Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0536, written 20 Dec 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Dec 2023 |
|---|---|
| Reference | 2023-0536 |
| Deceased | Joanne Constable |
| Coroner | Caroline Jones |
| Coroner area | Cambridgeshire and Peterborough |
| 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. Cambridgeshire County Council 1 CORONER I am Caroline Jones, Assistant Coroner for the coroner area of Cambridgeshire and 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. 3 INVESTIGATION and INQUEST On 10 August 2020 I commenced an investigation into the death of Joanne Comstable aged 52 years. The investigation concluded at the end of the inquest on 30 October 2020. The conclusion of the inquest was that: Joanne died from multiple unsurvivable injuries sustained in a road traffic collision on the A141 Isle of Ely Way in Cambridgeshire when the motorcycle on which she was a passenger was in collision with a tractor whose view of the road was obscured by overhanging trees and vegetation. 4 CIRCUMSTANCES OF THE DEATH On 2 August 2020, Joanne Constable was the passenger on a motorbike which collided with a trailer being pulled by a tractor as it turned right out of a field onto the A141 Isle of Ely Way near Wimblington, Cambridgeshire. Due to vegetation growth of trees and bushes on the verge of the public highway, the tractor driver’s line of sight was obstructed, making it impossible to assess whether there was adequate time and distance to safely exit the junction. Consequently, the motorbike’s path was blocked by the trailer and the rider could not take evasive action in time to avoid the collision. Mrs Constable was thrown from the motorbike in the collision, sustaining multiple injuries and she was pronounced deceased at hours. 1150 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: Regulation 28 – After Inquest Document Template Updated 30/07/2021 In the course of evidence from the local authority’s highway maintenance manager, I heard concerning testimony as to the apparent lack of systems and processes in place to record complaints or reports of hazards or defects with the highway. Consequently, there seemed to be no way of identifying which reports had been actioned or inspected and even when the system indicated that an inspection had taken place and led to a recommendation for work to be carried out within a statutory timeframe, there was no information available on the system to show if or when any work was carried out, much less to what specification. On the evidence I heard, the circumstances prevailing at the entrance to Bypass Field onto the A141 Isle of Ely Way are replicated at many points across the county and therefore, should those with a statutory responsibility to maintain the highways, including verges, at public cost be unaware of the status of reported hazards or defects, there is a clear risk of future deaths occurring due to those with the responsibility not taking steps to remedy the problem and more fatal road traffic collisions occurring. 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 You are under a duty to respond to this report within 56 days of the date of this report, namely by 14 February 2024. 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 1. Family of Joanne Constable 2. 3. The insurers for respectively 4. Cambridgeshire County Council. as landowner and tractor driver I have also sent it to Cambridgeshire Constabulary who investigated the road traffic collision and therefore 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. Regulation 28 – After Inquest Document Template Updated 30/07/2021 9 Dated: 20/12/2023 Caroline JONES Assistant Coroner for Cambridgeshire and Peterborough 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.
