Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0229, 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 | 2022-0229 |
| Deceased | Stephen Coombes |
| 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 General Manager Kier Highways Lid 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 7th September 2021 I commenced an investigation into the tragic death of Stephen John COOMBES The investigation concluded at the end of the inquest on 22nd July 2022. The conclusion of the inquest was that:- Stephen 'John' Coombes died on the 3rd September 2021, at the Addenbrookes Hospital, in Cambridge. John had been admitted to the Addenbrookes Hospital on the 29th August 2021 following a single vehicle road traffic collision on the A1101, Burnt Fen, near Mildenhall in Suffolk. Immediately after the road traffic collision, John was trapped upside down in his vehicle, and initially could not be extracted from it. Due to the position he was in, John's airway was closed, inducing postural asphyxia. The medical cause of death was confirmed as: 1a Complications arising from traumatic and hypoxic-ischaemic brain injury 1 b Head injury in association with postural asphyxia. 4 CIRCUMSTANCES OF THE DEATH Stephen 'John' Coombes died on the 3rd September 2021, at the Addenbrookes Hospital, in Cambridge. John had been admitted to the Addenbrookes Hospital on the 29th August 2021 following a single vehicle road traffic collision on the A 1101, Burnt Fen, near Mildenhall in Suffolk. The convertible Porsche John was driving left the road and came to rest upside down in a ditch. John was originally trapped in the upside-down car pinned to the ground. Attending police officers and ambulance crew were able to release John and extricate him from the vehicle. John was taken to Addenbrookes, but due to the injuries he had received, he continued to deteriorate until he passed away on the 3rd September 2021. Subsequent police investigation identified that a deep depression in the road surface contributed to John losing control of the vehicle he was driving. This depression was known to be present by the Highways authority, and a temporary 30 mph speed limit (instead of the usual 50mph) had been put in place. Inadequate road signage, did not reflect the temporary 30mph limit and John hit the depression at approximately 50mph, his vehicle being forced off the road as a result. Had John known to negotiate the depression at 30 mph, this tragic incident would not have occurred. 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 action is taken. In the circumstances it is my statutory duty to report to you; the MATTERS OF CONCERN as follows. - The court heard that the depression was known to be present by the Highways Authority, and a temporary 30 mph speed limit (instead of the usual 50mph) had been put in place. Evidence was heard from the Forensic Crash Investigation Officer from Suffolk Constabulary, who conducted an investigation into the road traffic collision which caused John's death. This officer told the court, how he and a colleague drove a police vehicle over the depression in the road at various speeds to observe the reaction the vehicle had to damaged road surface. At 30 mph the police vehicle negotiated the depression in the road with relative ease. At 50 mph, the police vehicle reacted significantly when negotiating the depression. At the time of Johns collision, he had just overtaken another vehicle and therefore crossed the depression a slight angle as he returned to his own side of the carriage way. When the police officers replicated this vehicle movement at 50 mph, the police vehicle reacted violently, with one of the rear wheels leaving the surface of the road. The officer driving that vehicle was not prepared to attempt the same manoeuvre at any higher speed due to the risk involved. The police officer then told the court that the attending officers themselves were unaware of 30 mph speed limit on this stretch of road. The officer told the court that the main 50 mph signs, the smaller repeater 50 mph signs and the 50 mph roundels painted on the road surface were all clearly visible on this stretch of road. Prior to the depression the officer saw one temporary 30mph partially obscured in the verge, but assumed it was left over from previous works, as all of the 50mph signs remained in view. Evidence was heard that in the normal course of events, when a temporary reduction in a speed limit is imposed on a stretch of road, any signage indicating a higher speed limit should be covered by either securing a dark bag or sack over the sign, or spray painting ii out. On the basis of the police officers' evidence, that clearly did not occur in this case, and this, coupled to there being only one 30mph temporary sign in place prior to the depression in the road, left road users (and attending police officers) unaware of the reduced speed limit in place. I am therefore concerned that should further identified road defects require a reduction in the speed limit, that any repeat of the provision of inadequate signage and/or a failure obscure higher speed limits may result in further fatalities. 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 ii 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. John'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 ii 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 V Niqel Parslev
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.
