Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0399, written 7 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 | 7 Dec 2022 |
|---|---|
| Reference | 2022-0399 |
| Deceased | Josie Archer-Smith |
| Coroner | James Dillon |
| Coroner area | Mid Kent and Medway |
| 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.
Mid Kent and Medway Coroners Cantium House 2nd Floor Maidstone Kent ME14 1XD REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Highways Agency 1 CORONER I am James Dillon, Assistant coroner, for the coroner area of Mid Kent and Medway 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 6th November 2020 Area Coroner Bina Patel commenced an investigation into the death of Josie Archer-Smith, aged 22. The investigation concluded at the end of the inquest on the 6th July 2021. The conclusion of the inquest was that the deceased Josie Archer-Smith died as a result of a road traffic collision. The medical cause of death was recorded as: 1a Traumatic Brain Injury and Skull Fracture 1b Road Traffic Collision 4 CIRCUMSTANCES OF THE DEATH The deceased Josie Archer-Smith died on 31/10/2020 on the M20 London bound carriageway between junctions 5 and 6 as a result of traumatic injuries sustained when the vehicle in which she was travelling as a front seat passenger slid out of control and struck a stationary vehicle on the passenger side. 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 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. – The M20, a multi lane motorway, at the location where the collision took place has had a number of collisions occur which appear to have been caused by water/aquaplaning. Investigating police from the Serious Collisions Investigation unit commented that they are aware that this location is a problem in heavy weather and have attended collisions at this location in the past. The crash location is at the bottom of an incline on the M20 motorway which normally would not cause an issue, however the road also has a camber which causes water to run across the carriageway rather than draining into either the central reservation of the drain on the hard shoulder. The police officer believes that it is when this heavy water is running across the carriageway that there is an issue which does require further investigation as to any remedial works that can be completed to prevent any further fatal/serious injury collisions. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe the Highways Agency 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 and no later than by 8th February2023. 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 and the family of Josie Archer-Smith. I have also sent it to Kent Police Serious Collision Investigation Unit 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 other 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. Signature James Dillon Assistant Coroner Mid Kent and Medway 7th December 202
C02758 – M20 J6 to J5 Drainage Overview 2 patches installed Cleaned out CP4009 & 4010 Cleaned out CP4011 Cleaned out CP2225, 2224 Cleaned out CP 2221 & CP2222 cleaned CR channel for 150lm Cleaned out CP1044 & MH2221 2 X PATCH REPAIR & ROOT CUT completed CP4009 2 X PATCH REPAIRED CP4052 MH4010 Cleaned out 21 x Gullies (Mainline Against DR Wall) 3 X PATCH LINERS installed Unable to patch at 3rd gully due to lateral connection 60% deformed. Replaced lateral connection with new pipe from gully. MH4009 Jetted and Cleaned CDKU= 200lm – Replaced grating clips (900) and cleaned out and sweep / flush ACO = 200lm x 2 = 400lm. Installed asphalt kerb at East end to capture any over run of surface water and direct to nearest gully located on Hard shoulder of mainline against concrete distributor road wall. Deformed lateral connection above MH4009 to MH4010 pipe C02758 – M20 J6 to J5 Drainage Gully pipe repair Post Repair CCTV footage of connection C02758 – M20 J6 to J5 Drainage Gully lead pipe replacement • Excavate and replace deformed pipe from Gully to carrier drain. • Reinstate with dry lean concrete mass fill • Permatrack surface treatment. C02758 – M20 J6 to J5 Drainage Installed 9lm of asphalt kerb to direct Water over run from linear drainage Channel to nearest gully grating C02758 – M20 J6 to J5 Drainage ACO CHANNEL GRATING BOLTS C02758 – M20 J6 to J5 Drainage LDC on J6 to J5 Distributor Road cleansed and every Grating bracket was replaced Cleansed the Combined Kerb Drainage Units (CDKU’s) along the central reserve at the Medway River and railway crossings including Removal of detritus build up in front of the inlet apertures. C02758 – M20 J6 to J5 Drainage Cleansed the Combined Kerb Drainage Units (CDKU’s) along the central reserve at the Medway River and railway crossings including Removal of detritus build up in front of the inlet apertures. C02758 – M20 J6 to J5 Drainage C02758 – M20 J6 to J5 Drainage Cleaned out Catchpits in central reserve. Whilst Traffic management in place took opportunity to clean drainage channel over 150lm Cleansed Catch pits in Central Reserve between VRS lines and although not part of original scope also cleansed 150 linear metres of wide concrete channel between the VRS lines. C02758 – M20 J6 to J5 Drainage
