Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0168, written 9 Jun 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Jun 2022 |
|---|---|
| Reference | 2022-0168 |
| Deceased | Jennifer Dyer |
| Coroner | James Healy-Pratt |
| Coroner area | East Sussex |
| 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.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 , Chief Executive of East Sussex County Council 1 CORONER I am James HEALY-PRATT, Assistant Coroner for the coroner area of East 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 INQUEST On 01 April 2021 I commenced an investigation into the death of Jennifer Ann DYER aged 36. The investigation concluded at the end of the inquest on 12 May 2022. The conclusion of the inquest was that: This young lady and mother lost her life due to a collision between her bicycle and a van. That collision was solely and proximately caused by a defective pothole, 58mm deep, in the road surface of the B2188, Cherry, Gardens Hill, Groombridge. Her death was avoidable. 4 CIRCUMSTANCES OF THE DEATH This young woman was catapulted from her bicycle when it hit a pothole, camouflaged by dappled sunlight and tree branch shadows. The pothole was 0.45m by 0.80m at its widest and broadest, and 5.8cm at its deepest point. The pothole evidenced a history of failed repairs since late 2019, with numerous concerns being raised about the continuing danger that it posed to road users, especially motorbikes and bicycles. The Sussex Police Forensic Reconstruction Report FC1/012/21 concluded that it was highly likely that the collision was as a result of the defect to the road, and the pothole specifically. 5 CORONER’S CONCERNS During the course of the investigation my inquiries 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: (brief summary of matters of concern) Under the East Sussex Highway Asset Inspection Manual, this pothole fell within the definition of Cat 3 - LOW for risk and remedial works. The definition is “Greater than 40mm and less than 59mm deep and at least 300mm in all directions”. Clearly, this pothole was the proximate cause of the death of a young woman, and the categorisation of potholes in East Sussex requires significant review, to prevent future avoidable deaths within the County. 6 ACTION SHOULD BE TAKEN Regulation 28 – After Inquest Document Template Updated 30/07/2021 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 5 August 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons I have also sent it to 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 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 by the Chief Coroner. 9 Dated: 09/06/2022 James HEALY-PRATT Assistant Coroner for East Sussex Regulation 28 – After Inquest Document Template Updated 30/07/2021
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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: James Healy-Pratt, Assistant Coroner, for the coroner area of East Sussex, in response to a Regulation 28 Report to Prevent Future Deaths following an inquest hearing into the death of Jennifer Dyer on 29 March 2021. 1 EAST SUSSEX COUNTY COUNCIL I am County Council, St Anne’s Crescent, Lewes, BN7 1UE , Director of Communities, Economy and Transport, East Sussex 2 CORONER’S MATTERS OF CONCERN The MATTERS OF CONCERN were identified as follows: – Under the East Sussex Highway Asset Inspection Manual, this pothole fell within the definition of Cat 3 - LOW for risk and remedial works. The definition is “Greater than 40mm and less than 59mm deep and at least 300mm in all directions”. Clearly, this pothole was the proximate cause of the death of a young woman, and the categorisation of potholes in East Sussex requires significant review, to prevent future avoidable deaths within the County. 3 Background Information Safety Inspections & Repairs Under section 41 of The Highways Act 1980, it is East Sussex County Council’s (the Council) statutory duty as the highway authority to keep the highway network safe for all highway users. Like most local highway authorities, the Council uses The Well-Managed Highways Infrastructure: A Code of Practice (the Code) to guide maintenance policies and practices in manging the highway network it is responsible for. This recommends a risk- based approach is used for highway infrastructure maintenance and to set levels of service for inspections, responses, resilience, priorities and programmes. Based on the Code and intervention level policies approved by the Councils Lead Member for Transport and Environment, the Councils Highway Asset Inspection Manual sets out how the authority has assessed risk and manages defects on the road network to fulfil its statutory requirements to maintain a safe, serviceable and resilient network. The manual sets out intervention levels based on size and depth of potholes to enable the Council to target limited resources effectively and manage its liabilities. For carriageway potholes they are: Category 1: Greater than 100mm and at least 300mm wide in all directions - Made Safe within 2 hours Category 2: Greater than 60mm and less than 99mm deep and at least 300mm in all directions - Repaired within 5 days Category 3: Greater than 40mm and less than 59mm deep and at least 300mm in all directions - Repaired within 28 days 1 Dedicated Cycleways In addition to the inspection of roads, within the Highways Inspection Manual there is a hierarchy for inspection and repair of specifically recognised cycleways that reflects the differing risks associated with shared, partially segregated and fully segregated cycle routes. 