Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0654, written 26 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 | 26 Nov 2024 |
|---|---|
| Reference | 2024-0654 |
| Deceased | Jay Whiting |
| Coroner | Nicholas Lane |
| Coroner area | Devon, Plymouth and Torbay |
| 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.
COUNTY OF DEVON, PLYMOUTH AND TORBAY CORONER AREA REPORT ON ACTION TO PREVENT OTHER DEATHS JAY STUART WHITING HM ASSISTANT CORONER NICHOLAS LANE REGULATION 28 – REPORT ON ACTION TO PREVENT OTHER DEATHS THIS REPORT IS BEING SENT TO: 1) Chief Executive, Plymouth City Council Via email: City Council – who has been relevant contact through investigation and inquest process) (Head of Legal Services and Monitoring Officer, Plymouth 1 2 CORONER I am Nicholas Lane, HM Assistant Coroner for County of Devon, Plymouth and Torbay 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: http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 17 January 2023 an investigation was commenced into the death of Jay Stuart Whiting. The investigation concluded at the end of the inquest hearing on 14 November 2024 at Exeter Coroner’s Court, in the County of Devon, Plymouth and Torbay Coroner Area. A short-form conclusion of ‘road traffic collision’ was determined. 4 CIRCUMSTANCES OF THE DEATH Jay Whiting was only 21 years old when he was fatally injured in a single-vehicle road traffic collision in Plymouth on 7 January 2023. Following medical evidence heard at the inquest, the cause of death was determined in Section 2 of the Record of Inquest as: 1a – head injury 1b – road traffic collision Section 3 of the Record of Inquest (which answered how, when and where Jay Whiting came by his death) was determined as follows: ‘Jay Whiting was the sole occupant of a vehicle registered to him when he was driving northbound on Embankment Road, Plymouth, in the early hours on 7 January 2023. Jay lost control, and was then unable to regain control, of the vehicle, owing to a number of relevant factors, including very wet weather and significant water collection on the road, the poor condition of the vehicle’s rear tyres and the reclined position of the driver’s seat. Jay’s vehicle left the road and hit a mature tree, which was situated on the pavement adjacent to the carriageway. The collision of the vehicle with the tree resulted in Jay suffering fatal injuries. Despite initial resuscitation by attending paramedics and transport to Derriford Hospital, Plymouth, Jay died there in the neuro-intensive care unit later on 7 January 2023.’ 5 CORONER’S CONCERNS During the course of the investigation and inquest the evidence revealed one matter 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 MATTER OF CONCERN is as follows: Although the determinations at the inquest found there to be a number of relevant factors which contributed to the fatal road traffic collision and, therefore, to Jay Whiting’s death (as set out in paragraph 4, above), one such contributing factor was that the vehicle being driven by Jay Whiting left the road and immediately collided with a mature tree (one of many such trees which line Embankment Road, Plymouth). Embankment Road (or at least this particular stretch) is a dual carriageway and a main route into the city centre of Plymouth. As part of the investigation and inquest process, photos were taken of the scene by forensic collision investigating officers, and these showed the large trees to be adjacent to the dual carriageway, situated on a pavement only a matter of inches from the kerb. It is clear from these photos that, firstly, any vehicle that, in whatever situation, has cause to leave the road and mount the kerb is very likely to immediately collide with one of the mature trees and, secondly, the size of the trees (the circumference of their trunks) make it difficult for pedestrians, or those using mobility aides, to safely walk/move along the pavement without having to step into the road. , road casualty reduction officer Evidence was heard at the inquest from Motor Police Constable for the Plymouth area (employed by Devon and Cornwall Police). MPC ’s unequivocal opinion was that the presence of these mature trees at this location (both on the northbound and southbound carriageways on Embankment Road, but particularly the stretch of trees at the location of this fatal incident on the northbound carriageway) is frankly dangerous from a road safety perspective. MPC stated that, in addition to this fatal accident in 2023, there was a fatal accident in 2008, where a vehicle collided with one of the trees along the same stretch of the northbound carriageway, resulting in the deaths of two occupants of the vehicle. MPC was therefore concerned that there had been three deaths arising in very similar circumstances at the same location, involving trauma brought about by vehicular collision with one of the mature trees. MPC stated that he was not aware of any other location in Plymouth where trees lining the road had been considered a contributory factor in a fatal vehicle collision. Owing to these concerns, MPC made a request that consideration is given by Plymouth City Council to removing the trees at this location. Evidence was also heard at the inquest from by Plymouth City Council). Police regarding the mature trees and that, personally, he would also like the trees to be removed. , senior traffic engineer for street services (employed stated that he was aware of the concerns held by Devon and Cornwall