These speeds indicate good compliance to the
National Speed Limit; however, we received a report highlighting that it was felt that these
speeds did not represent a true reflection of vehicle speeds travelling on this section of the
B5017.

The survey was completed following roadworks on Burton Road that involved temporary traffic
lights close to Five Ways Island and it was suspected that drivers had sought alternative routes
and traffic had not returned to normal. Following receipt of this local insight, it was agreed that
a new speed and volume survey would be undertaken. This second survey was undertaken
between the 7 and 15'% November and 85" percentile speeds of 51mph eastbound and
55mph westbound over a 24-hour period were recorded.

These speeds again highlight good compliance to the National Speed Limit. Based on this
data, speed enforcement activities either by fixed cameras or mobile camera vans would not
be initiated as criteria has not been met. There was a slight increase in vehicle volume for the
second survey as an average (7-day average) of 6526 vehicle speeds were recorded over a
24-hour period compared to 6153 vehicles for the first survey.

Regarding the request for additional signage to indicate the presence of private accesses onto
Burton Road, there is no prescribed sign within the Traffic Signs Regulations and General
Directions for concealed entrances and therefore this is not an option we can consider.

Following the Inquest, | received a letter from [J dated the 18th October where an
invitation was made to visit their property. On Friday 22nd November, [NN
(Strategic Community Infrastructure Manager) and SEN (Road Safety Manager) met
with RE at their property. A request for a speed limit reduction was made,
however it was explained that the budget available to the Council for highway improvements is
extremely limited and reducing speed limits is usually accompanied by additional robust
measures such as lining, signage, carriageway narrowing, gateway features or build outs — in
order to help promote good compliance with the lower limit.

These additional measures obviously come at a cost which must be justified, and it is right
therefore that we firstly target those locations where a demonstrable reduction in the number of
people killed or seriously injured on our roads can be achieved, by prioritising locations where
there is a cluster of incidents with a discernible trend or pattern within the accident data.

the knot unites

Staffordshire

County Council

| acknowledge that reducing the speed limit to 40mph for this section of the B5017 is desired,
however, this would be a significant reduction from the existing National Speed Limit, and it
would be very difficult to achieve driver compliance. Some drivers may choose to ignore such
a change which could lead to an increase in manoeuvres involving risk, for example overtaking
or tailgating. Any reduction is therefore unlikely to be successful without additional costly
engineering measures as discussed above.

In summary, based on the collision data we hold for this location, the site would otherwise not
be considered for any traffic calming measures at this time. However, there is a possibility that
it will be feasible to include this section of Burton Road as part of another funded scheme in

the local area, and we are investigating this possibility. Throughout these investigations, we
will endeavour to — informed.

| hope the above information is of benefit, however if further clarification or detail is required, |
am more than happy to provide further information.

Yours sincerely,

Assistant Director for Highways and the Built County

the knot unites

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