Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0047, written 8 Feb 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 Feb 2023 |
|---|---|
| Reference | 2023-0047 |
| Deceased | Stephen Wood |
| Coroner | Rachael Griffin |
| Coroner area | Dorset |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 5 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Rt Hon Mark Harper MP, Secretary of State for Transport 2. 3. 4. 5. Chief Constable of Dorset Police Chief Executive of Dorset Council Chief Executive of BCP Council Chief Executive Officer of National Highways Agency 1 CORONER I am Rachael Clare Griffin, Senior Coroner, for the Coroner Area of Dorset 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 the 10th June 2021, an investigation was commenced into the death of Stephen Robert Wood, born on the 18th March 1962. The investigation concluded at the end of the Inquest on the 07th February 2023. The Medical Cause of Death was: Ia Multiple injuries The conclusion of the Inquest was road traffic collision. 4 CIRCUMSTANCES OF THE DEATH At approximately 19.13 hours on the 30th May 2021, the deceased was riding his Harley Davidson XL1200 motorcycle in a northerly direction along Coombe Road, Winterbourne Steepleton, Dorchester which has a speed limit of 60mph. He was travelling at a speed of no more than 44mph when he had just driven over the brow of a hill and his bike entered a 60 metre stretch of grass in the carriageway, which covered the entire width of the carriageway and had been there from at least approximately 18.00 hours that day. His motorcycle slipped on the grass, and he became separated from the motorcycle. He travelled into the pathway of an oncoming Ford Focus Titanium TDCI in the southbound carriageway of the road, which passed over him. He came to rest under the vehicle and sustained numerous significant and unsurvivable injuries. 1 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. During the inquest evidence was heard that: i. On the 30th May 2021 a carpet of grass was obstructing the entire north bound carriageway of Coombe Road, Winterbourne Steepleton, Dorchester for a distance of 60 metres. This was described as dangerous and a hazard. On that day a road traffic collision occurred as a result of that hazard in which sadly Mr Wood died. ii. iii. iv. There was evidence that the grass had been seen at approximately 18.00 hours by a member of the public driving on the other side of the road. The collision occurred at approximately 19.13 hours. Between 18.00 hours and 19.13 hours, 3 people working on a local farm transporting sileage from a local field to the farm had seen the grass and had driven over it. Others may also have seen and/or driven over the grass. No one reported this obstruction in the road prior to the collision. Evidence was given that there is a legal requirement to remove or report any spillage if you cause it, but there is no obligation to report any hazard you see, which you have not caused. The owner of the farm, who was undertaking sileage transfer in the area at the time, has said that since the incident, if there is any spillage or obstruction he or his employees come across, they will report it, so it can be cleared. 2. I have concerns with regard to the following: i. That there is a lack of knowledge and/or understanding as to when people should report an obstruction in the road. I would request that consideration is given to making all road users aware of the dangers of obstructions in the road and to encourage them to report any hazard to the local Police force or Local Authority so that it can be removed as soon as possible, or at least other road users be warned of the hazard to prevent a future death. 6 ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I 2 believe you and/or 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, 4th April 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 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 Dated Signed 8th February 2023 Rachael C Griffin 3
5 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.
