Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0295, written 22 Dec 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Dec 2020 |
|---|---|
| Reference | 2020-0295 |
| Deceased | Daniel Hughes |
| Coroner | John Ellery |
| Coroner area | Shropshire, Telford and Wrekin |
| 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.
1 2 3 4 5 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Highways England National Traffic Operations Centre 3 Ridgeway Quinton Business Park Birmingham B32 1AF CORONER I am Mr John Penhale Ellery, Senior Coroner, for the coroner area of Shropshire, Telford & Wrekin. 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. INVESTIGATION and INQUEST On 5th June 2017 I commenced an investigation into the death of Daniel Mark HUGHES, 24 years of age. Following a suspension of the investigation for criminal proceedings the investigation concluded at the end of the inquest on the 18th November and 3rd December 2020. The conclusion of the inquest was a Road Traffic Collision and that the deceased had died from multiple injuries at the scene. CIRCUMSTANCES OF THE DEATH At approximately 2.15 pm on Sunday the 4th June 2017 outside the Bungalow on the A483 at Sweeney near Oswestry, Shropshire the deceased riding his motorcycle south was in collision with a motorcar as it was turning right north towards Oswestry. 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 will 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 motorist concerned was turning right from the driveway of a property approximately 90 meters south of a blind bend. There was little or no margin of error in crossing the southbound carriageway to travel north. There are specific areas of concern: 1) Whether and how visibility to the right may be improved or turning deterred. 2) Whether the speed limit at that bend is appropriate. 3) Whether a warning of a concealed driveway could be displayed. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 7 8 9 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 16th February 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 1) 2) concerned. solicitor for the family of the late Daniel Mark Hughes. solicitor of DWF for the motor insurers of the motorist 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. Mr John Penhale Ellery Senior Coroner Shropshire, Telford & Wrekin 22nd December 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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS RESPONSE IS BEING SENT TO: 1. The Senior Coroner for the coroner area of Shropshire, Telford & Wrekin, in response to a ‘Regulation 28 Report to Prevent Future Deaths’ following an inquest hearing into the death of Daniel Mark HUGHES that concluded on 03 December 2020. , Shrewsbury, Shropshire 1 HIGHWAYS ENGLAND I am Limited of The Cube, 199 Wharfside Street, Birmingham B1 1RN. , Regional Director for the Midlands, Highways England Company 2 CORONER’S MATTERS OF CONCERN The MATTERS OF CONCERN are as follows:– a. Whether and how visibility to the right may be improved or turning deterred. b. Whether the speed limit at that bend is appropriate. c. Whether a warning of a concealed driveway could be displayed. 3 DETAILS OF ACTION TAKEN a. Visibility / right turn We have reviewed the location of the incident and noted that responsibility for the visibility exiting a property entrance at this location is that of the property owner. We have checked the site in its present and previous layout using past photos, and have found that the visibility exiting the property is restricted. These restrictions are caused by a combination of the low boundary wall of the property which is further restricted with the addition of a wooden fence above it further to the north of the property entrance. Following this, there is also a hedgerow situated on the adjacent property which is maintained periodically by the adjacent landowner. The boundary wall and fence are the responsibility of the owner of the Bungalow, and the hedgerow is the responsibility of the adjacent landowner. b. Speed limit We completed a speed limit review for the A483 Trunk Road in 2016 when speed surveys took place both north and south of the incident site. The speed limit review showed that 85% of vehicle speeds recorded were found to be below the posted national speed limit of 60mph. When considering this speed survey result and the record of injury collisions on this section of the A483, this location was not identified as requiring consideration for a potential change in the speed limit. 4 EXPLANATION AS TO WHY NO ACTION IS PROPOSED a. Visibility / right turn Responsibility for the visibility exiting a property entrance is that of the property owner and not Highways England. Any steps to improve the visibility would also require amendments to boundary walls, fences and hedgerows on land which is not owned by Highways England. Therefore, no action is proposed. b. Speed limit 1 Recent surveys found the speed limit to be both appropriate and adhered to by the majority of road users at this location, as a result there are currently no plans to reduce the speed limit in this location. c. Warning of a concealed driveway Highways England has powers to place signs on the Strategic Road Network under Part V of the Road Traffic Regulation Act 1984, but signs placed on the Strategic Road Network must comply with the Traffic Signs Regulations and General Directions (TSRGD) 2016 as directed by the Secretary of State for Transport. The common means of warning a road user of a concealed entrance ahead is a concealed entrance warning sign, unfortunately this is not an authorised sign under the TSRGD and Highways England does not have the power to place such a sign on the A483 Trunk Road. Under the Highways Act 1980, should a property owner place such a sign on our roads it would be considered an obstruction of the highway or something deposited on the highway as to cause a danger and would be removed. Consequently, Highways England is not permitted to place such a sign at this location and no action is proposed. Notwithstanding the difficulties of authorisation for placing a “concealed entrance” sign on the Strategic Road Network, the siting of a sign in this location would be challenging in part due to the width of the verge and the likelihood of further impeding visibility. However, should the property owner seek to place a privately-owned warning sign on private land adjacent to and visible from the highway they could do so at their own risk, this may be a solution the property owner could explore if they wish to. 5 SAFETY OF ROAD USERS The safety of our road users is an imperative for our business and a core value of our organisation. We are working hard to make our entire network safer, but consider that the incident investigation we have undertaken does not highlight any actions that Highways England could carry out to prevent future deaths at this location. 6 12 February 2021 Signed: Regional Director, Midlands 2
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