Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0033, written 17 Feb 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Feb 2020 |
|---|---|
| Reference | 2020-0033 |
| Deceased | James Anthony Lewis and Lorraine Molyneaux |
| Coroner | Rachel Griffin |
| Coroner area | Dorset |
| Category | Road (Highways Safety) related deaths · Alcohol, drug and medication related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Mr Graham Farrant, Chief Executive for BCP Council, Town Hall, Bournemouth, BL2 6DY 2. Department for Transport, Great Minster House, 33 Horseferry Road, London, SW1P 4DR 1 | CORONER T am Rachael Clare Griffin, Senior Coroner, for the Coroner Area of Dorset 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 the 24" October 2019 I commenced an investigation into the death of Lorraine Anne Molyneaux, born on the 2"! March 1957 and on the 30" October 2019 I commenced an investigation into the death of James Anthony Lewis, also known as Anthony James Lewis born on 27" May 1969. These investigations concluded at the end of the joint Inquest on the 13% February 2020. The Medical Cause of Lorraine Anne Molyneaux’s death was: Ta Multiple Injuries The Medical Cause of James Anthony‘s Lewis’ death was: 1a Fatal Cranial and Brain Injury The conclusion at both Inquests, which were held jointly due to the circumstances of the death, was Road Traffic Collision. 4 | CIRCUMSTANCES OF THE DEATH On the 16" October 2019 Lorraine Molyneaux left her place of work at Dunelm Mill on Turbary Retail Park, Ringwood Road, Bournemouth on foot. She intended to visit her friend who lived on the other side of Ringwood Road. The road is a dual carriageway with a speed limit of 40mph. There are 2 designated | pedestrian crossings along the section between Mountbatten Roundabout and | Clock Garage Roundabout. Lorraine was seen to run across the southbound carriageway of Ringwood Road near to the entrance to Turbary Retail Park and was struck by a motorcycle being ridden by James Anthony Lewis. Prior to the collision James had consumed alcohol. Lorraine died at the scene and James was taken to Southampton General Hospital, Southampton where he was diagnosed with significant traumatic head injuries. His condition deteriorated, and he died on the 22" October 2019. CORONER'S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: 1. During the inquest evidence was heard that: i. Although there are 2 pedestrian crossings along Ringwood Road between the Mountbatten Roundabout and the Clock Garage Roundabout, people are regularly seen to cross the road at the location where this collision occurred where there is no crossing. The crossings are approximately 210 and 375 meters from the point where the collision occurred. ii. One of the reasons it is believed that people cross the road at this location is the proximity of the bus stops, on both sides of the road, to this point on the road which is by the entrance to Turbary Retail Park. If people travel to the Retail Park by bus, they cross at this point rather than walk the distance to the crossing. Evidence was given that people of all ages, including youngsters and older people, cross at this location. iti. | Evidence was further given that a very similar collision occurred at this location in September 2018, just under 13 months prior to this collision. That collision resulted in the death of a 74 year old pedestrian who had just got off the bus and was struck by a motorcycle whilst crossing the road at this location. iv. Evidence was given that the risk of further deaths at this location has been raised by Dorset Police to BCP Council and BCP Council submitted an application for funding to the Department for Transport for a controlled crossing to be installed or consideration be given to changing the layout of the junction. This application was made in November 2019 and it is understood that no action has been taken since. v. Evidence was also given by a witness at the Inquest, who is a local driving instructor and drives along Ringwood Road regularly, that the lighting in this area is dull. It was explained that along this stretch there are street lights in the central reservation of the dual carriageway but not on the sides of the road. She explained that on the night in question some of the lights were not working and are still not working. Lorraine was wearing dark clothing and James was not wearing any high visibility clothing which may have affected their visibility. I have concerns with regard to the following: i. The deaths of Lorraine and James now bring the total fatalities to 3 in the same location and in similar circumstances since September 2018. I have concerns that there could be future deaths at this location if action is not taken. ii. I therefore request that a review is undertaken of the pedestrian crossings and the layout of Ringwood Road outside of Turbary Retail Park. I request that consideration is given to the placing of a pedestrian crossing closer to the bus stops and the entrance to Turbary Retail Park as soon as possible to avoid future deaths. iii. I further request that the street lighting between Mountbatten roundabout and Clock Garage Roundabout is reviewed in relation to the amount of lighting and to ensure that the current lighting is working. ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe you and/or your organisation have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, 13" April 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (1) BE solicitors on behalf of Lorraine Molyneaux’s family (2) Members of James Lewis’ family I am also under a duty to send the Chief Coroner a copy of your response. T have also sent a copy of this report to Sergeant Burt of Dorset Police who was the lead investigator into Lorraine and James’ deaths. 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. Dated Signed Rachael C Griffin 17" February 2020 HM Senior Coroner for Dorset
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.