Date: Contact: 13th February 2024 Caroline Jones Assistant Coroner for Cambridgeshire and Peterborough HM Coroner’s Office Dear Ms Jones, REGULATION 28 REPORT – RESPONSE Chief Executive’s Office Cambridgeshire County Council New Shire Hall Emery Crescent Enterprise Campus Alconbury Weald Huntingdon PE28 4YE I write in response to the Regulation 28 Report to Prevent Future Deaths, dated 20 December 2023, which followed the Inquest into the death of Joanne Constable. This letter details Cambridgeshire County Council’s response to the matters of concern that were raised, as listed below: 1. “In the course of evidence from the local authority’s highway maintenance manager, I heard concerning testimony as the apparent lack of systems and processes in place to record complaints or reports of hazards or defects with the highway. Consequently, there seemed to be no way of identifying which reports had been actioned or inspected and even when the system indicated that an inspection had taken place and led to a recommendation for work to be carried out within a statutory timeframe, there was no information available on the system to show if or when any work was carried out, much less to what specification.” 2. “On the evidence I heard, the circumstances prevailing at the entrance to Bypass Field onto the A141 Isle of Ely Way are replicated at many points across the county and therefore, should those with a statutory responsibility to maintain the highways, including verges, at public cost be unaware of the status of reported hazards or defects, there is a clear risk of future deaths occurring due to those with the responsibility not taking steps to remedy the problem and more fatal road traffic collisions occurring.” The County Council has considered with care the issues that you have raised. The Council does have systems and processes in place to record reports of hazards or defects, which I will refer to later in this letter. However, the Council also continuously develops its systems and approaches to improve the management of the highway and to ensure that we meet our statutory duty to maintain them safely. Chief Executive cambridgeshire.gov.uk I have set out below the processes that we have in place. Furthermore, as part of the County Council’s commitment to continued improvement I set out changes that the Council has, or is in the process of implementing, that should ensure the risk of future similar incidents is reduced and further mitigated across the highway network. Issue 1: Systems and processes that are in place to record complaints or reports of hazards or defects with the highway. • A clear process is in place for the inspection of the highway network. The inspection regime used by the Council is risk based and operates in accordance with UK Roads Liaison Group (UKRLG) Code of Practice ‘Well-managed highway infrastructure. The County Council’s Highway Operational Standards1 document sets out our operational policies and identifies the types of defects to be inspected also details the required intervention and repair timescales for these defects. These standards are reviewed on a regular basis. • The inspections are carried out by dedicated Highway Inspectors. Principal A- Roads (such as the A141 Isle of Ely Way), and main and secondary distributors are inspected monthly, in accordance with the Highway Operational Standards. Identified defects are recorded on the County Councils Highways Asset Management System. • The County Council’s Highway Inspectors are accredited with a City and Guilds qualification in highway inspections to provide assurance that those undertaking inspections are appropriately qualified to do so. The City and Guilds training is based on the County Council Highways Operational Standards document. • In addition, members of the public can report defects they have identified themselves. This can be done directly through the Cambridgeshire Highways ‘Report it’ tool on the County Council’s website, where any defect, concern or issue can be raised. This is achieved by dropping a pin onto a digital map and then completing a description of the issue. In relation to the location on Isle of Ely Way where the collision that resulted in the death of Joanne Constable occurred: • The County Council does cut back vegetation and cut grass to ensure visibility at junctions and key accesses to the highway. • However, the field access in question is private and not a part of the adopted highway and therefore would not be routinely cut back by the Council under this regime. The County Council is implementing a new Highways Asset Management System which will replace and improve on the current IT system. The new system has been specified to deliver a range of enhancements, alongside a new public reporting system. This report system will function as an integral part of the wider 1 https://www.cambridgeshire.gov.uk/residents/travel-roads-and-parking/transport-plans-and-policies/highway- policies-and-capital-maintenance-programme#highway-operational-standards-2-0 Highways Management System supporting single source records and continuity of information from report to works completed to customer feedback. This will therefore provide further assurance that all required works are logged and implemented in accordance with the Highways Operational Standards Issue 2: Awareness across the county of circumstances replicated at Bypass Field onto the A141 Isle of Ely Way • The County Council has a Green Infrastructure Team which is responsible for the safe management of vegetation to ensure the Council effectively meets its duty to maintain the highway in accordance with the Highways Act 1980. • The Green Infrastructure Team is responsible for the management of verges, hedges, and trees within the highway. The team will enable and deliver approaches to the safe management of vegetation that is consistently applied across the county’s road network. • The Green Infrastructure Team is resourced so that it can proactively manage areas of known risk and identify similar locations, raising works orders to attend to overgrowing vegetation on a cyclic and reactive basis. This will include proactively cutting back vegetation on major stretches of road that require maintenance. • As outlined above the implementation of the new highways management system will provide increased assurance that such works are logged and implemented in accordance with the Highway Operational Standards. Summary The County Council’s Highways Service has appropriate systems in place to manage risk on the highway and is taking action to further improve these to ensure the risk of future deaths from similar circumstances and situations is minimised as far as practicable. I understand that this response may be shared with the interested persons and would therefore wish to take this opportunity to express my sincere condolences to Joanne’s family on behalf of Cambridgeshire County Council. Yours sincerely, Chief Executive
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