Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0125, written 9 Jun 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Jun 2020 |
|---|---|
| Reference | 2020-0125 |
| Deceased | Mitica Ladunca |
| Coroner | Anna Crawford |
| Coroner area | Surrey |
| 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.
IN THE SURREY CORONER’S COURT
IN THE MATTER OF:
__________________________________________________________
The Inquest Touching the Death of Mitica Mihaita Ladunca
A Regulation 28 Report – Action to Prevent Future Deaths
__________________________________________________________
1 THIS REPORT IS BEING SENT TO:
Senior Highway Engineer for Surrey
County Council County Hall
Penrhyn Road
Kingston upon Thames
KT1 2DN
2 CORONER
Ms Anna Crawford, HM Assistant Coroner for Surrey
3 CORONER’S LEGAL POWERS
I make this report under paragraph 7(1) of Schedule 5 to The Coroners
and Justice Act 2009.
4
INVESTIGATION and INQUEST
An inquest into the death of Mitica Mihaita Ladunca was opened on 19
November 2019. It was resumed and concluded on 8 June 2020.
The medical cause of death was found to have been:
1a. Adult respiratory distress syndrome AND cerebral infarction
1b. Multiple traumatic injuries
2. Pulmonary tuberculosis
The inquest concluded with a short form conclusion of ‘Road Traffic
Collision’.
1
5 CIRCUMSTANCES OF THE DEATH
On 10 October 2019 Mr Ladunca attempted to cross the northbound
lane of the A322 in Surrey approximately 425m north of Junction 3.
For reasons which remain unknown Mr Ladunca misjudged the situa-
tion and unintentionally stepped into the path of a DAF XF 460 articu-
lated large vehicle, resulting in fatal injuries. He died at St. George’s
Hospital on 8 November 2019.
At the collision location there is an asphalt pathway, approximately 1
metre wide, across the central reservation and a gap in the pressed steel
barrier. At this point, the kerb drops on both sides of the carriageway
for approximately 2.7 metres. This path links to Swift Lane which is
staggered across both carriageways. On the southbound side of the car-
riageway Swift Lane leads to Bagshot Community Recycling Centre and
a static home and caravan site for the Traveller Community. On the
northbound carriageway side of the carriageway, via a footpath, Swift
lane leads to Whitmoor Road and a number of residential properties.
During the course of the inquest I received evidence from DC Bloom-
field, a Collision Investigator for Surrey Police. He gave evidence that
the crossing is uncontrolled and that there is no signage warning driv-
ers that pedestrians may be attempting to cross the road in either direc-
tion.
Whilst the absence of any signage did not contribute to the particular
circumstances of Mr Ladunca’s death, I am concerned that it may give
rise to a risk of future deaths.
6 CORONER’S CONCERNS
The MATTERS OF CONCERN are:
- There is an absence of signage warning drivers on the A322 that
there is a crossing point for pedestrians which links to Swift Lane
across both carriageways.
- Consideration should be given to introducing such signage.
2
7 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I be-
lieve that the people listed in paragraph one above have the power to
take such action.
8 YOUR RESPONSE
You are under a duty to respond to this report within 56 days of its
date; I may extend that period on request.
Your response must contain details of action taken or proposed to be
taken, setting out the timetable for such action. Otherwise you must ex-
plain why no action is proposed.
9 COPIES
I have sent a copy of this report to the following:
1.
2. Surrey Police Forensic Collision Investigation Unit
3. The Chief Coroner
In addition to this report, 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 repre-
sentations to me, at the time of your response, about the release or the
publication of your response by the Chief Coroner.
10 ANNA CRAWFORD
DATED this 9th day of June 2020
3
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.
Subject: FW: Regulation 28 report. Mitica-Ladunca-2020-0125 Sent: From: To: 15/01/2025, 11:55:13 From: Sent: 08 September 2020 11:33 To: Coroners Office Cc: Subject: RE: Regulation 28 report. Mitica-Ladunca-2020-0125 Dear Assistant Coroner I have been asked to convey the response of our Area Highway Manager to your Regulation 28 Report on the death of Mitica Mihaita Ladunca. Thank you for sending this to us. The Inquest had heard from uncontrolled and that there is no signage warning drivers that pedestrians may be attempting to cross the road in either direction. You stated that while the absence of signage did not contribute to the particular circumstances of Mr Ladunca’s death, you were concerned that it may give rise to a risk of future deaths. , a Collision Investigator for Surrey Police, that the crossing across the carriageway is In light of your report the Area Highway Manager has reviewed the location and while it is clear that your findings are that lack of signage did not contribute to this fatality he will install advance signage at this location. He is pleased to confirm that this work will go ahead on 29/30 September. This will be coordinated with the County’s high speed Traffic Management programme. Yours faithfully | Principal Highways and Planning Solicitor | Surrey County Council Telephone: 0208 541 9095 | Email: COVID-19 NOTICE: I am working remotely until further notice and therefore unable to receive physical items of mail or DX. Any mail sent this way is not able to be processed in the current circumstances. Please send any items electronically. This is an exceptionally busy and challenging time as we manage the current public health crisis and your cooperation is appreciated . If your query relates to a new matter, please forward it to the following email address: matters should continue to be dealt with in the usual way. . Existing
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