Prevention of Future Deaths reports · 2020

Bartosz Kusiak

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 report10 Jul 2020
Reference2020-0139
DeceasedBartosz Kusiak
CoronerOliver Longstaff
Coroner areaCounty Durham and Darlington
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 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

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 Durham County Council (PDF)
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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