Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0459, written 31 Jan 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 31 Jan 2019 |
|---|---|
| Reference | 2019-0459 |
| Deceased | Garry Clarkson |
| Coroner | Paul Marks |
| Coroner area | East Riding and Kingston-upon-Hull |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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 238 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Highways Department ERYC Becklands Park Depot Becklands Park Industrial Estate York Road Market Weighton YO43 3GA 3 | CORONER'S LEGAL POWERS — CORONER | am Professor Paul MARKS, HM Senior Coroner for East Riding and Kingston-upon-Hull | 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. http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www. legislation.gov.uk/uksi/2013/1629/part/7/made ~~ INVESTIGATION and INQUEST On 02/07/2018 | commenced an investigation into the death of Garry CLARKSON. CIRCUMSTANCES OF THE DEATH At 1515 hours on Wednesday the 27th June 2018 Mr Garry CLARKSON was the front seat passenger of a Ford Transit Tipper VRM a The vehicle was travelling away from Hook when for unknown reasons it has gone onto the nearside grass verge and then entered a ditch to the nearside and collided into a tree. The male driver sustained minor injuries and was able to get out of the vehicle. The passenger, Garry, was trapped in the vehicie and unresponsive. The emergency services attended the scene and the fire brigade cut Garry out and the paramedics and doctors tried to save Garry but were unable to and he was pronounced dead at 1603 hours at the scene. He did appear to have severe facial injuries. He was transported to the mortuary at Hull Royal Infirmary by ambulance with a Police escort for continuity. There will be a full police investigation into the road traffic collision. | CORONER’S CONCERNS An Inquest has been opened but has not been concluded thus far in relationship to these tragic events. Nevertheless, | have been contacted on four occasions by Counsellor Keith Mocre who sits on the local Council in Goole. He has brought to my attention that there have been three fatalities on the Westfield Lane carriageway near Hook and at the end of December 2018 there were two further accidents which thankfully were not fatal. In view of Regulation 28 philosophy for the Prevention of Future Deaths, | feel it is imperative that | take action given that Mr Ciaricson’s death was not the first to have occurred in this vicinity which clearly must be regarded as an accident blackspot. 6 ACTION SHOULD BE TAKEN a In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action and investigate the problems that appear to be present in that area in the hope that some form of remedial action can be taken to decrease the chances of further accidents and fatalities occurring. i 7 YOUR RESPONSE / You are under a duty to respond to this report within 56 days of the date of this report, namely by 1* April 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. 8 | COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Counsellor | Mr Derek Winter, Assistant Chief Coroner j | 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. i 9 31° January 2019 Lt HM Senior Coroner, East Riding and Kingston-upon-Hull |
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.
E AST R I D I N G __ _. O F Y O R K S H I R E C O U N C I L www.eastriding.gov.uk Paul Bellotti Director of Environment and Neighbourhood Services Professor Paul Marks Her Majesty's Senior Coroner District of Kingston upon Hull and the East Riding of Yorkshire The Guildhall Alfred Gelder Street HULL HUI 2AA Dear ——A Re: Garry Clarkson (deceased) 22 March 2019 Thank you for your letter of 31 January 2019, and a report made under the Coroner's and Justice Act and Regulations 2013. The Council has carefully considered the Coroner's concerns and has responded with information which we hope you will find helpful. However, please let me know if we can be of any further assistance. Yours sincerely Director of Environment and Neighbourhood Services Enc www.eastriding.gov.uk Caroline Lacey Chief Executive K i Youfnm MATTER OF CONCERN - REGULATION 28 CORONER’S REPORT The Coroner has been contacted on four occasions by a local Councillor, a member of Goole Town Council. has brought to the attention of the Coroner that there have been three fatalities on the Westfield Lane carriageway near Hook and at the end of December 2018 there were two further accidents which thankfully were not fatal. The death which is the subject of the current inquest was not the first to have occurred in this vicinity which clearly must be regarded as an accident blackspot. REPONSE Hook Lane/Westfield Lane is shown on the attached plan and is a road of some 2.4 kilometres in length running from the A614 Boothferry Road roundabout to Church Lane in Hook. The road name changes from Hook Lane to Westfield Lane at the Parish boundary 200 metres east of the M62 Ouse Bridge. The route is single carriageway with an historical, un-engineered configuration, a two lane road having a predominantly straight alignment with large radius bends providing a slight deviation from straight at points approximately 400, 900, 1200 and 1900 metres from the A614. The road is subject to the national speed limit of 60mph, reducing to 30mph 130 metres prior to becoming Church Lane in Hook where there is a set of double bends. The Council regularly considers injuiy collisions that occur on the public highway network and any patterns that result. Further to your letter, my officers have undertaken a further review of the collisions along Hook Lane/Westfield Lane between the village of Hook and the A614 Boothfeny Road. Our records are based on the police injury collision database, we do not receive details of damage only collisions on the highway. The accident which led to the current inquiry occurred on Wednesday, 27 June 2018 this is marked as ‘2018 Collision’ on the attached plan and shown in the photograph A below: Iff® Photograph A: Westbound view of 2018 collision. The approach to the site is shown on photograph B: «! / (cid:127) *' M p A ' ; '■■ J' « Jr Photograph B: Westbound view o£ 2018 collision. The accident occurred on the opposite side of the carriageway to the pumping station; the driver of the van lost control of his vehicle, left the carriageway and collided with a tree. The