Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0139, written 10 Jul 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Jul 2020 |
|---|---|
| Reference | 2020-0139 |
| Deceased | Bartosz Kusiak |
| Coroner | Oliver Longstaff |
| Coroner area | County Durham and Darlington |
| 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 from is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: Durham County Council Highways Section 1 CORONER I am Oliver LONGSTAFF, Assistant Coroner for the area of County Durham and Darlington 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 Thirty-First January 2020 I commenced an investigation into the death of Bartosz Cezary KUSIAK aged 21. The investigation concluded at the end of the inquest on 10th July 2020.The conclusion of the inquest was that Mr Kusiak died in a road traffic collision. The medically certified cause of death was: I a Multiple Injuries Consistent with a Road Traffic Collision I b I c II 4 CIRCUMSTANCES OF THE DEATH Mr Kusiak left a bar in Durham city centre at approximately 01:30hrs on 23/01/2020 and began walking home towards his address in Cooper Square, Gilesgate. At about 0220h, the driver of a motor vehicle observed Mr Kusiak in his headlights. Mr Kusiak was standing (or walking slowly in the direction of Durham towards oncoming traffic) on the central lane markers of the eastbound dual carriageway of the A690 between the Gilesgate roundabout and the Belmont overbridge. Almost immediately thereafter, a second motorist struck Mr Kusiak, who had moved into the near side lane (Lane 1) of the A690, at a point approximately 245 metres northeast of a pedestrian crossing point on the carriageway. Mr Kusiak sustained fatal injuries, from which he died later in hospital. The relevant stretch of the A690 is unlit. Footage from the dashboard mounted camera in the impact vehicle showed that Mr Kusiak was not visible to the driver of the impact vehicle until he was only 29 metres away. 5 CORONER’S CONCERNS The MATTERS OF CONCERNS are as follows: (brief summary of matters of concern) The evidence established that the collision between Mr Kusiak and a motor vehicle occurred on an unlit dual carriageway subject to the national speed limit that runs alongside a housing estate and an industrial estate in Belmont. It is foreseeable that pedestrians will attempt to cross the road. The evidence established that at the point in the road where the impact occurred, a pedestrian was visible to a car being driven appropriately with headlights on and well within the prescribed speed limit only at a distance of 29 metres. The emergency stopping distance for such a car is between 75 and 87 metres. There is no footpath alongside the A690 along the stretch where the accident occurred. The circumstances of this incident were discussed with police at a Durham County Council Traffic Management meeting on 14th February 2020 when recommendations were made to improve the safety of the road where the incident occurred. 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 04 September 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: The next of kin of Bartosz Cezary Kusiak I have also sent it to Durham Constabulary who may find it useful or of interest. 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 Oliver LONGSTAFF Assistant Coroner for County Durham and Darlington Dated: 10 July 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.
Contact: Direct Tel: email: Your ref: Our ref: Mr Oliver Longstaff Assistant Coroner for County Durham and Darlington HM Coroner’s Office PO Box 282 Bishop Auckland County Durham DL14 4FY 4th September, 2020 Dear Mr Longstaff Regulation 28 – Mr Bartosz Cezary Kusiak (Inquest 31st January 2020) Thank you for your letter and Regulation 28 report dated 10th July 2020. This was a tragic accident and the Council wishes to express its sincere condolences to the family and friends of Mr Kusiak. The council is aware of the concerns expressed about this section of the A690 and have reviewed safety issues on a number of occasions, most recently in the form of an independent consultant’s report. The council remain of the view that there are no fundamental issues with this section of road which need to be addressed; however, a number of minor beneficial improvements have been identified and implemented as a result of a previous accident. These are listed in the Table 1 below. In accordance with Regulation 28 the council has considered whether any highway improvements can be made to the A690 between Gilesgate Roundabout and Junction 62 of the A1(M). Site Investigation Following Fatal Accident Report The Council has an Accident Investigation and Prevention Team and one of its roles is to investigate every fatal road traffic accident, on the council’s highway network, in conjunction with Durham Constabulary’s Traffic Management Unit. Please find attached a copy of the Accident Report (M_T_S04_20 (002)). These reports are undertaken to identify any defects or improvements to the highway street furniture and infrastructure. The report made the following observations / recommendations. Table 1 Neighbourhoods and Climate Change Durham County Council, County Hall, Durham DH1 5UQ Main Telephone (03000) 260 0000 Minicom (0191) 383 3802 www.durham.gov.uk Page 2 of 5 No. Observation / Recommendation 1 With reference to Fatal Road Accident Report M/T/S09/19, following a similar incident on the south-westbound carriageway, the Police requested an assessment of this section of road to determine whether the provision of street lighting should be considered, particularly in the vicinity of the pedestrian crossing point. This request was subsequently passed to Durham County Council’s Street Lighting Section for their deliberation. It is recommended that the outcome of these deliberations be presented for review at the earliest convenience. In addition to the request outlined in Item 1, the Police have also asked if a similar assessment process can be undertaken in consideration of footway provision adjacent to this section of the A690. 