Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2023-0003, written 30 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 | 30 Dec 2022 |
|---|---|
| Reference | 2023-0003 |
| Deceased | Jordan Pry |
| Coroner | Richard Travers |
| Coroner area | Surrey |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Re : JORDAN KEVIN PRY, DECEASED REGULATION 28 REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Secretary of State for Transport 2. National Highways Limited 3. Connect Plus (M25) Limited 1 CORONER I am Richard Travers, HM Senior Coroner for Surrey. 2 CORONER’S LEGAL POWERS I make this report under paragraph 7 of Schedule 5 to the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST I commenced an investigation into the death of Jordan Kevin Pry. The inquest concluded on the 22nd December 2022 when I found that the medical cause of death was : Ia Multiple Injuries and my Conclusion as to the death was that: In the early hours of the 2nd April 2018, Jordan Pry was driving his BMW-M3 motor car along the anti-clockwise carriageway of the M25 motorway, between junctions 6 and 5, and in an easterly direction. It was raining heavily and the road surface was wet. Jordan Pry was driving in the third of four lanes, at a speed of approximately 78 miles per hour, when he drove through an area of surface water on the road and the car began to aquaplane and rotate. Whilst still rotating, the vehicle travelled across the second and first lanes and then left the carriageway to the nearside in the vicinity of marker post B4348, which is approximately 200 metres before the start of the slip-road to the Clacket Lane Services. The car then moved down or over the verge and steep embankment to the nearside of the road and collided with a tree. As a result of the collision and its force, the tree intruded into the vehicle from its offside central pillar and through the driver’s compartment, causing Jordan Pry to suffer fatal injuries. The collision occurred at 02.33 hours on the 2nd April 2018 and it is likely that Jordan Pry died shortly thereafter, although his death was formally pronounced, at the scene, at 02.52 hours, following the arrival of the emergency services. The probable causes of the collision and Jordan Pry’s death were : (i) The presence of excessive surface water on the road which resulted from – (a) heavy rainfall, (b) a blockage of a drain in the central reservation at a point approximately 65 metres southwest of the collision location which had been caused, unusually, by a large piece of plastic entering the drainage system and which resulted in there being a flow of water across the carriageway, and (c) the profile of the road on the approach to the collision location which included a flat spot where the surface water was able to settle, and (ii) The speed at which the BMW was being driven, namely a speed of approximately 78 miles per hour. Prior to the collision there was a long history of wet-road related incidents at the location, including many aquaplaning events and a previous fatality. The absence of any warning on the approach to the collision location of the risk of aquaplaning, which was known to arise when there was excessive surface water on the road, and the absence of any vehicle restraint system at the nearside of the carriageway, were both possible contributory causes of the Deceased’s death. Jordan Pry died as a result of a Road Traffic Collision. 4 CIRCUMSTANCES OF THE DEATH Please see my Conclusion as to the death, as set out in section 3 above, together with my Findings and Conclusion document, a copy of which is attached hereto. 5 CORONER’S CONCERNS In the course of the inquest the evidence revealed matters giving rise to concern. In my opinion, there is a continuing risk that future deaths could occur unless action is taken in relation to the concerns set out below. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: As stated in my Conclusion (above), Jordan Pry died on the M25 motorway at marker post B4348, when he drove his vehicle through an area of surface water and the car began to aquaplane and rotate, causing it to leave the carriageway and collide with a tree. There is a long and significant history of aquaplaning incidents at the location, including a previous similar fatality following which, in 2010, a Prevention of Future Deaths Report was issued by the then Senior Coroner for Surrey. That report drew attention to the presence of surface water from rain and the effects of a blocked drain, and the presence of a flat spot on the road. Subsequently, changes were made to the drainage system at the location, first in 2011 by means of a small scale improvement scheme and secondly, as part of works completed in 2015, by means of the introduction of a slot drain. However, the flat spot still remains and aquaplaning incidents have continued. I was told in evidence that there are ongoing investigations concerning the risk arising at the location, that a decision as to whether or not the flat spot should be addressed is still to be taken, and that a comprehensive plan for the management of the risk at the location cannot be made until that decision is taken. The concern arising, therefore, is that there is an ongoing risk of further death at this location pending the implementation of an informed and comprehensive plan for risk management. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths by addressing the concerns set out above and I believe your organisation 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 the 25th February 2023. I, as 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, to the following Interested Persons: a. b. c. Connect Plus Services, d. Construction Joint Venture, and e. Atkins Limited. I am also under a duty to send the Chief Coroner a copy of your response. 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 by the Chief Coroner. 9 30th December 2022 Richard Travers
3 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.
