Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0121, written 27 Apr 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 27 Apr 2021 |
|---|---|
| Reference | 2021-0121 |
| Deceased | Caitlin Swan |
| Coroner | Stephen Covell |
| Coroner area | Cornwall and Isles of Scilly |
| 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.
Information Classification: CONTROLLED REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. CORMAC, part of Cornwall Council (Highways Department) 1 CORONER I am Mr Stephen Covell one of HM Assistant Coroners in the area of Cornwall and the Isles of Scilly. 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. [ INVESTIGATION and INQUEST 3 On 3 January 2020 HM Assistant Coroner Mr Guy Davies commenced an investigation into the death of Caitlin Ann SWAN. The investigation concluded at the end of the inquest before me on the 17 February 2021. The conclusion of the inquest was Road Traffic Collision. 4 CIRCUMSTANCES OF THE DEATH On 28 December 2019 sometime after 1300 Caitlin was descending Tubbon Hill between Stithians and the junction with the A393 to Ponsanooth on her road bicycle. A vehicle travelling in front of her down the hill was obliged to slow down to walking pace to negotiate an acute turn into Trebost Lane off to the left. Caitlin lost control of her bicycle as she attempted to slow down behind the vehicle, collided with the rear of the vehicle and fell into the path of an oncoming vehicle sustaining catastrophic head and neck injuries. 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 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. – There are no signs on Tubbon Hill to warn road users of the junction with Trebost Lane, notwithstanding that the junction is only visible between 75 and 50 metres away for a road user descending the hill and that any vehicles negotiating the acute left turn into Trebost Lane are likely to be almost stationary in the road at some point. 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. In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action which may include a review of road signage. Information Classification: CONTROLLED 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 26 June 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: 1. 2. 3. Devon and Cornwall Police 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. 9 DATE: 27 April 2021 SIGNED BY CORONER
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.
Information Classification: CONTROLLED Mr Stephen Covell Assistant Coroner H.M. Coroner’s Office Date: 12th May 2021 Dear Mr Covell Regulation 28 Report – Caitlin Ann SWAN (deceased) Thank you for your letter of 28th April 2021 and the accompanying Regulation 28 Report, in connection with the recent inquest into the tragic death of Caitlin Ann Swan. Although I was unable to attend the inquest on the day, I subsequently viewed the recording and have also visited the site of the collision. I have discussed the findings of the inquest and your recommendations with senior officers of Cornwall Council, and am pleased to confirm that they have approved the provision of additional warning signing. Notwithstanding this, I would like to correct a perhaps misleading impression that may have been given at the inquest about such signs. I note that at one point it was suggested that the provision of junction warning signs would be “normal”; this could imply the absence of such a sign is some form of specific omission, of course. I can assure you this is not the case, and the formal guidance on their provision is: “Warning signs…should only be used where there is a specific safety issue or hazard, not to sign readily apparent conditions or routine features of the road, such as bends or junctions. Overuse of warning signs can dilute their effectiveness and tends to bring them into disrepute…care should be taken that a route is treated consistently… “Junction warning signs should be used sparingly where there is a justification. They are not normally provided on very minor rural roads….They may of course be used where a specific need has been identified.” (Traffic Signs Manual Chapter 4, pars.1.6.2 & 2.2.6) In other words, warning signs are not routinely provided at every junction (or any other hazard) but are considered on merit at each site, usually in the context of the route, accident history, speed, visibility and similar factors. I hope that this is helpful in clarifying this matter for future reference. In the case of the Trebost junction at Tubbon Hill, the junction is marked with a direction sign, turning movements are infrequent, approach speeds are fairly well constrained by the nature of the road, Form CSL_DES_LTP Version 2.0 Last Reviewed 29/01/2021 A Cornwall Council Company Registered in England No. 07737430 Registered Office Cormac Head Office, Higher Trenant Road, Wadebridge, Cornwall, PL27 6TW www.cormacltd.co.uk Information Classification: CONTROLLED forward visibility in the context of speed is fairly good, and no other collisions – of any type – had been recorded in the previous twenty years. The absence of a junction warning sign was therefore not unusual in this situation. I would emphasize however, that in view of the awful collision at the end of 2019, and its particular circumstances, Cornwall Council has no hesitation in accepting your recommendation in this instance, and additional signing will be erected as soon as reasonably practicable. Yours sincerely Project Manager (Safety) Engineering Design Group
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