Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0609, written 7 Nov 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Nov 2024 |
|---|---|
| Reference | 2024-0609 |
| Deceased | Daniel Pinkney |
| Coroner | Paul Marks |
| Coroner area | City of Kingston Upon Hull and the County of the East Riding of Yorkshire |
| 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.
ANNEX A 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. Department of Transport and the Driver Vehicle Standards Agency 2. Royal Society for the Prevention of Accidents 3. 4. 5. 6. 7. 8. 9. 10. 1 CORONER I am Professor Paul Marks, Senior Coroner, for the Coroner Area of City of Kingston Upon Hull and the County of the East Riding of Yorkshire. 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 30th December 2022, I commenced an investigation into the death of Daniel Pinkney, aged 26 years. The investigation concluded at the end of the inquest on 21st October 2024. The conclusion of the inquest was: ROAD TRAFFIC COLLISION 4 CIRCUMSTANCES OF THE DEATH These are set out in my summary and findings of facts which are attached. At approximately 21:13 hours on 19th December 2022, Daniel PINKNEY was driving his Ford Focus motor car in a northerly direction on the A164 in the Skidby area. He encountered a large amount of surface water on his carriageway whilst travelling at approximately 50 miles per hour. His vehicle was subject to aquaplaning and consequent loss of directional control. As a result, he entered the opposite carriageway and collided with a third party vehicle travelling in the Hessle-bound direction. The force of the impact was such that the engine of Mr. PINKNEY's vehicle broke free of its mountings and came to lie 28 metres from the vehicle. Mr. PINKNEY suffered 1 devastating head and other injuries which were unsurvivable, and he was declared deceased by paramedics in his vehicle at 21:57 hours on 19th December 2022. Both of the involved vehicles were free from mechanical defects which could have caused or contributed to the accident. 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. – I believe that greater awareness of the phenomenon of aquaplaning is important, together with the need to reduce speed when surface water is present, coupled with basic knowledge about braking and steering, should a vehicle experience this phenomenon. I was informed by a forensic collision expert that the Highway Code is at present silent on this matter but road user should be familiar with it. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation has the power to take such action by considering adding guidance in the next iteration of the Highway Code. YOUR RESPONSE 7 You are under a duty to respond to this report within 56 days of the date of this report, namely by Thursday 2nd January 2025. 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 insurers of Mr PINKNEY’s vehicle - The insurers of the third-party vehicle - East Riding of Yorkshire Council - The family of Daniel PINKNEY I am also sending a copy to NHS England and equivalent organisations in the other countries of the United Kingdom. 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. 2 9 7th November 2024 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: 0300 330 3000 E-Mail: Web site: www.gov.uk/dft Our Ref: Professor Paul Marks Kingston Upon Hull Coroner’s Court, The Guildhall, Alfred Gelder Street, Hull, HU1 2AA 18 December 2024 Dear Professor Paul Marks, RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Thank you for your report of 07 November 2024 made under the Coroners and Justice Act 2009 and the Coroners (Investigations) Regulations 2013, following the inquest you conducted into the death of Daniel Pinkney. I am responding as the Minister for the Future of Roads. I am deeply saddened by the circumstances of Daniel Pinkney’s death, and I would like to extend my condolences to his family. I am determined that we learn from tragedies like this and that we take action to reduce those killed and injured on our roads. I want to assure you that the Government treats road safety with the utmost seriousness. Whilst UK roads are among the safest in the world, there is no room for complacency and I have carefully considered your report and its recommendations. You recommended updating the Highway Code to raise awareness about aquaplaning. You also mentioned the importance of reducing speed when surface water is present, and basic knowledge about braking and steering. While there is no specific mention of aquaplaning in The Highway Code. Rules 117 to 126 cover control of the vehicle. Rules 119 to 121 mention skidding, ABS and brakes affected by water. Rule 125 offers guidance on reducing speed, including when the road layout or condition presents hazards and weather conditions make it safer to do so. Rule 227 (Wet Weather) advises what action should be taken if steering becomes unresponsive, likely due to water preventing the tyres from gripping the road, and recommends that drivers ease off the accelerator and slow down gradually. As such, we consider that appropriate guidance is in place in the current text of the Highway Code. The Highway Code has historically undergone a major revision approximately every ten years and we currently have no plans to carry out a major revision. When we carry out the next revision to the Code, we will as usual undertake a consultation on proposed changes and this would offer the appropriate opportunity to consider including advice on aquaplaning. Additionally, the Driver and Vehicle Standards Agency (DVSA) already provides advice to drivers on aquaplaning. The DVSA’s driving tests are designed to make sure new drivers have the skills they will need to help them through a lifetime of safe driving. The DVSA also continues to encourage experienced drivers to read the Highway Code to refresh their road safety knowledge and check if there are changes. The Highway Code and