Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0197, written 5 Oct 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Oct 2020 |
|---|---|
| Reference | 2020-0197 |
| Deceased | Frazer Golden |
| Coroner | James Thompson |
| 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 REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1. Mr , Chief Executive, Durham County Council, County Hall, Durham 1 CORONER I am James E THOMPSON, 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 Eighteenth April 2017 I commenced an investigation into the death of Frazer GOLDEN aged 30. The investigation concluded at the end of the inquest on 2nd October 2020. The conclusion of the inquest was: Road Traffic Collision and the medical cause of death was: I a Head,Neck and Chest Injuries 4 CIRCUMSTANCES OF THE DEATH Frazer Golden died on 9th April 2017 on the A689 road near Whit's Hill, St John's Chapel, County Durham after his motorcycle & another motorcycle collided, the resultant injuries sustained by him caused his death. 5 CORONER’S CONCERNS The MATTERS OF CONCERNS are as follows: (brief summary of matters of concern) I heard evidence from 2 police collision experts who could not explain in their examination of the A689 road between Ireshopeburn & St Johns Chapel why SLOW road markings were displayed on the carriageway when immediately leaving these 2 villages and the 30mph limit and entering a 60mph limit. The evidence heard was that it would appear to be confusing that a warning to SLOW was displayed when the immediately adjacent signs were confirming a change in speed limit from 30 to 60 mph. Evidence was also heard that at the collision location near Whit’s Hill on the A689 road between the 2 villages there is a bend where forward visibility is reduced. This is accepted in a Durham County Council Highways report read as evidence at the inquest. There are no warning signs or double white hazard warning lines approaching the bend or at the bend in either direction. The police experts further opined that a speed travelled by one of the motorcyclists into the bend of 51mph was not supported when considering the reduced view created by the bend. The speed limit in this area of the A689 is 60 mph. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe 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 30 November 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 Chief Constable, Durham Constabulary, Akley Heads, Durham Mr Miss Mr , c/o Mr , Solicitor, Alderson Law 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 James E THOMPSON Assistant Coroner for County Durham and Darlington Dated: 05 October 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: 03000 email: @durham.gov.uk Your ref: 01009-2017 Our ref: OC 1587 By email hmcoroner@durham.gov.uk Mr James E Thompson H M Assistant Coroner for County Durham and Darlington H M Coroners Office P O Box 282 Bishop Auckland County Durham DL14 4FY 24th November 2020 Dear Mr Thompson Regulation 28 – Frazer Golden (Inquest 18th April 2017) Thank you for your correspondence dated 5th October 2020 which Executive, has asked me to respond to. Chief 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/TS05/17). These reports are undertaken to identify any defects or improvements to the highway street furniture and infrastructure. The report made the following observation / recommendation Although not considered contributory factors of this accident, it is suggested that Durham County Council Technical Services highway maintenance personnel address the following observations through the recommendations provided: Neighbourhoods and Climate Change Durham County Council, County Hall, Durham DH1 5UF Main Telephone 03000 26 0000 Text Messaging Service 07860 093 073 www.durham.gov.uk Page 2 of 3 A missing gully cover was identified within the north westbound channel, at a point approximately 70 metres northwest of the access road to Whit’s Hill dwelling. The relevant highway maintenance personnel should assess the issue and take appropriate action. The above item has been actioned and remedial measures implemented. Regulation 28 Report In your report of the 5th October 2020 you refer to three specific items for the council, as the highway authority for the A689, to address namely; 1. Why SLOW road markings were displayed on the carriageway when immediately leaving these 2 villages and the 30mph limit and entering a 60mph limit; 2. There are no warning signs; 3. Double white hazard warning lines approaching the bend in either direction. . After receiving your letter a road safety and traffic management engineer from the council visited the site on the morning of Thursday 22nd October 2020 and has carried out a review of the personal injury accident record for the A689 between Ireshopeburn and St. John’s Chapel. There has been one other accident in the past 10years, occurring 260metres northwest of Whit’s Hill, which involved a bird colliding with a motorcyclist who impacted against a lamp column and suffered fatal injuries. The Council’s Response and Proposed Course of Action. The council’s response and proposed course of action are: • The two SLOW road markings: there is no valid road safety / traffic management reason for these road markings. . As such, I will arrange to have the two road markings removed; • Bend warning signs: a bend warning sign will be erected on both approaches to the bend; • Double White Lines: the installation of a system of double white lines at this location is not considered appropriate as the road’s layout does not meet the criteria for this type of intervention as set out in the Traffic Signs Manual Chapter 5 Road Markings 2018. As stated in the Manual “It is important to note that the marking is not to be used where appropriate criteria are not satisfied otherwise it will be brought into disrepute”. It is also noted that the accident did not involve an overtaking manoeuvre It is the intention of the council to implement the above-mentioned measures by 31st March 2021. This timescale reflects the backlog in the council’s highway works caused by the Covid 19 Lockdown measures. Once again I wish to offer my condolences to Frazer Golden’s family and friends on their loss. I trust the above provides a considered response to your correspondence. Page 3 of 3 Should you wish to discuss further, please do not hesitate to contact Works Permit Scheme Project Manager, on telephone number 03000 at @durham.gov.uk , Street or by email Yours sincerely Corporate Director – Neighbourhoods and Climate Change Enc Fatal Accident Report (M/T/S05/17) Copies to , PA to , Chief Executive , Head of Transport & Contract Services (Interim) , Strategic Highways Manager , Traffic Asset and Streetworks Manager Street Works Permit Scheme Project Manager Legal Manager Litigation , Service Support Officer
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