Prevention of Future Deaths reports · 2020

Daniel Bancroft

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 report16 Nov 2020
Reference2020-0244
DeceasedDaniel Bancroft
CoronerSimon Ward
Coroner areaCumbria
CategoryRoad (Highways Safety) related deaths
Sourcejudiciary.uk record · original PDF
Responses published2

The report

Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.

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

Responses

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.

Response from Cumbria County Council (PDF)
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
Response from Highways England (PDF)
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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