Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0226, written 25 Jul 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Jul 2022 |
|---|---|
| Reference | 2022-0226 |
| Deceased | Ethan Wright |
| Coroner | Nigel Parsley |
| Coroner area | Suffolk |
| 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 (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Asset, Policy and Commissioning Manager, Suffolk Highways, 3 Goddard Road, Ipswich, IP1 SNP 1 CORONER I am Nigel Parsley, Senior Coroner, for the coroner area of Suffolk. 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 22,d November 2021 I commenced an investigation into the tragic death of Ethan Jake WRIGHT The investigation concluded at the end of the inquest on 21 st July 2022. The conclusion of the inquest was that:- Ethan Wright, a 16-year-old boy, died from the serious head injuries he suffered when the bicycle he was riding collided with a van, on the 17th November 2021 in Lowestoft, Suffolk. Despite undergoing emergency surgery, Ethan's injuries were not survivable, and he passed away the following day on the 18th November 2021 The medical cause of death was confirmed as: 1a Severe Traumatic Brain Injury 1 b Road Traffic Collision 4 CIRCUMSTANCES OF THE DEATH Ethan Wright died at the Addenbrookes Hospital, Cambridge in Cambridgeshire on the 18th November 2021. Ethan had been admitted to the Addenbrookes Hospital on the 17th November 2021 following a collision between the bicycle he was riding and a van. The collision occurred in Higher Drive, Lowestoft in Suffolk at approximately 10: 10am on the 17th November 2021. Ethan rode from a public bridle way (Woods Loke West) onto Higher Drive, where his bicycle hit the front nearside of the van, his head then hitting the near side A-pillar between the windscreen and passenger door. Ethan sustained serious injuries to his head and was subsequently airlifted to Addenbrookes hospital, where despite surgical intervention he tragically succumbed to his iniuries the follow dav. 5 CORONER'S CONCERNS During the course of the inquest the evidence revealed matters given rise to concern. In my opinion there is a risk that future deaths could occur unless actlon is taken. ln the circumstances it is my statutory duty to report to you; the MATTERS OF CONCERN as follows. In evidence it was heard that the public bridleway, Woods Lake West, is predominantly used by pedestrians and cyclists. As part of the police investigation, photographs were provided that showed the area where Woods Lake West joins Higher Drive. Woods Lake West joins Higher Drive at approximately a 90-degree angle and vehicle access to the Lake is prevented buy two concrete bollards. These bollards are placed wide enough apart as to not cause a hinderance to either cyclists or pedestrians. When cycling from Woods Lake West onto Higher Drive, the view afforded of Higher Drive is severely restricted by fencing, and it is only once a cyclist or pedestrian is on the pavement of Higher Drive itself, are they afforded any view of the main road to their right. This is the direction of travel of the van with which Ethan collided. The police officer who investigated Ethan's tragic death, stated in evidence that there was no physical barrier, or any other measure in place, that would make a cyclist or fast-moving pedestrian slow down before entering Higher Drive. The police officer was particularly concerned about children using the Lake as a cycle path, as these young riders have a much lower perception of risk. The officer was of the opinion that some physical means of preventing direct access onto Higher Drive from Woods Lake West, or some other measure to ensure a cyclist or fast-moving pedestrian slowed down on approaching Higher Drive, would prevent a further tragedy at this location. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken in order to prevent future deaths, and I believe you or your organisation have the power to take any such action you identify. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 19th September 2022 I, the Senior Coroner, may extend the period if I consider it reasonable to do so. 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;- 1. Ethan's next of kin. I am 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 Senior Coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 25th Julv 2022 \ /7 ./ /V (--:,,/ NiQel Parsley
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.
Julie Leacock From: Sent: To: Subject: Dear Julie, 14 September 2022 15:34 Julie Leacock RE: Inquest Touching the Death of Ethan Jake WRIGHT ... Suffolk County Council response to the Regulation 28 Report to Prevent Future Deaths concerning the death of Ethan Jake WRIGHT I said the county council would send a further response to the Regulation 28 Report. The matter of concern raised at the inquest and reported in the Regulation 28 report, was that there was no physical barrier, or any other measure in place, that would make a cyclist or fast moving pedestrian slow down before entering Higher Drive. In response to this matter, the County Council proposes to take the following action: Install an illuminated 'STOP' sign onto the existing post at the end of the public bridleway • • Paint a white stop line on the surface of the tarmac on the east side of the existing concrete bollards • Paint the word STOP on the surface of the tarmac on the west side of the existing concrete bollards • Paint the existing concrete bollards with yellow and black paint The Council also considered the installation of a physical barrier and concluded that it would not be possible, as there is not enough space to faci litate a staggered barrier system that would allow all users such as those with mobility scooters and cyclists with pull-alongs. The width is also constrained by the presence of an underground high voltage cable and other services within and at the edge of the bridleway. The timescale for this work is 15 weeks from the date of this email. Yours sincerely, Rights of Way and Access Manager Growth, Highways and Infrastructure Directorate Suffolk County Council 3, Goddard Road Ipswich Suffolk IP1 5NP Sent: 09 August 2022 13:37 To: Julie Leacock <Julie.Leacock@suffolk.gov.uk> 1
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