Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0088, written 21 Mar 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Mar 2022 |
|---|---|
| Reference | 2022-0088 |
| Deceased | Zoltan Torok |
| Coroner | Ian Wade QC |
| Coroner area | Berkshire |
| 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.
Reading Town Hall Blagrave Street Reading Berkshire RG1 1QH DX 40124 Reading Castle Street REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. HIGHWAYS ENGLAND 1 CORONER I am Ian Wade QC, Assistant Coroner for the area of Berkshire 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. http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 17th May 2021 I commenced an investigation into the death of Zoltan TOROK, aged 42. The investigation concluded at the end of the inquest on 18th March 2022. The conclusion of the inquest was that Zoltan died on the 7th May 2021 on the M4 motorway, Junction 5 towards Junction 6, Slough Berkshire from multiple injuries in a Road Traffic Collision. 4 CIRCUMSTANCES OF THE DEATH On 7th May 2021 at about 3pm Zoltan was driving his Honda motorcycle at a lawful speed westbound on the M4 motorway in the inner slow lane, along a part of the highway under construction and adaptation to be converted to a smart motorway, and which therefore had no hard shoulder/safety lane to his nearside, when he came upon a Land Rover Discovery motorcar which had suffered an unexpected and inexplicable mechanical defect rendering it not possible for it to proceed to a refuge but compelling it to come to a stop and remain broken down in the same westbound inner lane, just short of the exit sliproad at Junction 6. The driver and passenger of the Land Rover 1 were able to leave the vehicle and find safety beyond the roadside barrier but their presence standing by the side of the motorway momentarily distracted Zoltan’s attention from the road ahead and he rode into the rear of the stationary Land Rover without decreasing his speed, causing catastrophic multiple injuries from which he died in the highway. 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 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) On the date of the death the particular section of the M4 motorway was not completed as a smart motorway, but was substantially in course of conversion such that to all intents and purposes it had the intended characteristics of a smart motorway, specifically that there was no run-off lane or safety lane or hard shoulder, but all lanes were running lanes. The edge of the near side of the inner lane was a solid continuous concrete wall. The inquest heard evidence from the police collision investigator that the collision would not have occurred if the broken down Land Rover had been able to pull out of the running lane into a refuge or onto a traditional hard shoulder. (2) The hazard created for moving traffic by the obstruction of the stranded vehicle was compounded by the unexpected proximity of the occupants from the stranded vehicle standing immediately next to the running lane, albeit on the safe side of the barrier, which is likely to have been distracting to drivers moving at a typical and lawful motorway speed, and on the evidence was a distraction to the deceased. (3) In addition the court heard evidence from an experienced qualified mechanical engineer, fellow of the Institute of Mechanical Engineers, with over 40 years of professional engagement in the motor industry, that the policy of mixing smart motorways with traditional hard shoulder motorways created a latent risk that road users will become accustomed to treating the left or inner lane of motorways as a live running lane even when it remains a conventional hard shoulder, thereby endangering road users who have to pull off the road onto the hard shoulder. (4) The essential purpose of a motorway as a multi-lane high speed direct communication between locations likely to be long distances apart is both undermined, and has a tendency to potentiate risks to road users, if the running lanes are liable suddenly and unexpectedly to become blocked in a dynamic situation, with no refuge available to the stranded vehicle. 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. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 16th May 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 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the deceased. I have also sent it to Sergeant Valley Police Serious Collision Investigation Unit who may find it useful or of interest. of the Thames the wife of 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 Ian Wade QC Assistant Coroner for Berkshire 21st March 2022 3
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.
Our ref: Your ref: GC/RC/NM/Mr Zoltan Torok 00803-2021 Mr Ian Wade QC Assistant Coroner for Berkshire Reading Town Hall Blagrave Street Reading Berkshire RG1 1QH RE: Death of Zoltan TOROK Dear Sir, Director Smart Motorways Programme National Highways 5th Floor 2 Colmore Square Birmingham B4 6BN 27th June 2022 I write further to your letter dated 11 May 2022 seeking our further response to your concerns with regard to the removal of the hard shoulder, which is a feature of all lane running (ALR) smart motorways. As you recognise in your response, the section of the M4 within which Mr Torok met his tragic death was not at the time operating as a smart motorway (and so did not have the features of a completed section of an ALR smart motorway), but instead had temporary traffic management arrangements in place, necessary for completing roadworks safely and consistent with those found in sections of roadworks across the whole of the Strategic Road Network in England. As you will appreciate, we were not involved in the inquest, but from what we know about the tragic incident, we do not believe we should have taken or need to take any additional actions in response and your understanding of National Highway’s position is correct. We note from your response that you are interested to understand more about the safe operation of ALR smart motorways. Should it assist, we have provided some additional information below about the features of a completed section of an ALR smart motorway. Where the hard shoulder has been converted to a traffic lane, there is a system of inter- related features, working together to help reduce congestion and help keep drivers moving safely. This includes: variable speed limits to help keep traffic moving and reduce stop-start traffic clearly signed and orange-coloured emergency areas set back from the road and with telephones linking directly to our control rooms detection systems to monitor traffic for changes in flows 1 CCTV cameras that our operators are able to move and zoom to monitor and manage congestion and incidents, where notified. The system has the ability to see 100% of the carriageway signs and signals to provide better information to drivers which can alert drivers to hazards ahead and display Red X signs to close lanes to other traffic when a stopped vehicle is identified enforcement