4 Supporting Information Enhanced Risk based approach In May 2021 a revised Highway Inspection Manual introduced an enhanced risk assessment process where the highway inspector can consider other factors, such as the location of a defect and usage, as well as the defect category in determining whether a response is required or a different response time required. This means that, following the risk assessment, they are able to change the category of a defect such as changing a non-intervention defect to an intervention defect or reduce or increase the category response time if deemed appropriate. For example, if a category 3 pothole is located on the part of the carriageway cyclists are likely to use such as the nearside edge, this could be increased to a category 2 or 1 depending on risk assessment. To introduce this change, inspection staff were assessed in line with the UK Roads Liaison Group’s Asset Management Competence Framework and a programme of suitable training was developed to ensure the relevant officers were fully competent in their roles ahead of implementation of this policy. Regular reviews are held with all staff involved with inspections and the risk based approach to ensure it is being applied consistently. Cycleway Hierarchy and Road Maintenance In addition, following changes to the Highway Code introduced earlier this year, the Council have further researched best practice around cycling hierarchy, defect management and prioritisation of cycleway maintenance and road repairs. The Council are currently considering a number of potential actions that could be developed and costed to determine what additions or improvements can be incorporated to the current process. These includes: - Asset plan for cycling that includes a further risk based weighting for prioritisation on roads where cycling is known to be popular - Opportunities for improved public reporting of defects likely to impact cyclists to enhance our own inspections - Consideration of an increased list of defects in investigatory matrix, for example surface with loose gravel, pothole with sharp upstand, poor drainage and standing water that may impact cyclists - Winter maintenance of dedicated cycleways - A joined up approach to cycle route maintenance with organisations outside - ESCC that also manage cycleways Improved cycle route hierarchy; research in collaboration with cycling groups to gain data on most popular cycle routes across the county - Walked or cycled inspections for all dedicated cycleways 5 DETAILS OF ACTION TAKEN Since the tragic incident on 29 March 2021, the Council has introduced an enhanced 2 risk based approach to its safety inspection regimes which allows for a more flexible approach to determining risk for all road users and defect response times. This enables the inspector to change the categorisation of a pothole to include potholes for repair that do not meet the lowest category if required or to change the category of a pothole to a medium or high risk following an onsite risk assessment that now also considers location and road usage in addition to size and depth. Whilst this process was not in place at the time the pothole in this incident was identified and categorised, by introducing this new process, the Council believes that a specific review of the pothole categories is not required. Following the incident, the pothole was repaired the same day and the road was reinspected for other potholes. A separate review is underway to be completed by August to consider the circumstances of this specific case and in particular if there are any lessons to be learnt to further improve the service. 6 DETAILS OF FURTHER ACTION PROPOSED In response to the Coroner raising the above matters of concern, the Council will: - Continue to review the effectiveness of the implemented enhanced risk based approach and in particular review how it would have affected this case - Continue further research and consideration of cycleway hierarchy and cycle route maintenance in line with best practice and neighbouring authorities, including costing and trialling if required of the improvements/additions set out in section 4. 7 SAFETY OF ROAD USERS The Council is committed to improving communication with road users and improving the safety of the roads. The death of Jennifer Dyer is a tragic loss and the Council offer its’ sincere condolences to Ms Dyer’s family. 8 Signed: 02/08/2022 , Director of Communities, Economy and Transport 3
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