stated that the removal of trees in Plymouth was currently ‘a political topic’ and, for the trees on Embankment Road to be removed, a decision would need to be taken justifying the use of scarce local authority public funding. accepted that there had, thus far, been no formal risk assessment or evaluation carried out by Plymouth City Council as to whether the safety concerns identified warranted further accepted that this process should now take resources being used to remove the trees. place and that he had been waiting for the outcome of this inquest before deciding upon appropriate next steps. Owing to there being clear safety concerns regarding the continued presence of these mature trees on Embankment Road, Plymouth, in my view these need to be formally considered (it is for Plymouth City Council to consider issues of risk and cost/benefit analysis of any proposed action/inaction) with a view to determining what, if anything, should happen to the trees. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action (for the reasons set out in paragraph 5, above). 7 YOUR RESPONSE Your organisation is under a duty to respond to this report within 56 days of the date of this report, namely by 21 January 2025. I, the coroner, may extend this period. If any request is to be made for this period to be extended, please ensure this is made in writing at least 14 days prior to the above required response date. 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 Jay Whiting’s mother and father and Devon and Cornwall Police (via their road casualty reduction officer for Plymouth). I have also sent a copy of my report to the Chief Coroner. 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 Date: 26 November 2024 Signature: Nicholas Lane HM Assistant Coroner for County of Devon, Plymouth and Torbay
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.
OFFICIAL Sent by email to: Chief Executive’s Department Coroners Office County of Devon, Plymouth and Torbay Devon County Hall Topsham Road Exeter EX2 4QD Plymouth City Council Ballard House West Hoe Road Plymouth PL1 3BJ T E www.plymouth.gov.uk Please ask for: Tracey Lee Date: 20 January 2025 Dear Mr Lane Regulation 28 – Report on Preventing Future Deaths I refer to your Regulation 28 Report dated November 2024 to prevent future deaths, following an investigation into the death Jay Stuart Whiting. I have noted the matters of concern you have raised in the report and respond as follows: Following the collision, a Road Safety Engineer visited the site of the accident to assess the safety of this stretch of the road. This assessment concluded that a combination of matters including, heavy rainfall and the presence of mature trees along the side of the road was likely to have contributed to the fatality. Later discussions with the police confirmed this impression. Every road in Plymouth is assessed through an Annual Casualty Reduction Review with a minimum investigatory threshold of 5 injury collisions within a 50m radius over a 5-year period. When assessed in 2022 the area of the collision did not meet investigatory level with 3 minor injury collisions having been reported by the Police over that period. These collisions all occurred in dry weather although 2 did involve excessive speed. In order to address the safety issues raised within the report, Plymouth City Council plan to implement the following measures: 1. Implementation of a process to extend the 30mph Speed Limit on both sides of the A374 Embankment Road from its current terminal north-east of Stanley place to a point north-east of the Rowing Club, approximately 800 metres. This will involve the introduction of a Traffic Regulation Order (“TRO”) and as such will be subject to a statutory process which will include a statutory consultation followed by a formal decision to be taken in accordance with the Council’s constitution. If following this process the TRO is agreed, it is envisaged that the lower speed limit will be introduced at the beginning of April 2025. 2. We plan to remove a number of trees adjacent to the north-east bound carriageway between the Glendinning Depot and Arnold’s Point. The works for tree OFFICIAL removal will entail road closures and eventually require complete reconstruction of the carriageway and footway over approximately 450m of road. It is anticipated that removal of the trees in question will take place by the end of June 2025, but this will be subject to working through any relevant statutory requirements for tree removal. As part of this process, the City Council has considered removal of the trees sited on the south-west bound carriageway. These trees have no history of involvement in collisions with vehicles and are also planted in a way which does not block the adjacent footway/cycleway. This section of road is in- bound towards the City Centre and currently has lower traffic speeds due to the junction with Lanhydrock Rd and the presence of a Safety Camera in advance of the junction. As the speed limit will now be dropped to 30mph with a Speed Camera in place, it is not considered that the trees on this side of the road present a significant risk and will therefore remain in place. Given the constraint on Council budgets, work on roads which present a significant risk of collisions must be prioritised. I trust the above measures adequately rectify the concerns set out in your Regulation 28 Report. Yours sincerely Chief Executive
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