Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0193, written 4 Jun 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Jun 2021 |
|---|---|
| Reference | 2021-0193 |
| Deceased | Pathushan Sutharsan |
| Coroner | Penelope Schofield |
| Coroner area | West Sussex |
| Category | Road (Highways Safety) related deaths · Community health care · Other 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Chief Executive
West Sussex County Council
County Hall
Chichester
West Sussex
PO19 1DN
1
CORONER
I am PENELOPE SCHOFIELD, Senior Coroner, for the coroner area of WEST SUSSEX
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.
3
INVESTIGATION and INQU EST
On 24th September 2020 I commenced an investigation into the death of Pathushan
Sutharsan which concluded at the end of the inquest on 27th May 2021
At the end of the Inquest I concluded “Pathushan died as a result of an accident.”
Following the Inquest, I indicated that I was minded to make a Regulation 28 report
setting out my concerns surrounding the circumstances of Pathushan’s death.
4
CIRCUMSTANCES OF THE DEATH
On 22nd July 2020 Pathushan was taking part in a charity cycle ride on the Downs link
in West Sussex. He was cycling on the stretch from Cranleigh towards Southwater when
he went down a steep slope along the track that approached the junction with the A281.
As he got close to the A281 it appears that he braked but lost control of his bike
(probably caused by the gravel surface on the track). This caused him to fall from his
bike with a forward momentum pushing him out into the road directly into the path of a
Heavy Goods Vehicle being driven along the A281.
There is no physical barrier in place and the signage in the lead up to the junction at the
time to warn users on the Downs link of the immediacy of a major A-road was
inadequate.
Following Pathushan’s death a post mortem examination was carried out and this
showed the cause of death was due to 1a Blunt head injury.
1
5
CORONER’S CONCERNS
During 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. –
Whilst it was accepted that West Sussex County Council had, following Pathushan’s
death, made significant improvements to the junction between the Downs link and the
A281 evidence was heard from a number of different organisations (speaking on behalf
of all the different users of the Downs link) that the junction in question still posed a
substantial risk for cyclists, pedestrians and equestrians alike.
This junction is the only part of the Downs Link that crosses a major A-road where there
is no alternative safe crossing, a Pegasus crossing or bridge. Evidence was heard that
there is no pavement running alongside the A281 and therefore this causes poor sight
lines for horse riders and, in some circumstances, cyclists who have to put their horse’s
head or part of their bike out onto the road before they can see oncoming traffic.
It is understood that WSCC has identified a need to address the issues at this junction
and has undertaken (or is about to undertake a feasibility study) but it appears that at
this stage there are no definitive plans in place to take this forward. Therefore the
significant risk to the users of this junction remains.
The Downs link is actively promoted as a recreational activity by West Sussex County
Council.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe your
organisation have the power to take such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 24th August 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
8
I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons: -
and family
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.
Date 4th June 2021
9
Penelope Schofield, Senior Coroner
2
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.
West Sussex County Council response to the Regulation 28: Report to Prevent Future Deaths Relating to the inquest into the death of Pathushan Sutharsan Following the receipt of the covering letter and Regulation 28: Report to Prevent Future Deaths issued by Penelope Schofield, Senior Coroner for West Sussex, dated 7th June 2020 ( with the comments and actions detailed below. ), the County Council would like to respond Following the police notification of the fatal collision involving Mr Sutharsan the authority began its own now well-established investigation procedure. Based on the information available at the time a number of remedial measures were implemented to mitigate the occurrence of a similar incident involving cyclists travelling on the Downs Link. The measures were detailed in our report to the coroner dated the 7th December 2020. In summary these works consisted of: • Forming a chicane at the bottom of the downhill approach to the A281, compelling users to slow down as they enter the obstacle and to prevent a fast approach on to the junction with the A281 • Permanent, conspicuous signs have been installed down the slope and on the chicane with varying messages warning of the main road ahead • Traffic signs on the A281 warning motorists of the crossing point have been standardised in both directions. The new warning signs show warnings for equestrians, pedal cyclists and include a ‘Pedestrian Crossing’ plate. • Vegetation has been cleared back to improve visibility at the crossing point. It is considered that the combined above works will mitigate the risk of a similar collision to that of Mr Sutharsan occurring in the future at this location. With regard to the Matters of Concern raised: A feasibility study looking into ways to improve the crossing point is currently being undertaken by the authority’s term consultant, WSP. An options appraisal report will be completed by October 2021. The study is primarily focused on, but not limited to, the options for a bridge or traffic light controlled road crossing. If the report determines that there are appropriate, technically feasible solutions, the preferred option will be progressed through the WSCC’s capital governance procedures, either as a project to be taken forward in the Local Transport Investment Programme or as a major scheme. In either case a full business case will be developed, and the scheme assessed against the County Council’s objectives and priorities for potential inclusion in a future capital programme. Following consultation with the BHS, and in addition to those measures mentioned above, we have recently altered the height of the Speed terminal signs so that they do not block the site line for equestrians. Further planned improvements for this summer are enhanced red surfacing to further highlight the crossing to drivers and additional hedge cutting to further improve the visibility for people crossing the road. Regards, Chief Executive West Sussex County Council County Hall Chichester PO19 1RQ
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