Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0380, written 17 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 | 17 Jul 2024 |
|---|---|
| Reference | 2024-0380 |
| Deceased | Barry Howard |
| Coroner | Samantha Goward |
| Coroner area | Norfolk |
| 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: Lead Director Infrastructure Norfolk County Council Martineau Lane Norwich NR1 2DH 1 CORONER I am Samantha GOWARD, Area Coroner for the coroner area of Norfolk 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 December 2023, I commenced an investigation into the death of Barry John HOWARD aged 75. The investigation concluded at the end of the inquest on 16 July 2024. The medical cause of death was: Drowning 1a) 1b) 1c) 2) The conclusion of the inquest was: Accident contributed to by lack of visible warning signs of flooding and road closure. 4 CIRCUMSTANCES OF THE DEATH On 13 December 2023, Barry Howard was travelling along Mill Lane towards Shotesham Ford, an unbridged Ford, after 10pm. He was not familiar with the road which had previously been closed at the request of police due to flooding. The temporary signs indicating that the road was closed and impassable were not visible and the signs warning of the Ford and the depth of water, were beyond the flooded section of road, and on the balance of probabilities were not visible to Mr Howard before he entered the water. After entering the water his car was swept away into the river and he was found deceased in his car, which was almost completely submerged, at the Unbridged Ford, Mill Lane, Shotesham, Norfolk on 14 December 2023. Regulation 28 – After Inquest Document Template Updated 30/07/2021 The findings at Inquest were that: i. ii. iii. iv. v. vi. vii. viii. ix. Based on the evidence of the police and the fact that they found road closed signs on the side of the road and face down the morning after the collision, on the night of 13 December 2023, while Barry was travelling home after 10pm in the dark, on the balance of probabilities, there were no appropriate, visible signs or barriers, leading to the Ford at Shotesham, to tell him that the road was closed and impassable. Anyone unfamiliar with the road, or unaware of the flooding, would not therefore have known that the road was closed. There are no warning signs that the road is liable to flooding. I heard evidence that there are many Fords across the county, many of which may not significantly flood, but this Ford is prone to deep flooding. Without a sign warning that the Ford may also flood, it is unclear how anyone unfamiliar with that particular Ford would be aware of the level of risk. The road surface was completely submerged around 40m prior to the sign for a Ford. The sign for the Ford was beyond the area that was flooded so anyone unfamiliar with the road had no notice of the close proximity of the upcoming Ford before entering the area of flood water. The road slopes in the direction towards the Ford, so initially when entering the water it would not have been deep. It is not clear at what point it became so deep it was impassable or if there was a sudden change in depth. There was evidence in from reports from the Parish Counsil to Norfolk County Council that the surface of the road was very slippery. It is not possible to say whether Barry would have been able to brake and reverse easily after he entered the water and approached the Ford. I did not accept evidence that there is a gauge depth clearly visible from both approaches when the road is heavily flooded. Based on the police report & photographs the day after the accident, the gauge showing the depth of the flooded area was some way from the unflooded area of road and the road did not have street lights, and the gauge was on a bend - which, on the balance of probabilities, means that it would not have been clearly visible to Barry as he drove towards the flood, especially at night, so he had no way of knowing how deep the water was until he was some way in to the water. NCC Highways Dept were aware of difficulties with the Ford and that the signs and barriers, indicating that the road was closed were often moved and therefore not visible. They were also aware that the hinged sign to the east was damaged and inoperable. In accordance with the Traffic Signs and Regulations and General Directions 2016, when it became apparent that the road closure requested by police in October 2023 would be long lasting, there should have been an appropriate review and more permanent measures put in place including permanent and less mobile road closure signs, sufficient early warnings and a diversion. This would have prevented the issue of Barry driving down a closed and impassable road with no warning signs. It was my finding therefore on the evidence, that on the night of 13 December 2023 there was a lack of visible warning signs, before entering the flood water, of the proximity of the upcoming Ford, the impassable flooding and road closure. Regulation 28 – After Inquest Document Template Updated 30/07/2021 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) i. ii. iii. iv. v. vi. While the evidence I heard was that the Council consider that the current signage is adequate & has been inspected, there was a history of incidents reported to them, and sadly the very tragic death of Barry. That suggests that, while they consider it adequate, it was not sufficiently so to prevent those incidents & Barry’s death. I have heard nothing to reassure me that appropriate action has been taken to prevent others continuing to fail to be aware of the risk of the unbridged Ford, especially after heavy periods of rain. A lack of any appropriate warning signs that this Ford is prone to flooding which may make it unsafe to cross. A lack of signs sufficiently in advance of the Ford so as to warn road users at times of extreme flooding. The current signs were well within the flooded area on the night in question and I am concerned they would not be visible, especially to those unfamiliar with the road and in the dark, until they were already in the flood water. The slippery surface of the road. The insufficiency of the temporary road closed signs used and the lack of more permanent measures, in accordance with guidelines, once the closure lasted more than 24 hours. It was only a week prior to the inquest, some 7 months after this death, that action was taken. I am concerned that such lengthy delays to implement safety measures will lead to a risk in future incidents at this and possibly other locations. The evidence was that more appropriate measures for road closure should have been considered, but there was no evidence as to why they were not, or that this has been considered and action taken to address the reasons. I have not heard of any change to the way the team works, and I was repeatedly told they are a small team with a large area to cover – which means that there are risks of future issues with regards to the suitability of temporary signs and the correct procedures being followed when they need to be more permanent. 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 September 11, 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. Regulation 28 – After Inquest Document Template Updated 30/07/2021 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: Shotesham Parish Council RoSPA Department of Transport 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: 17/07/2024 Samantha GOWARD Area Coroner for Norfolk County Hall Martineau Lane Norwich NR1 2DH 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.
