Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0666, written 3 Dec 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Dec 2024 |
|---|---|
| Reference | 2024-0666 |
| Deceased | Gary Dunn |
| Coroner | Lorraine Harris |
| Coroner area | East Riding of Yorkshire and City of Kingston Upon Hull |
| 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 (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Traffic Services, Hull City Council National Highways – For area of Kingston Upon Hull 1 CORONER Miss Lorraine Harris, Area Coroner, East Riding of Yorkshire and City of Kingston Upon Hull. 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 19th December 2023 I commenced an investigation into the death of Gary Stephen DUNN, aged 47 years. The investigation concluded at the end of the inquest on 2nd December, 2024. The conclusion of the inquest was: Road Traffic Incident The following findings of fact were made: Lorry White Volvo LGV registration H4 LGE Mr Dunn was riding a bicycle. Neither vehicle had any defects. No weather conditions were contributory to the incident. There was no defect in the road that was contributory to the incident. I do acknowledge that the road had changed it markings, this was a relatively recent change. I acknowledge that there was an alternative route for Mr Dunn to navigate the busy roundabout, however Mr Dunn was within his rights to use the road. The issue of whether Mr DUNN was visible at any time was an issue at inquest. The driver of the LGV could not recall specifics about his mirror checks but stated a number of times that it was instinctive, constant thing, something that he does all the time. He was open about the fact that he did not see Mr DUNN at any time. I do find his evidence credible. When Mr Dunn is in a position where he could be started to be regarded 1 as visible, he is approximately 70 metres from the roundabout. I accept there was an opportunity for the LGV to see Mr Dunn and recognise him as a road user, but I also recognise that for the majority of the time Mr DUNN was in the inside lane, there were other vehicles on the road and the driver of the LGV would have also been looking to negotiate the roundabout. Mr Dunn did have lights on his bike but he was not wearing any clothing that would make him more visible. As stated previously, the driver of the LGV reported that at no time did he see him. At the time that the presence of Mr DUNN would have indicated a risk, he would have been in the blind spot of the LGV, high visibility clothing at that stage not have made a difference. This is relevant when at the give way line, albeit for a short period of time, Mr Dunn was positioned in the LGV driver’s blind spot before both move to negotiate the roundabout. The 1st lane of the roundabout is marked for those to leave the roundabout at the first junction. The 2nd lane of the roundabout allows users to both leave the roundabout at the 1st junction and also continue travelling forward on the roundabout. As the vehicles leave the give way line, the LGV is indicating to take the first junction. Mr Dunn was positioned very close to the cab. It would not be possible to say whether he noticed the indicator. As both the LGV and Mr Dunn leave the roundabout, they are both positioned in lanes that allow exit via the first junction. Mr Dunn is, however, not visible to the LGV driver. Mr Dunn is straddling both the 1st and 2nd lane and is going to travel straight over the roundabout. CCTV shows that as the LGV manoeuvres to take it’s exit, Mr Dunn rides across its front directly in its path. I note that the lorry does not cross the bicycles path, it does not leave it’s lane. It is evident that Mr Dunn does not appreciate that the vehicle was indicating to turn left at the 1st junction. At the time that the LGV takes its junction Mr Dunn may have been trying either to cycle quickly to out-manoeuvre the vehicle, or attempting to cut across the front of the LGV to reach the next junction, however the CCTV seems to indicate he simply does not appreciate the lorry is turning left and he carries on his route which takes him infront of the LGV. It was a quick misjudgement, with very tragic consequences. At the time the bicycle crosses his path, there was nothing that the driver of the LGV could do to avoid the collision. I find the LGV stopped appropriately. For the avoidance of doubt, I accept the evidence that the tachograph did not show that this slowing was in an attempt to avoid the accident. I do note that Mr DUNN was not wearing a cycling helmet, however given the gravity of his injuries, this piece of equipment would not have saved his life. Mr DUNN’s death was instantaneous. Toxicology revealed previous exposure to cocaine and tramadol in his system, but no evidence of acute toxicity. 