Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0028, written 3 Feb 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Feb 2022 |
|---|---|
| Reference | 2022-0028 |
| Deceased | Harry Simmons |
| Coroner | Deborah Archer |
| Coroner area | Plymouth, Torbay and South Devon |
| 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.
OFFICIAL
ANNEX A
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS
BEING SENT TO:
The Head of Plymouth Highways,
Plymouth City Council,
Plymouth,
PL1 3BJ
1 CORONER
I am Deborah Archer, Assistant Coroner, for the coroner’s area of Plymouth,
Torbay and South Devon.
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 18th September 2020 I commenced an investigation into the death of Harry
Edward Simmons age 87. The investigation concluded at the end of the inquest
on 20th January 2021. The conclusion of the inquest was as accident, and the
medical cause of death was 1a) Traumatic intracerebral haemorrhage with burst
lobe and II) Complications of bilateral lower limb fractures in an elderly man.
4 CIRCUMSTANCES OF THE DEATH
Mr Simmons was walking along the footpath on Beacon Hill Road, Plymouth PL2
3 LU and had got as far as crossing with the junction on Montpellier Road when a
driver of a red Astra Motor vehicle came from the direction of Beacon Hill Road,
turned right into Montpellier Road and struck Mr Simmons whilst he crossed
Montpellier Road. The driver had cut the corner of the junction and instead of
making a right hand turn into the left-hand side of Montpellier Road he had
crossed into Montpellier Road by turning in on the incorrect right-hand side of the
junction. As he did so he hit Mr Simmons who was ½ way across the road by the
time the collision happened.
As the driver struck Mr Simmons he fell to the floor and became trapped under
the front wheel of the car. Mr Simmons died of his injuries later in hospital. The
driver was prosecuted in the Magistrates court, and it was revealed during the
police investigation that there was no defect in the car, the driver provided a
negative breath test and also passed the eyesight test at the scene. The driver
accepted that he had not seen Mr Simmons and he was driving the car on a
bright sunny morning with his sun visor down, the driver was not speeding or
otherwise in a hurry.
1
OFFICIAL
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. –
(1) Acting Police Inspector
gave evidence to the inquest as follows:
1. In his opinion as Mr Simmons was at least ½ way across the road if the
driver had not turned into the junction on the incorrect side of the road, he
would have most likely avoided him
2. The sun is a particular hazard at that junction and would have had an
effect on the ability of the driver to see Mr Simmons.
3. Double yellow lines in his opinion would not prevent a further accident of
this nature.
4. A pedestrian refuge in the centre of the road on the junction of Montpellier
Road and Beacon Park Road together with a keep left sign would prevent
vehicles cutting the corner and causing a similar accident again.
5. There have been 3 collisions on this junction in the last 5 years, 2 of
which have cited the sun as a contributory factor.
6. There is local knowledge to suggest that drivers cutting this corner is a
commonplace occurrence as the sharp turn right to the correct side of the
road is a more difficult manoeuvre to make.
6 ACTION SHOULD BE TAKEN
In my opinion you should review the road safety measures at this junction and
action should be taken to prevent future deaths and I believe you and 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 Thursday 31st March 2022. 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.
2
OFFICIAL
8 COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following
Interested Persons:
Acting Police Inspector
find it useful or of interest.
of the Devon and Cornwall Constabulary who may
. I have also sent it to
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
Thursday 3rd February 2022
[Deborah Archer, Assistant Coroner]
3
File ref - c:\users\jedwa\documents\jec highway consultants - work pc backup\jec consulting\jechcltd-hp\pcc\pl00030_beacon park rd-montpelier rd_ped safety scheme\autocad\wip\pl00030_beacon park rd-montpelier rd_ped safety scheme_inset plan a_pl00030_02_rev
p01.dwg
0
100
ã
New f lat top road hump
i n c o r p o r a t i n g e x i s t i n g
2.4m wide Zebra crossing.
Existing round top road
hump to be removed.
LC
Beacon Park Road
DISABLED
DISABLED
Co-op Food
Store
Proposed short stay
parking bays.
Langstone Road
New uncontrolled
crossing.
Existing granite sets to
be removed and road
surface reinstated.
Road narrowed
to 6.0m wide.
N
d
a
o
R
r
e
i
l
e
p
t
n
o
M
Notes:
1.
I l l us t r a t iv e d es i g n b a s ed o n O r d n a nc e
Survey mapping, historical topographical
survey and chain survey.
2. Design to be confirmed following consultation.
All dimensions are in metres unless otherwise
3.
stated.
4. Surface water drainage works to be confirmed.
5. S e e d r a w i n g s , n o s . P L 0 0 0 3 0 - 0 1 a n d
PL00030-03 further proposed works details.
Legend:
New 'Manchester' type bollard.
Take up and re-lay existing granite kerbs
(kerb face varies)
Road resurfacing.
Existing granite sets to be removed and
road surface reinstated.
New flexible footway surfacing.
New buff blister tactile paving (to
uncontrolled crossing).
New road markings.
New double yellow lines
New f lat top road hump and
existing 2.4m wide zebra
crossing.
V ehicle swept path ( 16. 5m long
articulated lorry).
FOR COMMENT
P01 Initial issue
Rev
Revision details
JEC JEC 21/03/22
Chkd Appd
Date
Drawn:
Design:
Chkd:
Appd:
Date:
JEC
JEC
JEC
JEC
21/03/22
Preliminary
For comment
For tender
For construction
As constructed
Other
Prince Rock Depot | Macadam Road | Plymouth | PL4 0RZ
Public Helpdesk 01752 668000
Project Name
BEACON PARK ROAD /
MONTPELIER RD JUNCTION -
PEDESTRIAN SAFETY SCHEME
Drawing Title
ILLUSTRATIVE DESIGN
INSET PLAN A
Original Drawing Size :
Scale :
1:250 @ A3
A3
Dimensions :
m
Drawing No
PL00030 - 02
Rev
P01
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.
From: Sent: 12 August 2022 10:53 To: Subject: RE: Death of Harry Edward Simmons (ref: 5144012) OFFICIAL Dear HM Coroner’s Office, I apologise for the delay in responding to you on this matter. The City Council have undertaken a study into the circumstances leading to the collision and have commissioned a scheme design to deal with the identified highway issues involved. I attach a copy of the draft design which is not yet in the public domain. The scheme elements are as follows 1. Provision of a Humped Zebra Crossing to slow traffic down on the approach to the Montpellier Rd junction from the west. * 2. Narrowing of the junction bell mouth and provision of a formal pedestrian crossing facility 3. Introduction of Parking Restrictions at the junction to improve inter-visibility for all road users. * The scheme is estimated to cost in the region of £70,000 and I am currently bidding for funding to enable construction to go ahead. * Introduction of both road humps and waiting restrictions is subject to a statutory consultation process which cannot be predetermined. Conditional on the availability of a budget and the results of the public consultation I would hope to construct the scheme later in the current financial year or early in 2022/23. If you have any queries regarding the above please do not hesitate to contact me. Yours sincerely Senior Traffic Engineer Plymouth Highways Plymouth City Council Prince Rock Depot Plymouth PL4 0RZ
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