Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0158, written 17 May 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 May 2021 |
|---|---|
| Reference | 2021-0158 |
| Deceased | Lynne Lawrence |
| Coroner | Caroline Saunders |
| Coroner area | Gwent |
| Category | Road (Highways Safety) related deaths · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. (cid:9) Chief Executive, Blaenau Gwent County Borough Council 1 CORONER I am Caroline Saunders, Senior Coroner for the Area of Gwent CORONER'S LEGAL POWERS 2 3 1 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 13/10/20 an investigation was opened into the death of Lynne Pamela LAWRENCE The investigation concluded at the end of the inquest on: 23/4/21 The conclusion of the inquest was recorded as: Death By Accident The medical cause of death was: 1a) Subdural haemorrhage 2 Atrial fibrillation 4 CIRCUMSTANCES OF THE DEATH On 21St September 2020, Mrs Lynne Lawrence tripped on the pavement on her way home from Brynmawr. She was taken to hospital where the head injury she sustained was not initially diagnosed on scan but became evident after Lynne collapsed 2 days later. She had suffered an intracerebral haemorrhage made worse by the effects of warfarin which she took for atrial fibrillation. The bleed was catastrophic and Lynne Lawrence died at 15:54 on 23/9/20 in the Intensive Care Unit of the Royal Gwent Hospital in Newport. 5 CORONER'S CONCERNS During the course of the inquest, 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. (cid:9) Condition of Pavement on At the time of her fall, Mrs Lawrence was walking along a narrow pedestrian pavement near Alma Street, Brynmawr, Newport, NP23. The video footage available to me at the inquest demonstrated that the pavement was uneven. Whilst I could not conclude that it was the unevenness of the pavement that caused Mrs Lawrence to fall, nonetheless I consider that this is a factor which could people's lives at risk in the future, especially the elderly with reduced mobility. 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. I should be grateful if the following information be provided to me: 1. (cid:9) Confirm whether any steps have or will betaken to address the quality of the pavement. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely I, the Coroner, may extend this 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 necessary 8 COPIES AND PUBLICATION I have sent a copy of my report to the Chief Coroner and the following Interested Person (s) The family of Lynne Pamela Lawrence 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 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 17/5/21 Signed Caroline Saunders Her Majesty's Senior Coroner for the Area of Gwent.
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.
Date 6th July 2021
Caroline Saunders
Senior Coroner for Gwent
Gwent Coroner Services
The Civic Centre
Godfrey Road
Newport
NP20 4RU
Dear Ms Saunders
Blaenau Gwent County Borough Council
Central Depot
Barleyfield Ind. Est.
Brynmawr
NP23 4YF
Re: Response to Senior Coroners Report – Lynne Pamela Lawrence 17th May 2021
I write in response to a Regulation 28 report provided by Caroline Saunders – Senior Coroner
for the area of Gwent following an investigation that was opened on the 13th October 2020 into
the death of Lynne Pamela Lawrence.
During the course of the inquest, evidence revealed matters giving rise to concern in relation to
the footway condition outside
conclude the unevenness of the pavement caused the fall it is considered to be a factor which
could put people’s lives at risk.
Alma Street, Brynmawr and although the Coroner could not
Blaenau Gwent County Borough Council - Highway Authority have investigated this matter and
considered the Coroners opinion and I would advise as follows: -
“As a Highway Authority the council has a duty to meet the requirements of the following
legislation: The Highway Act 1980: this places a duty upon Highway Authorities to
maintain highways, maintainable at public expense, and to keep them safe for public
use”.
To assist authorities in meeting their duties National Guidance is provided and the methods
adopted are based upon the contents of the following “Well-Managed Highway Infrastructure: A
Code of Practice (CoP), UK Roads Liaison Group, 2016”. The Code is designed to promote the
adoption of an integrated asset management approach to highway infrastructure based on the
establishment of local levels through risk-based assessment. The Authority has developed their
own levels of service based on the above Code, along with adopting the County Surveyors
Cont.;
Society Wales (CSSW) principles (adopted 2018) as identified within the Blaenau Gwent
Highways Maintenance Plan (HMP), therefore provides guidance to when developing the
council’s approach in accordance with local needs, priorities and affordability.
