Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0075, written 12 Feb 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Feb 2024 |
|---|---|
| Reference | 2024-0075 |
| Deceased | Natalie Mountford |
| Coroner | Brendan Allen |
| Coroner area | Dorset |
| 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: 1. Wessex Water Services Limited, Claverton Down Road, Bath 2. Dorset Council, County Hall, Colliton Park, Dorchester 1 CORONER I am Brendan Joseph Allen, Area Coroner, for the Coroner Area of Dorset 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 the 22nd December 2022, an investigation was commenced into the death of Natalie Christina Mountford, born on the 9th March 1977. The investigation concluded at the end of the Inquest on the 5th February 2024. The Medical Cause of Death was: 1a Multiple Injuries Consistent with a Road Traffic Collision 1b 1c 2 The conclusion of the Inquest recorded that Natalie Christina Mountford died as a consequence of a Road Traffic Collision. 4 CIRCUMSTANCES OF THE DEATH Shortly after midnight on 18th December 2022, Natalie Chistina Mountford was travelling from Shaftesbury to Sturminster Newton on the B3019 in her Vauxhall Astra, when she came across a single vehicle road traffic collision in the St 1 James’ Common area: a Vauxhall Corsa, driven by , had lost control on ice that was present on the B3091 and collided with one or both verges, coming to rest in the opposing lane, with the front of the vehicle pointing into the verge. Ms Mountford came to assistance, and invited her to sit in the rear of her Astra to keep warm while they awaited the Emergency Services. Ms Mountford remained outside of the vehicle. Shortly thereafter, , driving a Citreon Berlingo, again travelling from Shaftesbury in the direction of Sturminster Newton, tried to stop at the scene, but lost control of his vehicle on the ice that was present on the road. He elected to mount the verge to drive around the passenger side of Astra. As he died so, Ms Mountord walked around the front of her vehicle and she was struck by the Berlingo. Ms Mountford died at the scene as a consequence of the injuries she sustained. Witnesses describe water flowing down the hill, with ice having formed as a consequence of the sub-zero temperatures that prevailed that night. 5 CORONER’S CONCERNS The MATTERS OF CONCERN are as follows: 1. During the inquest evidence was heard that: i. There have been multiple road traffic collisions on this section of road within the seven years prior to Ms Mountford’s tragic death, including another fatality in December 2017 caused by the presence of ice on this section of the road. ii. When Dorset Council highways inspections take place, the Inspectors will not consider or potentially investigate the possible source(s) of water running or on or across a road. While it is accepted that there will often be occasions where the source of the water will be obvious (eg excessive rain fall), there may 2 be occasions where the water is emanating from a source where remedial action can be taken to prevent the continued flow of water on to the road. iii. Wessex Water do not appear to have a system in place to log and progress reports of potential leaks made directly to Wessex Water staff: a member of Dorset Council staff sent an email to a member of Wessex Water staff subsequent to the events of 18th December 2022 to alert them to the presence of a possible leak from the water pipe running underneath the B3091, which was causing water to flow down and across the road, warning of the risk that the water may freeze with the forecast temperatures. In preparation for the Inquest, Wessex Water could not find the email send by Dorset Council or any responses. In addition, though action was subsequently taken on 17th January 2023 to repair a leak at this site, it was part of Wessex Water’s routine leak inspection process, and not in response to the information received from Dorset Council. 2. I have concerns with regard to the following: i. This section of the B3091 appears to be an accident “black spot”, with previous collisions likely to have occurred as a consequence of the presence of ice on the road, combined with a steep incline and a bend in the road; ii. The presence of flowing water in a road is not considered and/or investigated by Dorset Council Highways Officers when conducting a highway inspection, leading to a risk that remedial action to stem the flow may not be taken, further leading to the continued presence of flowing water on a road. The presence of water itself could cause or contribute to a road traffic collision, but if the water were to freeze in sub-zero temperatures, the risk of a collision increases further; 3 iii. There would appear to be no process in place at Wessex Water to log and action reports made directly to staff of water leaks onto a highway, or if a process is in existence it would appear not to be robust. The risk is that such reports may be “lost”, with the necessary work not undertaken, leaving water flowing from a leak on the highway, with the subsequent risk outlined above. 6 ACTION SHOULD BE TAKEN In my opinion urgent 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, by 8th April 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) Meesons & Spurlings Solicitors, representing , Natalie Mountford’s daughter; (2) (3) (4) Horwich Farrelly Solicitors, representing , Natalie Mountford’s father; , the father of Natalie Mountford’s children; on behalf of Ageas Insurance. 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 Dated 12th February 2024 Signed Brendan J Allen 4
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.
