Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0244, 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 | 2020-0244 |
| Deceased | Daniel Bancroft |
| Coroner | Simon Ward |
| Coroner area | Cumbria |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 4, MERE Chief Executive, Highways England Co. Ltd 2. Cumbria County Council ( Highways) CORONER jam Simon Ward, assistant coroner, for the coroner area of Cumbria CORONER'S LEGAL POWERS | 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, INVESTIGATION and INQUEST On 24! May 2019 an investigation was commenced into the death of Daniel Bancroft (37years). The investigation concluded at the end of the inquest on 29" September 2020, The conclusion of the inquest was that he died as a result of a Road Traffic Collision; the medical cause of death being severe cervical and thoracic spine injuries. CIRCUMSTANCES OF THE DEATH Mr Bancroft, an ex-serviceman, was happily married and a father of three. He had been for a night out socialising in Workington. He became extremely inebriated, and in the early hours of the morning decided to walk home to Cockermouth some 9 miles east of Workington. The evidence was that he had done this on a number of occasions. He decided to walk along the A66(Stainburn bypass) trunk road. He was struck by a motor vehicle being driven on the eastbound carriageway by an off duty special constable. He dled of the resultant injurles. The Inquest heard from a police officer that he himself had on previous occasions picked up three pedestrians on the stretch of road where the accident occurred In very similar circumstances, He described the road as a “fast road” and that the fack of lighting was “a massive factor’, and it“ needs lighting there definitely, it's so dark” The inquest had the benefit of collision investigator's report which stated amongst other things: 4 The accident occurred on the A66 just east of the roundabout adjacent to the Workington Academy. The eastbound carriageway has two lanes at this point with a speed limit of 6Omph. The westbound has one lane. There is limited lighting from the roundabout to the national speed limit sign on the bypass. 2. Mr Bancroft was struck on the nearside of the eastbound lane at 03:36 3. The car was travelling at about 60mph (26.82m/s) 4, The distance the driver would have first seen Mr Bancroft was 19.45-22.45m if the driver were not looking for, nor expecting to see a pedestrian. 5. The shortest stopping distance would be 48m an emergency stop. 6. There are no pedestrian facilities on this road. There have been three pedestrian fatalities on this stretch of road, all in the early hours, in the dark and whilst the deceased has been drunk. There has also been a non- fatal collision with a pedestrian, again In the early hours. CORONER’S CONCERNS During the course of the inquest the evidence revealed matters glving rise to concern, In my opinion there is a risk that future deaths will occur unless action |s taken. in the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows, — 4. There is nothing to discourage pedestrians from walking along the A66 eg signage 2. Cars are rapidly accelerating from the well-lit roundabout at Stainburn onto an unllt section of the A66 as the national speed limit sign is very close to the roundabout. The speed of traffic on this Initial stretch of the A66 The lack of lighting on this initial stretch of the A66 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you AND/OR your organisation have the power to take such action. Po YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 2020 |, 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, COPIES and PUBLICATION GOPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons , Mr Bancroft's family, and the Chief Constable of Cumbria Constabulary. | am also under a duty to send the Chief Coroner a copy of your response, The Chlef Coroner may publish elther 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, DATE U1, wy Dp re SIGNED BY CORONER
2 responses 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.
