Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0141, written 27 Apr 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 27 Apr 2023 |
|---|---|
| Reference | 2023-0141 |
| Deceased | Vivien Radocz |
| Coroner | Simon Milburn |
| Coroner area | Cambridgeshire and Peterborough |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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: 1 Peterborough City Council - Highways Department 1 CORONER I am Simon Milburn Area Coroner for the coroner area of Cambridgeshire & Peterborough. 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. The Coroners (Investigations) Regulations 2013 (legislation.gov.uk) 3 INVESTIGATION and INQUEST On 03.09.22 I commenced an investigation into the death of Vivien RADÓCZ, aged 28 years. The investigation concluded at the end of the inquest on 07.03.23. The conclusion of the inquest was: Medical cause of death:- 1a Drowning Inquest Conclusion – Road Traffic Collision 4 CIRCUMSTANCES OF THE DEATH Vivien was the driver of a Ford Focus motor vehicle travelling west along Old Oundle Road, Wittering at about 1035hrs on 03.09.22. The vehicle failed to negotiate a sharp left hand bend, left the carriageway to the offside before it entered a pond and became submerged upside down in water. Vivien was unable to escape from the submerged vehicle which was not discovered until around 1730hrs that day. Emergency services attended the scene and Fire Officers then extricated Vivien from the vehicle. Sadly her death was confirmed at the scene by a paramedic at 1942hrs 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: (brief summary of matters of concern) The vehicle involved in the collision failed to negotiate the left hand band on the westbound Old Oundle Road at Wittering adjacent to the rear crash gates of RAF Wittering. The vehicle left the road to its offside and entered a pond where it became submerged in water. The 2 occupants of the vehicle drowned as a result. There is sharp route deviation signage for vehicles travelling in the opposite direction but nothing to alert westbound drivers of the sharp left hand bend. The water beyond the bend Regulation 28 – After Inquest Document Template Updated 30/07/2021 clearly creates an additional hazard. Whilst the precise reason the vehicle failed to negotiate the left hand bend on this occasion is unclear I am concerned that the lack of signage alerting westbound traffic of the bend at this location creates a risk of future incidents and death, not least because of the water beyond. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has 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 July 05th, 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 AXA INSURANCE; (mother) I have also sent it to The Fenland Road Safety Campaign 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: 10/05/2023 Simon MILBURN Area Coroner for Cambridgeshire and Peterborough Regulation 28 – After Inquest Document Template Updated 30/07/2021
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