Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0521, written 1 Oct 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 Oct 2024 |
|---|---|
| Reference | 2024-0521 |
| Deceased | Scott Davies |
| Coroner | Christopher Murray |
| Coroner area | Manchester South |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Stockport Metropolitan Borough Council, Highways Department Secretary of State for Transport 1 CORONER Christopher Murray HM Assistant Coroner Manchester South Coronial Area Mount Tabor Stockport 2 CORONER’S LEGAL POWERS I make this report under the Coroners and Justice Act 2009, paragraph 7, Schedule 5, and The Coroners (Investigations) Regulations 2013, regulations 28 and 29. 3 INVESTIGATION and INQUEST On 29th August 2023 an inquest was opened into the death of Scott Bradley Davies aged 32. The inquest concluded on 19th September 2024. I made a determination at inquest that Scott Bradley Davies died as a result of an accident. 4 CIRCUMSTANCES OF THE DEATH Scott Davies had collected his modified Sur-Ron Light Bee Motorcycle on the evening of Friday 2nd February 2024 and returned home carrying the unregistered motorcycle in a van. He proceeded to attend upon Alexandra Park in Stockport to test out the vehicle. He collided with a steel barrier which was in a closed position. He was dismounted from the vehicle and sustained serious head injuries. He was not wearing a helmet at the time of his collision. He was given first aid at the scene and taken to Salford Royal Hospital by ambulance. He was treated by way of sedation and ventilation but never regained consciousness and died as a result of a traumatic brain injury on 8th March 2024 at Salford Royal Hospital. 1 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 will 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 section of road bisecting Alexandra Park, known as Cheadle Old Road Edgeley, is a legitimate right of way for bicycles and emergency services vehicles yet there is a matt black locked steel barrier that is hard to see at dusk and in the dark which could result in serious injury or death if struck by an oncoming legitimate user of that thoroughfare. 6 ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and I believe that 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 26th November 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 following Scott’s family. HHJ Alexia Durran, the Chief Coroner of England & Wales The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who she 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. 9 DATE 1st October 2024 Signed CSMurray HM Assistant Coroner 2 3
2 responses 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.
From the Parliamentary Under
Secretary of State
Great Minster House
33 Horseferry Road
London
SW1P 4DR
Tel:
E-Mail:
Web site: www.gov.uk/dft
Our Ref:
25 November 2024
Christopher Murray
HM Assistant Coroner
Coroner’s Court
1 Mount Tabor Street
Stockport
SK1 3AG
Dear Mr Murray,
Thank you for your letter of 1 October to the Secretary of State, enclosing a
Regulation 28 Report into the death of Scott Bradley Davies. I am responding
as the Minister for the Future of Roads, and I was very sorry to hear of his
death.
I am writing regarding your concern about the visibility of the barrier across
the right of way at Cheadle Old Road, Edgeley.
I note your concerns regarding the risk that the barrier poses to road users.
However, I should clarify that this is not a matter for the Department as it is
the highway authority, in this case Stockport Metropolitan Borough Council,
which is responsible for how traffic is managed on its roads, including rights
of way. As with all local roads, it is for the Council to ensure that any
infrastructure it installs on its network, including barriers and similar street
furniture, is fit for purpose. It is also responsible for maintaining any
infrastructure once installed.
The council has a duty under Section 122 of the Road Traffic Regulation Act
1984, to exercise its functions under the Act so as to secure the expeditious,
convenient, and safe movement of traffic, so far as practicable having regard
to various matters including the amenity of the area through which the road
runs. This Department’s role is to provide the legislation and associated
guidance.
Under section 97 of the Highways Act 1980 (“1980 Act”) highway authorities
may provide lighting for the purpose of any highway for which they are the
highway authority. They also have a duty under Section 41 of the 1980 Act to
maintain the public highways in their charge. This duty includes street
lighting.
A1
Decisions about the lighting of this barrier are for the highway authority, and it
is not for central government to intervene in these kinds of local issues.
We have provided guidance on traffic management for local authorities in
various publications, including the Traffic Signs Manual, as well as a variety of
Traffic Advisory Leaflets and Local Transport Notes. These stress the
importance of road safety when designing and installing road infrastructure.
This guidance is all free to download from the Department’s website. The
Department also encourages good practice in highway maintenance through
channels such as Well-managed Highway Infrastructure - A Code of Practice,
published by the UK Roads Leadership Group. This publication provides
advice to local highway authorities on a range of issues, including street
lighting.
The British Standards Institute publication, BS 5489-1:2020: Design of road
lighting, gives recommendations on the general principles of road lighting and
its aesthetic and technical aspects and advises on operation and
maintenance.
As such, I hope you will understand why I consider that the Department does
not need to take any action regarding this incident. I hope this is helpful.
Best wishes,
MINISTER FOR THE FUTURE OF ROADS
A2
Services to Place Stopford House, Piccadilly, Stockport SK1 3XE Email: Date:26th November 2024 Christopher Murray HM Assistant Coroner Manchester South Coronial Area Mount Tabor Stockport By email: Dear Mr Murray, Re: Inquest into the death of Scott Bradley Davies (ref: 35869178) Thank you for your letter of 1st October 2024 enclosing a Prevention of Future Deaths Report in reference to the inquest into the death of Mr Scott Davies held on the 10th April 2024 and concluding on 19th September 2024, at which you determined Mr Davies died as a result of an accident. On behalf of Stockport Council, I would like to offer my sincere condolences to the family and friends of Mr Davies. The section of road bisecting Alexandra Park, known as Cheadle Old Road, Edgeley, is a legitimate right of way for bicycles and emergency services vehicles. The reason for the installation of a barrier relates to the fact that this park is an area widely used by pedestrians, in particular, families who use the play equipment and green space available. It was considered that the risk posed to pedestrians by cyclists entering the park unhindered was sufficient to justify the installation of such barriers. However, upon considering the circumstances of Mr Davies accident and subsequent death and your report, Stockport Council has taken action to improve the visibility of barriers within parks by permanently affixing reflective panels and adding reflective tape to the uprights to all barriers of this nature situated in similar positions across the borough. This work has already been completed in Alexandra Park as of 21st November 2024. The remaining work in the other locations will be completed by 31st March 2025. To further ensure that we are maximising visibility of the barriers after dusk we are also auditing the lighting in surrounding areas to ensure they are not impeded by tree growth and that the levels are in accordance with BS:5489 lighting standards. Where remedial work is required, this will be complete by 31st March 2025. An audit of the trees in the vicinity of the Alexandra Park barrier was carried out on 21st November 2024 and it was determined that no arboriculture work was needed at that time. The lighting on Cheadle Old Road was upgraded in 2019 as part of the ongoing LED lighting replacement programme, and we can confirm that the luminescence report notes it is compliant with lighting class P5 to BS5489. A3 If Emergency services require access to a location with a closed barrier, they have direct contact to the council control room and vice versa. Where needed the council will attend urgently to ensure that access is provided. I trust the actions detailed fully address the concerns you have raised. Your sincerely, Assistant Director to Neighbourhoods A4
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