Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0096, written 17 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 | 17 Mar 2023 |
|---|---|
| Reference | 2023-0096 |
| Deceased | Benjamin Teague |
| Coroner | Anne Pember |
| Coroner area | Northamptonshire |
| 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. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive of National Highways National Highways Bridgehouse 1 Walnut Tree Close Guildford Surrey GU1 4LZ 1 CORONER I am Anne PEMBER, Senior Coroner for the coroner area of Northamptonshire 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 11 August 2021 I commenced an investigation into the death of Benjamin James TEAGUE aged 26. The investigation concluded at the end of the inquest on 08 March 2023. The conclusion of the inquest was: 1a Head Injury 4 CIRCUMSTANCES OF THE DEATH On the evening of 2nd August 2021, Benjamin Teague drove his BMW car on the A5 between Potterspury and Paulerspury. He overtook a vehicle, crossed to his incorrect side of the road where he collided head on with an approaching car. He was confirmed deceased at the scene. My conclusion was Road Traffic Collision 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 given that the A5 between Pottersbury and Paulesbury (scene of the collision) is in a very poor state with potholes. I understand that a repair was carried out shortly after the road traffic collision but has since deteriorated. I believe that this matter should be looked at by National Highways, 6 ACTION SHOULD BE TAKEN Regulation 28 – After Inquest Document Template Updated 30/07/2021 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. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by June 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons The family of Benjamin Teague 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: 14/04/2023 Anne PEMBER Senior Coroner for Northamptonshire 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.
REGULATION 29 RESPONSE TO A REPORT TO PREVENT FUTURE DEATHS THIS RESPONSE IS BEING SENT TO: 1. The Senior Coroner for Northamptonshire, Anne Pember, of The Guildhall, St Giles’ Square, Northampton NN1 1DE in response to a ‘Regulation 28 Report to Prevent Future Deaths’ following an inquest hearing into the death of Ben Teague that concluded on 08 March 2023. 1 NATIONAL HIGHWAYS , Regional Director, Midlands, Operations Directorate, I am responding on behalf of , Chief Executive of National Highways Limited of Bridge House, 1 Walnut Tree Close, Guildford, SURREY, GU1 4LZ. 2 CORONER’S MATTERS OF CONCERN The MATTERS OF CONCERN are as follows:– “During the course of the inquest evidence was given that the A5 between Pottersbury and Paulerspury (scene of the collision) is in a very poor state with potholes. I understand that a repair was carried out shortly after the road traffic collision but has since deteriorated. I believe that this matter should be looked at by National Highways.” 3 DETAILS OF ACTION TAKEN National Highways has a programme of routine safety inspections on the A5 All Purpose Trunk Road. Between the collision in August 2021 and October 2022 National Highways Inspectors instructed circa 1 pothole repair per month on the A5 between Potterspury and Paulerspury. This increased to over 3 per month in the last quarter of 2022. As a result, National Highways took the following actions: • • Increased the safety inspection regime from once every week to twice weekly to identify any immediate safety concerns in December 2022. Defects identified were made safe and repaired within risk based timescales set out in National Highways defect prioritisation guidance notes. Repair timescale is typically within 24 hours for defects which could impact safety and within 28 days for those defects with a high potential of deteriorating to a condition that could impact on safety. Imposed an advisory 40mph speed limit along the affected stretch (approx. 3km length between BP petrol station at Paulerspury and the Super Sausage Cafe at Potterspury) to further mitigate potential risks to road users in February 2023. • Carried out localised repair work of patches of between 7m to 160m in length over a 2-mile section of carriageway between Potterspury and Towcester between 9 and 10 January 2023. • Commenced work on an extensive seven-phase road resurfacing scheme to renew targeted sections of the running surface along the A5 between south Northamptonshire and Atherstone. This work commenced on 20 February 2023. The link to the A5 press release can 1 be found here: https://nationalhighways.co.uk/our-roads/east- midlands/east-midlands-maintenance-schemes/. o The phases are being implemented working northwards on the A5. o Phase 1 and 2 are the A5 from Old Stratford Roundabout (Junction with A508) and Weedon Bec (Junction with A45) and includes the road resurfacing between Paulerspury and Potterspury. o Work on the first phase was completed on the weekend of 13 and 14 May 2023. o The second phase is substantially complete. o Phase 3 and 4 are the A5 between Weedon Bec (Junction with A45) and Crick (Junction with M1 J18). The work on phase 3 and 4 was completed on 12 May 2023. o Work on Phase 5 from Crick (Junction with M1 J18) and Nuneaton (Junction with M69) is due to commence in early June 2023. o The programme for phases 6 and 7 is still being finalised. 4 DETAILS OF FURTHER ACTION PROPOSED SETTING OUT THE TIMETABLE FOR ACTION As the road resurfacing work on the A5 is taking place along a 47-mile stretch of the road it will take several months to complete. As the work programme for these remaining sections is confirmed we will update our website at https://nationalhighways.co.uk/our-roads/east-midlands/east-midlands- maintenance-schemes/. In the meantime, our National Highways Inspectors are continuing to carry out twice weekly safety inspections of the road with temporary repairs carried out as necessary until the road resurfacing work is completed. Once completed, the inspections will then revert back to a weekly inspection. 5 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 on the A5 to the road surfacing is designed in this light to help to prevent future deaths at this location. In addition to the surfacing, National Highways has delivered an improvement scheme on the A5 at the Paulerspury junction in March 2023. The safety improvement scheme at Paulerspury was identified and prioritised on the collision history at the location based on the validated data as published by the Department for Transport to reduce the incidence and severity of collisions at the location. The safety scheme installed anti-skid road surfacing and improved the warning signs for drivers and the visibility of road markings. 2 6 23rd May 2023 Signed: , Regional Director on behalf of 3
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