Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0355, written 7 May 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 May 2024 |
|---|---|
| Reference | 2024-0355 |
| Deceased | Matthew Scott |
| Coroner | Sabyta Kaushal |
| Coroner area | Derby and Derbyshire |
| 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 1 CORONER I am Sabyta KAUSHAL, Assistant Coroner for the coroner area of Derby and Derbyshire 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 21 March 2023 I commenced an investigation into the death of Matthew SCOTT aged 24. The investigation concluded at the end of the inquest on 22 April 2024. The conclusion of the inquest was that: Matthew James Scott died on 11th March 2023 whilst travelling east on Station Road, Melbourne. The road had a speed limit of 40mph. He was travelling to his place of work at East Midlands airport when he hit a lengthy defective and subsided stretch of road which was filled with ice. That combined with his speed, which was likely to be in excess of 40mph, caused him to lose control, impact with a tree and sadly resulted in his death. 4 CIRCUMSTANCES OF THE DEATH 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) At 6 weeks post Mr Scott's death - on the 28th of April 2023 - a discussion took place between collision investigator officers, a traffic management officer (all of Derbyshire police) with the Project Engineer of the Highways Authority of Derbyshire County Council. The officers raised their concerns that at the place where Mr Scott lost control of his vehicle (Station Road, Melbourne Derbyshire) there was a lengthy, defective and subsided stretch of road. Further that at the time of Mr Scott's death the subsided section of road was some 4 metres in width, 37 metres in length and 5 cms in depth. Further, that it was deep enough to have had standing water in it which at the time of Mr Scott's death had turned to ice. Ice in the said defect would likely cause a vehicle to lose grip on the road surface. At that section of road, the road starts to bend to the right such that losing control on the ice could cause a vehicle to veer to the offside of the road, either into the path of an oncoming vehicle, into the opposite field or as in Mr Scott’s case, a tree. The Project Engineer of the Highways Authority discussed his concerns and the concerns CONTROLLED Regulation 28 – After Inquest Document Template Updated 30/07/2021 that had been raised by the police, with the highway maintenance department in early May 2023. As at the date of the inquest into Mr Scott' death (22 April 2024) this stretch of road had not been surveyed, no consideration had been given to the concerns of the police and no decisions taken to repair the defect so as to prevent any further accidents. 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 July 02, 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 I have also sent it to PROJECT ENGINEER HIGHWAYS AUTHORITY 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: 07/05/2024 Sabyta KAUSHAL Assistant Coroner for Derby and Derbyshire CONTROLLED 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.
RESPONSE TO REGULATION 28 NOTICE FROM DERBYSHIRE COUNTY COUNCIL This is the response to the Regulation 28 Report to Prevent Future Deaths issued by Assistant Coroner for Derbyshire and Derby, Sabyta Kaushal dated 7th May 2024. It is noted in section 5 – Coroner’s Concerns that reference is made to the site visit on 28th April 2023 that the discussions that took place were that officers stated that “there was a lengthy, defective and subsided stretch of road. Further that at the time of Mr Scott's death the subsided section of road was some 4 metres in width, 37 metres in length and 5 cms in depth. Further, that it was deep enough to have had standing water in it which at the time of Mr Scott's death had turned to ice”. This appears to be information contained in the site report which appeared at section 6 page 19 of 38 in the redacted reconstruction report prepared by . It is however expressed somewhat differently in the actual site report than in the Coroners’ Regulation 28 Report. The site report states as follows “Large patch of ice on the road surface measuring 4 metres in diameter and 37 meters in length. Commencing the in the centre of the carriageway, 4 metres prior to the entrance of the Melbourne Hotel, and terminating in the south-east bound lane. The area predominantly covered the south-east bound lane. It must be noted that this had reduced in size during my attendance due to weather conditions”. This does not say that there was a defect in the road but ice formation. There were some minor differences in level within the carriageway which allowed water to stand, such minor differences in level would be typical of an evolved road network in similar settings such as this and other areas of road across the county. Due to the inconsistency between the site report carried out by and the concerns raised by the Coroner Derbyshire County Council have undertaken a laser survey dated 26/04/2024. The results of the survey also clearly shows there was not an actionable safety defect that measured 4m wide by 37 meters in length, as that was the ice formation. The largest depth of pooled water was 30mm in a small, isolated area of subsided carriageway. We can only conclude that the 50mm depth of water was a pothole within this localised subsidence. Ice also forms on flat surfaces, where water has been tracked, and it is the ice area that is referring to and not a defect. Further in order to consider the issue of pooled water we have had photographs taken over the area referenced by the coroner on two separate dates following periods of rain fall – these were dated 29th May 2024 and 4th June 2024. Although there is some pooling which is normal it is not evident that there are any large areas of concern. It should be noted that these investigations post date the issue of the Regulation 28 Report and some pothole areas have already been repaired. CONTROLLED As referenced above the road in question, Station Road, Melbourne is subject to quarterly inspections. We have noted the following from records; 13 January 2023 – 2 customer reports of pot hole received on the same day – area put in for ad hoc inspection 17 January 2023 - ad hoc inspection – a number of separate pot holes put in for repair ref. 50186345 works completed 1 March 2023 17 February 2023 routine inspection – defect noted – 28 day repair requested ref. 50189695 - completed 20 February 2023 9 May 2023 – routine inspection – jobs raised outside Melbourne view repair requested ref 50197481– completed 30 May 2023 ] 17 August 2023 – routine inspection – potholes repairs requested ref. 50204692 and 50204693 completed 04 September 2023. 22 November 2023 – routine inspection – potholes repairs requested ref. 50210507 completed on 21 December 2023. Competent inspectors have inspected the road and some defects have been noted and put in for repair. There have been no significant repairs requested and a defect as large as 37m long, 4 meters wide and a depth of 40mm or greater would certainly have been identified during a routine safety inspection. Nonetheless Derbyshire County Council take road safety very seriously and the area from Melbourne View Hotel to a point approximately 200 metres in an easterly direction has been put in for full width road surfacing work to be undertaken. This will be completed by 31 October 2024 and will level some of the deviations in the road surface caused by various pot hole repairs. It should however be noted that this road will continue to be treated as part of our Secondary salting network during the winter season, as per the Derbyshire County Council - Winter Service Policy. The resurfacing work will not prevent the formation of ice on the road surface should winter weather conditions be such that ice formation conditions are met. Director of Highways Derbyshire County Council 28 June 2024 CONTROLLED
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