Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0214, written 27 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 | 27 Jun 2023 |
|---|---|
| Reference | 2023-0214 |
| Deceased | Richard Littlewood |
| Coroner | Lorraine Harris |
| Coroner area | East Riding and Hull |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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: Local Authority for East Riding of Yorkshire – Highways Department 1 CORONER Miss Lorraine Harris, Area Coroner, East Riding of Yorkshire and City of Kingston Upon Hull. 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 2nd August 20222 I commenced an investigation into the death of Richard Stephen LITTLEWOOD, aged 40 years. The investigation concluded at the end of the inquest on 26th June 2023. The conclusion of the inquest was Road Traffic Incident. Box 3 of the record of inquest read: On 8th July 2022 Richard Stephen Littlewood was travelling on his motorcycle on the A1033. As he rounded a bend his motorcycle crossed the white line and he struck an oncoming vehicle. Mr Littlewood was conveyed to Hull Royal Infirmary with multiple traumatic injuries. He spent 3 weeks in intensive care but died on 29th July 2022, he was 40 years of age. One of the findings of fact stated: The Forensic Collision Investigator feels, and I agree, that it was likely rider error, braking on the bend caused the motorcycle to become upright and travel in a straight direction. Mr Littlewood’s medical cause of death was recorded as: COD: 1a 1b 1c Bronchopneumonia Multiple traumatic injuries Road traffic incident 1 4 CIRCUMSTANCES OF THE DEATH Mr Littlewood was travelling on his motorcycle with a friend in convoy, he has braked when taking a bend in the road causing his motorcycle to travel in a straight line and into the path of an oncoming vehicle. He was conveyed to Hull Royal Infirmary with traumatic injuries. He died 3 weeks later 29th July 2022. 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 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. – (1) Evidence was heard that, on this particular stretch/bend of the A1033, there have been 3 incidents that have occurred within a short space of time. • A fatality leading to the death of Mr Littlewood in July 2022. • A fatality leading to the death of another male in November 2022. • An incident involving a farm vehicle which shed its load in late June/early July 2022 (very little details are known of this, suffice that it occurred near the location of the bend in the road where Mr Littlewood died, albeit on the opposite side). I do acknowledge that each of these incidents are completely different scenarios. It may be worthwhile to note that it is local road users that have been involved in all the incidents. (2) During evidence it was heard that signage and road markings have been discussed between the police and Highways that may make the road safer. Some signage had been put in place but an assessment needs to be completed for additional road markings and the timings for this were unclear. I am aware that after every fatality in this area the police and the Highways liaise with each other over signage/road markings as a matter of course. I have concerns only regarding the fact that no timescale had been set for the assessment to take place. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your department/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 2 report, namely by 22nd 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 • The family of Richard Stephen LITTLEWOOD • Roads Policing for Humberside Police 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 other 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. 9 [DATE] [SIGNED BY CORONER] 27th June 2023 Lorraine Harris 3
2 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.
County Hall Beverley East Riding of Yorkshire HU17 9BA Telephone (01482) 393939 www.eastriding.gov.uk Executive Director of Communities and Environment Miss Lorraine Harris, Area Coroner, East Riding of Yorkshire and City of Kingston Upon Hull. Date: 31st July 2023 Dear Miss Harris Death of Richard Stephen Littlewood Following your email of 26th June 2023 and addressing your concerns raised in section 5(2) of your report to prevent future deaths, I can confirm the following: 1. The chevron signs warning of the bends facing traffic in both directions have been replaced. This work was carried out in July 2023. 2. A winter visibility survey was undertaken at the bends on 17th January 2023, 3. This has been followed by a summer visibility survey undertaken on 13th July 2023. 4. These surveys confirmed that the visibility available around the bends is suitable for the 40mph speed limit that is in place and that the existing hazard warning centre lines are appropriate. There are no additional works planned at this site, though we will continue to monitor the condition of the highway and signing. Yours sincerely Principal Engineer, Civil Engineering Services Chief Executive
From: Sent: To: Subject: 29 June 2023 11 :38 RE: Report to Prevent Future Death Richard Stephen LITTLEWOOD Follow Up Flag: Flag Status: Follow up Completed Caution - This email was sent from outside of our organisation. Do not click on any links, preview or open any attachments, or provide any log-in details unless you recognise the sender and know the content is safe. Good Morning, With reference to the death of Richard LITTLEWOOD, Ms Harris requested that I re-attend at the scene of the collision to ascertain if the East Riding Council had caried out any remedial work. I can confirm that new signage has been installed to pre warn drivers of the bends. If you could please ensure this is passed to the coroner for her reports. The generic email address for all staff in our unit is sou serious collision@humberside.police.uk If you require any further assistance please do not hesitate to contact me. Kind Regards Serious Collisions Investigator Serious Collisions Unit Humberside Police Wyke Way Melton HU143BQ 1
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