Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0396, written 8 Dec 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 Dec 2022 |
|---|---|
| Reference | 2022-0396 |
| Deceased | Mervyn Holbrook |
| Coroner | Adam Hodson |
| Coroner area | Birmingham and Solihull |
| 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.
1 2 3 4 5 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Infrastructure, Birmingham City Council CORONER Assistant Director of Highways and I am Mr Adam Hodson, Assistant Coroner for Birmingham and Solihull 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. INVESTIGATION and INQUEST On 4 July 2022 I commenced an investigation into the death of Mervyn Charles Gladstone Leonard HOLBROOK. The investigation concluded at the end of the inquest on 8 December 2022. The conclusion of the inquest was: Road traffic collision CIRCUMSTANCES OF THE DEATH At 14:30 on 16/06/2022, Mr Holbrook was knocked off his mobility scooter and was run over at the junction of Livingstone Road and the A435 Alcester Road. He had been travelling Southbound along the footpath and left the pedestrian walkway at the mouth of the junction (where the kerb had been worn down) and entered the carriageway at the same time as Nissan Qashqai tried to navigate and turn left onto the Alcester Road from Livingstone Road. He suffered catastrophic thoracic injuries, and despite life-saving treatment by emergency services, he could not be saved and was pronounced deceased at the scene at 14:57. Following a post mortem the medical cause of death was determined to be: 1a RIB FRACTURES WITH FLAIL SEGMENT 1b ROAD TRAFFIC COLLISION 1c ISCHAEMIC HEART DISEASE WITH CARDIOMEGALY II 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. I heard and considered evidence from West Midlands Police's Forensic Collision Unit which confirmed that where the footpath outside 214 Alcester Road South reaches the junction of Livingstone Road, it appears that there is a dropped kerb at the apex. On the opposite side of the junction, the kerbs are raised. West Midlands Police advise that this indicates that the dropped kerbs at this side of the junction are a result of vehicles mounting the kerb as they turn left from Livingstone Road to Alcester Road and therefore causing them to be eroded to be level with the road surface. There is also no tactile paving next to these kerbs, which indicate that this dropped kerb is not an "official" pedestrian crossing point - the same being situated approximately 9m from the end of Livingstone Road. 2. Mr Holbrook was able to leave the carriageway on his mobility scooter at apex/mouth of the junction due to the kerb being worn down to the road surface, and was struck in the carriageway. 3. On 12 September 2022, PC of West Midlands Police submitted a notification via Birmingham City Council's Highway Department's online portal of the defect, with the Highways responding via email on 20 September 2022 stating that it did not meet the intervention levels that require repair. 4. I am concerned that vulnerable road users - particularly users of mobility scooters or bicycles - may inadvertently consider the worn down and defective kerb to be an "official" crossing point and enter the carriageway when it is unsafe to do so. 5. Furthermore, if a mobility scooter or similar were to enter the carriageway at the mouth of the junction (as Mr Holbrook did), they would then be unable to mount the curb at the opposite side - they would have to travel West down the carriageway of Livingstone road to the official crossing point, or alternatively (and more dangerously) navigate South on the carriageway into oncoming traffic onto Alcester Road. 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 3 February 2023. 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons (daughter of the deceased) (brother of the deceased) 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. 08 December 2022 6 7 8 9 Signature: Adam Hodson Assistant Coroner for Birmingham and Solihull
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.
Date: 8th February 2023
Mr A Hodson
Assistant Coroner for Birmingham and Solihull
(via email)
Re: Mervyn Charles Gladstone Leonard Holbrook
(deceased) - Regulation 28 Report to Prevent Future
Deaths
Dear Mr Hodson,
Further to the issue of Regulation 28 Report to Prevent Future Deaths, dated 08th December
2022, following the inquest into the death of Mr Mervyn Charles Gladstone Leonard
Holbrook, I provide my response on the actions taken / proposed as follows;
1. I confirm the height of the kerb where the footpath outside 214 Alcester Road South
reaches the junction of Livingstone Road was amended by the City Council in early
January 2023 as per your recommendations.
Please refer to the photographs below showing the site before and after the remedial
works.
Birmingham City Council
Highways & Infrastructure
PO Box 37
Birmingham
B4 7DQ
Kerb line outside 214 Alcester Road South reaches the
junction of Livingstone Road BEFORE the remedial works
Kerb line outside 214 Alcester Road South reaches the
junction of Livingstone Road AFTER the remedial
works in January 2023
2. We have also commissioned to undertake a review of the available kerb defect
information to identify locations similar to the incident site on the network so that the
necessary processes are incorporated and similar sites are addressed as part of the
Council’s maintenance activities. The scope of the study also includes a review of
the intervention criteria and whether these need to be revised in the light of this
incident.
This study is well underway and is expected to be completed by March 2023. A copy
of the report will be shared with you as soon as it is available along with details of
further proposed actions.
3. An investigation into the PC Glyn Hanks’ submitted notification on 12th September
2022 via Birmingham City Council's Highway Department's online portal reporting the
defect and the Highways response, provided on 20 September 2022, has also been
undertaken and our findings are as follows;
a. Fatal and serious collisions are normally notified to BCC by the Staffordshire
and West Midlands Police Serious Collision Investigation Unit. On this
occasion however, the established protocol between BCC and West Midlands
Police had not been followed and as such BCC were unaware of the incident
until 12th September 2022.
b. Having reviewed the report submitted by
whilst somewhat
ambiguous, our Highway Inspector should have contacted
to
Birmingham City Council
Highways & Infrastructure
PO Box 37
Birmingham
B4 7DQ
obtain further information given the circumstances and the nature of the
incident. The issue should have been further escalated within BCC. Our
processes and procedures have been reviewed so that a similar occurrence
does not happen in the future.
c. BCC will also be contacting West Midlands Police, reiterating the need to
adhere to the already established protocol when reporting fatal or serious
road traffic collisions on the City’s highway network.
I trust the above addresses the concerns raised in your Regulation 28 Report to Prevent
Future Deaths. If you require any further information / clarification however, please do not
hesitate to contact me.
Yours sincerely,
Assistant Director (Highways & Infrastructure)
Birmingham City Council
Highways & Infrastructure
PO Box 37
Birmingham
B4 7DQ
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