2 I note that the dashcam was not seized immediately, and then there was a discrepancy over who seized it. I accept that one officer seized the LGV and the dashcam together but another then seized the dashcam itself. I note that the override on the dashcam was continuous even when the engine was running, and as such there was no dashcam footage. I appreciate that when officers attend these scenes there are many tasks and priorities, but it is regrettable that this footage was not seized immediately. This is something that could have given comfort to the family. However we do have the CCTV footage and while it does not give a view from the cab it does provide a record of the incident. I will be making a RPFD to highlight the officers concerns over signage. Box 3 of the record of inquest read: On 8th December 2023 Gary Stephen DUNN was riding his pedal cycle to college. At the Stoneferry Road/Ferry Lane roundabout, Kingston Upon Hull Mr DUNN’s bicycle collided with a Light Goods Vehicle. Mr DUNN was killed instantly. His medical cause of death was recorded as: 1a Severe Head Injuries 1b Road Traffic Incident 4 CIRCUMSTANCES OF THE DEATH Gary Stephen DUNN, aged 47 years, was cycling to college. En route he had to negotiate the Stoneferry Road/Ferry Lane roundabout in Kingston Upon Hull. Evidence was heard that the layout of the road had changed recently, whereby the centre lane could now also be utilised to turn left. An LGV was in this lane and indicating to turn left. Mr DUNN was intending to travel over the roundabout and was on the nearside of the LGV. The driver of the LGV said at no time did he see Mr DUNN. Mr DUNN attempted to travel towards his exit but rode into the path of the LGV as it turned left. He died instantly. 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 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. – 1. I appreciate it has been almost a year before this inquest was concluded 3 so the change in road layout may now be more known to regular drivers, however people unfamiliar with the road may also need to navigate the roundabout. The Officer in the Case, an experienced Serious Collision Investigation Officer, raised concerns regarding the signage of 2 aspects of this area of road: Firstly, although the road markings which indicate the centre lane can also be used for left hand turning vehicles was regarded as clear, the officer felt there was insufficient actual road signage to assist road users in how the roundabout can be navigated. This was of particular concern as this is a busy roundabout with a build up of traffic and so markings on the road are often obscured. Secondly, there is a dual use path for both pedestrians and cyclists as well as the availability of a Toucan Crossing. This provides cyclists with an alternative to using the road. Again, evidence was heard that there was inappropriate signage to instruct cyclists that this route was available. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your department/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 28th January 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 family of Mr Gary Stephen DUNN via counsel Counsel for 2nd Driver – Serious Collision Investigation Unit – Humberside Police 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 other 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. 4 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] [SIGNED BY CORONER] 3rd December 2024 Lorraine Harris 5
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: Date: Email: 4 March 2025 CONFIDENTIAL – ADDRESSEE ONLY HM Area Coroner Lorraine Harris East Riding of Yorkshire and City of Kingston Upon Hull The GuildHall Alfred Gelder Street Hull HU1 2AA PO Box 686 BLACKBURN BB2 9QY tel: 01254 222399 fax: 01254 52347 dx: 17952 Blackburn Dear Coroner Response to Regulation 28 – Report to Prevent Future Deaths Touching the Death of Gary Stephen Dunn (8/12/2023) The enclosed response is on behalf of Kingston Upon Hull City Council, as Traffic Authority. Yours faithfully : USER=TFB} For and on behalf of Forbes Solicitors LLP Forbes Solicitors is the trading name of Forbes Solicitors LLP, a limited liability partnership registered in England and Wales number OC433300, registered office, Rutherford House, 4 Wellington Street (St Johns), Blackburn, England, BB1 8DD. A list of partners can be found at www.forbessolicitors.co.uk/partners. To find your nearest office www.forbessolicitors.co.uk/ offices. Unless otherwise indicated either expressly or by context the word ‘partner’ describes a member of Forbes Solicitors LLP or an employee of Forbes Solicitors LLP in their capacity as partner. Forbes Solicitors LLP is authorised and regulated by the Solicitors Regulatory Authority (SRA number 816356). External certification and accreditations including a link to the SRA Standards and Regulations are detailed at www.forbessolicitors.co.uk/Certification &Accreditation. Kingston Upon Hull City