Prevention of Future Deaths reports · 2020

Grant Macdonald

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 report15 Jun 2020
Reference2020-0131
DeceasedGrant Macdonald
CoronerAnita Bhardwaj
Coroner areaLiverpool and the Wirral
CategoryRoad (Highways Safety) related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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

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 Liverpool City Council (PDF)
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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