Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0510, written 17 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 | 17 Dec 2019 |
|---|---|
| Reference | 2019-0510 |
| Deceased | Jamie Finlay |
| Coroner | Jacqueline Devonish |
| Coroner area | Suffolk |
| 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 (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: General Highways Manager and Councillor Andrew Reid, Cabinet Minister for Highways, Transport and Rural Affairs, at Suffolk County Council. 1 CORONER I am Jacqueline Devonish, Area Coroner, for the coroner area of Suffolk. 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 16 December 2019 I commenced an investigation into the death of Jamie Finlay. The investigation concluded at the end of the inquest on 16 December 2019. The conclusion of the inquest was that Jamie Finlay died whilst a passenger of a car which had been driven at speed without braking to avoid a collision with an oncoming vehicle which was turning right before a filter lane bollard on the A1088 junction with Thetford Road, Ixworth. The medical cause of death was: 1a. Raised intracranial hypertension 1b. Traumatic Brain Injury 1c. Road Traffic Collision 4 CIRCUMSTANCES OF THE DEATH On 8 May 2017 Jamie Finlay had been collected from home in Woolpit at around 6.16am by his work colleague to drive to Thetford to meet the works vehicle. They journeyed through Norton Village to the A1088 where the colleague drove at the speed limit of 60mph. Jamie’s colleague did not brake as he approached a sweeping bend at the junction with Thetford Road and was perhaps going too fast to avoid a collision with another oncoming vehicle negotiating a right turn from the filter lane. Both drivers swerved to avoid the other. The colleague swerved to the wrong side of the road colliding with the other drivers’ passenger front and side, whilst the other driver swerved to his left into the collision and suffered similar damage to the front left. The other driver had attempted to take the right turn into Thetford Road on the wrong side of the bollard, where there was a clear view into Thetford Road from the A1088 and a wide radius for undertaking such a manoeuvre. He swerved back into the A1088 when he saw the car, in which Jamie Finlay was a passenger, appear around the bend prior to the junction. Jamie Finlay was transported from the scene to Addenbrooke’s Hospital where his life support was switched off on 11 May 2017 at 15:59 hours. CORONER’S CONCERNS 5 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 MATTER OF CONCERN is as follows:- The design of the filter lane and junction from the A1088 to Thetford Road does not prevent drivers turning right ahead of the bollards, and onto the wrong side of those bollards into Thetford Road. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you or 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 25 February 2020. I, the Area Coroner, may extend the period if I consider it reasonable to do so. 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: I am 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 Area Coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 Jacqueline Devonish 17 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.
Our Ref: MA / EC
Date: 24 February 2020
Email:
Sent by email to: coroners.service@suffolk.gov.uk
Jacqueline Devonish
Area Coroner
Suffolk Coroners Office
Beacon House
Dear Ms Devonish
I am responding to the Regulation 28 report dated 17 December 2019 received by me and
Cllr Andrew Reid regarding the findings of your investigation into the sad death of
Jamie Anthony Finlay.
Following the road traffic collision on the 8 May 2017, one of my highly experienced road
safety engineers (
requested to accompany officers from the Suffolk Police Serious Collison Investigation
Team (SCIT) on a site visit, this was undertaken on the 13 December 2017.
Safety and Speed Management Engineer) was
observations from the site meeting with the Police were as follows:
•
•
•
•
•
Eastbound drivers on the A1088 could physically turn south into Thetford Road on
the wrong (west) side of the Thetford Road splitter island and bollard to cut-the-
corner.
It was discussed that this could be the manoeuvre of the eastbound vehicle involved
in the fatal collision – he was attempting this then saw V2 approaching at speed
westbound whereby V1 pulled back to his side of the road which resulted in a head
on collision.
AccsMap (SCC collision database) over the last 5 years shows the fatal with
causation factors of V1 being careless / reckless / in a hurry and V2 failed to look
properly.
There was one slight in 12 / 2015 involving V1 emerging from the side road that
failed to look properly and collided with a westbound A1088 vehicle.
As such this is not a high collision cluster site based on 3 or more injury collisions in
last 5 years.
Suffolk County Council: Endeavour House, 8 Russell Road, Ipswich, Suffolk IP1 2BX
www.suffolk.gov.uk
•
•
•
Looking at the side road junction layout, we can see that turning left out of the side
road traffic enjoys a long taper but it is not a slip on (where speed could build up
before joining the main road) as it’s tapering.
Any alterations could involve removing the taper and squaring up the layout to
discourage misuse. This would need to be a physical change (rather than hatching)
and involve carriageway break out and new lining works.
In terms of expected accident reduction / cost-benefit / value-for-money this is
expected to be low / poor
When considering this junction and the circumstances in which the collision took place,
officers have also noted that whilst undertaking the annual review of injury collisions
across the county, there are other locations where a higher number and severity of
collisions takes place, and as such officers make decisions on sites for remedial
engineering solutions taking the whole county into account. Sites are selected and
prioritised for remedial works where there is considered to be a high likelihood of a
reduction in the frequency and severity of collisions occurring and where vulnerable road
users are prioritised, as set out in the Suffolk RoadSafe Strategy (2012-2022).
In reviewing the concerns your raise in your report, to take action to prevent drivers from
turning right from the A1088 into Thetford Road in advance of the centre island and
bollard, Suffolk County Council proposes the following action:
•
•
undertake a review of the junction design and layout and potential engineering
solutions that would reduce the opportunity to turn right in advance of the centre
island
continue to monitor the collisions across the county to identify where remedial
action is required by the Council.
Yours sincerely
Mark Ash
Executive Director of Growth, Highways and Infrastructure
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