Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0084, written 26 Mar 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Mar 2021 |
|---|---|
| Reference | 2021-0084 |
| Deceased | Lee Marsden |
| Coroner | Matthew Cox |
| Coroner area | Manchester North |
| Category | Road (Highways Safety) related deaths · Police related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Highways England 2. North West Motorway Police Group CORONER | am Matthew Cox, Assistant Coroner for the Coroner area of Manchester North CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroner’s and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 INVESTIGATION and INQUEST On the 15 March 2021 | concluded an inquest into the death of Lee David Marsden who died on 20 December 2019. | reached the following conclusion: Road Traffic Collision CIRCUMSTANCES OF DEATH The deceased was seen accessing an area between junctions 2 and 3 of the M66 motorway on foot at 20:04 hours on 20 December 2019, The North West Motorway Police Group (NWMP6G) notified Highways England of the sighting via electronic interface at 20:05:28 hours. As a result of this communication, Highways England set advisory speed limits of 60 mph between junctions 2 and 3 at 20:08:01 hours. Two further reports of sightings were made, one of which (at 20:10 hours) was by an off-duty police officer who asked that consideration be given to imposing a speed-limit of 30mph at junction 3. NWMPG updated Highways England of these reports using the prefix 06/8126 to indicate that one of the informants was a police officer. The significance of the prefix 06/8126 was not appreciated by Highways England. The evidence was that had Highways England appreciated that the informant was a police officer, the speed limit would have been set at 30mph between junctions 2 and 3 with a target time for implementation of 2 minutes. This would have meant that the 30 mph speed limit would have been in place by 20:12:58 hours. At 20:16 hours, the Deceased was struck by a vehicle in the third land of the northbound carriageway. His body was projected into the southbound carriageway where other vehicles collided with him. He sustained fatal injuries and his life was pronounced extinct at the scene. At 20:22:17 hours, almost six minutes after the impact, an advisory speed limit was set on both carriageways by Highways England between junctions 2 and 3. Evidence from the Forensic Collision Investigator was that had the speed limit of 30mph been in place, the Deceased would have had a greater chance of avoiding the impact. CORONER’S CONCERNS SURONER'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:- 1. There was a delay in activating the warning signals to reduce the speed of traffic travelling along the M66 motorway between junctions 2 and 3 to 30mph, . The efficacy of communication between Highways England and North West Motorway Police Group in that there was a failure to appreciate the significance of the prefix numbers 06/8126 . No internal review of the circumstances of this fatal accident has been undertaken by Highways England with the consequent loss of an opportunity for learning ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe each of you respectively have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely 21 May 2021. I, the Assistant 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 | have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely:- The family of Lee David Marsden | am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both ina complete or redacted or summary from. 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. Signed) WA
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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS RESPONSE IS BEING SENT TO: 1. The Assistant Coroner for the Coroner area of Manchester North, Matthew Cox of Newgate House, Newgate, Rochdale OL16 1AT in response to a ‘Regulation 28 Report to Prevent Future Deaths’ following an inquest hearing into the death of Lee David Marsden that concluded on 15 March 2021. 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 was a delay in activating the warning signals to reduce the speed of traffic travelling along the M66 motorway between junctions 2 and 3 to 30mph. b. The efficacy of communication between Highways England and North West Motorway Police Group in that there was a failure to appreciate the significance of the prefix numbers 06/8126. c. No internal review of the circumstances of this fatal accident has been undertaken by Highways England with the consequent loss of an opportunity for learning. 3 DETAILS OF ACTION TAKEN a. Activating warning signals Please see paragraph 5a. below. b. Prefix numbers 06/8126 Prior to the incident on 20 December 2019, Highways England Regional Operations Centre staff were not aware of the significance and meaning of the prefix numbers transferred from the North West Motorway Police Group (NWMPG) incident logging system via an automatic, electronic interface which allows the log to be edited and confidential information redacted prior to being transferred, into the Highways England Incident Management System. In this case, ‘06’ is the police force identifier for Greater Manchester Police, and ‘8126’ is the police officer’s ‘collar’ number. The prefix numbers were included within the electronic transfer of information from the NWMPG to the Highways England incident log however, the textual description did not state that the information had come from a (off-duty) police officer. If it had, the information could have been treated as an approved ‘trusted’ source confirming the presence of a pedestrian on the motorway. In discussions with the NWMPG it has been agreed that the use of prefix numbers as numerical identifiers in such circumstances could lead to relevant information not being considered, and could lead to a delay in confirming the presence of a pedestrian on the Strategic Road Network and the signing of a further reduced advisory speed limit in accordance with our company policy and work instruction. Highways England and the NWMPG have agreed that