Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0413, written 3 Dec 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Dec 2019 |
|---|---|
| Reference | 2019-0413 |
| Deceased | David Moore |
| Coroner | Jeremy Chipperfield |
| Coroner area | County Durham and Darlington |
| 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 REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 , Corporate Director Regeneration and Local Services Durham County Council County Hall Durham DH1 5UL 1 CORONER I am Jeremy Chipperfield, Senior Coroner for the County Durham and Darlington coroner area. 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 Seventh February 2019 I commenced an investigation into the death of David Steward MOORE aged 45. The investigation concluded at the end of the inquest on 27 November 2019, The conclusion of the inquest was: ACCIDENTAL DEATH I a Head and Neck Injuries I b I c II 4 CIRCUMSTANCES OF THE DEATH At around 1830hrs on 28 January 2019, the deceased was crossing an area of unlit road on the A693, around 565 metres west of the Beamish roundabout, when he was struck by a motor car being driven westbound, within the speed limit, with dipped headlights. 5 CORONER’S CONCERNS The MATTER OF CONCERN is that the following circumstances together create the risk that other deaths will occur. Those circumstances are that - The section of the A693 where the collision occurred is: a de facto pedestrian crossing point connecting footpaths intersecting that road; an area to which the national speed limit applies (60mph for cars); very dark at night, being unaffected by ambient illumination; without street lighting The material section of road is a natural crossing point for pedestrians travelling between two footpaths leading between the collision site: and (i) the village of No Place, to the south of the A693 and (ii) the village of Kip Hill, to the north of the A693. I accepted the following evidence about the material section of road (given by a police Collision Investigator): (i) the road is approximately 12m wide, and after nightfall is “in complete darkness”, being bordered by dense trees and unaffected by discernible ambient light; (ii) drivers are entirely reliant on headlamp illumination to detect pedestrians; (iii) in reliance on his own dipped headlamps, a driver could gain first sight of a static pedestrian in the carriageway at a distance of no more than 40m from that pedestrian; and (iv) a motor car travelling at 60mph would require significantly more than 40m (around 80m) to come to a halt (taking into account driver reaction time and mechanical stopping distance). In this case, the driver first saw the deceased “just prior to the collision” when the latter was running “with large strides” towards the southern side of the A693. Despite emergency breaking, he failed to avoid the collision. It was impossible to stop in the available distance. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation have 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 24 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 who may find it useful or of interest: Chief Coroner of England and Wales, Strategic Traffic Manager, - Kingsley Napley Solicitors, Highways England. , , 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 Jeremy CHIPPERFIELD Senior Coroner for County Durham and Darlington Dated: 03 December 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.
Contact: Direct Tel: email: Your ref: Our ret: Durham: County Council Mr Jeremy Chipperfield HM Senior Coroner for County Durham and Darlington HM Corners Office PO Box 282 Bishop Auckland County Durham, DL14 4FY 21 January 2020 Dear Mr Chipperfield Re: Regulation 28 — Mr David Steward Moore (Inquest 27th November 2019) Thank you for your letter and Regulation 28 report dated 5" December 2019. This was a tragic accident and the Council wishes to express its sincere condolences to the family and friends of Mr Moore. In accordance with Regulation 28 we have considered whether any improvements can be made to the section of A693 road to prevent future accidents. Site Investigation Following Fatal Accident Report The Council has an Accident Investigation and Prevention team and one of their roles is to investigate every fatal accident in conjunction with Durham Constabulary’s Traffic Management Unit. Please find attached a copy of the report at Appendix 1. These reports are undertaken to help identify any defects or improvements to the highway infrastructure. The report made the following observations / recommendations although it noted that they were not considered contributory factors in the accident. Observation / Recommendation 1. | No warning sign is provided for An additional warning sign indicating that westbound road users for the pedestrian may be crossing will be pedestrian crossing immediately considered for introduction west of the east of the accident location. As accident location as part of future this crossing appears similar to the | highway maintenance work. crossing further west (for which signs are provided) the provision of warning signs should be considered. Regeneration and Local Services Durham County Council, County Hall, Durham DH1 5UF Main Telephone 03000 26 0000 Text Messaging Service 07860 093 073 www.durham.gov.uk Page 2 of 5 2. | The location of the existing pedestrian crossing should be assessed and, if still deemed appropriate, then dropped kerbs on the north side of the A693 should be provided to mirror those already in place on the south side. The existing pedestrian crossing facility, which is located west of Park Nook Farm access road junction remains appropriately located. Dropped kerbs on the northern side of the carriageway will be provided to mirror those on the south side of the carriageway as part of future highway maintenance. 3. | The informal pedestrian route on the south side, which has been created through the trees to provide a more direct route to cross the A693, should be appropriately ‘stopped up’ to prevent pedestrians being led to an inappropriate location from | | where to cross. _ 4. | Given the A693 in this location is a wide single 2 + 1 lane carriageway (two lanes westbound & one lane eastbound), guidance would suggest that simple priority junctions should not be provided on a road of this type without the appropriate turning facilities. The access road leading to Park Nook Farm is considered a simple junction and as turning facilities are not currently provided, measures should be considered in order to provide appropriate access. The informal pedestrian route on the south side, appears to represent the desire route for pedestrians gaining access and egress from No Place and travelling west to East Stanley. The formalisation of the route or otherwise stopping up of it has been passed to Paul Watson, Highway Assets Manager for | consideration. The A693 Stanley to Chester-le-Street improvement scheme was constructed in the 1970s and would have been designed using the standards of the day, being “Roads In Rural Areas”; this has been superseded by the Design Manual for Roads and Bridges (DMRB). There is no requirement in DMRB for the provisions of DMRB to be retrofitted to roads not designed to the current day standards. There is no history of accidents occurring at this private (unadopted) access road | which serves one farm, a number of | agricultural fields