Connect Plus House St Albans Road South Mimms Hertfordshire EN6 3NP Mr Richard Travers HM Senior Coroner for Surrey HM Coroner’s Court Station Approach Woking GU22 7AP 23 February 2023 Dear Sir Re: JORDAN KEVIN PRY, DECEASED Regulation 28 report to prevent future deaths Thank you for your report of 30 December 2022 (Report) following the conclusion of the inquest into the death of Jordan Kevin Pry. This letter seeks to address HM Senior Coroner's concerns set out in section 5 of the Report; namely that, in HM Senior Coroner's opinion, there is an ongoing risk of further death at the location of marker post B4348 on the M25 anti-clockwise carriageway (Location), pending the implementation of an informed and comprehensive plan for risk management. I would like to emphasise to Jordan's family and the Coroner's Court that Connect Plus takes safety very seriously, and we remain absolutely committed to maintaining and enforcing the highest standards of road safety across the M25 Project Road Network. Set out below is an overview of enhanced measures at the Location which have been or are in the process of being implemented (Enhanced Measures), together with the programme of work to complete the comprehensive plan for risk management (GG 104 Programme). Connect Plus Services (CPS) has provided a written commitment to Connect Plus to implement both the Enhanced Measures and the GG104 Programme. (1) Enhanced Measures HM Senior Coroner will recall from evidence heard at the inquest that in May 2009 the Secretary of State for Transport signed a 30 year contract with Connect Plus (M25) Limited (Connect Plus) for the M25 Project Road Network. The Secretary of State's interest has since been transferred to National Highways Limited (National Highways). As is the case with privately financed projects, Connect Plus subcontracted a significant proportion of its core operations and maintenance obligations to CPS under a 30-year operations and maintenance agreement. National Highways retained control of most of the technology for the functioning of the M25 Project Road Network related to safety-critical assets, such as the setting of speed limit signs on overhead gantries. Connect Plus House St Albans Road South Mimms Hertfordshire EN6 3NP Evidence heard at the inquest established that the Location is included on a list of vulnerable locations in the CPS Severe Weather Plan. Since the inquest, CPS have developed a number of further enhanced risk management measures, summarised below. These enhanced measures are required to be kept under review by CPS; and any updates are to be made on an annual basis, or more frequently as the data dictates. Connect Plus will continue to monitor CPS's implementation of the enhanced measures through regular meetings with CPS, through audit, and through monthly steering group meetings with CPS and National Highways. 1.1 Enhanced inspections a) CPS Incident Support Unit (ISU) crews are carrying out weekly driven visual inspections to observe the slot drains and catchpit surfaces in order to identify debris build up, such that the catchpit inlets are not covered by debris and the slot drains are not obscured by debris for a continuous length of greater than 15m. Should any issues be identified, CPS will liaise with National Highways to secure the necessary lane closures to enable such issues to be addressed. b) CPS and National Highways are discussing the implementation of the following procedure: i) National Highways Traffic Officers, through their regular routine patrols, will monitor the presence of surface water at the Location; ii) When CPS is notified of a severe wet weather event by either National Highways or via the CPS weather service provider, the ISU crew will, as part of their network safety patrol function, be deployed to the Location by the CPS Network Control Room Team. The ISU crew will monitor if there is excess surface water in the Location; iii) Where excess surface water is identified by the ISU crew or the National Highways Traffic Officer, they will contact the National Highways South East Regional Operations Centre (SEROC) and request that appropriate signs and signals are set. National Highways will then consider whether this will include either reduced speeds and/or Variable Message Sign (VMS) stating “SURFACE WATER SLOW DOWN”; iv) The CPS Network Control Room will create an INFORM incident log, for command- and-control logging and audit purposes, to record the observation and interventions made; v) The CPS Network Control Room will arrange and deploy secondary response/s intervention as required/requested by SEROC; vi) The CPS Network Control Room will use National Highways network CCTV images to monitor surface water until it has been notified that there is no longer excess surface water present. Connect Plus House St Albans Road South Mimms Hertfordshire EN6 3NP c) CPS are developing