Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0295, written 8 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 | 8 Jun 2022 |
|---|---|
| Reference | 2022-0295 |
| Deceased | Paul Morris and Alison Morris |
| Coroner | Hugh Bricknell |
| Coroner area | Herefordshire |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
H G Mark Bricknell
Senior Coroner
for County of Herefordshire
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
, Chief Executive, Herefordshire Council and
, Contract Director, Balfour Beatty Living Places
1
CORONER
I am Hugh Gregory Mark Bricknell, Senior Coroner for County of Herefordshire.
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/ukpga/2009/25/schedule/5/paragraph/7
http ://www.legislation .gov.uk/uksi/2013/1629/part/7/made
3
INVESTIGATION and INQUEST
On the 13th day of September 20211 commenced an investigation into the deaths of Paul Haydn MORRIS
and Alison Margaret MORRIS. The investigation concluded at the end of the inquest on the 25th day of
May 2022. The conclusion of the inquests were Road Traffic Collision.
4
CIRCUMSTANCES OF THE DEATH
Mr and Mrs Morris died together with their family dog following a Road Traffic Collision on the A44 at
Crooked Well, Kington, Herefordshire. They were on holiday and followed a recognised footpath which
crossed the A44. The inquest heard from (inter alia) a Collision Investigator of the West Mercia Police
who confirmed:
a) The curve of the road and foliage restricted the view to a maximum of 78 metres in the relevant
direction.
b) There were no advance warning signs for motorists approaching from the Leominster direction
of the footpath which crosses the A44 at this location.
c) Calculations show the oncoming vehicle was travelling at or below the speed limit for the area .
d) The pedestrians likely left the safety of the pavement at around the same time the oncoming
vehicle would have come into view.
e)
In only a few seconds both motorist and pedestrians would be required to react and consider
what action to take.
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) The point where the footpath crosses the A44 provides limited visibility to both pedestrians and
motorists
(2) You may care to give consideration to
(i) the prevailing foliage
(ii) the position of the safety barriers for both the pedestrian and the motorist
(iii) the position or nature of the crossing
(iv) the speed of traffic at this point on the A44
(v) the level of signage
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
3rd 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, the
Chief Constable of West Mercia Police.
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
8th June 2022
Signaturfl fV\./VV
HG Mar~ry{I, HM Senior cl/oner: Herefordshire
.
2 responses 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.
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Balfour Beatty O Council
• Herefordshire
Working for Herefordshire
Thorn Depot
Unit 3, Thom Business Par!<
Rotherwas, Hereford
Herefordshire
HR2 6JT
H G Mark Bricknell
H.M. Senior Coroner Herefordshire
Town Hall
St Owen Street
Hereford
HR1 2PJ
26 July 2022
Dear Mr HG Mark Bricknell ,
Inquest into the deaths of Alison Margaret Morris and Paul Haydn Morris
Your ref: MB/NP/ab/4523/21 & MB/NP/ab/4524/21
Thank you for proving us with your Regulation 28 report raising your concerns following the tragic deaths of
Mr and Mrs Morris whilst crossing the A44 at Kington.
As you know, Balfour Beatty Living Places Limited (BBLP) are contracted by Herefordshire Council to
provide public realm services in accordance with the terms of the Highways Maintenance Plan (HMP) .
The HMP sets out a risk-based approach and refers to the location of the accident in terms of the USRN
which is unique reference number. The location of the accident is not an accident cluster site and did
therefore not fall into any special remit for inspections and maintenance and was inspected in line with the
HMP.
The Site History Report (SHR) shows the area is subject to a statutory monthly driven inspection which was
carried out prior to the accident on 1 September 2021 and no actionable defects were raised. By way of
clarification , in a driven inspection there are two individuals in the vehicle, one acts as driver and one
inspecting in order to pick up actionable defects and looking for damaged sign age or damaged trees in
accordance with the list set out in page 24/25 of the HMP.
The SHR also indicates that the public right of way footpath located at the accident locus was inspected
prior to the accident on the 17 March 2021 and no action or defects were found .
As you note there is a safety barrier located at the crossing point to prevent pedestrians from walking
straight out into the A44.
Under the contract, verges were subject to two planned cuts per year, the last prior to the accident being on
27/28 August 2021 .
Further in accordance with the contract, the trees in the stretch leading up to the area were not subject to
any proactive survey and therefore were only cut back when there was a request to do so or if they were
Balfour Beatty Living Places Limited , registered in England and Wales no. 02067112 ,
registered office. The Curve , 2nd Floor, Axis Business Park, Langley , Berks SL3 8AG
an agent of Balfour Beatty Group Limited, registered no. 101073, registered office. 130
Wilton Road. London SW1V 1 LQ
Page 2
noted to be affecting visibility during the driven inspection . There had been no reports of any visibility issues
in the 12 months in the area prior to the accident.
The verges and tree foliage were cut back following the accident at the request of West Mercia Police
following their accident investigation.
The signage erected in the area predates the BBLP contract and had remained unchanged since BBLP
commenced the public realm contract.
We have been consulting with Herefordshire Council subsequent to the accident and can report the
following in relation to the concerns raised:
In relation to the prevailing foliage , Herefordshire Council have visited the site and now requested
improvements to the sight lines. The Council have now instructed BBLP to remove vegetation from the
wall, cut back trees and the verges on both side of the road, so as to increase sight lines to 160 metres.
The order is at quotation stage . Cyclical grass cutting will take place in May and August each year.
Herefordshire Council have confirmed to BBLP that it does not have any concerns in relation to the
pedestrian of vehicle restraint system (VRS) barriers, but has commissioned BBLP to carry out bi-annual
clearance around the VRS barrier. The Council have further confirmed that the position and nature of the
pedestrian crossing will not require altering .
