Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0035, 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 | 2022-0035 |
| Deceased | Stephen Cloudsdale |
| Coroner | Craig Smith |
| Coroner area | Cumbria |
| Category | Road (Highways Safety) related deaths · 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.
KALLY CHEEMA SENIOR CORONER County of Cumbria Fairfield Station Rd Cockermouth, CA13 9PT REGULATION 28: REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. National Highways (formerly Highways England) of Bridge House, 1 Walnut Tree Close, Guildford, GU1 4LZ. 2. Cumbria County Council of Cumbria House, 117 Botchergate, Carlisle, CA1 1RD CORONER I am Craig Smith, Assistant Coroner for the coroner area of Cumbria. CORONER’S LEGAL POWERS I make this report pursuant to 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 19 November 2019 an investigation was commenced into the death of Stephen Cloudsdale (61 years). The investigation concluded at the end of the inquest on 27 January 2022. The conclusion of the inquest was that Mr Cloudsdale died as a result of a Road Traffic Collision; the medical cause of death being severe head injuries. CIRCUMSTANCES OF THE DEATH At approximately 5:30am on 11 November 2019, Stephen Cloudsdale had been travelling in the eastbound dual carriageway of the A66 at Stainmore in Cumbria. At the time, Mr Cloudsdale was travelling to his place of work in North Yorkshire, having set off from his home address in Millom. He was familiar with the road and with the controls and handling of his vehicle (a Ford Fiesta) which he had owned for approximately two years. At the time of the incident, it was dark, and it was raining heavily. As Mr Cloudsdale approached the Stainmore Café, which is set back from the dual carriageway to the left, he moved into the second lane of the dual carriageway in order to initiate an overtake of a vehicle travelling in the first lane. He was utilising his car’s dipped beams at this time, and it is estimated that he was travelling at a maximum speed of 75 mph. As Mr Cloudsdale approached the area of the central reservation connecting the east and westbound dual carriageways, he collided with the rear offside corner of an LGV which was positioned in the central reservation waiting to turn right onto the westbound carriageway. The rear offside corner of the LGV encroached into lane 2 of the eastbound carriageway by approximately 1 metre. Mr Cloudsdale sustained non-survivable traumatic head injuries as a result of the collision and death was diagnosed at the scene at 5:50am. The LGV had been parked overnight in the carpark of the Stainmore Café and the driver had set out to enter the westbound lane to begin his working day. The café is frequently used by LGV drivers, and the central reservation will be used by the drivers of such vehicles upon exiting the carpark in order to enter the westbound carriageway. The café does not remain open 24 hours a day and the premises are unlit after the daily close of business. The inquest heard from a police officer who had prepared a collision investigation report and who had carried out a reconstruction of the incident utilising the LGV and a Ford Fiesta to simulate the positions of the vehicles at the time of the collision. The reconstruction was conducted during the hours of darkness to replicate the visibility conditions as far as possible. It was determined from the evidence heard that: • there is no lighting on the stretch of dual carriageway where the collision occurred; • the national speed limit (70mph) applies to this stretch of carriageway; • there does not appear to be sufficient or any signage warning of the dangers of large vehicles crossing the eastbound dual carriageway; • visibility would have been further hampered by the adverse weather conditions at the time of the collision; • Mr Cloudsdale had been travelling at a maximum speed of 75mph at the time of the collision; • the hazard lights/reflectors on the side of the LGV would have been visible to Mr Cloudsdale from a distance of 223.7 metres; • at a distance of 223.7 metres, the hazard lights could easily be mistaken for lights in the opposing carriageway and that the outline of the LGV could not be seen at that distance when dipped beams were employed; • the LGV would have become clearly visible to Mr Cloudsdale at 32.1 metres when dipped beams were employed; • travelling at 75mph, Mr Cloudsdale would have had 0.96 seconds in which to take evasive action to avoid a collision; • research suggests that most drivers will respond to a hazard in 1.5 to 2.0 seconds; • the collision occurred when Mr Cloudsdale’s vehicle struck the rear offside corner of the LGV which encroached into Mr Cloudsdale’s lane by approximately 1 metre. 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: 1) The lack of lighting near to or at the point of the A66 dual carriageway where the collision occurred which renders the presence of vehicles crossing the carriageway from the café difficult to see by approaching drivers during the hours of darkness and/or during adverse weather conditions. 2) The lack of appropriately positioned signage, warning approaching drivers of the possibility of vehicles crossing the carriageway from the café. 3) The speed of traffic on this stretch of the A66. 4) The sufficiency of the width of the central reservation to accommodate large vehicles fully without the danger of encroaching into either of the opposing carriageways. ACTIONS SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and I believe you AND/OR your organisation has the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report. 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 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons, Mr Cloudsdale’s family, the insurers of the LGV driver, and the Chief Constable of Cumbria Constabulary. 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. SIGNED BY THE CORONER DATE – 3 February 2022