Growth and Infrastructure - Transportation
Civic Centre
Poole, BH15 2RU
The Coroner’s Office for the County of
Dorset
Date: 6th April 2020
Your Ref: 174318
Bournemouth Town Hall
Our Ref: T/1185
Bournemouth
BH2 6DY
Contact:
Email:
Tel: 01202 262073
For the attention of Rachael Griffin H M Senior Coroner for Dorset
Dear Mrs Griffin,
Re: Regulation 28 report – Inquests Touching the deaths of Lorraine Anne Molyneux and
James Anthony Lewis - Deceased
I refer to your letter dated 17 February 2020 to the BCP Council’s Chief Executive, Mr Graham
Farrant, and the investigations into the death of Lorraine Anne Molyneux on 16th October 2019
and the death of James Anthony Lewis on 22nd October 2019.
I was very sorry to hear about these incidents and would like to pass on my sincere condolences
to family and friends with regards to their loss both personally and on behalf of BCP Council.
With regards to your report under Regulation 28 of the Coroner’s (Investigations) Regulations
2013 to prevent future deaths I respond on behalf of BCP Council as follows:
BCP Council Fatal Accident Investigation Visit
The information available to BCP Council indicates that Lorraine Molyneux and James Lewis
died due to injury sustained at a road traffic collision in Ringwood Road, Bournemouth, near its
junction with High Howe lane, at 21.36hrs on Tuesday 16th October 2019.
BCP Council carries out joint investigations into all fatal road traffic collisions in conjunction with
the Dorset Police Road Casualty Reduction Officer. With regards to the incident on Ringwood
Rd, the site was visited by three officers at 10.00hrs on Tuesday 26th Nov 2019 (see Appendix
A).
The relevant observations from this joint investigation include noting that at this location the road
is a 40mph dual carriageway with a central median strip separating both carriageways. At the
time of the fatal road traffic collision, it was dry and fine; the streetlighting present in the area
was working at the time of the collision and the road surface was dry and in good condition. It
was also noted by officers that while carrying out the site investigation a number of pedestrians
were seen crossing the road at this location.
‘BCP Council’ is the operational name for Bournemouth, Christchurch and Poole Council.
bcpcouncil.gov.uk
2
Recommendations following Site Visit
As you have clearly indicated in your report, BCP Council has identified this location as a
priority for the funding of a crossing facility following a previous incident in September 2018
which involved the death of a pedestrian crossing the road at this location. The Fatal Accident
report that followed the site visit recommended the following remedial action:
“To consider the installation of a controlled crossing at this location. Transforming
Cities Fund (TCF) bid submitted to DfT on 28 November (2019). Ringwood Road is on
a TCF route where treatment may be considered. This may be in the form of a
controlled crossing or the installation of a new signalised junction with pedestrian
facilities. Any works at this location to be discussed with TCF programme manager”.
As confirmed by the Chancellor of the Exchequer in the recent budget (announced on 11
March 2020) under the Transforming Cities Fund, £79 million has been allocated for the
Bournemouth, Christchurch & Poole journey to work area (which includes an area to the north
of the BCP authority boundary). The announced funding shall now include for four new cycle
freeways and new bus priority infrastructure with a range of schemes for delivery by 2022/23.
This means that there is now a very good prospect of some form of signal controlled crossing
facility being installed in this area during the funding period.
Your report also raised that there were concerns raised by one witness about the perceived
level of street lighting and the fact that some of the lanterns were not working.
The Council has carried out a careful review of the lighting design at this location and this has
determined that the lighting levels meet or exceed those required for this type of road layout.
The lighting at this location is triggered by light sensor and these sensors appear to have been
working satisfactorily at the time of the incident and indeed since that time. We are aware of
some lighting defects on Ringwood Road but some distance from the incident. Although not
material to this incident this may possibly account for the suggestion that some lighting was not
operational.
As a part of our normal working practice and in order to carry out a full and detailed check of the
actual illumination levels on site we are required to visit the location during the day to measure
and mark out several light calculation points on the road and footway then followed up with a
visit during the hours of darkness for measurement to be made by use of a light meter.
The adverse weather conditions during February and March 2020 delayed the anticipated site
monitoring given that the road surfaces need to be dry for accurate measurement so as not to
influence the ambient lighting levels.
Please be reassured that a site assessment shall be carried out as soon as possible now that
the weather conditions are more suitable and when circumstances allow. The results of this
additional survey shall seek to confirm the actual lighting level on site and shall help us then
determine the detail of a new lighting design and current adequacy linked to the anticipated
adjustment to road layout with a new crossing once installed. BCP Council does not normally
make any improvement to the existing illumination levels on a road unless this was specifically
recommended as part of any safety report.
Although it is not possible to provide definitive timescales at present, I shall ensure that our
officers now prioritise the additional survey and that our work within the confines of TCF
requirements allows for prioritisation of our design work for the crossing.
3
I trust that the above response is helpful but please feel free to contact me again if you require
further clarification about any point I have raised or if you feel you would wish for a further
update on our TCF related progress.
Yours sincerely
Service Director
Growth and Infrastructure
cc Graham Farrant, Chief Executive
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