Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0088, written 13 Mar 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Mar 2023 |
|---|---|
| Reference | 2023-0088 |
| Deceased | Kelly Dunne |
| Coroner | Janine Richards |
| Coroner area | County Durham and Darlington |
| 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.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. 1 2 3 4 REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1. (Chief Executive Officer) Durham County Council CORONER I am Janine RICHARDS, Assistant Coroner for the coroner area of County Durham and Darlington. 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 12/07/2022 an investigation was commenced into the death of Kelly Nicola DUNNE. The investigation concluded at the end of the inquest on 20/02/2023. The conclusion of the inquest was one of Road Traffic Collision. The medical cause of death was:- 1a) Subdural Bleed, Diffuse Axonal Injury and Brain Swelling (Craniectomy on 02/07/2022) 1b) Road Traffic Accident Causing Severe Head Injury CIRCUMSTANCES OF THE DEATH The deceased died at the Royal Victoria Infirmary in Newcastle on the 4th of July 2022 as a result of fatal head injuries sustained in a road traffic collision on the 2nd July 2022. The collision occurred when the deceased pulled out of a side road, Pittington Road, into the path of a vehicle travelling in the outside lane of the A690. Regulation 28 – After Inquest Document Template Updated 30/07/2021 5 CORONER’S CONCERNS During the course of the investigation my inquiries 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: During the course of the Inquest evidence was heard from the lead road traffic collision investigator in the case that there are significant concerns in relation to the adequacy and layout of this particular junction and the five other junctions on this stretch of road (A690). Evidence was given that since this fatality, there has been another fatal road traffic collision on the 22/12/22, at the junction directly opposite. Further that between 11/01/00 and 31/12/22 there have been 21 collisions at this junction (including this fatality and 3 other serious collisions) and that there have been 29 collisions at the other junctions on this stretch of road (including one further fatality and 6 other serious collisions). The concerns in relation to this junction, and the other junctions relate to:- 1. The volume of traffic that the junctions must manage. 2. The complexity of traffic movement at the junctions. 3. The speed limit in the vicinity of the junctions. Concerns were also raised in relation to the planned extensive expansion/development of the area in the vicinity of the junction, including increased housing development, a proposed retail park, football site, as well as developments occurring more widely in the area which will lead to increased traffic, and that any proposed improvements to the junction are not required until prior to the occupation of the 39th dwelling on the site. The concern is that the proposals to improve the safety of the junction are not sufficient nor timely, and that consideration does not appear to have been given to reducing the speed limit within the junction series. A further concern was raised that the proposed improvements to the junction considered this junction in isolation, and did not consider the series of junctions on this stretch of road. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. Regulation 28 – After Inquest Document Template Updated 30/07/2021 7 8 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by May 08, 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 I have also sent it to 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 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 Dated: 13/03/2023 Janine RICHARDS Assistant Coroner for County Durham and Darlington Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
Janine Richards Assistant Coroner Coroners Office Civic Centre North Terrace CROOK DL15 9ES Dear Madam 04 May 2023 I refer to your report dated 13 March 2023 made pursuant to Regulation 28 of the Coroners (Investigations) Regulations 2013 (“the Report”). The Report was made following the inquest into the death of Kelly Nicola DUNNE, who died on 4th July 2022, which concluded was as a result of fatal head injuries sustained as a result of a road traffic collision on 2nd July 2022. The circumstances of the collision being identified as driver error when the deceased pulled out of a side road, Pittington Road, into the path of a vehicle travelling in the outside lane of the A690. The Council notes the Report indicates that you consider there is a risk that further deaths could occur on the A690 unless action is taken. You have indicated you believe that action should be taken to prevent further deaths and that the Council has the power to take such action. The Council is under a duty to respond to the report setting out what action it has taken (or proposes to take together with a proposed timetable) or provide an explanation as to why no action is proposed. As you will be aware the A690 at this location is a dual carriageway and serves as a strategic east/west route linking Durham to Sunderland, A1M / A19, with a number of minor side road junctions along its length and carries a significant number of