The Highway Authority deploys Highway Inspector’s to undertake a regime of inspections to
monitor the condition and repair needs of the public highway, they have received and passed
accredited training programmes for specific competency in highway inspections to allow them to
assess the condition of the public highway.
Details of asset hierarchy, inspection and repair regimes are adopted by the Council and
implemented. For the purpose of managing maintenance Councils allocate a hierarchy level to
each road and footway to establish inspection frequencies and repair regimes. The most
significant factor affecting the risk presented to users is the level of use. As no footfall data is
available in many situations across the council, officer judgement is used to estimate footfall for
different footways in order to apply the CSSW principles.
From a nationally consistent approach the following table gives an indication of the principles
adopted by CSSW, as follows;
Code of Practice
Footway Network Hierarchy Category
CSSW Footway Hierarchy
Footfall Level
(indicative)
City Centre Pedestrian Area
FHVHU
> 10,000 (15,000 used for
Town Centre Pedestrian Area
Footway Outside Public Facilities
FH1
FH2
Link Footway (between estates / areas) FH3
Housing Estate Footway
Little Used Rural Footway
FH4
FH5
calculations)
5,000 - 10,000
1,000 - 5,000
500 - 1,000
< 500
< 100
Cont.;
The footway outside
footfall and inspected on a 6 monthly basis, the purpose of inspections are to identify defects
that have the potential to cause harm to users and to identify defects that require repair in order
to prevent escalation of deterioration and increased (avoidable) maintenance needs.
Alma Street, Brynmawr (Lower Alma Street) is considered to have a low
Defect types identified and the intervention levels that are prescribed for each defect category
in the footway is a guidance and minimum standards created by considering risk to users, see
below;
Safety Defects Table
Asset
Type
Defect Type
Hierarchy
Dimensional Criteria
CSSW National Minimum Standard
Depth/Height
Extent Depth/Hieght
Extent
Carriageways
Footways
Kerbing
Pothole
Pothole
Pothole
Crack or Gap
Trip
Rocking Slabs
Dislodged,
Loose, Missing,
Damaged -
Causing a trip
hazard
CHSR,
CH1 and
CH2
CH3, CH4
and CH5**
All
All
All
All
> 50mm
>50mm
> 25mm
> 25mm
> 25mm
Any
Size
Any
Size
Any
Size
Any
Size
Any
Size
> 50mm
>75mm
> 40mm
> 40mm
> 40mm
Maximum horizontal
dimension greater
than 150mm
Maximum horizontal
dimension greater
than 150mm
Maximum horizontal
dimension greater
than 75mm
Maximum horizontal
dimension greater
than 75mm
Maximum horizontal
dimension greater
than 75mm
> 30mm
N/A
> 40mm
N/A
All
> 25mm
N/A
> 40mm
N/A
Cont.;
Blaenau Gwent County Borough Council has chosen to exceed the CSSW national minimum
standards for safety and maintenance defects intervention as shown in the Safety Defects
table above. A method has been developed under CSSW’s Highways Asset Management Plan
(HAMP) project designed to allow all authorities to adopt the risk-based approach
recommended by the new code of practice (CoP).
Highway Inspections prior to the accident in July 2020 and post accident in January 2021 have
not identified defects approaching this standard >25mm. A further assessment on receipt of the
Regulation 28 report has been undertaken and although the footway reconstruction has raised
paving <16mm (photo’s attached) they are not at a standard that the Highway Authority would
intervene or consider a risk to the highway user and as such there are no proposals for BGCBC
Highway Authority to take remedial works actions at this location.
Blaenau Gwent CBC is fully commited to the national inspection regime and the importance of it
when it comes to preventing accidents across the highways infrastructure.
Head of Service
Environment & Community Services
Blaenau Gwent County Borough Council
CC
– Chief Executive BGCBC
Photo’s taken immediately outside number
Alma Stree Brynmawr 4th June 2021
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