Cumbria County Council County Council Highways and Transport Parkhouse Building - Baron Way « Kingmoor Park -« Carlisle - CA6 4SJ oN «a Kally Cheema, Her Majesty’s Senior Coroner, Fairfield, Station Street, Cockermouth, CA13 9PT 148 April 2021 Your ref: i Dear Kally, Re; Daniel Geoffrey Fred Bancroft Deceased Inquest; 29/09/2020 at the Coroner’s Court. Cockermouth | have been asked to respond on behalf of the Head of Economy and Highways to the Regulation 28 letter relating to the above matter. Having examined the report, | wish to advise that the Road Traffic Collision that resulted in the death of Mr Bancroft occurred entirely on the road network that is the responsibility of the Highways England Authority. The County Council do meet Highways England regularly to discuss road safety matters which are relevant on both networks such as media campaigns and we share the overall objective of reducing serious collisions throughout Cumbria. Thank you for bringing this to our attention, but in this case Highways England will address the issue raised. Yours sincerely, Road Safety Coordinator
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS RESPONSE IS BEING SENT TO: 1. The Assistant Coroner for the coroner area of Cumbria, Simon Ward of Fairfield, Station Street, Cockermouth, Cumbria CA13 9PT in response to a ‘Regulation 28 Report to Prevent Future Deaths’ following an inquest hearing into the death of Daniel Bancroft that concluded on 29 September 2020. 1 HIGHWAYS ENGLAND I am Limited of Piccadilly Gate, Store Street, Manchester M1 2WD. , Regional Director for the North West, Highways England Company 2 CORONER’S MATTERS OF CONCERN The MATTERS OF CONCERN are as follows:– a. There is nothing to discourage pedestrians from walking along the A66 eg signage. b. Cars are rapidly accelerating from the well-lit roundabout at Stainburn onto an unlit section of the A66 as the national speed limit sign is very close to the roundabout. c. The speed of traffic on this initial stretch of the A66. d. The lack of lighting on this initial stretch of the A66. 3 DETAILS OF ACTION TAKEN a. Pedestrians We have investigated the options to reduce any potential conflict between motor vehicles and pedestrians along the A66 Stainburn Bypass at this location. Whilst the bypass route was constructed as a rural All Purpose Trunk Road it was not intended to support pedestrian traffic and has a robust physical layout at the junction to direct pedestrians and vulnerable road users along the line of the original route (Stainburn Road) and hence away from the bypass. b. Proximity of the National speed limit to the (lit) roundabout c. Speed of traffic on the initial stretch of the A66 d. Lighting on initial stretch of A66 We have visited the site in both daylight and dark conditions to assess the suitability of the current road lighting provision and speed limit extents. The illuminated section at the end of the bypass ensures consistent and uniform lighting levels around the full footprint of the junction, and approaches, within the restricted 30mph speed limit. This is in line with the guidance and recommendations contained within BS EN 5489-1 ‘Design of Road Lighting ’. DETAILS OF FURTHER ACTION PROPOSED 4 a. Pedestrians Whilst there is a clear and secure routing for pedestrians along Stainburn Road there are no physical barriers or signing to indicate that pedestrians should not use the route of the bypass. This is a common layout in relation to rural routes where no footpath facilities are in place and does not generally cause any road safety concerns. However, there is now evidence to indicate that there are issues with the presence of pedestrians at this location, consequently Highways England are proposing to consult with Cumbria Constabulary with a view to making a legal order to prohibit pedestrians from using the bypass, with associated regulatory signing, together with pedestrian direction signs 1 along the existing footpaths at the roundabout and along Stainburn Road to reinforce the use of this route by pedestrians. 5 TIMETABLE FOR ACTION TIMESCALES ACTION 4 weeks 2 – 3 months 2 – 3 months 3 - 6 months Consult with Cumbria Constabulary on a Traffic Regulation Order to restrict use of the road by pedestrians. If agreement is reached, follow statutory procedure to make a Traffic Regulation Order (TRO) in order to prohibit pedestrians from using the bypass. To coincide with the making of the order, installation of associated regulatory signing. Installation of pedestrian direction signing. 6 EXPLANATION AS TO WHY NO ACTION IS PROPOSED b. Proximity of the National speed limit to the (lit) roundabout c. Speed of traffic on the initial stretch of A66 The roundabout junction provides a physical speed reduction feature which serves to moderate speeds as drivers enter the bypass. In normal circumstances the national speed restriction (and signing) would be located at the interface with the roundabout. However, at this location, the 30mph speed restriction already extends a short distance along the bypass to coincide with the start / end of the road lighting. Having assessed the site, we have concluded the current highway layout and speed limit extents are appropriate at this location and consequently no action is proposed. d. Lighting on initial stretch of A66 The current road lighting provides the interface with the roundabout lighting, specifically on the westbound approach, and supports the lighting infrastructure along the adjacent road network. Having assessed the site, we have concluded that the current extent of the road lighting at this location is appropriate and in line with guidance outlined within BS EN 5489-1 and the Design Manual for Roads and Bridges (DMRB) Technology appraisal guidance TA 501(formerly TA 49/07) ‘Road Lighting Appraisal’, and therefore no action is proposed. Lighting additional lengths of the bypass may also further encourage pedestrian use. 7 SAFETY OF ROAD USERS The safety of our road users is an imperative for our business in what we set out to achieve, and a core value of our organisation. We are working hard to make our entire network safer, and consider that the action we have taken to date and propose to take could reduce the possibility of such incidents occurring in the future at this location. 8 14 January 2021 Signed: Regional Director for North West 2
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