an inspection guide/checklist to enable CPS ISU crews to have a clear understanding of the acceptable levels of surface debris on the hardstrip, central reserve and slot drains. This will be issued in March 2023 as an addendum to the ISU inspection check sheet. d) CPS are carrying out a trial of catchpit sensors to monitor the level of water and flow at the Location. The data gathered will be used to monitor asset performance and inform any changes to intervention frequency. CPS have installed these sensors at two catchpits in February 2023. e) CPS are investigating the developing technology market to establish whether there are reliable and suitable passive monitoring systems for detection of surface water at the Location. f) CPS are reviewing the best practice within ‘Asset delivery asset maintenance requirements’ standards and intend to incorporate any relevant elements in the Services Plan 2023. 1.2 Enhanced maintenance a) Signage i) CPS will continue to maintain the existing permanent ‘Road Liable to Flooding’ sign at MP35/2 in accordance with signage asset requirements. ii) Temporary ‘Road Liable to Flooding’ signs were installed in advance of the Location at MP436/7 & MP436/4 on the anti-clockwise B carriageway, and these are subject to a weekly driven visual inspection at prevailing traffic speeds to ensure presence and function. b) Drainage system inspection and cleanse i) Visual inspections will be undertaken by a CPS specialist drainage subcontractor of the slot drains and catchpits on the nearside and central reserve of the anticlockwise B carriageway (including the last catchpit located on A carriageway in the central reservation). The assets will be cleansed if the slot drain inlets are blocked or silt levels in the pipes or catchpits are 25%, or greater, full; ii) Inspection and cleanse will be undertaken by a CPS specialist drainage subcontractor of the crossing pipe and catchpits around the Location; iii) The hardstrip and central reserve will be swept by the CPS maintenance team. iv) The next planned visits to undertake the above activities bi), bii) and biii) are April 2023 (three months after the last visit) and October 2023 (in readiness for the winter period). Connect Plus House St Albans Road South Mimms Hertfordshire EN6 3NP c) Vegetation management i) A swathe cut to 3m will be carried out by CPS to control vegetation and reduce the risk of leaf fall; ii) CPS will also attend the adjacent landscape plot (LV1972) to remove excess vegetation and reduce leaf burden. iii) The next planned visits to undertake activities ci) and cii) are June 2023. (2) GG 104 Programme Evidence heard at the inquest included the completion of the recommendations and complementary measures detailed within the Clacket Lane Surface Water Safety Risk Assessment dated April 2022. This risk assessment was undertaken by Atkins in 2021, was commissioned by Connect Plus and CPS, and follows the framework contained within National Highway’s GG 104 - Requirements for Safety Risk Assessment in the Design Manual for Roads and Bridges. The purpose of the safety risk assessment was to establish what further control measures could be introduced to reduce the risk of collisions due to excess surface water, and whether such measures The Clacket Lane Surface Water Safety Risk Assessment makes four key are recommendations, together with three complementary measures. justified. Connect Plus and CPS meet on a fortnightly basis to discuss progress with the GG 104 Programme. Connect Plus, CPS and National Highways also hold monthly steering group meetings. Enclosed with this letter is an outline of the GG 104 Programme timetable. A summary of the recommendations and complementary measures is set out below together with what has been carried out to date, and what is planned. 2.1 Recommendations a) Recommendation 1 – Review of, and if appropriate improvements to, the drainage maintenance and inspection regime Review of the existing maintenance and inspection regime to ensure that existing requirements are being met, whether there is a case for exceeding the Network Management Manual requirements, and consideration of best practice for the maintenance of slot drains. WSP, an independent engineering consultancy with highways and drainage experience, have been appointed by CPS to deliver recommendations 1-3 and complementary measure 3. WSP's findings will be discussed with Connect Plus, CPS and National Highways by 16 June 2023. b) Recommendation 2 – Development of surface water contingency plans Connect Plus House St Albans Road South Mimms Hertfordshire EN6 3NP Review and develop the effectiveness of existing contingency plans, with the aim of taking a proactive approach to managing heavy rain events and surface water to reduce the risk of a collision occurring, including consideration of existing systems in place to assess how warnings or