Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0711, written 23 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 | 23 Dec 2024 |
|---|---|
| Reference | 2024-0711 |
| Deceased | Nigel Sweet |
| Coroner | Guy Davies |
| Coroner area | Cornwall and Isles of Scilly |
| 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.
Information Classification: PUBLIC REGULATION 28: REPORT TO PREVENT FUTURE DEATHS IN THE MATTER OF THE INQUEST TOUCHING THE DEATH OF NIGEL WILLIAM SWEET REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: , Chief Executive Officer, National Highways 1 CORONER I am Guy Davies, His Majesty’s Assistant Coroner for Cornwall & the Isles of Scilly. 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. [HYPERLINKS] 3 INVESTIGATION and INQUEST On 18 March 2024 I commenced an investigation into the death of 63 year old Nigel William Sweet. The investigation concluded at the end of the inquest on 19 December 2024. The medical cause of death was found as follows: 1a Multiple Injuries 1b Road Traffic Collision 1 Information Classification: PUBLIC The four questions - who, when, where and how – were answered as follows: Nigel William SWEET died on 7 March 2024 on the A38 between Trerulefoot and Tideford Cornwall from injuries sustained after he lost control of his motorcycle due to rider error whilst attempting to complete an overtake of another vehicle in wet conditions. The motorcycle fell onto its side as Nigel lost control. Nigel was separated from his motorcycle and he slid across the carriageway into the path of an oncoming vehicle which was unable to avoid him despite emergency braking and steering input. That oncoming vehicle drove over Nigel who suffered unsurvivable injuries as a consequence. The conclusion of the inquest was as follows: Road Traffic Collision 4 CIRCUMSTANCES OF THE DEATH The reason for the collision was found to be rider error by Nigel, in wet road conditions whilst attempting an overtake in a creeper lane. A creeper lane is an additional lane, added to a single carriageway for a short stretch to allow for overtaking. There are a number on this stretch of the A38 which present road users with brief opportunities to overtake slower moving vehicles, before the road reverts to single carriageway on both sides. Nigel had overtaken at least one vehicle and was attempting to overtake a second vehicle by using the additional lane of the creeper lane. There was steady and oncoming traffic on the other carriageway. Nigel had insufficient space in the creeper lane to safely complete the overtaking manoeuvre of the second vehicle. Nigel lost control of his motorcycle whilst under braking at which time he was likely trying to get back into the single carriageway at the end of the creeper lane. In that sense the creeper lane contributed to the collision. The court found that there was nothing that the driver of the oncoming vehicle could have done to avoid Nigel. 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. – 2 Information Classification: PUBLIC (1) The court found that this stretch of the A38 from Carkeel roundabout to Trerulefoot roundabout has a history of a higher proportion of road traffic collisions compared to equivalent roads. This is because of the nature of the A38 over this stretch which features predominantly single carriageway layout with occasional creeper lanes. (2) The court heard evidence that a safety scheme had been developed to introduce average speed cameras for this stretch of the A38 but that funding had not yet been approved. The safety scheme was specifically designed to reduce the higher proportion of collisions on this stretch of road. 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 17 February 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, namely Nigel’s family. I have also sent it to MPC who may find it useful or of interest. 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 23 December 2024 Guy Davies 3
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.
REGULATION 29 RESPONSE TO PREVENT FUTURE DEATHS THIS RESPONSE IS BEING SENT TO: The Assistant Coroner for Cornwall & the Isles of Scilly, Guy Davies, of Pydar House, Pydar Street, Truro, Cornwall TR1 2AY. 1 National Highways I am Limited of Ash House, Falcon Road, Sowton, Exeter EX2 7LB. , Regional Director for the South West, National Highways 2 CORONER’S MATTERS OF CONCERN The MATTERS OF CONCERN are as follows: – a. The court found that this stretch of the A38 from Carkeel roundabout to Trerulefoot roundabout has a history of a higher proportion of road traffic collisions compared to equivalent roads. This is because of the nature of this stretch which features predominantly single the A38 over carriageway layout with occasional creeper lanes. b. The court heard evidence that a safety scheme had been developed to introduce average speed cameras for this stretch of the A38 but that funding had not yet been approved. The safety scheme was specifically designed to reduce the higher proportion of collisions on this stretch of road. DETAILS OF ACTION TAKEN 3 a. Nature of the A38 All Purpose Trunk Road The A38 Trunk Road between Carkeel Roundabout and Trerulefoot Roundabout is a single carriageway road approximately 6.0 miles (9.6km) in length and traverses through rural and urban areas. Carkeel Roundabout is situated to the east in Saltash and Trerulefoot to the west. The geometry of the route is constrained by topography, development, water courses, structures and open countryside. The route is subject to a 50mph speed limit which reduces to 40mph in the villages of Landrake and Tideford. The matter of concern raised refers to ‘creeper lanes’, which is known in highways terms as a wide single (carriageway) 2 + 1 road layout. This means 1 direction of travel allows for 2 lanes of traffic and the other direction of travel allows for 1 lane of traffic. This road layout is detailed in the Design Manual for 1 Roads and Bridges (DMRB), Standard CD109 Highway link design. The Standard can be found on the following link1 and the layout described under section 6 pages 26-37. Wide single 2 + 1 road layouts provide an opportunity for vehicles to