Prevention of Future Deaths reports · 2023

Absolom Duffy

Regulation 28 report to prevent future deaths, reference 2023-0295, written 16 Aug 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report16 Aug 2023
Reference2023-0295
DeceasedAbsolom Duffy
CoronerMarianne Johnson
Coroner areaLincolnshire
CategoryRoad (Highways Safety) related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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  Highways AGENCY 

1  CORONER 

I am Marianne JOHNSON, HM Assistant Coroner for the coroner area of Lincolnshire 

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 16 July 2021 I commenced an investigation into the death of Absolom Adolphus 
Abraham Zephaniah DUFFY aged 21.  The investigation concluded at the end of the inquest 
on 17 May 2023.  The conclusion of the inquest was that: 

Absolom Duffy was travelling in his Land Rover Defender motor vehicle on the 8th July 
2021 when he exited from Sand Lane, Saxilby onto Doddington Road and collided with 
another vehicle.  Paramedics attended however he died as a result of his injuries. 

4  CIRCUMSTANCES OF THE DEATH 

Absolom Duffy was travelling in his Land Rover Defender motor vehicle on the 8th July 
2021 when he exited from Sand Lane, Saxilby onto Doddington Road and collided with 
another vehicle.  Paramedics attended however he died as a result of his injuries. 

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 B1190 Tom Otter’s Lane junction with  the C267 Sand Lane, Saxilby, Lincolnshire 
provides for the road user approaching from either direction on Sand Lane to give way to 
traffic on the major B1190 road.  There is a restricted view of the B1190 as a road user 
approaches the junction.  To be certain the B1190 road is clear a road user would be 
required to stop, however the road signage only requires a road user to give way.  Would 
the junction be safer for road users if it displayed a stop command rather than a give way 
warning? 

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. 

7  YOUR RESPONSE 

Regulation 28 – After Inquest 
Document Template Updated 30/07/2021 

 You are under a duty to respond to this report within 56 days of the date of this report, 
namely by October 10, 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 

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: 16/08/2023 

Marianne JOHNSON 
HM Assistant Coroner for 
Lincolnshire 

Regulation 28 – After Inquest 
Document Template Updated 30/07/2021

Responses

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.

Response from Lincolnshire Council (PDF)
Marianne Johnson
HM Assistant Coroner

Date: 19th September 2023

Dear Mrs Johnson,

Head of Highways Asset and Local
Management Services
Lincolnshire County Council
County Offices
Newland
Lincoln LN1 1YL

Tel: 
Email: 

REGULATION 28 REPORT – ABSOLUM ADOLPHUS ABRAHAM ZEPHANIA DUFFY

Thank you for your letter dated 16th August 2023 enclosing your Regulation 28 Report
following the inquest investigating the death of the late Mr Duffy. As required under Section
7 of your report, we have now considered your points and respond accordingly.

CIRCUMSTANCES OF THE DEATH:

Absolom Duffy was travelling in his Land Rover Defender motor vehicle on the 8th July 2021
when he exited from Sand Lane, Saxilby onto Doddington Road and collided with another
vehicle. Paramedics attended however he died as a result of his injuries.

YOUR MATTERS OF CONCERN:

Your concerns listed in the Report are:



The B1190 Tom Otter’s Lane junction with the C267 Sand Lane, Saxilby, Lincolnshire
provides for the road user approaching from either direction on Sand Lane to give
way to traffic on the major B1190 road. There is a restricted view of the B1190 as a
road user approaches the junction. To be certain the B1190 road is clear a road user
would be required to stop, however the road signage only requires a road user to
give way. Would the junction be safer for road users if it displayed a stop command
rather than a give way warning?

RESPONSE:

We have conducted a thorough investigation into this location, with your concerns in mind.
Over the last 5 years, there has been one other collision at this location. This was on the
South-West junction arm, the opposite side to this collision. This was a serious collision and
involved a lorry travelling South-West to North-East, not giving way at Sand Lane junction

_________________________________________________________________________________
County Offices, Newland
Lincoln LN1 1YL
www.lincolnshire.gov.uk

 with Tom Otters Lane, colliding with a car driving South-East to North-West. The collision

was during foggy and wet weather at 08:00 in the morning on 17

th

December 2021.

Tom Otters/Sand Lane junction is within a 60mph speed limit on all approaches. The
approaches along Tom Otters Lane have both map signs and crossroad warning signs on
each approach.

The warning signs from the North-West arm of the junction also have “370 yds” plates
below them. The ones from the South-East arm have “Reduce Speed Now” plates below
them. The North-Eastern arm, where the collision occurred, has an advanced “Give Way
300yds” sign with countdown marker signs at every 100 yards to the junction. The junction
mouth itself has a large yellow backed “Give Way” warning sign on each side. There are
centre lines on the approach and the give way markings at the junction.

The visibility at the junction to the South-East is approximately 220m. The visibility to the
North-West is approximately 200m. There is vegetation that could be cut back to improve
this further.

The Traffic Signs Regulations and General Directions deals with STOP signs. It states:







2.2.1.  STOP signs, other than at junctions with tramways, should be provided only
where visibility is so restricted that it is essential for drivers to stop before entering
the major road. The sign will be well respected only if drivers can see the need for it.

The possibility of making a visibility improvement at a junction should always be
investigated before considering a STOP sign. Restriction of visibility caused, for
example, by a hedge that can be reduced in height or removed will not normally
justify a STOP sign, particularly as highway authorities have powers under section 79
of the Highways Act 1980 to remove such obstructions.

2.2.2.  Visibility distances which a STOP sign might be considered are specified in
Table 2-1. Other factors which should be taken into account include traffic volumes
on both the major and minor roads, gradient of the minor road, accident record,
poor alignment or any other factors which cause unusual difficulty. It does not
automatically follow that STOP signs should always be provided at sites where the
criteria are met.

The visibility distance below which a STOP sign might be considered at this location is 90m
(based on using 85th percentile speed of 60mph) as specified in Table 2.1 of Traffic Signs
Manual Chapter 3.

In conclusion, as outlined above the visibility at the junction to the South-East is
approximately 220m. The visibility to the North-West is approximately 200m. As such, the
visibility at this junction far exceeds that required to consider a STOP sign (and would do
so for any 85th percentile speed) and so on consideration, we are not proposing to change
the existing GIVE WAY signage at this time.

2

 ACTIONS TAKEN (TO BE TAKEN):

 Vegetation at approaches to this junction will be assessed regularly by the Local

Highways team, with appropriate enforcement action taken to ensure that it gives
maximum visibility and does not reduce the splays when exiting onto the B1190.

Yours sincerely,

Head of Highways Asset and Local Management Services

3

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