Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0252, written 21 Jul 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Jul 2021 |
|---|---|
| Reference | 2021-0252 |
| Deceased | Oscar Seaman |
| Coroner | Yvonne Blake |
| Coroner area | Norfolk |
| Category | Road (Highways Safety) related deaths · Child Death (from 2015) |
| 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 . REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: Chief Executive Officer, Norfolk County Council County Hall, Martineau Lane, Norwich NR1 2DH 1. CORONER I am Yvonne BLAKE, Area Coroner for the area of Norfolk 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 INQUEST On 18/09/2020 I commenced an investigation into the death of Oscar Anthony SEAMAN aged 17. The investigation concluded at the end of the inquest on 19/07/2021. The medical cause of death was: 1a) 1b) 1c) 2 Multiple Traumatic Injuries Road Traffic Collision The conclusion of the inquest was: Road Traffic Collision. 4. CIRCUMSTANCES OF THE DEATH Oscar Seaman was returning home on his bicycle. It was after 8:30pm. He approached the main A134 carriageway from a crossroads junction at Northwold. According to witness evidence he went onto the main carriageway without pause and was struck by a 4x4 vehicle causing his death. There is no definite evidence of the driver’s speed. Oliver was declared dead at the scene. 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 could occur unless action is taken. In the circumstances, it is my statutory duty to report to you. The matters of concern are as follows: I am informed that the road where Oscar was killed is the scene of at least 126 road traffic collisions. The speed limit was reduced from 60mph to 50mph, but this has not deterred people using the road from ignoring the limits. The crossroads where Oscar, who was just 17 years old, emerged onto the main road has give way signs but not stop signs painted on it. The view from one direction appears to be reasonable in daylight but at night, and if the weather is inclement, visibility is reduced. The person who lives on the corner of that junction has had to buttress his garden fence against collisions. The parish council has reported many concerns about people speeding on the road especially HGV lorries as well as cars. It is apparent that people regularly break the law on this stretch of road and that a speed camera or average speed cameras would address the problem and slow motorists down. A mirror would be able to be placed at the junction, an inexpensive but important item which is likely to reduce death and accident when people venture onto the main highway. 6. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or 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 15 September 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: (Oscar’s mother and father) I have also sent it to: Northwold Parish Council Department of Transport, London Child Death Overview Panel, Norfolk County Council , Coroner’s Society who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. 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. 9. Dated: 21 July 2021 Yvonne BLAKE Area Coroner for Norfolk Norfolk Coroner Service County Hall Martineau Lane Norwich NR1 2DH
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.
Community and Environmental Services
County Hall
Martineau Lane
Norwich
NR1 2DH
via e-mail
Yvonne Blake
Area Coroner for Norfolk
Norfolk Coroner Service
County Hall
Norwich, NR1 2DH
Your Ref: Reg 28 Report
Date:
27 August 2021
Dear Ms Blake,
Firstly, may I take this opportunity to express sincere and heartfelt condolences to Oscar’s
family and friends; this certainly is a tragic and awful incident.
Thank you for your report concluding your investigation into the death of Mr Seaman. The
Council’s specialist Network Safety Engineers have considered your observations in detail,
and our responses are recorded below.
Firstly, it is beneficial for Norfolk County Council (NCC) as Highway Authority to attend
inquests where a fatality has occurred on the highway where there may be an implication
for the Council. This enables officers to help explain the Council’s policies with regard to
road safety and highway engineering, and provides an opportunity to discuss any such
matters with all interested persons. I am advised that unfortunately the Council were not
invited to the inquest and therefore were unable to contribute to this important element of
your investigation.
Taking each point in turn:
You report that the road where the incident occurred is the scene of at least 126 traffic
collisions. Highway authorities (including NCC) do not analyse collision only data; this is
because collisions are generally not reported in a consistent manner to the police and
therefore cannot be accurately relied upon when prioritising road safety interventions.
Rather, highway authorities only analyse personal injury accident data from the police in
order to identify where the greatest casualty reduction benefits can be achieved.
Continued…/
Continuation sheet to: Yvonne Blake
Dated : 27 August 2021
-2-
In terms of this junction, the ten-year personal injury accident data identifies eight injury
accidents (five related to the southwest arm of the junction, two related to the northeast
arm of the junction, and one single accident at the junction).
There have been a number of highway safety interventions introduced to include: red
centre hatch treatment, provision of bend warning chevron boards which better reflect the
alignment of the bend to the southeast, sign relocations, provision of hedges to control
visibility, provision of ‘Slow’ markings on the carriageway, cutting back of other vegetation,
and addition of side road triggers to the existing junction warning vehicle activated signs.
In addition to the above interventions, the speed limit was reduced to 50mph in response
to this incident. In light of your comments concerning vehicle speeds, it is agreed that
NCC will undertake speed surveys to measure driver compliance.
With regard to the provision of “STOP” road markings and signs, such measures are
restricted to those locations where visibility of a junction is severely impaired whereby
highways users are reminded to stop and giveway to traffic before proceeding ensuring it
is safe to do so. This has been investigated previously in accordance with national
guidance contained within the Traffic Signs Manual (Chapter 3), and neither junction met
the requirements for the introduction of “STOP” markings and signs. This is particularly so
for the southeast arm, where existing visibility is well above the minimum requirements
even for a 60mph speed limit. However, a further review will be undertaken to reassess
the visibility approaching the A134 from the northeast arm of the junction.
Your report mentions that the provision of a speed camera or an average speed camera
system would help with speed limit compliance. Highway Authorities are required to follow
Department for Transport (DfT) guidance when considering whether speed camera
provisions are required to improve road safety. DfT circular 01/2007 recommends that
only those sites with three recorded injury accidents within 36month period could be
considered where excessive speed was a factor. This is not the case at A134 Northwold.
I acknowledge your observation concerning the provision of a mirror at the junction. I
regret that the installation of mirrors is not authorised or recommended by the County
Council. This is because mirrors can dazzle highway users and can affect driver’s ability
to judge the distance of on-coming traffic.
I trust the above information is useful and I would be happy to clarify any further points you
have in this regard.
Yours sincerely
Head of Paid Service
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