Prevention of Future Deaths reports · 2019

Garry Clarkson

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 report31 Jan 2019
Reference2019-0459
DeceasedGarry Clarkson
CoronerPaul Marks
Coroner areaEast Riding and Kingston-upon-Hull
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 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 |

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 East Riding of Yorkshire Council (PDF)
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:

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Photograph A: Westbound view of  2018 collision.

 The approach to the site is shown on  photograph B:

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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:

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' 

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’

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:

, 

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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:

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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]

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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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