Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0208, written 22 Jun 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Jun 2023 |
|---|---|
| Reference | 2023-0208 |
| Deceased | Mason French |
| Coroner | Derek Winter |
| Coroner area | Sunderland |
| Category | Child Death (from 2015) · 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.
Derek Winter DL
Senior Coroner for the City of Sunderland
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Road Safety Manager, South Tyneside Council
1
CORONER
I am Derek Winter DL, Senior Coroner for the City of Sunderland
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.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
3
INVESTIGATION and INQUEST
On 31st October 2022 I commenced an Investigation into the death of Master Mason
French, who was born on 2nd January 2011 and who died at Lizard Lane, Whitburn,
Sunderland on 25th October 2022 aged 11 years. The Investigation concluded at the end
of an Inquest on 22nd June 2023.
The conclusion of the Inquest was ‘Road traffic collision’.
The medical cause of death was: -
Ia Blunt Head Injury
4
CIRCUMSTANCES OF THE DEATH
Mason French died on 25th October 2022 at a concealed junction on Lizard Lane,
Whitburn., when his bicycle collided with a passenger bus.
Office of HM Coroner for the City of Sunderland, City Hall, Plater Way, Sunderland, SR1 3AA
www.sunderlandcoroner.co.uk
5
CORONER’S CONCERNS
The MATTERS OF CONCERN are, as follows: –
Despite the safety improvements at the location of the road traffic collision, I continue to
be concerned that without further measures cyclists in particular remain at risk in that
area.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you 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 21st August 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: -
• Family
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 this 22nd day of June 2023
Signature
Senior Coroner for the City of Sunderland
Page 2 of 2
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.
This document has been classified as: Protectively Marked Response to Regulation 28 Report – Response to Regulation 28 Report Subject: Mason French Date: 04/07/2023 Purpose of Report This report is to provide a response from South Tyneside Council to the Regulation 28 Report to prevent future deaths ( ) regarding the Death of Mason French. Background Information The coroners report raised the following concerns; Despite the safety improvements at the location of the road traffic collision, I continue to be concerned that without further measures cyclists in particular remain at risk in that area. The Report also identified that the following action should be taken; In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. Proposed Measures Officers in the road safety team have considered additional measures to improve road safety in the location of the collision and along the entire length of Lizard Lane, Whitburn. The options considered looked at the following road safety concerns. • Visibility - the visibility coming out of the lane is restricted by the existing stone walls on either side. This restricts visibility between road users. • Parking – Vehicles can park on Lizard Lane opposite the junction with the lane. This results in vehicles traveling Northbound on Lizard Lane, having to travel on the opposite side of the carriageway. • Traffic Speeds – Speed survey data indicates that traffic speeds on Lizard Lane are compliant with the 30mph due to the existing traffic calming measures. Due to the residential nature of this section of Lizard Lane a 20mph speed limit would be more appropriate. To address the above concerns, the road safety team are proposing to implement 3 schemes to improve road safety for all road users. -Road Safety Manager Page 1 This document has been classified as: Protectively Marked Response to Regulation 28 Report – To improve visibility, it is proposed to reduce the height of the stone wall on both sides of the access to the lane, by approximately 1m. This will greatly improve the visibility splay and will improve the intervisibility between road users. The proposals shown in Appendix A will keep the area clear of parked vehicles in the area around the collision. This will ensure that vehicles can remain on the correct side of the carriageway when passing the junction. The proposed parking restrictions will also look to protect the junctions of Highcroft Park, Westcroft and Maple Grove and further improve visibility. To improve road safety along the entire length of Lizard Lane in Whitburn, it is proposed to make Lizard Lane 20mph. As traffic speeds are currently above the compliance level for 20mph, it is proposed to implement additional traffic calming to further reduce speeds. Appendix B shows the extent of the proposed 20mph Zone and details of the proposed traffic calming. Next Steps As the stone wall is a council asset, works have been programmed to undertake the visibility improvements at the earliest possible opportunity. As this will require traffic management on the highway, an application has been made for the street works permit to undertake the works. The parking restrictions and change of speed limit require Traffic Regulation Orders (TRO’s). There is a formal legal process which must be followed to allow these restrictions to be implemented. This includes a formal consultation process with statutory consultees, elected members and residents. The changes to traffic calming do not require a TRO however, there is still a formal legal notification process which must be followed. For the measures that must follow the TRO process or legal notification, we cannot guarantee that the measures can be implemented as this would be seen to pre-judge the outcome of the consultation process. However, given the recent fatality, there should be sufficient grounds to overturn any objection on road safety grounds. -Road Safety Manager Page 2
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