Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0379, written 12 Nov 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 Nov 2019 |
|---|---|
| Reference | 2019-0379 |
| Deceased | Costel Stancu |
| Coroner | Peter Sigee |
| Coroner area | Cheshire |
| 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 THIS REPORT IS BEING SENT TO: 1. The Chief Executive Officer, Highways England 1 CORONER I am Peter Sigee, assistant coroner, for the coroner area of Cheshire. 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 9th April 2019 the Senior Coroner for Cheshire commenced an investigation into the death of Mr Costel Daniel Stancu, aged 37 years. The investigation concluded at the end of the inquest on 8th October 2019 when I determined that: 1. 2. the medical cause of Mr Stancu’s death was 1(a) hypoxic encephalopathy, 1(b) asystolic cardiac arrest, 1(c) traumatic brain injury; and these injuries were sustained in a series of road traffic collisions in which Mr Stancu was involved on 29th March 2019. 4 CIRCUMSTANCES OF THE DEATH Mr Costel Daniel Stancu died at the Royal Stoke University Hospital on 3rd April 2019, aged 37 years; Mr Stancu had been admitted to hospital on an emergency basis following a number of road traffic collisions which occurred shortly after 02:00am on 29th March 2019 and he died despite intensive medical care from the injuries sustained in this incident. Mr Stancu had driven his car from Liverpool at approximately 01:00am on 29th March 2019, intending to drive to London. A sample of blood serum taken from Mr Stancu at 03:47 am on 29th March 2019 revealed that at that time his blood alcohol concentration was more than 2½ times the legal drink driving limit within England & Wales; the alcohol that Mr Stancu had consumed prior to his journey significantly impaired his observation, driving and reaction to other road users. Mr Stancu was driving at excessive speed and without adequate care or consideration for himself or other road users. Mr Stancu drove his car along the M6 between junctions 18 and 19 in a southbound direction. This section of motorway had recently been changed from 3 traffic lanes plus a hard shoulder in each direction to a new ‘smart motorway’ with 4 lanes for vehicles to travel in each direction and occasional refuges to enable vehicles to come to a stop away from the moving traffic lanes. There was no refuge on this immediate section of the motorway. At this time there was only moderate traffic upon the motorway, it was pitch black, there was no residual lighting from the surrounding area and this section of motorway was unlit. 1 Mr Stancu drove his vehicle into collision with the rear of a van which was properly proceeding in lane 3 with its rear lights illuminated in front of Mr Stancu. This caused a series of collisions between Mr Stancu’s car, the van and a lorry which had been properly proceeding in lane 1 (“the First Series of Collisions”). Following the First Series of Collisions, the lorry came to stop in lane 1 with its hazard lights illuminated, the van came to rest in lane 4 adjacent to the central reservation with a rear hazard light illuminated and Mr Stancu’s car came to rest a short distance beyond the van in lane 4. Mr Stancu’s car was dark blue in colour, it was upside down, sideways on to the oncoming traffic and all its lights were turned off; it was not visible to other road users until the headlights from their vehicle illuminated it. Other vehicles continued to pass these stationary vehicles with various of them narrowly avoiding a collision at high speed. Approximately 4 minutes 10 seconds after the First Series of Collisions there was a further series of impacts between vehicles which were still travelling south along this section of the motorway and the stationary vehicles (“the Second Series of Collisions”). The drivers of the other vehicles involved in the Second Series of Collisions had no adequate opportunity to see and avoid colliding with the stationary cars which were partially obstructing the motorway. Following the Second Series of Collisions the motorway was blocked by traffic, warning signs were activated to warn approaching vehicles of the incident ahead and the emergency services were able to attend and respond to the incident. There had been no warnings given to approaching vehicles of the incident prior to the Second Series of Collisions. 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. The MATTERS OF CONCERN are as follows. – I determined that the lack of lighting on this section of the motorway was a contributory factor to the Second Series of Collisions; the evidence at inquest was that this section of the motorway remains unlit at night and I am concerned that this creates an ongoing risk to life. Whilst I found that none of the collisions were caused by the conversion of this section of the motorway to a ‘smart motorway’ I am concerned that this change in layout may have increased the risks posed to users of the motorway including the risk arising from the lack of lighting. The evidence that I heard during the inquest suggested that the risk arising from the lack of lighting had not been re-assessed either as part of the conversion to a ‘smart motorway’ or following the incident on 29th March 2019. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and/or your organisation have the power to take such action. 2 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 8th January 2020. 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 Mr Stancu. 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 November 2019 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.
