Prevention of Future Deaths reports · 2023
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 report | 16 Aug 2023 |
|---|---|
| Reference | 2023-0295 |
| Deceased | Absolom Duffy |
| Coroner | Marianne Johnson |
| Coroner area | Lincolnshire |
| 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: 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
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.
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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