going forward details relating to the source of information should be clearer and relayed between 1 organisations in a ‘free text’ format as part of the electronic interface of incident logs. Highways England will brief the circumstances of this incident together with the outcome of our review to the North West Regional Operations Centre staff. The (Cheshire, Merseyside, Greater Police Operators within Manchester), as well as Lancashire Constabulary and Cumbria Constabulary will similarly be briefed. This joint approach will cover all the police forces operating within the North West geographic area of the Strategic Road Network. the NWMPG c. Internal review of the circumstances An internal review has been carried out into the Regional Operations Centre handling of the incident in December 2019, as requested by the Coroner. Our review concluded that on the information available to the Operations staff at the time, our staff complied with the company policy and work instructions in place, and the incident was managed appropriately. Highways England Regional Operations Centre staff were not aware that one of the entries on the log originated from a call from an off-duty police officer, or the significance and meaning of prefix numbers electronically transferred to the Highways England incident log from the NWMPG. The Coroner’s Officer brought this point to our attention shortly before the inquest. With that information, we have taken action as explained at paragraph b. above. 4 TIMETABLE FOR ACTION Date Action 01/06/2021 Briefing for the North West Highways England Regional Operations Centre staff and police officers in relation to the use of ‘free text’ entries transferred between organisations within incident logs where appropriate. This briefing will be shared with all Highways England Regional Control Centres as best practice nationally. 5 EXPLANATION AS TO WHY NO ACTION IS PROPOSED a. Activating warning signals Highways England has a national policy and a work instruction in relation to the activation of motorway variable signs and signals. The notification of ‘unconfirmed pedestrian’ on the carriageway initially results in the setting of signs and signals to indicate an advisory 60mph speed limit supported by ‘unconfirmed’ signing, where available. Once the presence of a pedestrian has been confirmed by an approved, trusted source such as a Highways England Traffic Officer or Highways Inspector, or the police, the advisory speed limit is lowered further and supported by ‘confirmed’ signing, where available. We have reviewed our procedure and consider it to be robust and appropriate so no action is proposed. 6 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 will improve safety through enhanced communication. 2 7 18 May 2021 Signed: Regional Director for North West 3
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS RESPONSE IS BEING SENT TO: 1. The Assistant Coroner for the Coroner area of Manchester North, Matthew Cox of Newgate House, Newgate, Rochdale OL16 1AT in response to a ‘Regulation 28 Report to Prevent Future Deaths’ following an inquest hearing into the death of Lee David Marsden that concluded on 15 March 2021. 1 HIGHWAYS ENGLAND I am Superintendent West Motorway Police Group Regional Control Centre. of Cheshire Constabulary, responsible for the North 2 CORONER’S MATTERS OF CONCERN The MATTER OF CONCERN for this report:– The language and manner of communication between Highways England and North West Motorway Police Group in that there was a failure to appreciate the significance of the prefix numbers 06/8126. 3 DETAILS OF ACTION TAKEN Prefix numbers 06/8126 Prior to the incident on 20 December 2019, Highways England Regional Operations Centre staff were not aware of the significance and meaning of the prefix numbers transferred from the North West Motorway Police Group (NWMPG) incident logging system via an automatic, electronic interface into the Highways England Incident Management System. Highways England operate a tiered response to reports of incidents on the network, giving a higher degree of priority to information from a ‘trusted source’ (including police officers) than that received from other sources. In this case, the police operator used ‘06’ the police force identifier for Greater Manchester Police, and ‘8126’ the police officer’s force identification or ‘collar’ number. The prefix numbers were included within the electronic transfer of information to the Highways England incident log however, the textual description did not state that the information had come from a (off-duty) police officer. The Highways England operator has not recognised this as information from a ‘trusted’ source. Highways England has a national policy and a work instruction in relation to the activation of motorway variable signs and signals. The notification of the carriageway initially results in the setting of signs and signals to indicate an ‘unconfirmed’ signing, where advisory 60mph speed available. Once the presence of a pedestrian has been confirmed by an approved, trusted source such as a Highways England Traffic Officer or Highways Inspector, or the police, the advisory speed limit is lowered further and supported by ‘confirmed’ signing, where available. ‘unconfirmed pedestrian’ on limit supported by Highways England and the NWMPG have agreed that going forward details relating to the source of information will be clearer and a free text description will be added to the log to identify the source of information in clear language. Police operators and supervisors within NWMPG will be briefed to add this plain language to logs. 4 TIMETABLE FOR ACTION 1 Date Action 25/05/2021 Briefing note for North West Motorway Police Group staff circulated advising of the need to use ‘plain language’ when identifying Police or other Emergency services employees who are referred to on a log corroborating an incident report. 6 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 will improve safety through enhanced communication. 7 25 May 2021 Signed: Superintendent. 2
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