Council (The Council) Response to Regulation 28 Report to Prevent Future Deaths (PFD) Dated 3rd December 2024. The following has been prepared in response to the Coroner’s Regulation 28 PFD issued to Traffic Services, Hull City Council. This is further to the Inquest of the 2nd December 2024 touching the death of Gary Stephen Dunn who died in a tragic road traffic collision on the 8th December 2023, at the Stoneferry Road/Ferry Lane roundabout, Kingston Upon Hull. The Council were not an interested person at the inquest hearing held on the 2nd December 2024 and had not been invited to provide any evidence to assist the coroner in her investigation prior to receiving the Regulation 28 PFD. The PFD notes the coroner’s concerns in box 5 as follows: 1. “The Officer in the Case, an experienced Serious Collision Investigation Officer, raised concerns regarding the signage of 2 aspects of this area of road: • Firstly, although the road markings which indicate the centre lane can also be used for left hand turning vehicles was regarded as clear, the officer felt there was insufficient actual road signage to assist road users in how the roundabout can be navigated. This was of particular concern as this is a busy roundabout with a build-up of traffic and so markings on the road are often obscured. • Secondly, there is a dual use path for both pedestrians and cyclists as well as the availability of a Toucan Crossing. This provides cyclists with an alternative to using the road. Again, evidence was heard that there was inappropriate signage to instruct cyclists that this route was available.” The Council’s Response to the Coroner’s concerns: 1. Road Signage in Advance of the Roundabout The Council does not accept that there was insufficient actual road signage to assist road users in how the roundabout could be navigated. It is accepted that there were alterations to lane designations at the roundabout in question, this being undertaken on or about January 2022. Following those road alterations to lane designations, “New Road Layout Ahead” signs were erected and remained in place until after May 2022. There is a 3 month minimum requirement to provide advanced warning for new road layout works. The Council follow and adopts advice and guidance provided within The Traffic Signs Manual. There is no statutory requirement for there to be Lane Designation Signage in accordance with the Traffic Signs Regulations and General Directions 2016 (as amended) (TSRGD). The Manual offers advice to traffic authorities on the use of traffic signs and road markings on the highway network. Section 1.1.3 of Chapter 1 provides that “reducing sign clutter was a key aim of the revision of TSRGD…Following the advice in the Manual can help traffic authorities reduce the amount of sign clutter on their roads.” In accordance with Chapter 5, Section 9.1.3 of the Traffic Signs Manual, “…lane arrows may be supplemented by a matching indication on an upright sign to diagram 877 (S11-2-22).” Lane designation signage is not a mandatory requirement in accordance with the Manual and guidance. However, following this tragic incident and in accordance with powers conferred upon the traffic authority under section 39 Road Traffic Act 1988 “for controlling, protecting or assisting the movement of traffic on roads”, and to promote road safety, the Council intend to install Lane designation signage for Northbound traffic to ensure that advanced signage is clearer on the approach to the roundabout for all road users. The Council propose to undertake the signage changes as a works programme during the 2025/26 financial year subject to approval for funding and resources. The Highway Code specifically rules 76 to 78 applicable to cyclists at roundabouts and rules 184 to 190 are relevant for road users especially cyclists on how to navigate roundabouts. 2. Signage on the cycling route The start/end and connecting side streets are signed setting out the cycle route. It is understood from the evidence that the deceased cyclist came off the cycle route in order to join the traffic flow on the carriageway. Whilst there was provision of a cycle lane to keep cycles off the road, cyclists have a choice of whether to remain or not on the cycle route. There is no mandatory requirement for cyclists to remain on the dual cycle path. The Council propose to make changes to the cycle signage to highlight the presence of the Toucan crossing route available to cyclists on the dual use path. The Council propose to put in place an applicable sign to be implemented before August 2025. The Council send their deepest condolences to the family of the deceased and intend to take the above changes to ensure that future road traffic accidents are minimised.
See every Prevention of Future Deaths report matching Road (Highways Safety) related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.