restrictions can be signed for road users, especially at night. c) Recommendation 3 – Improvement to drainage system Follow up on the previous review of flooding hotspots to investigate possible anomalies and identify potential improvements that are justified. d) Recommendation 4 – Cost benefit analysis of carriage reprofiling Undertake an assessment to determine the presence of flat sections on the approach to Clacket Lane services and if the profile of the surface can be amended to improve water flow paths. Should the assessment highlight issues, high level remediation proposals will be developed to a point where a cost-benefit analysis can be undertaken. The CPS design team are developing design proposals which will be costed, and a cost benefit analysis undertaken with assistance from the author of the Clacket Lane Surface Water Safety Risk Assessment. Buildability advice will be provided by one of Connect Plus's Framework contractors. National Highways have provided CPS with their standard Scheme Appraisal Report template which is envisaged will provide the structure for the cost benefit analysis. The outcome of the cost benefit analysis will be discussed with Connect Plus, CPS and National Highways by 1 September 2023. 2.2 Complementary measures 1) Review of carriageway resurfacing: CPS are reviewing whether changes to the type of carriageway surfacing would provide any beneficial risk mitigation. CPS will discuss the outcome of their review with Connect Plus and National Highways by 6 March 2023. 2) Investigate whether the existing fixed warning sign could be illuminated: National Highways, Connect Plus and CPS have decided to undertake a thorough review of the signage required at the Location against NH standards. CPS will discuss the findings of the CPS design team’s review with Connect Plus and National Highways by 28 April 2023. 3) Verge review: A review of any residual hazards in the verge at this Location is being undertaken by WSP as part of the Recommendation 2 workstream to determine if there are further changes that can be made to reduce the risk to vehicles. WSP's findings will be discussed with Connect Plus, CPS and National Highways by 16 June 2023. Connect Plus House St Albans Road South Mimms Hertfordshire EN6 3NP (3) Update to HM Senior Coroner Connect Plus has a shared commitment with National Highways and CPS to deliver the programme of work set out above. Accordingly we believe that we will be in a position to provide HM Senior Coroner with an update by 29 September 2023 on the recommendations and complementary measures of the GG 104 Programme, together with any further actions that have been taken, or are planned, to mitigate the risk of further collisions at the Location. Yours faithfully Chief Executive Connect Plus (M25) Limited
From the Secretary of State The Rt Hon Mark Harper MP Great Minster House 33 Horseferry Road London SW1P 4DR 23 February 2023 Richard Travers HM Senior Coroner for Surrey HM Coroner’s Court Station Approach Woking Surrey GU22 7AP Dear Mr Travers, Thank you for your letter of 30 December 2022 enclosing a copy of your Regulation 28 report also sent to National Highways, following the inquest into the death of Jordan Pry. Firstly, I would like to place on record my sincere condolences for the death of Mr Pry. It is a tragedy when any person dies on our roads. I note that your inquest raised concerns about the risk of further deaths at this location without a comprehensive plan for managing surface water remaining on the carriageway. I take the safety of our roads very seriously. The Government and National Highways continually work hard to improve road safety. Responsibility for the safe management of the Strategic Road Network, which includes the location of this accident, falls to National Highways and I am aware that work has already been undertaken at this site since the accident, including the installation of a vehicle restraint system. National Highways are writing to you separately to set out the actions they are taking jointly with their partners Connect Plus (M25) Limited and Connect Plus Services to reduce the risks of future collisions on this part of the Strategic Road Network. My DfT Officials will continue to work with National Highways on the points you have raised in your enquiry. Yours sincerely, Rt Hon Mark Harper MP SECRETARY OF STATE FOR TRANSPORT