and is also a bridleway. The provision of a Protected Right Turn (PRT) facility at this private access would | require the entire removal of the climbing lane as the length from the roundabout to the PRT would be sub-standard. TD70 requires the desirable minimum length of overtaking lane to be 800 metres which may be relaxed to 600 metres — the introduction of a PRT would limit the length of the climbing lane to less than 500 metres. It should be noted that a PRT is not permitted on a 2+1 road within the length of overtaking lane. Page 3 of 5 With reference to the previous point, the junction ahead warning sign provided for approaching road users appears small given the 60mph speed limit. If the junction is to remain to operate as it does currently, a larger sign should be provided. The sign plates which are rotated on the same assembly (road narrows ahead & pedestrians crossing warning signs) should be rotated to face oncoming westbound traffic. Should the climbing lane be removed, the width of road would need to be reduced by road markings to limit the possibility of motorists attempting overtakes; double white lines would only be permitted on one side of the hatching. This would still provide a large area of carriageway covered by hatching, over which it is possible to drive if a motorist considers it safe to do so. This increases the potential for some motorists to attempt overtakes by utilising this road space. The gradient of the road varies between approximately 1 in 14 and 1 in 10 therefore, the loss of the climbing lane could be significant given the volume cf HGVs and other traffic using this road. It is considered that the removal of the climbing lane could lead to a greater risk taking resulting from motorists going for overtakes when not permitted, when they are faced with slow moving vehicles. Therefore; given the good previous accident history of this junction it is not considered practicable to change the current layout. The junction ahead warning sign provided for approaching road users will considered for replacement with a larger sign as part of future highway , maintenance work. Information from the attached report (Appendix 1) relating to the sign plates which are rotated on the same assembly (road narrows ahead & pedestrians crossing warning signs) have been passed to Paul Anderson, Highway Inspection Manager for action. All actions from the above have been progressed. Page 4 of 5 In responding to the ‘Matters of Concern’ that you raise we would comment as follows: The A693 is a principal road through the County which is primarily rural in nature and follows the topography of the land through which it passes. The road bisects many Public Footpaths, Bridleways and footways linking communities. Along the route there are sections of the road which have systems of street lighting where there are areas of conflict such as at junctions and roundabouts. However, the street lighting does not cover all pedestrian or bridleway crossing points. The non- provision of street lighting along the route was considered and examined through a robust Risk Assessment process between 2013 and 2015, with this location being assessed in 2013. An integral part of the assessment process is the consideration of the previous accident history along the section of road and the circumstances relating to any accidents which have occurred. There were no previous accidents over the 10 years prior to the assessment in 2013 relating to periods of darkness. There are a significant number of locations across the road network in the County where there are footpaths crossing de-restricted roads without the provision of street lighting. Many of these locations are on roads where vehicle speeds can be at the higher levels and most do not have warning signage provided. Many also do not benefit from the ample visibility available at this location. From an analysis of accident records, there is not a trend of pedestrian accidents occurring at these locations during the hours of darkness. The visibility available at the accident location far exceeds the minimum requirements indicated in the current Highway Design Standards. The Design Standards require 215m of forward visibility which is substantially more than the Stopping Distance given by Rule 126 of the Highway Code which is 73m for a 60mph (100kph) road. The minimum visibility for a pedestrian at this location differs depending upon the side of road they are stood, to the east this is greater than 300m and to the west greater than 400m. Given that a vehicle has right of way on a carriageway, this distance should be more than necessary for a pedestrian to view an approaching vehicle and decide whether or not to cross. Having checked the accident database for the location of the accident subject to your inquest, we have noted that there have been no previous incidents involving pedestrians. The check was done for both daylight incidents and ones during the hours of darkness. This indicates that there is not a history of incidents at this location. Design Standards and Regulations do not permit the introduction of a formalised crossing such as a Zebra or Puffin Crossing at this location. The Department for Transport advice indicating that such a crossing could be dangerous. It would not be practicable to introduce a subway at this location due to the topography. However, even the presence of a subway does not remove the possibility of an accident occurring. This is evidenced by a relatively recent incident a few miles east on this road, where a pedestrian chose to cross the road rather than use the subway which ran beneath his chosen crossing point. Page 5 of 5 Where there is an element of human interaction with the highway and its users, it is not practicable or possible to introduce engineering measures to ensure that an accident will not re-occur. Unfortunately, this may be due to any one or more of many indeterminate scenarios such as a poor decision made in judging and timing when it is safe to cross. Unlike most locations, this crossing point does benefit from warning signage to advise approaching motorists. These signs are manufactured from a highly reflective material which makes the sign face visible even if the vehicle is being operated on dipped-beam headlights. Therefore, there is always a case of the individual being responsible for their actions, whether that is in the manner in which they drive or choice of opportunity to cross a road. Whilst it was not considered appropriate to introduce a system of street lights or further engineering measures at this location, it was noted during the accident investigation that the size of the signage could be increased. An order for the replacement of the signs was subsequently made and they have since been changed. Our condolences go to Mr Moore’s family and friends on their tragic loss. | hope the above goes some way towards offering a considered response to your correspondence. If you would like to discuss further please contact David Battensby, Traffic Asset Senior Engineer, on telephone number 03000 263681 or by email at david.battensby @ durham.gov.uk Yours sincerely Corporate Director — Regeneration and Local Services Enc Appendix 1 trategic Highways Manager Traffic Asset and Streetworks Manager , Traffic Asset Senior Engineer ervice Support Officer
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