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 THIS RESPONSE IS BEING SENT TO: 1. The Assistant Coroner for Mid Kent and Medway, Mr James Dillon, of Cantium House, 2nd Floor, Maidstone, Kent ME14 1XD in response to a ‘Regulation 28 Report to Prevent Future Deaths’ following an inquest hearing into the death of Josie Archer-Smith that concluded on 06 July 2021. 1 NATIONAL HIGHWAYS I am , Interim Regional Director, South East, responding on behalf of , Chief Executive of National Highways Limited of Bridge House, 1 Walnut Tree Close, Guildford, SURREY GU1 4LZ. Unfortunately, National Highways was not made aware of the inquest, so we did not have an opportunity as the highway authority to assist you by answering questions at the time. The Regulation 28 Report is dated 07 December 2022, a significant time after the conclusion of the inquest on 06 July 2021 and was received by National Highways on 14 December 2022. However, we welcome the opportunity to address your concerns and we hope our response assists. In complying with our duty, National Highways has responded within 56 days of the report, namely by 08 February 2023. 2 CORONER’S MATTERS OF CONCERN The MATTERS OF CONCERN were identified are as follows:– The M20, a multi lane motorway, at the location where the collision took place has had a number of collisions occur which appear to have been caused by water/aquaplaning. Investigating police from the Serious Collision Investigation unit commented that they are aware that this location is a problem in heavy weather and have attended collisions at this location in the past. The crash location is at the bottom of an incline on the M20 motorway which normally would not cause an issue, however the road also has a camber which causes water to run across the carriageway rather than draining into either the central reservation of the drain on the hard shoulder. The police officer believes that it is when this heavy water is running across the carriageway that there is an issue which does require further investigation as to any remedial works that can be completed to prevent any further fatal/serious injury collisions. 3 DETAILS OF ACTION TAKEN Location The M20 motorway at the collision location is a 3-lane dual carriageway with a nearside hard shoulder (‘the mainline’). The collision occurred on the London bound carriageway. To the nearside there is a distributor road with 2 lanes and a hard shoulder (‘the distributor’) that provides access to the M20 Junction 5 exit. The mainline and distributor road are separated by a concrete vehicle restraint system. The location of the collision was on the mainline on the overbridge of the Network Rail line between Aylesford and Maidstone West. The topography is complex. The scene is approached by the mainline and distributor road via a bridge over the River Medway and at that point the road is on an uphill slope with a crossfall from offside to nearside (right to left). The crossfall reduces as the point of collision is approached, then the crossfall changes from nearside to offside (left to right). At the same time the road breasts the 1 incline before continuing on a gentle downhill slope towards the Junction 5 on-slip. Action taken In the days immediately following the collision, and then over a period of approximately 18 months (as road space booking allowed for the lane closures) National Highways staff and our contractors carried out the following actions: • Temporary “Road liable to flooding” signs installed just after Junction 6 on the London bound mainline (to remain in place until the proposed permanent works described below are complete). • South East Regional Operations Centre (SEROC) set variable message signs to display “Skid risk slow-down” or “Surface water slow-down” on the overhead signals between Junction 6 to 5 when they have confirmation of water on the carriageway at the collision location. • To maximise drainage efficiency, 170 metres of combined kerb drainage jetted, 200 metres x 2 Acco drains jetted and a full CCTV drainage survey carried out on the London bound mainline. • Remedial works carried out following a full CCTV drainage survey: o Traffic management put in place to carry out the works: ▪ 6 Shifts - Full closure of London bound distributor and lane 1 of the London bound mainline; and ▪ 3 Shifts - Lane 3 closure on the London bound mainline and a lane 3 closure on the coast bound mainline due to working in the centre reserve. o Remedial works: ▪ 200 metres of combined kerb drainage jetted and cleaned; ▪ 150 metres of centre reserve drainage channel cleaned; ▪ 400 metres of Acco type drain (200 metres x 2) between distributor and mainline gratings removed and cleansed and new clips installed for the gratings; ▪ 7 x drainage pipe patch repairs; ▪ Cleansed 21 x gullies; ▪ Cleansed 11 x catchpits; ▪ ▪ Installed 1 x drainage pipe from end of Acco channel between distributor and mainline; and Installed 9 metres of extruded asphalt kerb to direct surface water to the nearest gully on the hard shoulder. • Also carried out within these road closures, our contractors carried out routine cyclical works as below: o Grass cutting; o Sweeping of whole of the distributor road; and o Cleansing of remaining gullies within the site area which are not part of the remedial works listed above. 2 4 DETAILS OF FURTHER ACTION PROPOSED The M20 Medway and Allington Deck Refurbishment scheme is due to be delivered between June and July 2023 at an estimated cost of £3 million. In order to reduce the likelihood of future similar events, the scope of the scheme includes; • Complete refurbishment of the London bound carriageway (mainline and distributor road) including replacement of the waterproofing, surfacing, joints, white lines and road studs from 15 metres before the River Medway to 15 metres past Allington Railway. • Thin Surface Course surfacing to be replaced with Hot Rolled Asphalt Wearing Course. The Hot Rolled Asphalt is textured to provide more grip and also to allow water to drain away more quickly. • Vehicle Restraint System and drainage to the distributor road to be replaced. 5 TIMETABLE FOR ACTION DATE ACTION June-July 2023 M20 Medway and Allington Deck Refurbishment scheme. 6 SAFETY OF ROAD USERS The safety of everyone on our road network matters; it is an imperative for our business in what we set out to achieve and a core value of our organisation in how we go about it. The action taken and those proposed are designed in this light to help to prevent future deaths at this location. 7 01 February 2023 Signed: , Interim Regional Director on behalf of 3
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