Our ref: Your ref: Mr Richard Travers HM Senior Coroner for Surrey HM Coroner’s Court Station Approach Woking SURREY GU22 7AP Dear Mr Travers, Head of M25 Bridge House 1 Walnut Tree Close Guildford SURREY GU1 4LZ 24 February 2023 Inquest into the Death of Jordan Pry on 2 April 2018 Regulation 28 Report Thank you for providing National Highways (NH) with the Regulation 28 Report on 30 December 2022 following the recent inquest into the tragic death of Jordan Pry in a road traffic collision on the M25 on 2 April 2018. In your report you raised concerns about the risk of further deaths at this location pending the implementation of an informed and comprehensive plan for managing the risk of surface water remaining on the carriageway in periods of heavy rain. In your finding you identified the blocked drain in the central reservation and the profile of the road surface as probable causes of Mr Pry’s death and absence of any warning sign and the absence of vehicle restraint system in the verge as possible contributory causes. Since the collision leading to Mr Pry’s death, a vehicle restraint system has been installed in the verge at this location. During the course of the inquest a document “Clacket Lane Surface Water – Safety Risk Assessment” produced by Atkins was presented in evidence. The recommendations in this document form the basis of the actions National Highways is taking jointly with Connect Plus (M25) Limited (CP) and Connect Plus Services (CPS) to reduce the risk of future collisions in wet weather at this location. Against the four key areas for action highlighted in the Risk Assessment I set out below the actions NH has taken and plans to take to progress these actions. Registered office Bridge House, 1 Walnut Tree Close, Guildford GU1 4LZ National Highways Limited registered in England and Wales number 09346363 Drainage Maintenance and Inspection Regime Actions Taken CP have commissioned a review from WSP, an independent engineering consultant, of CPS drainage maintenance arrangements for all the roads for which they are responsible. Pending the outcome of this review CPS have implemented an enhanced maintenance and inspection regime for the drainage near Clacket Lane. This includes biannual cleansing of the slot drain, catchpit and cross-drain. Actions Planned and Timescales The finding of the independent review, together with the actions CP and CPS intend to take will be reported to me by 16 June 2023. Should this review lead to a change in CPS’s approach to drainage maintenance then NH will require the changes to be included in a revision to their Services Plan which would be submitted for formal review to NH. After any revised maintenance arrangements have been in place for six-months NH will undertake an audit of CPS’s activities to ensure they are complying with the submitted plan. Warning Messages for Drivers Actions Taken With CP, NH have commissioned CPS to review the effectiveness of the existing fixed warning sign to identify whether any measures are possible, within the legislative provisions that govern signage, to enhance the visibility of the sign. Until the review above is complete, additional temporary surface water warning signs have been installed in the verge of the M25 at Marker Posts 36/7 and 36/4. NH has implemented a specific protocol to monitor the Clacket Lane area in times of wet weather and set warning messages of the form “Surface Water – Slow” on the variable message signs in the location when appropriate. Actions Planned and Timescales The findings from CPS’s review of the existing fixed warning sign at Clacket Lane will be reported to me by 28 April 2023 Registered office Bridge House, 1 Walnut Tree Close, Guildford GU1 4LZ National Highways Limited registered in England and Wales number 09346363 Improvement to the Drainage System Actions Taken With CP, NH has commissioned WSP to undertake an independent review of the drainage system in the vicinity of Clacket Lane to identify whether any improvement could be made which would be likely to reduce the risk of flooding on the carriageway. Actions Planned and Timescales The finding of the independent review, together with any recommended actions, will be reported to me by 16 June 2023. Profile of the Carriageway Actions Taken With CP, NH has commissioned CPS, with support from a contractor, Milestone Infrastructure, to consider the viability of reprofiling the carriageway to shorten the drainage flow paths across the carriageway. This will include the outline design of possible options and a review of the feasibility and cost of constructing these options. Actions Planned and Timescales CP will be reporting their findings from these investigations, together with their recommendation by 1 September 2023. Following conclusions of the various investigations set out above I will write to you again by 29 September 2023 setting out the further actions NH has taken and intends to take. If any recommendations are not to be pursued, I will set out the reasons for that decision. I am meeting with CP and CPS monthly to monitor progress on these actions and ensure they remain on track to achieve the timescales indicated above. Yours sincerely, Head of M25 Registered office Bridge House, 1 Walnut Tree Close, Guildford GU1 4LZ National Highways Limited registered in England and Wales number 09346363
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