Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0489, written 1 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 | 1 May 2024 |
|---|---|
| Reference | 2024-0489 |
| Deceased | George Dillon |
| Coroner | Henry Charles |
| Coroner area | Hampshire, Portsmouth and Southampton |
| 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 Hampshire County Council Legal Services 1 CORONER I am Henry CHARLES, Assistant Coroner for the coroner area of Hampshire, Portsmouth and Southampton 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 01 June 2023 an investigation was commenced into the death of George Robert DILLON aged 19. The investigation concluded at the end of the inquest on 24 April 2024. The conclusion of the inquest was that: On the evening of Thursday 18th May 2023 the Deceased was driving a VW Golf south along a country road, namely Lee Lane, Romsey, in the vicinity of its junction with Spaniard Lane when at around 22.16 to 22.26 he lost control of the car by reason of his speed on a crest in the road, and hit a large tree. He was the sole occupant of the car. There is no evidence that any other vehicle was involved. He suffered catastrophic and unsurvivable injuries. He was taken to the Neurosurgical Unit at Southampton General Hospital where he died from his injuries on 20th May 2023. 4 CIRCUMSTANCES OF THE DEATH On the evening of Thursday 18th May 2023 the Deceased was driving a VW Golf south along a country road, namely Lee Lane, Romsey, in the vicinity of its junction with Spaniard Lane when at around 22.16 to 22.26 he lost control of the car by reason of his speed on a crest in the road, and hit a large tree. He was the sole occupant of the car. There is no evidence that any other vehicle was involved. He suffered catastrophic and unsurvivable injuries. He was taken to the Neurosurgical Unit at Southampton General Hospital where he died from his injuries on 20th May 2023. 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) A. Lee Lane, near Romsey, Hampshire, is a country road, subject to the National (60mph) speed limit. There is a crest in the road at its junction with Spandard’s Lane. The Deceased lost control of his vehicle on the crest. B. The maximum speed at which a person can travel over the crest whilst remaining in full control of the vehicle is 45mph. A driver negotiating the crest around the speed limit of Regulation 28 – After Inquest Document Template Updated 30/07/2021 When travelling south, approaching the crest, as the Deceased did, it is possible to 60 mph will run the risk of the vehicle leaving the ground, or at the very least a momentary loss of effective steering control, followed by the underside ‘bottoming out’ on the road surface. Numerous historical gouge marks on the road surface either side of the junction demonstrate that “numerous vehicles have previously ‘bottomed out.’” C. see a bend in the road in the distance, but the road immediately beyond the crest is not visible to a car driver. It is suspected that there have been previous collisions at the scene. D. E. I am concerned that at night the extent of the hazard posed by the crest even to a vehicle travelling within the speed limit is not readily apparent and there is an absence of warning signs 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 June 26, 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 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: 01/05/2024 Regulation 28 – After Inquest Document Template Updated 30/07/2021 Henry CHARLES Assistant Coroner for Hampshire, Portsmouth and Southampton 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.
Coroner’s Office The Castle Castle Hill Winchester SO23 8UL – sent by email only Hampshire Legal Services Hampshir e County Counci l The Castle, Winchester Ham pshi r e, SO23 8UJ T el ep hon e 0300 555 137 5 Mi ni co m 0300 555 1390 www.hants.g ov.uk Enquiries to: Direct Line: Date: Dear Sirs 28/08/2024 Our Reference: Your Reference: Email: Re: Inquest of Mr George Dillon – Response to Reg 28 Report Highway Accident: 18/05/2023 in Lee Lane, Romsey We acknowledge receipt of your Prevention of Future Death (PFD) report dated 01/05/2024. We appreciate the concerns you have raised following the inquest into the death of George Dillon and apologise for the delay in responding to you. Actions Taken Your report highlighted several areas of concern, particularly regarding the speed of vehicles and number of collisions at this location. This has prompted another review by the Casualty Reduction Programme team into the circumstances of Mr Dillon’s collision. We attach this review for your attention. In summary, after careful consideration, we have recommended that crossroad warning signs and reduce speed now signs together with SLOW road markings are provided along Lee Lane on both approaches to the Spaniard’s Lane crossroads. Should you require any further information or clarification, please do not hesitate to contact us. Yours faithfully Page 1 of 2 Senior Legal Adviser For Assistant Director – Legal Services and Monitoring Officer Page 2 of 2
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