Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0358, written 3 Jul 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Jul 2024 |
|---|---|
| Reference | 2024-0358 |
| Deceased | Sonny Farrier |
| Coroner | Jeremy Chipperfield |
| Coroner area | Durham and Darlington |
| 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 (After Inquest) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive, Durham County Council 1 CORONER I am Jeremy Chipperfield , senior coroner, for the coroner area of Durham and Darlington 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 (linked here) and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 (linked here). 3 INVESTIGATION and INQUEST On 08-Dec-23, I commenced an investigation into the death of Sonny James FARRIER , 18 years old. The investigation concluded at the end of the inquest on 03-Jul-24. I concluded that death resulted from head injuries sustained in a road traffic collision, as described below. 4 CIRCUMSTANCES OF THE DEATH At around 1300 hrs on 2nd December 2023, the deceased was a passenger in a van travelling north-east along Butsfield Lane in Consett, when driving control was lost as the van slid downhill on ice and collided with a tree at the bottom of the hill, where the road changes direction. Having disembarked from the van, the deceased was struck by a car travelling in the same direction, a few minutes after the van; at the point of collision, the car 1 was also out of control due to slippery conditions on the same stretch of Butsfield Lane. On the same day, at least two further independent incidents of loss of vehicular control were caused by slippery conditions on the same stretch of Butsfield Lane. 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 MATTERS OF CONCERN are as follows. – The Road called Butsfield Lane in Consett (locally known as “Bogle Hole Lane”), approximately 1 km north-east of its junction with Delves Lane, includes a hill of between 19 and 21% gradient, with a bend immediately beyond its lower portion. In slippery conditions, and in the absence of effective mitigation, passage of vehicular traffic along this stretch of Butsfield Lane presents a hazard and risk of death to road users. 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 29 August 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. 2 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the family of the deceased. 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 03-Jul-24 Jeremy Chipperfield 3
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.
Mr Jeremy Chipperfield Senior Coroner for County Durham and Darlington HM Coroner’s Office Fourth Floor Civic Centre North Terrace Crook DL15 9ES By email 3rd September 2024 Dear Mr Chipperfield Fatal Road Traffic Accident Saturday 2nd December 2023 – Unclassified 11.3 – Butsfield Lane I write regarding the attached correspondence dated 3rd July 2024 relating to the unfortunate fatal accident which took place on the Unclassified Butsfield Lane in Consett, known locally as “Bogle Hole Lane”, on 2nd December 2023. The fatal accident investigation team identified six observations/recommendations. I can confirm following receipt of the fatal accident report council officers took the following actions regarding the observations/recommendations: • Replace damaged black and white marker post – The post has been replaced; • Check accuracy of gradient and if required change the existing sign with the “new” gradient – The gradient was checked between 2 known points 120m apart. It is accepted there are some isolated locations between the 2 points where the gradient exceeds 13% but the average gradient is 13%. No further action required/taken; • Repair existing weight restriction sign – Work completed; • Consider the provision of an additional salt bin – New additional salt bin provided; Neighbourhoods and Climate Change www.durham.gov.uk Page 2 of 3 • Consider repairing void “off the carriageway” near to the accident location – Work completed; and • Determine if the existing timber post and rail fencing surrounding the bridge parapet is sufficient - The bridge parapet (designed with a return) was assessed under IAN 97/07 Parapet Assessments as part of a Principal Bridge Inspection in 2017 and its condition at that time was deemed adequate for containment. As there has been no significant deterioration in the bridge condition these findings remain current. The existing timber post and rail fence is not part of the bridge structure and is in private ownership. No further action required/taken. In terms of the council’s winter maintenance policy I can confirm. Gritting Routes The Council precautionary salts 45% of our highway network as part of our Priority 1 network, with a further 10% being treated in prolonged severe weather as part of our Priority 2 network. This is much higher than many other similar Highway Authorities and shows the Council’s commitment to provide the best winter maintenance service we can in line with available resources. However, we need to ensure that these limited resources are used where they are most effective. Therefore, we concentrate our resources on strategic roads. Butsfield Lane is not a strategic road, and therefore, like many other rural / residential roads countywide it is not included in our priority treatment network. Our Winter Service Plan explains the rationale for our priority treatment routes and this is available on our website as follows: http://www.durham.gov.uk/winterserviceplan Emergency Assistance Our Winter Service Plan details how we can assist in the event of emergencies and prolonged severe weather. In summary, routes not on the priority treatment routes will be cleared at the request of the Emergency Services as appropriate. Prolonged Severe Weather The public may request for routes not on the priority treatment routes to be cleared by contacting our Customer Services team by one of the following routes: • Website: https://doitonline.durham.gov.uk/ • Telephone: 03000 260000 However, these requests can only be considered once the Priority 1 and Priority 2 routes are cleared and are prioritised subject to available resources. Salt Bins In addition to the gritting routes the council provides salt bins placed strategically across the highway network. Page 3 of 3 The assessment uses a salt bin scoring system for footways and carriageways which considers local factors such as gradients, highway usage, severity and frequency of bends, accident history, etc., in determining whether a request is justified. As a Council we currently provide over 2,400 salt bins countywide, and we must target our resources where they are most needed and where they can have the greatest impact considering the local factors mentioned above. Signage Following receipt of the council’s fatal accident report and the concerns highlighted in your report we have also investigated other potential safety features we could facilitate to improve safety on Butsfield Lane for example the introduction of additional signage. However, having reviewed and considered the advice provided in The Traffic Signs Regulations and General Directions 2016 there is not a sign, or combination of signs which would be suitable for this location. The council takes its responsibility to ensure the highway network is maintained in a safe and serviceable condition all year round and especially during the winter period. This can be evidenced by the importance it places on its winter service. However, on this particular road, having reviewed all options we don’t consider improvements to the network can be achieved practically and therefore whilst we accept the death of an individual as a result of weather conditions is a very emotive subject we have come to the very difficult conclusion that no further action is required on Butsfield Lane. Yours sincerely Head of Highways Copy , Strategic Highways Manager
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