Road Safety Team County Hall Colliton Park Dorchester DT1 1XJ www.dorsetcouncil.gov.uk Date: 26 April 2024 Mr B J Allen, HM Area Coroner The Coroner's Office for the County of Dorset Civic Centre Bournemouth BH26DY Dear Mr Allen Natalie Christina Mountford deceased I write to provide a response to your Regulation 28 Report, received on the 12 February 2024, following the conclusion of the inquest into the death of Natalie Christina Mountford. You raised urgent concerns with regards the following: I. II. This section of the 83091 appears to be an accident "black spot", with previous collisions likely to have occurred as a consequence of the presence of ice on the road, combined with a steep incline and a bend in the road. The presence of flowing water in a road is not considered and/or investigated by Dorset Council Highways Officers when conducting a highway inspection, leading to a risk that remedial action to stem the flow may not be taken, further leading to the continued presence offlowing water on a road. The presence of water itself could cause or contribute to a road traffic collision, but if the water were to freeze in sub-zero temperatures, the risk of a collision increases further. I have discussed the concerns raised within the report with colleagues across the Council's Highway Service as well as road safety professionals within the Dorset Road Safety Partnership (DRSP). I am proposing the following commitments in response to your report. Point I - Commitment 1 Within the report I noted reference to the term accident "black spot". Our local Emergency Services and local Highway Authorities have worked hard to stop using the word 'accident' in their communications, as it implies road traffic collisions are unavoidable, and risks obscuring accountability for death and injury on the roads. The National Police Chiefs' Council and Parliamentary Advisory Council for Transport Safety are among those calling on others to use the term 'collision' or 'crash ' instead and whilst the term 'accident' remains in legislation the Department for Transport have recently announced it would no longer use 'accident' in some publications, after feedback from affected families and transport professionals. Dorset Council and the wider DRSP remain committed to using appropriate language when describing road traffic collisions especially those involving loss of life. Point I - Commitment 2 The Inquest heard what was described as multiple road traffic collisions that had occurred on this section of road within the seven years prior to Ms Mountford's tragic death, including another fatality in December 2017 caused by the presence of ice on this section of the road which led to the observation that it appears to be an accident "black spot". A wide variety of factors influence the occurrence of road traffic collisions, many of which are outside the direct control of the council such as human error and behaviour. Road safety is a statutory responsibility and one of the highest priorities for the council. We adopt the safe systems model which seeks amongst other things to implement mitigations that can address common human errors or the consideration of more significant highway improvements when required. We work with partners to reduce serious collisions and after every fatal road traffic collision the Road Safety Team conduct a joint site visit with Dorset Police to consider any factors regarding the condition of the highway which could have contributed to the collision and take any necessary mitigating action to maintain the highway to a safe standard to prevent future collisions. On the 4 January 2023 a joint site visit was conducted by qualified Road Safety Auditors from the team during which it was identified that water flowing out of the road surface over the middle of the carriageway (leading to the possible build-up of ice/slush) was a likely contributing factor. The water appeared to be emanating from a Wessex Water (WW) trench reinstatement and therefore contact was made with WW to ensure that they would take action to address the risk with their asset. The auditors were notified by Dorset Police that water on the road was an active line of enquiry and that investigators from the Serious Collisions Investigation Team were in contact with WW. The auditors noted that as a precaution the local Highways Team would be digging out the existing and some additional drainage ditches to assist water flow. The auditors did not identify any other safety factors that were required to maintain the road to a safe standard. As part of the site investigation consideration was given to the tragic road death which occurred near to this location on the 19 December 2017. It was noted that after this collision (2017) the road was resurfaced with the roads camber being adjusted to improve the ride quality and to ensure that any naturally occurring surface water entered the existing drainage system in an efficient manner. These works were complete in September 2018. Dorset Council uses the criterion of 4 or more collisions over 5yrs within a 30-meter radius to identify a collision cluster site. The dataset is run every year and leads to a programme of investigative work to identify locations and themes that can receive a proportionate intervention linked to either an engineering, educational or enforcement solution. This year the analysis identified 72 collision cluster sites requiring assessment. We believe this focus on collision cluster sites has helped the downward trend in fatalities and serious injury collisions. The location where this collision occurred was not an identified cluster site prior to the fatality on the 18 December 2022 and has not been identified as a cluster site during the most recent analysis. The Road Safety Team also conduct a rolling programme throughout the year of what are called Route Treatments which is a process of addressing any collision problems on key roads across the county ensuring a holistic safety assessment of the network occurs in addition to focusing on individual collision cluster sites. I will commit my team to review the B3091 between Sturminster Newton and Shaftesbury within the next three months to consider whether there are any additional proportionate improvements required. Point 1- Commitment 