Chief Executive BCP Civic Centre Bourne Avenue Bournemouth BH2 6DY HM Coroner Mrs Rachael Griffin Coroner’s Office Civic Centre Bournemouth BH2 6DY Date: 11 April 2023 Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths I am writing to confirm that the response letter from the Dorset Police Chief Constable, , dated 3 April (attached) is intended to convey the views of BCP Council, via the Dorset Road Safe Partnership, which is our official partnership that considers road safety issues across the wider area covering both the Dorset Council and BCP Council areas. Please let me know if you need anything else from me. Yours sincerely Chief Executive BCP Council
Ms Rachael Clare Griffin Senior Coroner for the Coroner Area of Dorset Bourne Avenue Bournemouth BH2 6DY From the Secretary of State The Rt Hon Mark Harper MP Great Minster House 33 Horseferry Road London SW1P 4DR Web site: www.gov.uk/dft 05 April 2023 Dear Ms Griffin, Thank you for your letter of 8 February 2023 enclosing a copy of your Regulation 28 report, regarding the death of Mr Stephen Robert Wood. I was very sorry to hear about his death, and my condolences are with his friends and family. I am grateful for a copy of your report into the circumstances of Mr Wood’s death and the matters of concern you raised to help prevent similar deaths in the future. I have considered the report carefully and set out my thoughts below. In your report you have requested that “consideration is given to making all road users aware of the dangers of obstructions in the road and to encourage them to report any hazard to the local Police force or Local Authority so that it can be removed as soon as possible, or at least other road users be warned of the hazard to prevent a future death.” Under Section 41 of the Highways Act 1980, local highway authorities, in this case Dorset Council, have a duty to maintain the highways network in their area. The Act does not set out specific standards of maintenance, as it is for each individual local highway authority to assess which parts of its network are in need of repair and what standards should be applied, based upon their local knowledge and circumstances. There are powers available to local highway authorities against road users who deposit material on the highway. Under Section 148 of the Highways Act 1980, it is an offence to deposit anything whatsoever on the highway which interrupts its use. Section 149 of the Highways Act 1980 provides the local highway authority the power to recover the cost of clearing the road from those responsible for the obstruction. Finally, Section 161 states that it is an offence if anyone deposits anything on the highway which causes a user of the highway to be injured or endangered. The Department has also made it easier for the travelling public to notify the relevant highway authority of hazards, such as a spillage, on a highway, by providing the facility to do this on GOV.UK. In England, hazards on the highway can be reported nationally at the following link: https://www.gov.uk/report-road-spillage. In addition, the Government encourages all local highway authorities in England to have dedicated web pages for reporting defects to its highway network. Dorset Council has gone further with a dedicated 24-hour telephone highways line to report hazards, obstructions, and dangerous situations which could cause injury or damage. Alternatively, hazards can be reported via Dorset Council’s dedicated page for reporting problems on a road or pavement at the following link: https://www.dorsetcouncil.gov.uk/roads-highways-maintenance/report-a- problem-on-the-road-or-pavement. Finally, the Department regularly updates and promotes The Highway Code. Under Rule 280 of The Highway Code, if anything falls from a vehicle on to a motorway or other high-speed road, road users are advised to stop in a place of relative safety and call the emergency services on 999. On other roads, road users are advised to only remove obstructions if it is safe to do so. The Highway Code was last updated in September 2021, and under The Highway Code rules 277, 279, and 283 now advises the use of ‘eCall’ to contact the police and to provide a specific location directly to a 999 operator. Based on this, we have concluded that there is no further action that would be appropriate for the Department to take at this stage. Yours sincerely, The Rt Hon Mark Harper MP SECRETARY OF STATE FOR TRANSPORT
Senior Leadership Team Dorset Council, County Hall, Colliton Park, Dorchester, Dorset DT1 1XJ 01305 251010 www.dorsetcouncil.gov.uk HM Coroner Mrs Rachael Griffin The Coroner’s Office Civic Centre Bourne Avenue BOURNEMOUTH Dorset BH2 6DY Date: 3 April 2023 Ref: Officer: Dear Mrs Griffin Regulation 28 - Report to Prevent Future Deaths I write to provide a response on behalf of Dorset Council and the key stakeholders of Dorset Road Safe to the Regulation 28 Report, received on the 8 February 2023, following the conclusion of the inquest touching the death of Stephen Robert Wood. You raised a concern in which your opinion is that urgent action should be taken to prevent future deaths. Your concern was: ‘That there is a lack of knowledge and/or understanding as to when people should report an obstruction in the road. I would request that consideration is given to making all road users aware of the dangers of obstructions in the road and to encourage them to report any hazard to the local Police force or Local Authority so that it can be removed as soon as possible, or at least other road users be warned of the hazard to prevent a future death.’ The report was sent to a number of stakeholders who have been involved in activity in response to the concern. Temporary Assistant Chief Constable chairs the Dorset Strategic Road Safety Partnership (DSRSP) and as such, it was seen as most appropriate for Dorset Police to consolidate a response on behalf of the Partnership. DSRSP is the governance body of Dorset Road Safe (DRS). DRS is a partnership consisting of; Dorset Police, Dorset Council, BCP Council, Dorset & Wilts Fire Service, National Highways, South- West Ambulance Service Trust, DocBike, & Dorset’s Office of Police & Crime Commissioner (OPCC). Dorset Road Safe is a well established and strong partnership. The Partnership have proposed the following commitments in response to the concern raised. The DSRSP will formally ratify these commitments, at its next meeting to be held on 28 April 2023. • Commitment 1 Websites for Dorset Police, the respective Local Authority for Dorset and BCP, along with National Highways, will all review and ensure there is a clear link to enable reporting of obstructions and debris on the road by the public. These links will start with clear instructions and information to the public to call 999 if they believe any obstruction or debris is putting road users in immediate danger. Further information on these respective websites, and in the same reference area, will also advise the public on how to report smaller, non-urgent debris. All these websites will be cross-referenced to each other to ensure the public have the right information irrespective of which organisation they contact in the first instance. Partnership members will be reviewing their respective websites and contact details, to ensure improvements can be made to assist the public in reporting any concerns on the roads around obstructions and debris. • Commitment 2 Dorset Road Safe’s Partnership website will introduce a clear link around who to contact in respect of an obstruction/debris on the road. There will also be a section devoted to highlighting the associated dangers to road users. This section of the website will act as a further cross-referencing point with all respective Partners, to ensure that the public are well informed and signposted to the correct organisation and method of contact. • Commitment 3 Corporate communications colleagues from Police, Councils, and National Highways, we will be constructing a communications campaign, ready for this Spring/Summer’s increased road activity, to alert all road users around obstructions/debris on Dorset’s roads. This will be conducted via various media platforms including DRS Twitter, and roadside Vehicle Activated Signs (VAS). The sustainability of message will be an important part of this communications package, with partners ensuring that messaging continues at an agreed frequency in perpetuity, through various media – Roadside, twitter, websites etc.. In relation to those members of the public who call the police directly, I have been advised that the Force Command Centre (FCC) assesses and triages all reports of road concerns, considering an appropriate response or deployment based on the threat and risk posed. They will also advise the respective Highway Authority where a police deployment is not considered necessary. Partnership colleagues in both Councils and National Highways have good existing arrangements for the Public to report issues on the road. I hope this letter provides you with the assurance that Dorset Council as a part of Dorset’s Strategic Road Safety Partnership is committed to keeping Dorset’s road network safe for everyone and has made specific commitments to mitigate the concerns raised as a result of this particular Preventing Future Deaths report. Yours sincerely Chief Executive
HM Coroner Mrs Rachael Griffin Coroner’s Office Civic Centre Bourne Avenue BOURNEMOUTH Dorset BH2 6DY ) Dorset Police Force Headquarters Winfrith DORCHESTER DT2 8DZ 3 April 2023 Dear Mrs Griffin Re: Regulation 28 Report to Prevent Future Deaths I write to provide a response on behalf of Dorset Police and the key stakeholders of Dorset Road Safe to the Regulation 28 Report, received on the 8 February 2023, following the conclusion of the inquest touching the death of Stephen Robert Wood. You raised a concern in which your opinion is that urgent action should be taken to prevent future deaths. Your concern was: ‘That there is a lack of knowledge and/or understanding as to when people should report an obstruction in the road. I would request that consideration is given to making all road users aware of the dangers of obstructions in the road and to encourage them to report any hazard to the local Police force or Local Authority so that it can be removed as soon as possible, or at least other road users be warned of the hazard to prevent a future death.’ The report was sent to a number of stakeholders who have been involved in activity in response to the concern. One of my Chief Officers, Temporary Assistant Chief Constable chairs the Dorset Strategic Road Safety Partnership (DSRSP) and as such, it was seen as most appropriate to consolidate a response on behalf of the Partnership. DSRSP is the governance body of Dorset Road Safe (DRS). DRS is a partnership consisting of; Dorset Police, Dorset Council, BCP Council, Dorset & Wilts Fire Service, National Highways, South- West Ambulance Service Trust, DocBike, & Dorset’s Office of Police & Crime Commissioner (OPCC). Dorset Road Safe is a well established and strong partnership. The partnership have proposed the following commitments in response to the concern raised. The DSRSP will formally ratify these commitments, at its next meeting to be held on 28 April 2023. • Commitment 1 Websites for Dorset Police, the respective Local Authority for Dorset and BCP, along with National Highways, will all review and ensure there is a clear link to enable reporting of obstructions and debris on the road by the public. These links will start with clear instructions and information to the public to call 999 if they believe any obstruction or debris is putting road users in immediate danger. Further information on these respective websites, and in the same reference area, will also advise the public on how to report smaller, non-urgent debris. All these websites will be cross-referenced to each other to ensure the public have the right information irrespective of which organisation they contact in the first instance. Partnership members will be reviewing their respective websites and contact details, to ensure improvements can be made to assist the public in reporting any concerns on the roads around obstructions and debris. • Commitment 2 Dorset Road Safe’s Partnership website will introduce a clear link around who to contact in respect of an obstruction/debris on the road. There will also be a section devoted to highlighting the associated dangers to road users. This section of the website will act as a further cross-referencing point with all respective Partners, to ensure that the public are well informed and signposted to the correct organisation and method of contact. • Commitment 3 Corporate communications colleagues from Police, Councils, and National Highways, we will be constructing a communications campaign, ready for this Spring/Summer’s increased road activity, to alert all road users around obstructions/debris on Dorset’s roads. This will be conducted via various media platforms including DRS Twitter, and roadside Vehicle Activated Signs (VAS). The sustainability of message will be an important part of this communications package, with partners ensuring that messaging continues at an agreed frequency in perpetuity, through various media – Roadside, twitter, websites etc.. In relation to those members of the public who call the police directly, our Force Command Centre (FCC) assess and triage all reports of road concerns, considering an appropriate response or deployment based on the threat and risk posed. They will also advise the respective Highway Authority where a police deployment is not considered necessary. Partnership colleagues in both Councils and National Highways have good existing arrangements for the Public to report issues on the road. I hope this letter provides you with the assurance that Dorset’s Road Safe Partnership is committed to keeping Dorset’s road network safe for everyone and has made specific commitments to mitigate the concerns raised as a result of this particular Preventing Future Deaths report. Yours sincerely Chief Constable
REGULATION 29 RESPONSE TO A REPORT ON ACTION TO PREVENT FUTURE DEATHS THIS RESPONSE IS BEING SENT TO: 1. The Senior Coroner for the Coroner Area of Dorset, Rachael Griffin, of Civic Centre, Bourne Avenue, Bournemouth BH2 6DY in response to a ‘Regulation 28 Report to Prevent Future Deaths’ following an inquest hearing into the death of Stephen Wood that concluded on 07 February 2023. 1 NATIONAL HIGHWAYS Chief Director of Road Safety, responding on behalf of I am Executive of National Highways Limited of Bridge House, 1 Walnut Tree Close, Guildford, SURREY, GU1 4LZ. I note that the collision occurred on Coombe Road, Winterbourne Steepleton, Dorchester, Dorset. For clarity, National Highways is the Government-owned company, sponsored by the Department for Transport (DfT), charged with operating, maintaining and improving England's motorways and major A-roads. Responsibility for local roads, including Coombe Road, rests with local highway authorities (not National Highways), and the road network in other parts of the UK rests with the devolved administrations. I am responding in the capacity of National Highways’ responsibility for operating, maintaining and improving England's motorways and major A-roads. 2 CORONER’S MATTERS OF CONCERN The MATTERS OF CONCERN which were identified are as follows – “That there is a lack of knowledge and/or understanding as to when people should report an obstruction in the road. I would request that consideration is given to making all road users aware of the dangers of obstructions in the road and to encourage them to report any hazard to the local Police force or Local Authority so that it can be removed as soon as possible, or at least other road users be warned of the hazard to prevent a future death.” 