vehicles daily (A690 25,000, Pittington Lane 4,000 and Lambton View 5,000). The junction in question is a standard layout across Durham and the wider national network. The section of A690, in the vicinity of the junctions, is designed to national speed limit standards and affords good sightlines however, due to the junction configurations, a lower limit of 50mph has been implemented. Historical speed data for the shows an average speed of 49 mph so drivers are complying with the posted speed limit. Unfortunately, there will always be a small percentage of drivers who drive at an inappropriate speed, and this happens regardless of the posted limit. Chief Executive Durham County Council, County Hall, Durham, DH1 5UF Main Telephone (03000) 26 00000 Text Messaging Service 07860 093 073– Your message must start with the word: INFO www.durham.gov.uk A speed limit is an absolute maximum, and it is the driver’s responsibility to drive at a speed suitable to the environment and conditions. It is an intention of the Department for Transport guidance to ensure that speed limits are credible with the aim that they become self-evident and self-enforcing, by virtue of their surroundings. A limit lower than the current posted limit would not be credible or appropriate and would likely result in a significant proportion of motorists ignoring the limit. In addition, the imposition of non- credible lower limits can raise expectations that the speeds of vehicles will be reduced but seldom realised in practice, resulting in greater danger with drivers making decisions based on incorrect assumptions, and also unfair criticism of the police who have to enforce the speed limits. With regard to section 6 of your report I can confirm we will continue to carry out our duty under Section 39 of The Road Traffic Act 1988 ‘to carry out studies into accidents arising out of the use of vehicles and, in the light of those studies, take such measures as appear to the authority to be appropriate to prevent such accidents’. When considering the need for road safety solutions, each scenario is analysed and prioritised accordingly, in the context of a Durham County road network of 3792km, with 2920 recorded personal injury accidents over a 5 year period (2018-2022) and, of those, approximately 32% were serious or fatal injury. It is appreciated that the circumstances surrounding every accident can be very emotive and in most cases, there can be demands for engineering measures to be implemented. We, like other Authorities, use a prioritised approach utilising the personal injury accident database. By using this database, it helps inform the decision-making process using factual data gained during Police investigations from each accident. It also helps identify accident profiles which may be suitable for consideration of engineering measures. We also consult with Durham Constabulary Traffic Management Officers for their input. Prior to the most recent accident there had been 6 accidents in the previous 5 years giving the site an annual average of 1.2 accidents per year, which was highlighted by our AIP team during their cluster analysis in the 22/23 financial year. However, given that the annual average accident total was remaining the same and, on the understanding that the impending traffic signals scheme was in development, it was considered that no further action was warranted in terms of AIP intervention. The impending traffic signals schemes in the area has been developed as part of a new housing development in West Rainton, where the developer was required to submit a Transport Assessment (TA) as part of their proposed housing development at the planning application stage. The TA details the impact on local traffic and transport that the development is likely to have and, in some cases, offers mitigation measures. When the TA was appraised for the development, volumes generated by the proposed housing development and future expected traffic growth were used to model the impact that it will likely have on the highway network caused by additional trip generation. Appraisal of the TA established that the West Rainton junction would be over capacity as the development became occupied and mitigation measures were required to alleviate traffic pressures. For this reason, a planning condition was placed on the developer to install traffic lights at the West Rainton location only upon occupancy of the 39th dwelling, and the impacts on the Pittington Road / A690 junction were assessed as being negligible. However, the Council took the opportunity to maximise improvements around this junction and made the decision to improve the Pittington Road / A690 junction in tandem with the West Rainton junction, using central government funding via the Local Transport Plan. Whilst the planning approval included the ‘trigger’ for signal installation, officers have worked closely with the developer and have successfully secured the necessary funding to allow the signal installation to be brought forward and a scheme to implement signal control at both the West Rainton and Pittington Lane junctions is programmed to commence 2nd May for approximately 14 weeks. I trust the above satisfies section 7 of your report. Yours faithfully, Chief Executive Officer
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