driver received slight injuries and the passenger fatal injuries. I understand that this case is currently still under investigation by the The Council has records of three previous fatal collisions on different parts of Hook Lane/Westfield Lane in the past four decades these are: Thursday, 7 August 1997 at the entrance to Westfield Park Nursing Home. This is marked as ‘1997 Collision’ on the attached plan and shown in photograph C: .. AIL ' ■ - ’ Photograph G Eastbound view of 1997 collision. The 1997 collision occurred 850 metres from the site of the 2018 collision which led to the current inquiry. The 1997 collision occurred when an eastbound car driver turned right into the property across the path of an oncoming motorcycle rider. Forward visibility is good at this location. The collision resulted in fatal injuries to the rider of the motorcycle and slight injuries to the driver of the car. The Westfield Park Nursing Home entrance was improved when the site was redeveloped we believe in the late 2000’s and there have been no collisions at this site since this was done. A fatal incident occurred on Monday, 9 October 2006 at the pumping station near the site of the collision which led to the current inquiry. The site of the collision is marked as ‘2006 Collision’ on the attached plan and shown in photographs B and D: , ■ f t ■ ■■ 4 Photograph D: Westbound view of 2006 collision. The accident occurred when a westbound car driver lost control and left the carriageway colliding with the pumping station fencing. The car driver and passenger suffered fatal injuries. The police investigation concluded that the driver had his vehicle in an inappropriate position on the carriageway and lost control on the slight right hand curve, failing in his responsibility for both his safety and that of his passenger due to his actions or inactions, probably through error, misjudgement of inexperience. The site of the collision on Tuesday, 19 April 2016 between Ouse Bridge and the A614 is marked as ‘2016 Collision’ on the attached plan and shown in photograph E: d - ' > ' ' ■ < ..-■ * ' ""ft i fy? f v V ■ * ■ - - Photograph E: Westbound view of 2016 collision. This collision occurred 500 metres from the site of the 2018 collision which led to the current inquiry. The collision occurred when a westbound car driver was taken ill at the wheel and drifted into the path of oncoming traffic, colliding with an oncoming car. The injuries received exacerbated pre-existing ill health issues and the driver died on 30 April 2016. The other driver received slight injuries. The Council has no records of any non-fatal collisions on Westfield Lane, Hook Lane or Church Lane in December 2018. We have a record on one other injury collision on the road in 2018, on 20 November where an eastbound car driver lost control on the double bends in the 30mph Hook speed limit and left the carriageway into the ditch receiving serious injuries. The site of this collision is marked as ‘2018 Bend Collision’ on the attached plan and shown in photograph F: Photograph F: Eastbound view of 2018 bend collision. This collision occurred approximately 1500 metres east of the site of the 2018 collision which led to the current inquiry. The Council does not propose to take any further action or to carry out further works to Westfield Lane or Hook Lane for the reasons set out below. Each year, the Council carries out a programme of highway engineering works prioritised on where injury collisions have been recorded. In the five years prior to 2008, there were twelve recorded injury collisions (comprising one fatal, two serious and nine slight injury collisions) on Hook Lane/Westfield Lane/ Church Lane, Based on this injury collision record works were carried out in 2008/9 along the length of the road including surface dressing and inlays, an extension of the 30mph speed limit from Hook to incorporate the double bends and new signing along the route including chevron boards for the double bends on Church Lane as shown in photograph G: [30] 3CT Photograph G: Eastbound view of 30mph speed limit entry and view to Church Lane bends. Since that time, we have monitored recorded injury collisions, traffic flow and speed. Injury collisions have reduced and some 3000 vehicles use the road each day, generally well within the speed limit, with an 85%ile, or typical speed, of just over 47mph. In the five year period following the works carried out in 2008/ 09, there were four collisions (all slight injury collisions). To bring the figures up to date; in the ten years before the works thirty-two people were injured in collisions. In the ten years since the changes nineteen people have been injured, a decrease of 41%. Of those nineteen, four were injured due to drivers being taken ill at the wheel. This period of time includes the accidents set out above that occurred in April 2016 and November 2018 as well as the 2018 fatal accident the subject of your inquiry. The overall reduction in collisions and casualties since the works would not indicate that further works need to be undertaken on Hook Lane/Westfield Lane/ Church Lane. Overall, this authority’s targeted action has resulted in a reduction in the number of collisions on Hook Lane/Westfield Lane. We have no evidence that Westfield Lane in the vicinity of the collision which is the subject of your investigation is a "black spot". There have been three fatal collisions on Hook Lane/Westfield Lane in the past four decades. In relation to the 1997 fatality this would appear to be down to driver error, the entrance was improved when the site was redeveloped and there have been no collisions at the site since this was done. The collision at the pumping station in 2006 would also appear to be the result of driver error and the 2016 fatality because of a pre-existing illness. Neither of these collisions suggest that further highway improvements would have prevented them from occurring. The information we have thus far in relation to the 2018 fatality does not alter this conclusion. I hope this will make it clear that the authority has previously considered the number and type of collisions that have occurred and has taken action to reduce them by works already carried out. We will continue to monitor the route for flow, speed and injury collisions and take future action as appropriate. 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