3 DETAILS OF ACTION TAKEN Mr Wood’s death was a tragedy and our sympathies are with his family and friends. At National Highways safety is at the forefront of every decision we make, and we are committed to the safety of everyone who uses our roads. Rule 280 of the Highway Code gives the following instruction to motorists in relation to obstructions – “If anything falls from a vehicle on to a motorway or other high-speed road, DO NOT remove the obstruction yourself. Stop in a place of relative safety (see Rule 275) and call the emergency services on 999. On other roads, you should only remove obstructions if it is safe to do so.” In September 2022, National Highways launched a road user notification study exploring additional actions that could be taken to further increase awareness among the public of what they can do if they spot someone in difficulty on any road. We have begun dialogue with external stakeholders. Our initial scoping discussions have revealed this to be a complex area which impacts and requires engagement with a wide range of public bodies (such as the Department for Transport, emergency services and local authorities) and other interested parties. 1 More generally, National Highways has an ongoing national programme of road safety campaign activity, intended to provide important guidance to drivers to make journeys safer, easier and more reliable. This ongoing campaign work includes a specific section on breakdown advice. We worked with external stakeholders to launch England’s first major campaign, in 2021, to raise awareness of the eCall or 'SOS' button function, which increasing numbers of newer cars come with. This button can be used to call for help, by the driver for themselves, or by the driver for someone else needing help, if a situation requires emergency services. This was on digital channels, including a dedicated campaign page on our website at nationalhighways.co.uk. The Highway Code as published by the Department for Transport was updated in September 2021, and also now advises the use of eCall to contact the police and to communicate a specific location directly to a 999 operator, under the Highway Code rules 277, 279 and 283. Further details are available on YouTube. We have since delivered further waves of the eCall awareness campaign, with updated messaging about using eCall if a driver sees somebody else in difficulty. In January 2022 we launched a ‘Driving on motorways' hub on our website, which provides a central point for our information and advice on motorway driving. The hub was launched alongside a multimedia campaign and radio day, with content featured on over 450 stations reaching over 6 million listeners. These activities were designed to provide even further information and safety advice to drivers travelling on all types of roads. We are committed to providing even more information that is accessible to drivers. 4 DETAILS OF FURTHER ACTION PROPOSED National Highways remains committed to helping drivers and their passengers be even safer and feel safer on all roads for which we are responsible. We will continue with our programme of road safety campaign activity as described above, which is intended to provide important guidance to drivers to make journeys even safer, easier and more reliable. We are also continuing the road user notification study launched in September 2022 as described above. It is our intention that, as part of the study, a shortlisted set of options will be prepared that could be implemented to further increase awareness among the public of what they can do if they spot someone in difficulty on any road. We plan to use the initial findings from our study to enable more detailed external stakeholder engagement to help shape these options. Subject to this wider engagement, we aim to complete the study by late Summer/Autumn 2023. Our next step will then be to prepare an implementation plan. 5 TIMETABLE FOR ACTION DATE ACTION Late Summer / Autumn 2023 Planned completion date of the road user notification study, subject to the wider engagement with external parties. Late Summer / Autumn 2023 Prepare a shortlisted set of options that could be implemented, along with an implementation plan. 2 6 SAFETY OF ROAD USERS The safety of everyone on all roads 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 on the Strategic Road Network. Although roads, especially high-speed roads, can never be risk-free environments, our absolute priority is the reduction of road deaths and injuries on our network. Every road death is a tragic loss of life. We are determined to reduce the number of fatal incidents and injuries on the Strategic Road Network, and we want everyone who travels or works on any of our roads to feel confident and safe. This is why we invest in road safety initiatives and public awareness campaigns, to help prevent death and injury and to help give drivers the information they need to have safer journeys. This is in addition to information provided in other areas, for example The Highway Code. We urge road users to act safely and sensibly, including by informing themselves about what to do in an emergency, who to contact, and how to avoid dangerous situations where possible, thereby minimising the risks to themselves and other road users. We remain committed to providing even more information that is accessible to drivers. 7 31 March 2023 Signed: Director of Road Safety Chief Executive 3
See every Prevention of Future Deaths report matching Road (Highways Safety) related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.