5s highways
england 99 JAN 2020
Mr Peter Sigee Mike Wilson
Assistant Coroner for Cheshire Chief Highways Engineer
West Annexe National Traffic Operations Centre
Town Hall, 3 Ridgeway
Sankey Street Quinton Business Park
Warrington Birmingham
Cheshire B32 1AF
WA1 1UH
07 January 2020
Dear Mr Sigee,
Regulation 28 Report following the Inquest into the death of Mr Costel Daniel
Stancu
On behalf of Mr Jim O’Sullivan of Highways England Company Limited, please find
enclosed the Highways England response to the Regulation 28 Report to Prevent
Future Deaths dated 12th November 2019 following the Inquest into the death of Mr
Costel Daniel Stancu. As per our duty, we have responded within 56 days, namely by
8th January 2020.
We have also posted a hard copy to the Warrington Coroner’s Court in Sankey Street,
Warrington.
Yours sincerely,
4
{p—
Mike Wilson
Chief Highways Engineer
Registered office Bridge House, 1 Walnut Tree Close, Guildford GU1 4LZ E32 disability
Highways England Company Limited registered in England and Wales number 09346363 BES confident
COMMITTED
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS RESPONSE IS BEING SENT TO:
1. The Assistant Coroner for Cheshire, Mr Peter Sigee, of West
Annexe, Town Hall, Sankey Street, Warrington, Cheshire WA1 1UH
in response to a ‘Regulation 28 Report to Prevent Future Deaths’
following an inquest hearing into the death of Mr Costel Daniel STANCU
that concluded on 8" October 2019.
HIGHWAYS ENGLAND
lam Mr Mike Wilson, Safety, Engineering and Standards Executive Director and
Chief Highways Engineer, responding on behalf of Mr Jim O’Sullivan, Chief
Executive of Highways England Company Limited .of Bridge House, 1 Walnut
._Tree Close, Guildford, SURREY GU1 4LZ.
CORONER’S MATTERS OF CONCERN
The MATTERS OF CONCERN were identified as follows:
(a) Lack of lighting on the section of the M6 motorway between junctions 18
and 19 on the southbound carriageway was a contributory factor to the
Second Series of Collisions; the. evidence heard at inquest was that this
section of the motorway remains unlit at night and it is a concern that this
creates an ongoing risk to life.
(b) Whilst it was found that none of the collisions were caused by the
conversion of this section of the M6 motorway to a ‘smart motorway’, it is
a concern that the change in layout may have increased the risks posed
to users of the motorway including the risk arising from the lack of
lighting.
(c) The risk arising from the lack of lighting had not been re-assessed either
as part of the conversion to a ‘smart motorway’ or following the incident
on 29" March 2019.
DETAILS OF ACTION TAKEN
(a) We provide lighting on our network where there are positive safety
benefits to road users that exceed; the risk to road workers from
installing and maintaining the lights, the spend from the public purse and
the environmental impact. We have a comprehensive understanding of
where night-time collisions occur and the impact road lighting would
have. This enables us to install lighting where it is needed, rather than
installing lights across our entire network. Currently, one third of the
strategic road network is lit and two thirds is unlit.