RESPONSE BY KIER INTEGRATED SERVICES LIMITED TO THE REGULATION 28 REPORT TO PREVENT FUTURE DEATHS FOLLOWING THE CONCLUSION OF THE INQUEST INTO THE DEATH OF STEPHEN JOHN COOMBES Kier Integrated Services Limited (“Kier”) write in response to the regulation 28 report to prevent future deaths made following the inquest touching upon the death of Stephen John Coombes that took place on 22 July 2022 before Senior Coroner Nigel Parsley. The inquest concluded with a short form conclusion of ‘road traffic accident’. The matters of concern stated within the regulation 28 report included the following: The court heard that the depression was known to be present by the Highways Authority, and a temporary 30 mph speed limit (instead of the usual 50mph) had been put in place. The police officer then told the court that the attending officers themselves were unaware of 30 mph speed limit on this stretch of road. The officer told the court that the main 50 mph signs, the smaller repeater 50 mph signs and the 50 mph roundels painted on the road surface were all clearly visible on this stretch of road. Prior to the depression the officer saw one temporary 30mph partially obscured in the verge, but assumed it was left over from previous works, as all of the 50mph signs remained in view. Evidence was heard that in the normal course of events, when a temporary reduction in a speed limit is imposed on a stretch of road, any signage indicating a higher speed limit should be covered by either securing a dark bag or sack over the sign, or spray painting it out. On the basis of the police officers' evidence, that clearly did not occur in this case, and this, coupled to there being only one 30mph temporary sign in place prior to the depression in the road, left road users (and attending police officers) unaware of the reduced speed limit in place. I am therefore concerned that should further identified road defects require a reduction in the speed limit, that any repeat of the provision of inadequate signage and/or a failure obscure higher speed limits may result in further fatalities. This regulation 28 report issued by the Senior Coroner was addressed to both Suffolk County Council Highways department and Kier. Kier were not previously asked to provide any information to assist the Coroner or invited to attend the inquest as an Interested Person or otherwise, and as such there was limited opportunity for Kier to provide assistance to the Coroner during the course of the coronial proceedings. Kier takes its responsibilities and obligations extremely seriously, has considered the Senior Coroner’s concerns and is responding accordingly. Kier would like to take this opportunity to convey their sincere condolences to the family of Mr Coombes following the tragic incident that occurred on 29 August 2021. By way of background and to assist the Coroner, Kier Integrated Services Limited have been contracted by Suffolk County Council to provide highways maintenance services in Suffolk, to include reactive works, since October 2013. Suffolk County Council instructs Kier to carry out these works, providing the necessary details regarding the location and nature of the works required. Once Kier receives instructions for reactive works these are planned and scheduled using the Works Manager System (“WMS”). WMS is used by Kier to plan, schedule and record the delivery of highways maintenance works. The works orders are then delivered by the works gangs in accordance with the contractual requirements. These works orders can include the imposition of temporary speed limits as part of temporary traffic management measures. It should be noted that the instructions from Suffolk County Council relating to the imposition of temporary speed limits forms only a very small proportion of the total number of reactive works instructions received by Kier relating to the maintenance of the highways in Suffolk. Kier is committed to protecting road users and the workforce in relation to the installation of traffic management by or on behalf of Kier. To this end, Kier has in place a specific traffic management design standard setting out the necessary process, which includes the planning of traffic management checks and maintenance following installation on site the purpose of which is to maintain the safety and integrity of the traffic management measures for the duration of the scheme. The reactive works instructed by Suffolk County Council at Burnt Fen Turnpike involved the design and installation of the temporary traffic management, to include the imposition of a temporary speed limit of 30mph. These works were instructed to be carried out by Kier’s sub-contractor, Highway Assurance Limited, who were assessed as being competent to carry out such work and had demonstrated compliance with Kier’s Traffic Management design standard. The installation of the temporary Traffic Management included the obscuring of the existing pole mounted speed limit signs and the installation of 30mph temporary speed limit signs. Checks of the traffic management measures were carried out on a number of occasions following installation. Since the incident Kier has reviewed its procedures relating to checks and maintenance of traffic management measures at unattended sites in Suffolk. In the event that Kier receives an instruction from Suffolk County Council that includes the imposition of a temporary reduced speed limit the existing speed limit signs are fully covered with an opaque material. In the event that there are roundels displaying the existing speed limit on the road surface these will also be appropriately obscured and/or removed. Checks of installed temporary traffic management measures, to include temporary speed limit signs, are undertaken on a daily basis, to include weekends and bank holidays, at all sites. In the event that an issue is identified with the traffic management measures on site requiring additional or replacement measures these are duly installed. WMS has been updated to continue to ensure that traffic management checks are scheduled from the point of installation. This update of WMS has been underpinned by the implementation of an enhanced procedure, with an associated audit programme, to help ensure that traffic management checks and maintenance, to include signs showing temporary speed limits, are planned, scheduled, allocated and undertaken. All staff responsible for the planning, scheduling and allocation of traffic management works have been trained on and are working to this enhanced procedure. In addition, enhanced guidance has been developed for works gangs carrying out checks of traffic management measures on site, this includes the taking and recording of photographs to show that the measures remain in place. In conjunction with this guidance, toolbox talks on undertaking traffic management checks have been delivered to the work gangs engaged by Kier on the contract with Suffolk County Council. A site investigation and options study of Burnt Fen Turnpike was requested by Suffolk County Council, to review the carriageway conditions and identify proposals for the improvement of the road. This was completed in July 2022 for Suffolk County Council’s consideration.
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