2 Any deteriorating road markings and missing/damaged road stud inserts should be recovered as part of the Council’s ongoing maintenance programme at the earliest convenience. Action This matter has been discussed with both Traffic Assets Team, Street Lighting Team and Strategic Highways Team in relation to the provision of street lighting and footways. As a result of these discussion it has been agreed that an independent road safety assessment will be commissioned at the earliest possibility. The results of which will be reviewed and discussed further with our partners, Durham Constabulary. This matter has been discussed with both Traffic Assets Team, Street Lighting Team and Strategic Highways Team in relation to the provision of street lighting and footways. As a result of these discussion it has been agreed that an independent road safety assessment will be commissioned at the earliest possibility. The results of which will be reviewed and discussed further with our partners, Durham Constabulary. Information contained within this report regarding the condition of road markings and missing /damaged road studs has been raised with the Traffic Assets team. Although not a contributory factor and still retaining some residual life, they will arrange for the renewal of road markings to be considered as part of future routine maintenance. Independent Road Safety Assessment Report 1. As identified in the above actions an independent road safety assessment has been carried out to assess the appropriateness of introducing street lighting along the A690 and a pedestrian route review. Please find attached a copy of the independent consultant’s report A690 Safety Review (60343839_AEC_L1_RP_ZZ_00-005) The report includes the following key actions and recommendations. Table 2 No. Action 1 Appropriateness of introducing street lighting on the A690 between Gilesgate and A1(M) Junction 62. Page 3 of 5 Recommendation A Cost / Benefit Analysis (C/BA)of a street lighting scheme between Gilesgate and the C13 Belmont Link Road junction, with costs estimated at £1.65 million discounted to 2010 prices, resulted in a Benefit Cost Ratio (BCR) of 1.01. This means the investment would be cost neutral with no positive return on the investment, particularly as the lighting appraisal undertaken in accordance Department of Transport Document TA 501 (Road Lighting Appraisal) does not include non- lighting costs that would be required, for example provision of a footway and associated fencing along the length of the A690. 2 Review of pedestrian footway provision along the A690. The predominant movements between trip generators in the area are provided for via existing footway / footpath routes including: • the A690 footbridge, approximately 250m north- east of Gilesgate roundabout, towards Heaviside Place and the wider residential network parallel to the A690; • Station Road towards Heaviside Place and the wider residential network; and • Gilesgate, south-east of Gilesgate roundabout There are footpaths running along section of the A690 that provide access to the dual carriageway, including immediately east of the A690 footbridge and on the westbound onslip at the C13 Belmont Link Road junction. Given there are designated alternative, street lit routes alongside the A690, if access to the A690 could be pro-actively discouraged and the footbridge access to Heaviside Place promoted then the A690 could be seen as a less attractive route. A proposed scheme with a reported BCR of 26.1 is presented to physically prevent/segregate pedestrians from the A690, including guardrail adjacent to the southern kerbline approaching Gilesgate Roundabout, signing of the A690 footbridge pedestrian route and fencing to segregate pedestrians using the footpath north east of the footbridge. Page 4 of 5 Based on the above recommendation, the council proposes the following course of action: • It is not proposed to promote the high speed A690 dual carriageway as a pedestrian route through the introduction of street lighting and footways, acknowledging the council provides a footway / footpath network on parallel street lit, lower speed roads. The independent C/BA concludes the investment in street lighting in isolation would be broadly cost neutral and not deliver a return on the investment. It is also noted the addition of a parallel footway and fencing for segregation on the A690 would invite a higher overall scheme cost. • The council is committed to reducing the potential for similar accidents to occur. To that end the recommendation in the independent consultant’s report is accepted to introduce interventions to proactively deter access to the A690 dual carriageway and promote existing pedestrian routes. These measures include: o Proactively signing the Gilesgate area via the footbridge from the northern footway of the A690; o Guardrail and wayfinding signs to discourage pedestrian access to the south- westbound carriageway and south-eastern verge, between Gilesgate Roundabout and Station Lane; o Based on the footpath north-east of the footbridge being retained, foliage clearance to improve access to the footpath and a timber post and rail fence to discourage access to the A690 from this path beyond the footbridge; and o Removal of access to the public footpath on the south-westbound on-slip at the C13 junction. It is the intention of the council to install the above-mentioned measures by 31 March 2021. This timescale reflects the backlog in the council’s highway works caused by the Covid 19 Lockdown measures and the closure of New Elvet Bridge which has made the A690 a priority route for emergency service vehicles. I wish to offer my condolences to Mr Kusiak’s family and friends on their loss. I hope the above goes some way towards offering a considered response to your correspondence. If you would like to discuss response this further, please contact number or by email at on telephone Yours sincerely Corporate Director Neighbourhoods and Climate Change Copies to: , Strategic Highways Manager , Head of Transport & Contract Services (Interim) Page 5 of 5 Danny Harland, Traffic Assets and Street Works Manager Bryan Smith Legal Manager Litigation (Res.) Jane Bromley, Service Support Officer (Technical Services) Enclosures: 2. Fatal Accident Report (M_T_S04_20 (002)) 3. A690 Safety Review (60343839_AEC_L1_RP_ZZ_00-005)
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