Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0260, written 1 Mar 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Mar 2024 |
|---|---|
| Reference | 2024-0260 |
| Deceased | Tina Neverland |
| Coroner | Bina Patel |
| Coroner area | Mid Kent and Medway |
| 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.
REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Highways Department Medway Council 1 CORONER I am Bina Patel, Area Coroner, for the coroner area of Mid Kent and Medway. 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. 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 8th August 2023 I commenced an investigation into the death of Tina NEVERLAND. The investigation concluded at the end of the inquest on the 30th January 2024. The conclusion of the inquest was that the deceased Tina Neverland died as a result of a Road Traffic Collision. The cause of death having been determined as: 1a Traumatic Brain Injury 1b Road Traffic Collision 1c 2 4 CIRCUMSTANCES OF THE DEATH The deceased Tina Neverland, a pedestrian was walking south along Maidstone Road before using the grassy central reservation on Maidstone Road, Chatham (A229) and has crossed the northbound carriageway when she was hit by a motorcycle which was being driven within the speed limit for the road. She suffered traumatic brain injury following the collision on the 26th July 2023 and despite treatment died at Kings College Hospital on the 30th July 2023. 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 could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The collision occurred on the northbound carriageway of the A229, Maidstone Road in Chatham near to the Holiday Inn. This section of road is within a heavily populated area to the south of Chatham and is subject to a 40mph speed limit. It is recognised as a busy road. The road consists of two carriageways, both of which have two lanes within them, the road effectively appears as a dual carriageway which is separated by a grass island. There are no barriers which separate the north and southbound carriageways. The MATTERS OF CONCERN are as follows. – (1) Evidence at the inquest revealed that at the point where the collision took place there is an area of pavement within the grass island which appears to be an area for pedestrians to cross, however, there are no road markings or signs to illustrate a pedestrian crossing. (2) The inquest heard evidence that there is also the presence and position of a bus stop in the area where the collision took place, however, there are no markings or signs to alert drivers as to illustrate a pedestrian crossing particularly where it appears a convenient place for pedestrians to alight a bus and use this area to cross the carriageway. (3) The evidence at the inquest also heard that was that whilst there is a traffic light controlled pedestrian crossing approximately 74 metres away from the site of the incident, the presence of the grass island close to where the incident occurred, which appears to be an area for pedestrians to cross on a busy carriageway in the absence of signage or warning to approaching vehicles is of safety concern. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 26th 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 namely the family, and Kent Police. 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 1st March 2024 Bina Patel Area Coroner Mid Kent and Medway
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: 25 March 2024 Ms Bina Patel Area Coroner Mid Kent and Medway Oakwood House Oakwood Park Maidstone Kent ME16 8AE Deputy Director’s Office Regeneration, Culture & Environment Medway Council Gun Wharf Dock Road Chatham Kent ME4 4TR Dear Madam, RE: Response to Regulation 28 Report Thank you for providing Medway Council with a Regulation 28 Report to Prevent Future Deaths, dated 1 March 2024, in relation to an incident on the A229 Maidstone Road, Chatham, on 26 July 2023. We are always deeply saddened to learn of loss of life on Medway’s roads, and I would like to extend my heartfelt condolences to the family and loved ones of the deceased. I write to provide you with Medway Council’s response to the Regulation 28 Report, in accordance with our duty to do so. As set out within Section 5 of the Regulation 28 Report, the incident occurred at a point on Maidstone Road, Chatham, where there are no formal pedestrian crossing facilities. As also noted within the Report, there is a controlled pedestrian crossing facility to the north (74m away) of this location. At present there is an existing paved area within the central reserve which can be accessed by road users, should they choose to. As noted, this location does not benefit from traffic controlling facilities, and is therefore currently uncontrolled in nature. This location has not previously come to the attention of the Council in relation to concern for safety, nor collision occurrence. Following becoming aware of the fatal collision, the safety history of this location was investigated. This indicated that prior to the tragic incident of July 2023, there had no collisions involving pedestrians recorded during the previous five years of operation on or around this part of Maidstone Road. Notwithstanding this, in response to the clear Coroner’s concerns raised, Medway Council shall programme a safety scheme to investigate the potential for safety enhancements at and/or approaching this location. This might involve for example consideration of signs and lines or layout changes. In order to consider any amendments to the existing layout and ensure no detriment to safety as a result of any amendments, Medway Council shall instigate a safety scheme which aims to aid safe operation at this location. Any amendments will be determined by the appropriate and proper study. This information is available in other formats and languages from the Medway Council on 01634 333333 - or - https://www.medway.gov.uk/contact If you wish to contact the Council through the Minicom (text) facility please ring 01634 333111 This piece of work will be included within the programme of projects commencing from April 2024. It is typical for such projects to be progressed as part of a programme under the Council’s Local Transport Plan for the financial year. The delivery timescales of any resultant amendments may be dependent on the scale of those amendments along with any associated necessary processes or works, however, it is anticipated that any resulting amendments would be delivered as soon as available within the 2024/25 programme. Should you require clarification in relation to the above, or require any further information, please do let me know. Yours sincerely Deputy Director of Place 2
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