BBLP have been informed that Herefordshire Council have commissioned a Traffic Regulation Order
review of the speed limit at the site, with a view to the speed limit being reduced to 50mph . The review will
also consider appropriate signage at the site. The Council have reported that it is hoped that this review
will be completed within 9 months and although BBLP will play no part in the review, it will of course carry
out any further works as instructed by the Council with a view to preventing further accidents.
Yours sincerely
Contract Director
Balfour Beatty Living Places
Mr M Bricknell Coroner’s Office Town Hall St Owen Street Hereford HR1 2PJ Dear Mark, Your Ref: Our Ref: Please ask for: Direct line / Extension: Fax: E-mail: Chief Executive 1 August 2022 Inquest into the deaths of Alison Margaret Morris and Paul Haydn Morris Thank you for providing us with your Regulation 28 report raising your concerns following the tragic deaths of Mr and Mrs Morris whilst crossing the A44 at Kington. I am writing to you in the capacity of the Chief Executive Officer for Herefordshire Council, the Highway Authority for the A44 Kington Bypass. I am responding to your concerns as outlined in Section 5 of your Regulation 28 report, namely: “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 section 5 (1) the Coroner notes the matter of concern as: “The point where the footpath crosses the A44 provides limited visibility to both pedestrians and motorists.” The Coroner further states that the Council may wish to give consideration to the following: I. The prevailing foliage; II. The position of the safety barriers for both the pedestrian and the motorist; III. The position or nature of the crossing; IV. The speed of the traffic at this point on the A44; V. The level of signage. I will address each point in turn. Herefordshire Council, Plough Lane, HR4 0LE www.herefordshire.gov.uk | facebook: hfdscouncil | twitter: @hfdscouncil The A44 Kington bypass was designed as an all-purpose single carriageway road and was opened in 1982. At the time that the road was constructed the design allowed for a forward visibility of 160m, this being the acceptable minimum within the design standards at that time. In accordance with the Road Safety Policy contained within the current Local Transport Plan, and in line with Section 39 of the Road Traffic Act 1988 together with historic national best practice guidance, Herefordshire Council undertakes an annual review of all recorded personal injury collisions on roads within the County. In line with the agreed criteria, these sites are subject to investigation and, where appropriate, additional measures may be introduced to improve road safety in line with available resources. Locations where such works have been carried out are subject to an ongoing enhanced inspection and maintenance regime, in addition to the monthly driven safety inspection policy, as detailed within the current Highways Maintenance Plan and the Public Realm Annual Plan. The location in question has not previously been identified as having a defined history of collisions from the above approach and has therefore not been subject to any form of enhanced maintenance regime. Following the collision, works were immediately undertaken to remove foliage and to improve the forward visibility at the location, this work taking place after the joint inspection by the Police and the Council’s lead road safety officer. An instruction has subsequently been issued to Balfour Beatty Living Places for the reinstatement of visibility splays along the length of the bypass; it is anticipated that this additional work will be complete before the end of September 2022. This piece of work will improve the visibility for pedestrians and motorists alike. Moving to the individual points within the Regulation 28 report: i) The issue of prevailing foliage is addressed above. In addition, the Council will add the Kington Bypass to its list of sites that require an enhanced maintenance regime. On top of regular monthly maintenance inspections for the A44, the whole site will have specific quarterly safety inspections that will include the side road and the footpath. The locality steward responsible for the inspections will be made aware of the requirements needed to ensure safety at this location. The regime will also ensure that the forward visibility along the bypass is maintained as per the original design requirements, taking into account the prevailing speed limit in force. ii) The safety barrier, in the form of pedestrian guardrail, was installed to prevent pedestrians moving from the river bridge directly onto the bypass. It has the effect of halting pedestrians and encouraging them to check for traffic prior to crossing the road. There are no plans to move or alter the position or layout of the pedestrian guardrail as it is considered adequate to prevent inadvertent entry onto the bypass. The police are aware of this and have not raised any objections. iii) The crossing point is a historic one and pre-dates the construction of the bypass. The line of the path is a public right of way, reference Kington Urban Footpath 29. The line of the path is complicated by the presence of a footbridge over the adjacent Gilwern Brook. The path is popular locally and provides ready access to the Offa’s Dyke. There are no plans at this time to either move the line of the footpath or to provide a footbridge over the A44. The presence of the pedestrian guardrail is considered to offer adequate protection and is standard practice for numerous situations where public rights of way cross a highway in the county. iv) The A44 is currently subject to the National Speed Limit, i.e. 60mph for a single carriageway road. The Council is soon to consult on the lowering of the speed limit to 50mph, the lowest speed limit that is considered appropriate for this class of road and its nature, i.e. a road with minimal access points and good overall visibility. The Council will not be seeking to lower the speed limit further in the vicinity of the collision as speed limits are not set for point locations but rather for the overall look and feel of the network over a section of road. It is anticipated that this will take up to nine months to complete in order to allow for consultation and the statutory processes for making the necessary traffic regulation orders. v) It is noted that warning signs for pedestrians crossing exist only on the eastbound approach. A review of the location, using Google Maps StreetView, shows that this has been the case since at least 2009. That said, the Council will be reviewing signing and lining along the length of the bypass and will implement any improvements prior to March 2023. While this review will ultimately determine the details of the proposals, it is likely to at least include pedestrian warning signs on each approach to the three existing locations where public rights of way cross the bypass. The extended period for implementation is required to ensure that any proposed design complies with the requirements of the Traffic Signs Regulations and General Directions 2016, and that there is sufficient time to make any relevant orders. Should you have any further queries or questions then please do not hesitate to contact me. Yours sincerely CHIEF EXECUTIVE
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