Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0241, written 16 Nov 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Nov 2020 |
|---|---|
| Reference | 2020-0241 |
| Deceased | Daniel Waite |
| Coroner | Bina Patel |
| Coroner area | Mid Kent and Medway |
| 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.
Mid Kent and Medway Coroners Cantium House 2nd Floor Maidstone Kent ME14 1XD Telephone: New and Current Cases: 03000 410502 General Enquiries: 03000 410503 Email: KentandMedwayCoroners@kent.gov.uk REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Highways Department Kent County Council 2. TARMAC A CRH Company 1 CORONER I am Bina Patel, Area coroner, for the coroner area of Mid Kent and Medway 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 11th July 2019 I commenced an investigation into the death of Daniel Waite, aged 43. The investigation concluded at the end of the inquest on the 6th October 2020. The conclusion of the inquest was that the deceased Daniel Waite died as a result of a road traffic collision. The medical cause of death was recorded as: 1a Multiple injuries b c II 4 CIRCUMSTANCES OF THE DEATH The deceased Daniel Waite was riding a pedal cycle at approximately 19:55 hours on a dry clear sunny day on the A20 Ashford Road, Hollingbourne, Kent. He had approached a stationary convoy of eight tipper trucks parked and awaiting deployment and for reasons unknown he has collided with the rear of the last tipper truck and as a result sustained fatal injuries and died at the scene on the 3 July 2019. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – The A20 Ashford Road is a four lane dual carriageway which is aligned approximately east to west. The collision occurred on the east to west direction leading towards the M20 Motorway. At the collision site lane separation is by way of intermittent white painted lines. The edges of the carriageway are denoted by a solid edge of carriageway lines. The road at the collision site is subject to the national speed limit. (1) The A20 Ashford Road has no parking restrictions in force for this stretch of road. A total of 8 tipper lorries had been directed to stop on the A20 Ashford Road, Hollingbourne, close to the Mercure Hotel to await the deployment of motorway works on the M20 Motorway. The evidence at the inquest revealed that there was no requirement for coning or signage that may have alerted other road users to their presence. (2) There is not at present any restriction to parking or a requirement for signage on this section of the road such as a clearway and this is of particular concern. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe the Highways Department, Kent County Council and Tarmac 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 11th January 2021. 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 Mrs (wife of Mr Daniel Waite), Moore Blatch Solicitors (Family representatives), BLM Law Solicitors (Representatives for Driver of the Second Vehicle involved in the collision); Eversheds Solicitors (Representative for Tarmac). I have also sent it to Kent Police Serious Collision Investigation Unit who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. 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. 9 Signature: Bina Patel Area Coroner Mid Kent and Medway 16th November 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.
Hi , Please can you pass the below response onto the Coroner. Many thanks. Dear Ms Patel I would refer to your REGULATION 28 REPORT TO PREVENT FUTURE DEATHS in respect of Daniel Waite (ref: and would respond as follows: ) dated 16 November 2020 Section 5, Coroner’s Concerns: “There is not at present any restriction to parking or a requirement for signage on this section of the road such as a clearway and this is of particular concern.” I would confirm that there are now ‘clearway’ signs in place at both ends of this section of dualled carriageway and a temporary traffic regulation order has been put in place to enable immediate enforcement of this clearway. This order prohibits any parking along this section of carriageway. Additionally, Kent County Council are implementing a sealed permanent traffic regulation order to replace the temporary order, with permanent posts and signage to replace those temporarily put on site. It will be robustly indicated on site that this road is designated a ‘Clearway’ and that no parking can take place. I trust that this meets with the Coroner’s approval and reassures her that measures have been put in place to mitigate any such parking in the future. Yours sincerely Director Highways, Transportation & Waste A3 12 February 2021 Dear Sirs Inquest touching the death of Daniel Waite Regulation 28 – Report to Prevent Future Deaths This response is submitted on behalf of Tarmac following a Regulation 28 Report to Prevent Future Deaths (“the Report”) made by the Area Coroner for Mid Kent and Medway on 16 November 2020. Before providing the response outlined below, we wish to express our condolences