Infrastructure Department
County Hall
Martineau Lane
Norwich
NR1 2DH
NCC contact number:
Text relay no.:
Samantha Goward
Area Coroner for Norfolk
County Hall
Martineau Lane
Norwich
NR1 2DH
Your Ref:
Date:
04 September 2024
My Ref:
Tel No.:
Email:
Dear Madam
Thank you for your recent email and for the Regulation 28: Report to Prevent Future
Deaths following the recent Inquest relating to Mr Howard.
Please can I start with passing on my condolences onto the family of Mr Howard regarding
this tragic accident.
I would also like to take this opportunity to provide more detail with regard to the weather
conditions and the Council’s response to the recent tragic events, as part of the response
to the Regulation 28 Report.
Recently, the weather conditions in Norfolk have been extremely challenging – it having
been a very wet autumn, winter and spring period, with abnormally high levels of rainfall.
This has caused water levels across the county to remain high and the usual drop we
experience in spring each year did not materialise. These conditions explain why the peak
flows at Shotesham Ford have not reduced as they usually would each year, resulting in
the road closure being extended.
As the local highway authority for Norfolk, the Council is responsible for 47 fords across
6,200 miles of highway network. Within days of the incident on 13 December 2023, all
these fords had been inspected by the local Highways teams to ensure vehicle users
would encounter safe conditions. This initial review identified other locations where roads
were closed due to higher than usual water levels, and replacements for any missing and
damaged warning signs were also arranged. As a result of these actions, two further fords
on the Norfolk network (at West Acre and Caste Acre) were closed and remain closed to
ensure public safety.
Continued…/
-2-
Alongside this initial inspection work, more detailed safety reviews of all 47 fords in the
Norfolk network were commissioned. The characteristics of each ford across the Norfolk
highway network are different and therefore each ford requires a detailed, individual
assessment. As part of this review, Engineers are considering the points you have raised
in the Regulation 28 Report and are investigating other opportunities to further improve
safety at each ford location.
A specific safety review has also been undertaken by the Council at Shotesham Ford.
This has involved an initial scoping of options for addressing the specific issues identified
at Shotesham, which has developed into a full feasibility assessment of alternative
treatments at this location.
In terms of the Matters of Concern identified in the Regulation 28 report, please note the
following responses which follow the original numbering used:
i)
ii)
iii)
iv)
As stated above, a detailed safety review of Shotesham Ford has been
undertaken and a number of actions have already been completed, with further
planned. In addition, regular inspections have been undertaken to assess the
safety of reopening the ford on a weekly basis and the results of these,
combined with the groundwater challenges explained above, have resulted in
the ford remaining closed to traffic. Despite regular complaints from local
residents and businesses, this remains the case. Given the longer than
expected ongoing nature of this closure and evidence to suggest that the road
closed warning signs and barriers were being ignored by motorists, the Council
therefore recently improved the barriers, by way of installing immovable barriers,
to ensure motorists could not continue ignoring the warning signs and barriers.
Your comments about lack of warning signs have been noted – please see the
Actions Already Undertaken & Proposed Actions section below.
Your comments about lack of warning signs in advance of the ford have been
noted – please see the Actions Already Undertaken & Proposed Actions section
below.
Your comments about the slippery surface of the road have been noted – please
see the Actions Already Undertaken & Proposed Actions section below.
Continued…/
-3-
v)
vi)
The temporary road closed signs that have been used are the standard types of
signs and barriers used across the country by highway authorities to implement
closures such as these. They are usually effective. As explained above, water
levels had been expected to return to their normal safe levels in spring.
However, due to wider weather conditions, this has not been the case. Highway
users have a statutory right to pass and repass on the highway and therefore a
longer term closure requires consultation to ensure legitimate access to nearby
properties and agricultural land is not impinged. Planning the measures that are
currently in place, which included a localised consultation (given the complaints
received that the ford was temporarily closed), was undertaken this spring and
the measures installed on 9 July 2024. Regrettably, I report that since these
more robust measures were installed in July 2024, the warning signs have been
stolen on one side of the ford (identified on 1 August 2024) and the local
Highway team have made safe with temporary signs and ordered replacement
more permanent signs.
As outlined earlier in this response, there have been lessons learned from this
tragic incident. Safety inspections of all fords in Norfolk were undertaken
immediately after the event. Subsequently, more detailed site by site safety
reviews have also been undertaken, with measures such as improved signage
installed at a number of locations, and even some further road closures where
water levels were observed to be high.
Actions Already Undertaken & Proposed Actions
In summary, given the concerns raised in the Regulation 28 Report, together with the
fluctuating and higher than usual water levels at Shotesham, the Council deems it is not
safe to reopen Shotesham Ford at the current time and the option of permanent closure to
ensure public safety is being evaluated by the Council as part of the feasibility assessment
of longer-term options at Shotesham. Until the completion of this feasibility work, which is
expected later this year, the ford will remain closed.
In addition, every other ford location across the county has had an initial safety
assessment, resulting in the temporary closure of a further two fords, and more detailed
site-specific assessments are ongoing and, if deemed necessary, signing to improve road
safety is being identified and delivered.
I hope this provides further context and reassurance around the actions that the Council
has already undertaken and the further steps planned to be undertaken to help improve
highway safety at not just the ford at Shotesham but also the other fords across the
county.
Yours faithfully
Lead Director - Infrastructure
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