the DVSA Guide to Driving; the Essential Skills (DES) are both source material for the car theory test. DES is a source that goes into more detail about driving on standing water (aquaplaning) which can be purchased by candidates and this allows the DVSA to ask questions in the theory test. The DVSA produces a number of guidance documents to assist all drivers and riders on Great Britain’s roads. The DVSA publishes this advice for all drivers, not just for learners. Further free information about driving in standing water can be found in their following publications: Driving conditions (skills 24 to 26) - Ready to Pass?: https://readytopass.campaign.gov.uk/driving-skills/driving-conditions/ There are numerous sections on recognising and handling risks when operating a motorbike in deep water or rainy conditions, as well as when operating a heavy-goods vehicle and driving a car, at https://www.safedrivingforlife.info/advice/ The DVSA is aware of the importance of reminding drivers of their road safety responsibilities. The agency regularly posts articles on social media platforms, and this month the DVSA also plans to launch and promote a winter driving e-learning course through www.safedrivingforlife.info You also mentioned blockage of drainage gulleys as a factor in the collision. Local highway authorities have a duty under Section 41 of the Highways Act 1980 to maintain the public highway network in their area. The Act does not set out specific standards of maintenance, as it is for each individual local highway authority to assess which parts of its network need repair and what standards should be applied, based on its local knowledge and circumstances. DfT strongly advocates a risk-based whole lifecycle asset management approach to local authority highways maintenance programmes. This considers all parts of the highway network, such as bridges, cycleways, drainage gullies, and lighting columns – and not just the fixing of potholes. It is up to the respective highway authority how best to spend this funding to fulfil their statutory duty under Section 41 of the Highways Act 1980. Further information and best practice on the on the importance of ensuring adequate drainage and tackling surface water is available from the UK Roads Leadership Group website1: Guidance on the management of highway drainage assets within the Code of Practice for Well Managed Highways. We will continue to work with stakeholders to amplify road safety messages and will encourage them to do this with aquaplaning where appropriate. This Government takes road safety very seriously, and we are committed to reducing the numbers of those killed and injured on our roads. My Department is developing our road safety strategy and will set out more details in due course. Best wishes, MINISTER FOR THE FUTURE OF ROADS 1 https://ukrlg.ciht.org.uk/
RoSPA 28 Calthorpe Road Birmingham, B15 1RP | United Kingdom 7: +44 (0}121 248 2000 help@rospa.com ® accidents don’t have to happen aie ewan Patron: His Majesty The King Professor Paul Marks HM Senior Coroner Kingston upon Hull and East Riding of Yorkshire The Guildhall Alfred Gelder Street Hull HU1 2AA Wednesday, December 18, 2024 Dear Professor Marks Regulation 28 Report to Prevent Future Deaths: Daniel Pinkney We acknowledge receipt of your Regulation 28 Report following the inquest into the tragic death of Mr Daniel Pinkney. We at the Royal Society for the Prevention of Accidents (RoSPA) extend our deepest condolences to Mr Pinkney’s family and loved ones and are committed to addressing the concerns you have raised. Background The Royal Society for the Prevention of Accidents (RoSPA} is a charity in existence for over a century, we are concerned with the prevention of accidents across the full range of life, both in the UK and abroad. ROSPA has no regulatory role, or enforcement powers. We are therefore not in a place to comment on the circumstances of the incident, nor are we able to place blame or identify liability. Actions to be taken by RoSPA Your report highlights the issue of aquaplaning, and the risks associated with driving through surface water. In response to your concerns, we outline below the actions RoSPA intends to advocate for to enhance road safety and reduce the risk of similar incidents in the future: Description Timeline Engage with the Department for Transport and DVSA regarding coroner’s findings: Q4 2024 Create and share digital education materials on aquaplaning awareness through social media and website Q2 2025 We appreciate your report’s emphasis on proactive education, and we are dedicated to working with other stakeholders to improve safety standards across the country. In memory of Daniel Pinkney, we hope these initiatives will contribute to preventing future tragedies on our roads. We would like to emphasise that we enjoy an excellent working relationship with the DVSA, and look forward to working with them, in order to protect the public. The Royal Society for the Prevention of Accidents A company limited by guarantee registered in England and Wales with No. 231435 Registered Charity No. 207823 (England & Wales) and $C039289 (Scotland) Registered office: RoSPA Hause, 28 Calthorpe Road, Edgbaston, Birmingham, B15 1RP ROSPA 28 Calthorpe Road Birmingham, 815 1RP United Kingdom T: +44 (0)121 248 2000 4 help@respa.com a O app www.rospa.com Patron: His Majesty The King Should you require further details regarding our planned actions, or if RoSPA can assist in other areas related to road safety, please do not hesitate to contact us. Yours sincerely Policy, Campaigns, Public Affairs Director The Royal Society for the Prevention of Accidents A company limited by guarantee registered in England and Wales with No. 231435 Registered Charity No, 207823 (England & Wales) and SCO39289 (Scotland) Registered office: ROSPA House, 28 Calthorpe Road, Edgbaston, BiemIngham, B15 1RP-
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