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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS RESPONSE IS BEING SENT TO: 1. The Assistant Coroner for the coroner area of Cumbria, Craig Smith of Fairfield, Station Street, Cockermouth, Cumbria CA13 9PT in response to a ‘Regulation 28 Report to Prevent Future Deaths’ following an inquest hearing into the death of Stephen Cloudsdale that concluded on 27 January 2022. 1 NATIONAL HIGHWAYS I am Alan Shepherd, Regional Director for the North West, National Highways Limited of Piccadilly Gate, Store Street, Manchester M1 2WD. 2 CORONER’S MATTERS OF CONCERN The MATTERS OF CONCERN are as follows:– a. The lack of lighting near to or at the point of the A66 dual carriageway where the collision occurred which renders the presence of vehicles crossing the carriageway from the café difficult to see by approaching drivers during the hours of darkness and/or during adverse weather conditions. b. The lack of appropriately positioned signage, warning approaching drivers of the possibility of vehicles crossing the carriageway from the café. c. The speed of the traffic on this stretch of the A66. d. The sufficiency of the width of the central reservation to accommodate large vehicles fully without the danger of encroaching into either of the opposing carriageways. 3 DETAILS OF ACTION TAKEN a. Lighting We have confirmed that the rural sections of the A66 trunk road, including the area around the Stainmore Café Services do not have road lighting installed, and have never been lit. This is not uncommon as 70% of the Strategic Road Network in England is unlit, and there is no statutory requirement for highway authorities to provide road lighting. b. Signage National Highways is already in the process of promoting a focused improvement scheme in the immediate area of Stainmore Café Services which includes upgraded traffic signs and associated road markings. The scheme includes interactive electronic, vehicle activated signs that warn approaching drivers of both the junctions and vehicles turning. The scheme is on course to deliver the improvements by the end of October 2022. c. Speed of the traffic Observations and spot speed surveys have confirmed that a small proportion of drivers, generally of smaller vehicles, drive at speeds above the national speed limit of 70mph for cars and 60mph for larger goods vehicles in place on the road. d. Width of central reservation We have undertaken specific observations at the site looking at the turning movements of large vehicles exiting the café, crossing the eastbound carriageway to proceed in a westerly direction. In accordance with the Design Manual for Roads and Bridges CD123 Geometric design of at-grade priority and signal-controlled junctions, the central reserve 1 is 14m wide at the crossing points and the vast majority of large articulated vehicles up to 16.5m long are positioned within the marked extents of the central reserve when turning right from the café car park to travel west. It was observed that larger vehicles, up to 18m in length are having more difficulty waiting fully within the protected extents of the central reserve whilst acceptable gaps in west bound traffic materialise. 4 DETAILS OF FURTHER ACTION PROPOSED b. Signage An improvement scheme to install local direction signs, vehicle operated ‘junction ahead’ and ‘turning vehicle’ signs on both approaches to the site, together with solar powered road studs and improved carriageway markings, is programmed for construction during October 2022. Please find attached a copy of the design drawing for the proposed signing improvement works. c. Speed of the traffic The proposed improvements in the immediate area of the café are expected to have a positive impact on general vehicle speeds along the approaches to the service area. It is for drivers to comply with the speed limit in place on the road and the enforcement of the speed limit is a matter for the police. d. Width of central reservation National Highways are currently progressing a major projects improvement scheme along the A66 Northern Trans Pennine route. Whilst these works do not include the section of the A66 at Stainmore, we are looking to secure funding for a wider study that would include Cumbria County Council and North Yorkshire County Council, to help in identifying potential mitigations and opportunities that may benefit residents, communities and drivers who would be impacted by the construction of the Trans Pennine scheme. Identifying potential opportunities for upgrading facilities will be included in the scope of the wider study. 5 TIMETABLE FOR ACTION DATE ACTION April 2022 26 Sep to 14 Oct 2022 A66 Stainmore resurfacing 17 Oct to 28 Oct 2022 Stainmore Services Sign / markings improvement scheme A66 Stainmore enabling works 6 EXPLANATION AS TO WHY NO ACTION IS PROPOSED a. Lighting Having assessed the site, we have concluded that road lighting cannot be justified along this section of the A66 trunk road when applying the requirements of the Design Manual for Roads and Bridges Road Lighting Appraisal guidance TA 501 (formerly TA 49/07). This is based upon the whole life costs of installation, maintenance and power over a 30-year period, offset against the potential benefits in terms of collision savings and therefore no action is proposed. It is also counterproductive to light short sections of an otherwise unlit carriageway as drivers eyesight reacts and adjusts to changes in lighting levels. c. Speed of the traffic We believe that the current speed limit in place is appropriate for this type of road. The 2 proposed advanced warning signs (outlined at section 4b above), indicating the presence of the junctions, entrances and turning vehicles at the café site should have a beneficial impact on vehicle approach speeds. d. Width of central reservation General widening of the central reserve area is not feasible as it would require the realignment of a considerable length of the mainline carriageway, to both the east and west of the café site. This being further complicated by the varying vertical levels of the adjacent agricultural land to the south. We believe that the proposed electronic, interactive signing will increase driver awareness of the operation of the junction and the café exit and specifically the presence of turning vehicles crossing the central reserve. 7 SAFETY OF ROAD USERS The safety of our road users is an imperative for our business in what we set out to achieve, and a core value of our organisation. We are working hard to make our entire network safer, and consider that the action we have taken to date and plan to take could help to prevent future deaths at this location. 8 28 March 2022 Signed: Regional Director for North West 3
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