safely overtake slower moving vehicles on single carriageways (e.g. heavy goods vehicles are restricted to 40 mph on single carriageway roads). The layout is also used where uphill gradients exceed 2% and are over 500 metres long. In this situation the layout provides a climbing lane for slower vehicles and an opportunity for other road users to safely overtake them. As wide single 2 + 1 road layouts help prevent congestion, which could result in road users performing injudicious overtakes in undesirable locations, we have no plans to remove this layout from the DMRB Standards or at this location. Road traffic collision review National Highways is the Highway Authority for the Strategic Road Network (SRN) of major A-roads and most motorways in England including the A38 at the location of this collision. The safety performance of all roads that National Highways is responsible for is continually monitored using STATS19 data (the Department for Transport’s validated collision data). The most recent 5-year validated data (between 2019 and 2023) shows that 60 collisions (97 casualties) have been recorded for the 6 mile (9.6km) section of the A38 between Carkeel and Trerulefoot roundabouts. This is summarised as follows: • 2 Fatal collisions (2 casualties) • 13 Serious collisions (17 casualties) • 45 Slight collisions (78 casualties) Road traffic collision comparison The same validated collision data as published by the DfT annually, is used to compare the safety performance of all roads we are responsible for in England. The A38 between Carkeel and Trerulefoot roundabouts has a 51% higher injury collision rate than the national average for our similar single carriageway roads in the South West. This section of the A38 road is 35th lowest performing route in the South West out of 39 routes, in terms of its collision rate performance. 1 https://www.standardsforhighways.co.uk/tses/attachments/c27c55b7-2dfc-4597-923a- 4d1b4bd6c9fa?inline=true 2 For fatal and serious injuries, this section of the A38 has a 20% Killed and Seriously Injured (KSI) rate which is 8% higher than the national average for our similar single carriageway roads. However, the Road Accidents Great Britain database2 for 50mph single carriageway roads during the same data period shows that the KSI rate for the whole of Great Britain is 23%. This is higher than the 20% of this section of the A38. Therefore, whilst the KSI-to-total casualties ratio on the A38 in Cornwall is higher than our NH average, it is better than GB wide. Although this data demonstrates there are other similar roads with greater need, we completed a pipeline study ‘A38 Carkeel to Trerulefoot’ in 2022. The study considered many options for interventions ranging from providing a dual carriageway around the villages, widening of the A38, to small targeted interventions. The outcome of this study found that the extensive engineering required to dual or widen the A38 within the existing topography was unaffordable at the time and a proposal largely focused on several online interventions was selected. Following the Secretary of State’s Written Ministerial Statement published on 9 March 2023 that the pipeline schemes, which included the A38 Carkeel to Trerulefoot scheme, previously earmarked for RIS3 (2025- 30) would continue to be developed and considered for inclusion within RIS4 (2030-35). b. Safety scheme to introduce average speed cameras Following deferral of any major improvement scheme, as a member of the external South West Vision Zero Road Safety Partnership, National Highways has been working closely with Cornwall Council, Devon and Cornwall Police and other external partners to identify interventions that could reduce the number of collisions on this section of the A38 and improve the safety of residents in Landrake and Tideford. Our current plan is to implement an Average Speed Camera Systems (ASCS) between Carkeel and Trerulefoot and to reduce the speed limit through the villages of Landrake and Tideford to 30 mph. We aim to publish the notice for the Traffic Regulation Order (TRO) in March 2025 and begin implementation of the ASCS and signs in May of financial year 2025/2026. ASCSs have already been successfully used on our Strategic Road Network to reduce collision rates. This includes on the A38 in the Glyn Valley, where collision rates have reduced. It is anticipated that the ASCS planned for the A38 between Landrake and Tideford will increase speed limit compliance and driver concentration, both of which are known to reduce collision rates. I can confirm that since the inquest on 19th December 2024, the business case and funding for the ASCS has been agreed, but not yet secured, and work is 2 Reference RAS0301 casualty tab row 29 of https://assets.publishing.service.gov.uk/media/66f44bd1c71e42688b65ec3e/ras0301.ods 3 scheduled to commence in Q1 2025/26. Once installed, the road safety performance of the whole length of the A38 will continue to be monitored and if necessary, further improvements considered. 5 TIMETABLE FOR PLANNED ACTION DATE ACTION March/April 2025 Initial design completion package for ASCS and speed limits. March 2025 Publish TRO Notice May FY Year 2025/26 Works start on site for the installation of Average Speed Camara System and revised speed limits. 6 SAFETY OF ROAD USERS The safety of our road users is an imperative for our business and safety is a core value of our organisation. We are working hard to make our entire network safer. We consider that the action we have both taken to date, and plan to take, could help to prevent future deaths on the A38 at this location. All improvements to the network require to be progressed in a considered and controlled fashion so that the consequences of changes to the network are fully understood and any linked safety risks are eliminated or reduced as far as possible. Furthermore, works to the Strategic Road Network are required to demonstrate value for money, in accordance with the Highways England: Licence (April 2015), and our duty to manage public funds. 7 11 February 2025 Signed: Regional Director for the South West 4
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