Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0009, written 8 Jan 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 Jan 2024 |
|---|---|
| Reference | 2024-0009 |
| Deceased | Walter Faulder |
| Coroner | Nicholas Shaw |
| Coroner area | Cumbria |
| 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.
Kally Cheema LLB | Senior Coroner | Cumbria
Fairfield, Station Road, Cockermouth, Cumbria CA13 9PT
REGULATION 28 TO PREVENT FUTURE DEATHS
8 January 2024
THIS REPORT IS BEING SENT TO:
Highways, 3 Ridgeway, Quinton Business Park, Birmingham B32 1AF,
, Chief Executive, National
Area Transport & Highways Manager, Lillyhall Depot,
Workington (by email)
1 CORONER
I am Dr Nicholas Shaw, HM Assistant Coroner for Cumbria
2 CORONER’S LEGAL POWERS
I make this report under paragraph 7, Schedule 5, of the Coroner’s 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 20 December 2022 I commenced an investigation into the death of Walter
FAULDER. The investigation concluded at the end of the inquest . The
conclusion of the inquest was Death due to Road Traffic Collision and the
medical cause of death was 1a Multiple Injuries
4 CIRCUMSTANCES OF THE DEATH
Walter Faulder BEM was an 88 year old gentleman who lived alone in Wigton,
Cumberland. He had recently been discharged from hospital.
On Saturday 10th December 2022, Walter's daughter visited his address and
there was a Cranston’s shopping bag next to his chair. He said he had got the
bus to Orton Grange (where the shop is) and back which raised alarm bells to
his daughter. She asked him not to do this journey again as it is unsafe. Walter
stated that he believes there is a pelican crossing to assist him crossing the
road (A595). This is not the case at Orton Grange.
On Tuesday 13th December 2022, Walter has got the 400 bus at 16:10 hours
from Wigton and got off at Orton Grange. Walter has forgotten his wallet and
crossed the road to the middle island and continued onto the South-West
carriageway. He then collided with a vehicle, causing him to fall into the
chevrons in the middle of the road. At the time of the collision it was nearly dark
and the road was busy with a steady flow of traffic in both directions moving at
normal speed.
Walter was given first aid at scene, however he was pronounced deceased at
scene in the rear of the ambulance at 17:20 hours.
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 will 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) Walter seems to have believed that as a pedestrian he had right of way, he
may have been a bit confused having forgotten his wallet however the day
before the collision be referred to the illuminated pole in the central refuge as a
Belisha Beacon.
(2) I heard that this is a busy crossing point, schoolchildren cross morning and
evening for busses too and from school. There are also an increasing number
of older people living in nearby developments.
(3) I am concerned that without safety alterations further accidents and
possible fatalities may occur. Is there a case for lights to be installed?
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you
and 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 4th March 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 Walter's daughter
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 8th January 2024
Signature
Dr Nicholas Shaw
HM Assistant Coroner for Cumbria
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.
Good morning I am replying in response to the Regulation 28 Report concerning the death of Mr Walter Faulder. As previously stated we delayed a response until we carried out a survey. Connect Roads is responsible for the maintenance of the A595 at this location and is not aware of any previous incidents or concerns raised regarding the safety of the crossing point. To establish the numbers of pedestrians crossing at this point, a 12 hour survey was carried out at the pedestrian refuge location on Friday 8th and Saturday 9th March 2024 to ensure we captured a week and weekend day. The surveys were delayed so they were undertaken when it was fine weather. On the Friday there were 5 pedestrians crossing in the morning peak hour and 7 in the afternoon peak hour and on the Saturday there were there were 4 pedestrians crossing in the morning peak hour and 6 in the afternoon peak hour. Due to the numbers of pedestrians the existing refuge has been deemed an adequate crossing point, There are no concerns regarding the design or operation of the crossing, therefore no measures are proposed to alter the current arrangement. Any future concerns received or reported incidents will be reviewed accordingly. Kind regards Assistant Director of Highways and Transport, Place Sustainable Growth and Transport
Walter FAULDER - Regulation 28 Report 16/01/2024, 11:53:58 Subject: Sent: From: To: Cc: Attachments: Walter-Faulder-Prevention-of-future-deaths-report-2024-0009_Published.pdf @nationalhighways.co.uk> Follow Up Flag: Follow up Flag Status: Flagged Dear Dr Shaw, Re: Inquest Touching the Death of Mr Walter Faulder – Regulation 28 Prevention of Future Deaths Report I refer to the above Inquest and the Regulation 28 Report issued to the Chief Executive of National Highways Limited on 8th January 2024 as published on the Chief Coroner’s website. I am writing to inform you that National Highways is not the highway authority for the A595 at Orton Grange and is therefore not the appropriate authority to respond to the Regulation 28 report. The highway authority for the A595 at the location identified is the responsibility of Cumberland Council. I hope this assists. I would be grateful if you could confirm receipt. Yours sincerely, On behalf of , Chief Executive | Senior Lawyer Legal Services National Highways | Bridge House | 1 Walnut Tree Close | Guildford | Surrey | GU1 4LZ Mobile: Web: nationalhighways.co.uk
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