to Mr Waite’s family and friends. Following the tragic incident on 3 July 2019 Tarmac undertook a detailed investigation to understand the fact pattern of the incident. Tarmac was keen to ensure that there was a proper understanding so that any potential lessons could be learned. The factual pattern gathered by Tarmac is aligned to that captured by the Police and conveyed during the Inquest proceedings. We understand from the Report that the Coroner’s concerns are two-fold: 1. The A20 Ashford Road has no parking restrictions in force for this stretch of road. A total of 8 tipper lorries had been directed to stop on the A20 Ashford Road, Hollingbourne, close to the Mercure Hotel to await the deployment of motorway works on the M20 Motorway. The evidence at the inquest revealed that there was no requirement for coning or signage that may have alerted other road users to their presence. 2. There is not at present any restriction to parking or a requirement for signage on this section of the road such as a clearway and this is of particular concern. Taking both of the Coroner’s concerns, it is Tarmac’s respectful position that the parking restrictions and requirements for signage are matters that are within the power of the relevant Highways Authority. Indeed, any requirement to install signage or other forms of traffic management on the road would have required the approval of the Local Authority. For these reasons, it is not within the power of Tarmac to be able to make direct changes as a result of the matters raised by the Coroner. With regard to Tarmac’s own process, it may be of assistance to understand the process for locating the vehicles as they were on the day of the tragic incident. Tarmac Trading Limited Registered in England and Wales. Company No. 453791 Tarmac Cement and Lime Limited Registered in England and Wales. Company No. 66558 Tarmac Services Limited Registered in England and Wales. Company No. 8197397 Registered address for all companies: Portland House Bickenhill Lane Solihull Birmingham B37 7BQ credit. ‘Tarmac’ and the ‘circle logo’ are registered trademarks. ©2019 Tarmac Trading Limited. Tarmac Trading Limited is authorised and regulated by the Financial Conduct Authority for consumer A12 The vehicles (“wagons”) are used in order to collect road planings, i.e. the top layer of the road surface that is removed as part of any resurfacing exercise. The top layer of the road will be removed by a large planing machine and the debris will travel up a conveyor and drop into the waiting wagons for onward transport. The nature of such work is that it can only be performed when safe access to the working area (i.e. the road) can be confirmed. There needs to be suitable signage and traffic management to ensure that those involved in the planing process and all other road users will not be put at risk. The appropriate period is often dictated by traffic flows which will be closely monitored and the planing works will commence when traffic flows are sufficiently low that the traffic management can be installed and the planing operatives can safely commence work. The need for the wagons will depend on when the planing operations commence. There is therefore a requirement for the wagons to be available at relatively short notice. On some occasions, the wagons may be required immediately, and on other occasions they may be waiting for a significant period of time before being called upon. A significant amount of scheduling is undertaken by Tarmac to co-ordinate the process of traffic management, planing operations, and the removal of the planing material to ensure that the work is performed safely and efficiently, and minimises disruption as far as possible. It is not possible to have the wagons waiting on the hard shoulder of the road to be resurfaced, in this case the M20, and the option of waiting on the slip road also presents dangers. The location of the wagons is a matter that is carefully considered by the individuals within Tarmac, who will take a risk-based approach on the appropriate location. Such an approach was adopted on the day of the incident, locating the vehicles in what was considered to be an appropriate location to respond to the work being conducted on the M20. As noted by the evidence, the vehicles were parked in accordance with the Highway Code, and no criticism is made of their location by the investigating Police officers. We can assure the Coroner, and Mr Waite’s family, that this incident is treated with the utmost seriousness. Tarmac is committed to the health and safety of its workforce and all those who we come in to contact with. The business has reviewed its approach and considers that its risk based approach to vehicle location remains appropriate but has nonetheless reacted and reflected on the tragic events; we have circulated the details of the incident internally so that those involved in future risk decisions are fully aware of what happened. . A13
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