3 There is no recognised national criterion for identifying collision cluster sites leading to a degree of autonomy and variance between local Highway Authorities. The report has helped to identify that whilst Dorset Council has a documented collision cluster site criterion there is no recognised criterion used by Dorset Police. I will commit to reviewing Dorset Councils collision cluster site criterion to ensure that our processes are sufficiently robust to provide the greatest opportunity to identify high risk locations within the urban and rural network. I will also commit to bringing this to the attention of the DRSP to consider the potential benefits of agreeing a criterion across the partnership which may help to inform future road death Inquests. Point II - Commitment 4 Section 41 of the Highways Act 1980 places a statutory duty on highway authorities to maintain highways in such a state of repair that it is reasonably passable for the ordinary traffic without danger being caused by its physical condition. The standard of repair of the highway must reflect the type and level of use that is made of it. The Highways Act provides a special defence for highway authorities where it can be demonstrated that such care was taken as in all the circumstances was reasonably required to secure that the part of the highway in question was not dangerous to traffic. In this regard, Dorset Council undertakes a programme of scheduled inspections of the highway network. The operating parameters for these inspections, including the frequency and method of inspection, as well as prescribed investigation levels for safety defects are set out within the Council's Code of Practice for the Classification of Highway Safety Hazards & Defects. All officers undertaking inspections complete LANTRA Awards Highway Safety Inspectors Training and are registered on the Institute of Highway Engineers National Register of Highway Inspectors. The Council's Code of Practice adopts a risk-based approach to safety inspections in accordance with guidance provided by the UK Roads Liaison Group's publication 'Well-Managed Highway Infrastructure" (2016). In addition to this hazards which may affect the safety and/or the serviceability of the highway network can be identified through various routine highway maintenance operations such as cyclical maintenance activities e.g. gully emptying and through ad-hoc inspections undertaken in response to public enquiries. The Code of Practice provides advice and guidance for instances wherein flooding, surface water and slippery fluids may present a hazard to the highway user. However, we will commit to reviewing this policy document with in the next six months to ensure that it is sufficiently robust. Point II - Commitment 5 There is no positive statutory duty placed upon a highway authority to drain a highway; however, section 41(a) of the Highways Act (1980) places a duty upon highway authorities to ensure, so far as is reasonably practicable, that safe passage along a highway is not endangered by snow or ice. This particular duty is not an absolute duty as it is not always possible to clear snow and ice. It does, however, require that the highway authority plans, in accordance with best practice, to address the foreseeable risks. In this regard, best practice guidance is provided by the UK Road Liaison Group in its publication 'Well Maintained Highway Infrastructure'; (2016). This guidance notes that given the scale of financial and other resources involved in delivering the Winter Service, it is not considered reasonable either to provide the service on all parts of the Network; and ensure carriageways, footways and cycle routes are kept free of ice or snow at all times, even on the treated parts of the network. Dorset Council sets out its plan for managing the highway network during winter in its 'Winter Service Policy and Operational Plan'. This policy is reviewed annually, and we will commit to reviewing the measures and actions set out in this policy with regards to the presence of water on the highway network encountered during precautionary salting operations. This review will be complete, and any identified amendments implemented, by September 2024. Your sincerely, Road Safety Manager Economic Growth and Infrastructure Dorset Council
Wessex Water YTL GROUP Mr Allen Area Coroner for the Coroner Area of Dorset The Coroner's Office for the County of Dorset Civic Centre Bourne Avenue Bournemouth BH26DY 8 April 2024 Dear Mr Allen Regulation 28: Report to Prevent FuturP. Death Investigation into the Death of Natalie Christina Mountford We have carefully reviewed your report into this tragic incident, following attendance by representatives from Wessex Water at the inquests on 31 January and 5 February 2024. In particular we have considered your comments on our record keeping processes, including the potential for reports of water on the highway to potentially be "lost". We have reviewed our processes and have made the following changes: • Where a Local Authority Highways team raises concerns of water on a highway potentially caused by a Wessex Water asset, we shall log these on our customer services system. This generates a 'record' for each report which will allow us to formally acknowledge receipt, track investigations and send updates of findings and actions taken. This will reduce the risk of reports potentially being lost. • We are engaging with Local Authority Highways teams to identify actual or potential risks to users of the highway. Reports identified as high risk will be treated as a priority and all reports will be inspected as soon as possible. • We shall hold briefing events for all Highways teams in our area on the changes to our reporting system as the process rolls out. The operation and effectiveness of this process will be kept under review and may be amended if further improvements are identified. On behalf of myself and Wessex Water, I would like to extend our sincere condolences to the family and friends of Natalie Mountford. Yours sincerely Group Chief Executive Wessex Water Claverton Down Bath BA27WW 01225 526 000 Tel Web wessexwater.co.uk Wessex Water Services Limited registered office Registered in England No 2366648
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