Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0131, written 15 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 | 15 Jun 2020 |
|---|---|
| Reference | 2020-0131 |
| Deceased | Grant Macdonald |
| Coroner | Anita Bhardwaj |
| Coroner area | Liverpool and the Wirral |
| 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) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Tony Reeves, Chief Executive of Liverpool City Council 2 Merseyside Police 1 CORONER I am Anita BHARDWAJ, Area Coroner for the area of Liverpool and Wirral 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 30/08/2019 I commenced an investigation into the death of Grant Alexander Macdonald aged 27. The investigation concluded at the end of the inquest on 15 June 2020. The conclusion of the inquest was: I a Multiple Trauma I b Road Traffic Collision I c II 4 CIRCUMSTANCES OF THE DEATH Grant Alexander Macdonald was a 27 year old gentleman who, on 19 August 2019, was riding a Honda CBR600 motorcycle, on Hornby Road, Liverpool, Walton, Liverpool, near to the HMP Liverpool, in the direction of Rice Lane when he collided with the rear offside area of a Mercedes CLK200, which had pulled out of the Prison carpark and was stationary or slow moving, waiting to turn right in a gap in the central reservation of the road and perform a U-turn in order to travel on the opposite side of the carriageway towards Southport Road. As a result of the collision, Grant suffered significant injuries and died the same day. In this case there were a number of contributory factors to the collision, including the manner in which the motorcycle was being driven and the speed at which it had been driven, however, issues were raised at the inquest by the family and Merseyside Police suggestive of the fact that the junction is unsafe and that there have been a number of collisions at that junction. 5 CORONER’S CONCERNS The MATTERS OF CONCERNS are as follows: (brief summary of matters of concern) In this case there were a number of contributory factors to the collision, including the manner in which the motorcycle was being driven and the speed at which it had been driven, however, issues were raised at the inquest by the family and Merseyside Police suggestive of the fact that the junction is unsafe and that there have been a number of collisions at that junction. There is concern it is unsafe for a car to go across the carriageway to the central reservation to carry out a u turn manoeuvre. The Court would request the Council to review the safety of this junction. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/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 10 August 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons 3 Liverpool City Council 4 Merseyside Police I 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. 9 Anita BHARDWAJ Area Coroner for Liverpool and Wirral Dated: 15 June 2020
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.
Anita Bhardwaj Area Coroner for Liverpool and Wirral Gerard Majella Court House Boundary Street Liverpool L5 2QD 07 August 2020 Dear Anita, Chief Executive Re: Regulation 28 – Fatality on Hornby Road, Liverpool Further to your email dated 15 June 2020, and the enclosed Regulation 28 report, relating to the fatality on Hornby Road on 19 August 2019. Hornby Road is a classified road, bearing the reference A5098. It is the continuation of Aintree Road (A5098 - Sefton Borough Council) and links Southport Road (A5038) and Rice Lane (A59). The road itself is a dual carriageway, separated by a central reserve for the majority of its length. The central reserve is separated from the carriageway by a mix of standard half batted kerb faces (with varying degrees of upstand), as well as TRIEF/KASSEL type passive safety kerbs, which are designed to prevent or limit vehicle access to the footway areas. On the north east bound carriageway, there is a with flow cycle lane that runs the full length of the carriageway from Southport Road to where it meets a bus stop just prior to Noonan Close. At the initial site meeting, shortly after the collision occurred, the carriageway surface was observed to be in a good state of repair, which remains the same opinion following an observation from one of Highways Engineers last week. The road is subject to a series of street lighting columns, providing illumination to both the carriageway and footway. The posted speed limit is 30mph and as per Traffic Signs Regulations and General Directions - there is no requirement to provide signs to this effect, save for when the speed limit changes. In this case, 30mph roundels are visible on adjacent side roads, which themselves are subject to a 20mph limit. The north east bound carriageway is also subject to double yellow lines for the material location. The section of highway is straight with limited left to right or up and down deviation. Liverpool City Council, Chief Executive’s Office Cunard Building, Water Street, Liverpool, L3 1AH T: E: @liverpool.gov.uk www.liverpool.gov.uk Sightlines, exiting the prison car park are in excess of 150m at a distance of 2.4m from edge of carriageway. Engineers have reviewed the collision statistics along the full extent of Hornby Road, from Aintree Road to Rice Lane, and between 01/05/2010 and 30/04/2020 there have been 10 recorded injury collisions with 15 casualties (11 slight and 3 serious and 1 fatal). Of these, 4 collisions involved vehicles performing U-turns. 2 were at the gap in the central reservation at the main HMP Walton car park entrance to the west of Hornby Close (in 2010 and 2012), 1 was at the gap in the central reservation at Hornby Place (in 2018), and the other was the fatal collision at the gap in the central reservation at the service road leading to Walton train station in 2019. Based on the number of vehicles, which undertake these U-turn manoeuvres at the different gaps on a daily basis, the number of collisions that have occurred is relatively low. Any proposal to close the gaps would need to have sound justification and would also be subject to consultation with stakeholders and the local community and is likely to lead to objections based on the loss of amenity and long diversion routes that road-users would need to embark on to access or exit their properties. There is also a high likelihood that road-users may simply drive over the central reservation, as has been observed by officers of the city council and Merseyside Police, which would bring about road safety concerns in its own right. In view of this, the city council does not consider that there is adequate justification to consider closing these gaps at the present time. This route will continue to be monitored and should there be any marked deterioration in terms of road safety or an increase in collisions then appropriate action may be considered in the future. It is our Highways Engineer’s opinion, that no engineering measures, signage, lines or physical infrastructure currently in place, or lack thereof, contributed to this fatal collision. Yours sincerely Chief Executive
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