Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0477, written 27 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 | 27 Aug 2024 |
|---|---|
| Reference | 2024-0477 |
| Deceased | Mason Portman |
| Coroner | Martin Fleming |
| Coroner area | West Yorkshire Western |
| 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 National Highways Company Limited National Traffic Operations Centre 3 Ridgeway Quinton Business Park Birmingham B32 1AF 1 CORONER I am M D FLEMING, HM Senior Coroner for the coroner area of West Yorkshire Western Coroner Area 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 22 December 2023 I commenced an investigation into the death of Mason John PORTMAN aged 21. The investigation concluded at the end of the inquest on 13 August 2024. The conclusion of the inquest was that: I found that the cause of death to be: - 1a. Multiple injuries I arrived at a conclusion of road traffic collision 4 CIRCUMSTANCES OF THE DEATH At approximately 6.10am on 17/12/23, Mason John Portman, who was driver and sole occupant, lost control of his motor vehicle as he exited the slip road at junction 22 on the east bound carriageway to the M62, and collided with a wooden fence and road sign, prior to travelling across the moorland and towards the A672,where it collided with an unoccupied motor vehicle parked on the layby, before then tumbling across the A672 where it came to rest, causing him to sustain fatal injuries. At post-mortem he was found to have taken cocaine (less than 0.10mg/L) and his blood alcohol was 211 mg/dL. 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) Regulation 28 – After Inquest Document Template Updated 30/07/2021 During the inquest I heard that as Mason approached the location of the collision via the slip road that there were no road markings or signs displayed to advise on appropriate speed or road curvature ahead. The MATTER OF CONCERN is as follows. – • merits of the placement of appropriate road markings and signage. To review the safety of the road conditions at this location and to consider the 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 October 17, 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. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons I have also sent it to – Mason’s mother – Mason’s uncle 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: 27/08/2024 M D FLEMING HM Senior Coroner for West Yorkshire Western Coroner Area 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.
Our ref: Your ref: Mr M D Fleming Senior Coroner for West Yorkshire Western Coroner Area HM Coroner’s Court, Cater Building 1 Cater Street Bradford BD1 5AS Operations Regional Director Piccadilly Gate Store Street Manchester M1 2WD www.nationalhighways.co.uk 16 October 2024 Dear Mr Fleming Reg 28 Report - After Inquest PORTMAN M J 17122023 Thank you for your correspondence dated 27 August 2024. National Highways has investigated the circumstances of the incident and the items raised by the Coroner at this location. This includes undertaking a site visit on the 4th September 2024 and talking to both West Yorkshire Police and Calderdale Council representatives. I can confirm that National Highways is the Highway Authority for the M62 motorway and the exit slip roads at junction 22. This extends up to the marked timber boundary fence and cattle grid at the interface with the A672. Beyond this point Calderdale Council is the relevant highway authority, including the A672 carriageway and immediate slip road interface. The slip road from the east bound M62 consists of a single wide lane dropping down from the mainline carriageway with open forward visibility. The alignment of the slip road includes two progressive bends, first to the left and then right, prior to the interface. Drivers leaving the motorway have a full and uninterrupted view of the slip road, including the changes in longitudinal alignment, for over 250m along the approach to the junction. At the end of the slip road, prior to the junction with the A672, a metal cattle grid spanning the full width of the slip road is installed to deter stray animals entering the motorway. The junction of the exit slip road and the A672 is controlled by ’Give Way’ signs. From the mainline diverge the slip road drops towards the junction which is located below the level of the mainline carriageway. An overhead concrete sign gantry, showing the destinations accessible at the junction, is located approximately 200m prior to the A672. Registered office Bridge House, 1 Walnut Tree Close, Guildford GU1 4LZ National Highways Limited registered in England and Wales number 09346363 From this position the forward visibility is such that there is a clear and unobstructed view along the slip road up to the junction. There are additional warning and direction signs installed along the slip road, between the gantry and A672 junction, as outlined below: i) ii) iii) iv) v) A warning sign assembly, consisting of a ‘hazard ahead’ triangular sign, together with a supplementary plate indicating ’cattle grid’ is located within the nearside verge, 135m prior to the junction. A large ‘map’ type direction sign is also located within the nearside verge, approximately 35m further along the slip road (100m from the junction). This clearly shows the A672 dual carriageway footprint and layout, indicating the destinations that can be accessed from the junction. A ‘chevron’ type sign, indicating the change of alignment to the right, approaching the junction interface, is located within the nearside verge, 10m prior to the cattle grid. The nearside and offside extents of the cattle grid are adjacent to timber boundary fences and are marked with vertical black and yellow reflective signs to visually highlight these areas. At the time of the incident in question there was also a post mounted ‘End of Motorway Regulations’ sign installed in the nearside verge, in line with the cattle grid itself. This was damaged in the collision and at the time of the site visit had not been replaced. The above signs are installed along the section of the slip road for which National Highways is responsible. Between the cattle grid and the A672 carriageway there are some additional traffic signs and carriageway markings. These are on the section of the slip road that is outside National Highways area of responsibility. The traffic signs are installed on both the near and offside of the carriageway interface with the A672 and consist of co-mounted ‘Give Way’ and 50mph speed limit signing. These were installed by Calderdale Council in April 2024 as part of a 50mph speed limit scheme on the A672, replacing the previous ‘Give Way’ signs in the same locations. There are also white thermoplastic carriageway markings in the form of Give Way triangles and broken white lining to delineate two traffic lanes and a ‘ghost island’ separation at the junction. The ghost island arrangement would normally consist of a hatched area which is not present at this site. Forward visibility along the slip road is clear and uninterrupted, and the current ‘chevron’ signing specifically addresses the change of alignment at the A672 junction approach. Registered office Bridge House, 1 Walnut Tree Close, Guildford GU1 4LZ National Highways Limited registered in England and Wales number 09346363 The traffic and signs installed at this location all comply with best practice guidance and current legislative requirements. The damaged ‘End of Motorway’ sign identified during the site visit is scheduled to be replaced by the end of October. We have access to historical records of collisions that result in personal injuries or fatalities for the motorway network and can confirm that, with the exception of this incident, there have been no other recorded incidents over the previous 10 year period at this location. In examining and assessing the current situation, we believe that the current layout and signing strategy adequately conveys the necessary and appropriate information regarding alignment and detail of the junction in order to enable the slip road and junction to be approached at an appropriate speed. We therefore do not propose any alterations to the current junction layout or speed limit along the slip road. I hope that you find this information helpful. Yours sincerely Operations Regional Director Email: Registered office Bridge House, 1 Walnut Tree Close, Guildford GU1 4LZ National Highways Limited registered in England and Wales number 09346363
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