cameras to deter the minority who break speed limits and ignore Red X signs To further enhance safety, we are also rolling out a relatively new technology, a radar- based stopped vehicle detection (SVD) system, on ALR sections of smart motorway which will allow us to detect stopped vehicles. We have committed that by the end of September 2022 SVD will be in place on every operational all lane running smart motorway and no new ALR schemes will open without it. This technology does not exist on other high-speed roads. On ALR sections, it adds to the system of inter-related features to further reduce the risks associated with live lane stops. The SVD system identifies a stopped vehicle and provides an alert to our regional control room. At the same time, it automatically sets a message sign to warn of a report of obstruction, whilst the alert is verified by an operator. This enables us to respond more quickly through the setting of Red X signals to close lanes (with associated messages, to warn approaching traffic), adjusting speed limits, and deploying traffic officers. In addition, you may not be aware that a significant amount of changes have been made, and continue to be made, to smart motorways. It is now two years since the Transport Secretary published the Smart Motorway Stocktake and Action Plan1, which set out the Government's 18 point action plan to further improve safety on smart motorways. Last year we published the smart motorways Stocktake first year progress report2 detailing our progress in delivering those actions. In September 2021, the Office of Rail and Road (ORR) published an independent review on the available safety evidence for smart motorways. This review found no errors in our underlying calculations, and that the comparisons about the relative safety of ALR motorways were made in an appropriate way. Over the past year, the Transport Select Committee (TSC) completed an inquiry and published its report into the ‘Rollout and safety of smart motorways’. In response to that report, the Government agreed to all the TSC’s recommendations. We welcomed the TSC’s scrutiny and we are fully committed to playing our part in taking forward all the recommendations. These included pausing the roll out of new ALR smart motorways until five years of safety and economic data is available for schemes opened before 2020. 1 https://www.gov.uk/government/speeches/strategic-roads-update-smart-motorways-evidence-stocktake 2 https://nationalhighways.co.uk/media/bb4lpkcp/smart-motorways-stocktake-first-year-progress-report-2021.pdf 2 On 12 May 2022 we published our Smart motorways stocktake second year progress report3. It set out our continued progress since 2021 and the latest safety data for 2016 to 2020. It also sets out our additional commitments to further enhance the safety of, and further improve public confidence in, smart motorways following the 2021 TSC inquiry. For the latest analysis presented in our May report, we used an extended range of metrics to understand road safety across road types. This followed a safety evidence review carried out by the Office of Rail and Road in 2021, and is because robust and transparent safety data, along with the delivery of our actions, is critical in further increasing safety and confidence in our roads. To gain further confidence in the safety conclusions of this report, we worked closely with ORR, who undertook additional independent assurance for the supporting analysis in March 2022. The latest data shows that, overall, in terms of serious or fatal casualties, smart motorways are our safest roads. We are continuing our work to make them our safest roads in every way. We are doing this by making further improvements across our smart motorway network and delivering the actions committed to in the 2020 Action Plan. Over the past year we have made the following further improvements across our smart motorway network. As of February 2022, we have: worked to put SVD technology in place on over 100 miles of ALR motorway installed more than 330 additional signs so that drivers will almost always be able to see a sign informing them of the distance to the next place to stop in an emergency upgraded 96% (92) of enforcement cameras on smart motorways so they can be used, and enforced by the police, to detect vehicles passing under a Red X or entering a lane beyond a Red X we have also provided more information to drivers aimed at increasing awareness of how to drive on motorways. The update to The Highway Code, the launch of the ‘Driving on motorways’ hub4 and our road safety campaigns have reached drivers up and down the country to provide a better understanding, and help increase their confidence, when travelling on all roads. It remains too early to quantify the effect of all the actions we have delivered. But we will continue to monitor and evaluate the safety of our network over the coming years and in so doing expect those effects, plus any other actions that we take, to be reflected. Despite good progress, we are not complacent, and we continue to put safety first to further increase drivers’ confidence in the motorway network. By the end of September 2022, we will have: 3 https://nationalhighways.co.uk/media/uivj2zem/smart-motorways-stocktake-second-year-2022.pdf 4 https://nationalhighways.co.uk/road-safety/driving-on-motorways/ 3 completed the roll-out of SVD on more than 200 miles (in total) of ALR motorway meaning stopped vehicle detection is in place on every existing ALR smart motorway completed the installation of extra signs, so drivers will almost always be able to see a sign informing them of the distance to the next place to stop in an emergency completed the upgrade of all enforcement cameras to enable them to be used, and enforced by the police, to detect vehicles passing under a Red X or entering a lane beyond a Red X. This will further increase the safety of drivers, their passengers, road workers and emergency services In addition to all of the above, working with Government we have committed to make further changes to ALR smart motorways. This includes delivering a £390 million programme to install additional emergency areas across operational sections. Our smart motorways stocktake second year progress report details all the work we are doing to continue to make enhancements to our smart motorway network. We believe that our actions are having an effect and will continue to make a positive difference to people’s journeys. The risk of an accident on a motorway compared to other roads remains low, but we want to make this figure as close to zero as possible. We are determined to do all we can to help drivers feel safe and be safer on all our roads, and I would like to assure you that safety is at the forefront of every decision we make and we are committed to the safety of everyone who uses our roads. Every road death is a tragedy and our deepest sympathies remain with the family of Mr Torok. Yours sincerely Director – Smart Motorways Programme Email: 4
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