Our analysis of lighting on a motorway shows that lighting reduces the
probability of accidents at night-time by 10%. Specifically, for those
incidents involving a collision with an obstruction, our analysis suggests
lighting can reduce such incidents by up to 138%. However, this type of
collision is not related to specific locations and therefore, it is not
possible to target specific points on our network by installing lighting to
prevent such incidents occurring.
(b) Introduction of smart motorways has been Government policy since
2008. The smart motorway package of measures is considered
appropriate for Highways England’s network and gives flexibility to allow
for increased demand from road users, whilst maintaining or improving
the safety of our roads. ;
Safety is Highways. England’s top priority and something we will not
compromise on, with smart motorways being no exception. Smart
motorways are based on a comprehensive safety assessment and
hazard analysis which demonstrated that they would be as safe, if not
safer than the conventional motorway they replaced. The use of
roadside technology and operational procedures has enabled them to be
managed in an effective and appropriately safe manner.
(c) The M6 motorway, junctions 16 to 19 ‘smart motorway’ scheme was
designed to the smart motorway design standard in place at the time
published in 2013. The 2013 design standard stated that, where the
motorway is not currently lit, lighting shall not be considered. Therefore,
the scheme did not undertake a lighting assessment because. this
section of the M6 motorway was not lit prior to the smart motorway
scheme being designed.
We revised our smart motorways design standard in 2015. The 2015
' design standard has an updated lighting requirement instructing
‘schemes to review the number of night-time personal injury collisions,
and to determine whether there is any justification for introducing road
lighting as part of the scheme. Subsequent changes to design standards
are not applied retrospectively to operational schemes but would be
considered as part of a corporate standard programme of investment for
the renewal or improvement of the strategic road network at a future.
date.
4
Every scheme we install is required to undergo Road Safety Audits over
time both before: and after the installation of the scheme. The final Road
Safety Audjt (Stage 4) is conducted 12 months after the road is open to
traffic. The audit focusses on collision monitoring where road traffic
collisions (from STATS19 data) have been recorded in the vicinity of the
highway scheme over the 12-month period after the scheme was
operational. The audit for the M6 motorway junctions 16 to 19 scheme
has not been completed to date because the. scheme has not been open
to traffic for 12 months. The final Road Safety Audit (Stage 4) is due to
be carried out in the Summer of 2020. ;
DETAILS OF FURTHER ACTION PROPOSED
(c) Lighting assessment
Given the concerns expressed following this particular incident, we will carry out
a lighting assessment to determine whether lighting would now be required on
this section of motorway.
The final Road Safety Audit (Stage 4) will be completed as planned following the
end of the 12-monith period of the scheme being open to traffic.
TIMETABLE FOR ACTION
Date Action
January 2020 Carry out a lighting assessment for the M6 motorway
junctions 16 to 19
Summer 2020 Complete the final Road Safety Audit (Stage 4) of the M6
motorway junctions 16 to 19 scheme
SAFETY OF ROAD USERS
Roads, especially high-speed roads, can never be __ risk-free
environments. Highways England prioritises the reduction of road deaths and
serious injuries on the strategic road network through its Road Investment
Strategy, investing large amounts of public money, to create as safe an
environment as possible.
We also rely on road users to be informed on what to do in an emergency and
who to contact, and just as importantly how to avoid dangerous situations in the
first place. Drivers must take responsibility for their own vehicle, behaviour and
safety when using any road, to help all road users arrive at their destinations
safe and well.
The safety of road users is our first imperative and a core value of our
organisation. Our company vision for safety is that “no one should be harmed
when travelling or working on the strategic road network”. Any improvements or
enhancements that we make must be done in a considered and controlled
fashion so that the consequences of any improvements are fully understood,
and any safety risks linked to proposed changes are eliminated or reduced as
far as possible. We always strive to improve safety through enhancing
infrastructure and communication.
7 January 2020 _— Signed: 2 \
Mike Wilson, Safety, Engineering and Standards
Executive Director and Chief Highways Engineer, on
behalf of Jim O’Sullivan, CEO
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