Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0454, written 13 Aug 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Aug 2024 |
|---|---|
| Reference | 2024-0454 |
| Deceased | Kial Thurman |
| Coroner | Nicholas Walker |
| Coroner area | Staffordshire and Stoke on Trent |
| 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 (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. Staffordshire County Council 1 CORONER I am Nicholas Walker, assistant coroner, for the coroner area of Staffordshire and Stoke- on-Trent. 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 18th December 2023 an investigation was commenced into the death of Kial Ryce Thurman. The investigation concluded at the end of the inquest on 2 nd August 2024. The conclusion of the inquest was that Kial Ryce Thurman died in a road traffic collision on 1 st December 2023. 4 CIRCUMSTANCES OF THE DEATH Kial was driving a transit van at speed along the A518 in the Lower Loxley area of Staffordshire heading in the direction of Uttoxeter when he lost control while navigating a right-hand bend immediately before a bridge that crossed the River Blythe. Either because Kial over-corrected his steering, or because the van hit the nearside kerb and rebounded, the van entered the opposing carriageway and into the path of an HGV. The impact caused the van to enter the river. Kial suffered multiple injuries and died at the scene. 5 CORONER’S CONCERNS During 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 rural, unlit road is governed by the national speed limit of 60 mph and narrows in both directions at the point of the bridge. Driving towards Uttoxeter, drivers are faced with a right-hand bend that the inquest heard can catch drivers unawares and has been the location of other road traffic accidents. The inquest heard that the bridge has been repaired a number of times as a consequence of collisions. Although the road has signs that warn drivers of the nature of the hazard ahead, a police collision expert considered that a reduction in the speed limit at this location would reduce the risk of collisions. I am concerned that the national speed limit on the A518 at the point of the Blythe Bridge at Lower Loxley is too high and carries the risk of future deaths. 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 8th October 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: The family of Mr Thurman 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 Signed by the Coroner 13th August 2024
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.
Accident Investigation Unit
Staffordshire County Council
Staffordshire Place 1
Tipping Street
Stafford
ST16 2DH
E-mail:
07/10/2024
Mr N Walker
Assistant Coroner
Staffordshire and Stoke-on-Trent
Coroners Service
Stoke Town Hall
Stoke on Trent
ST4 1HH
Dear Mr Walker,
Re: K Thurman (Deceased)
A518 Lower Loxley
I refer to your Regulation 28 report regarding the inquest into the death of Kial Ryce Thurman
and your comments concerning the A518 Lower Loxley.
This letter is in response to the matters of concern recorded in section 5 of your report,
which states the following points.
(1) Drivers travelling towards Uttoxeter are faced with a right-hand bend that the
inquest heard can catch drivers unawares and has been the location of other
road traffic accidents
(2) Although the road has signs that warn drivers of the nature of the hazard ahead,
a police collision expert considered that a reduction in the speed limit at this
location would reduce the risk of collisions.
To date, the following action has been taken in response to the concerns raised:
• A site visit with representatives from Staffordshire County Council Highways has taken
place to review the layout of the road and consider the points raised through the PFD
report submitted.
• Research and analysis of historical personal injury collisions has been undertaken at the
point of the right-hand turn and bridge location of concern.
• Wider highways asset management colleagues have been consulted regarding the
history of the bridge and immediate area.
• An assessment of the general speed of traffic has taken place.
Personal Injury Collision History
During the last complete 5-year period (2018-2022) and including any reports we have received
from Staffordshire Police since, there has been one other (slight injury) collision recorded in this
area of concern, and not associated with the right-hand turn heading towards Uttoxeter. The
causation of this other collision was due to a vehicle following another too close, there is no
indication of excessive or inappropriate speed.
Staffordshire County council are aware of a number of minor non-injury collisions which are not
reportable/recordable that may have occurred on the bridge over the last decade, but we do not
have any the details of the mechanics of these collisions required to analyse vehicle movements
or contributory factors to assess the common patterns.
Site Layout
In relation to point 1, upon approach to the right hand turn when travelling towards Uttoxeter
drivers are pre-warned by the following highway features:
• Large yellow backed right hand bend & narrow carriageway signage.
• SLOW markings on the carriageway.
• Double while line system.
•
Illuminating ‘Bend Ahead’ electronic vehicle activated signage (inspected and in good
working order on 16/11/2023).
• Large yellow backed chevron signage at the point of the right-hand bend along the
highway curvature.
• Reflective marker posts on the bend and at the point of the bridge.
It is assessed that the current safety features are sufficiently appropriate to warn drivers of the
approaching bend. The same features exist when approaching from the opposite direction.
Of note, a future long-term proposal to replace the bridge structure is currently underway
depending on funding.
Speed Limit
National speed limit roads are applied throughout the county network in accordance with the
Department for Transport “setting of local speed limit” guidelines. Speed limits should be
evidence-led and self-explaining and seek to reinforce people’s assessment of what is a safe
speed to travel. They should encourage self-compliance. Speed limits should be seen by drivers
as the maximum rather than a target speed. An assessment of the speeds at this location shows
and all-day average traffic speed of 39.7mph, with 85% of the traffic travelling at 45.5mph or
less.
When setting a lower speed limit, robust consideration needs to be applied to assess if motorists
will then interpret a lower limit as the recommended safe target speed rather than the maximum,
thus causing more of a risk.
As part of our statutory functions and commitment to our communities and road safety,
Staffordshire County Council routinely monitors personal injury collision data reported on the
public highway to identify accident clusters and trends. Any treatable pattern of accidents
identified will have proportionate remedial measures put forward for funding and will be
prioritised against other locations around Staffordshire. Any appropriate mitigating solutions
identified at this location will be prioritised alongside our annual programme of road safety
schemes.
I hope the information provided within this letter is useful. Please let me know if you require
anything further.
Yours sincerely,
Road Safety Manager
Staffordshire County Council
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