Prevention of Future Deaths reports · 2019

David Moore

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 report3 Dec 2019
Reference2019-0413
DeceasedDavid Moore
CoronerJeremy Chipperfield
Coroner areaCounty Durham and Darlington
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

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

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 Durham County Council (PDF)
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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