Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0074, written 6 Feb 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Feb 2025 |
|---|---|
| Reference | 2025-0074 |
| Deceased | Jane Bennett |
| Coroner | Anne Pember |
| Coroner area | Northamptonshire |
| 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 2 3 Chief Coroner’s Office 1 CORONER I am Anne PEMBER, Senior Coroner for the coroner area of Northamptonshire 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 19 March 2024 I commenced an investigation into the death of Jane BENNETT aged 65. The investigation concluded at the end of the inquest on 09 January 2025. The medical cause of death was given as: 1a 1b 2 Multiple organ failure Severe trauma following road traffic collision. Obesity, Type II Diabetes. 4 CIRCUMSTANCES OF THE DEATH Mrs Bennett was a 65 year old lady. She drove her car on the 13th March 2024 at around 5pm when she exited the junction at St Johns Road, Tiffield travelling eastbound. She was in collision with a vehicle travelling on the A43 in the direction of Northampton. Mrs Bennett was conveyed to University Hospital Coventry and Warwick. Her condition deteriorated. She was confirmed deceased on 15 March 2024. 5 CORONER’S CONCERNS During the course of the investigation my inquiries 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: (brief summary of matters of concern) The junction of St Johns Road, Tiffield and the A43 Northamptonshire is very difficult to manoeuvre. Witnesses who attended at the inquest gave evidence to the effect that unless some changes are made there are likely to be further accidents/or fatalities. I concur with this view. 6 ACTION SHOULD BE TAKEN Regulation 28 – After Inquest Document Template Updated 30/07/2021 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 April 4th, 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. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons I have also sent it to of Northamptonshire Police who may find it useful or of interest. 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 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. 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 Dated: 06/02/2025 Anne PEMBER Senior Coroner for Northamptonshire Regulation 28 – After Inquest Document Template Updated 30/07/2021
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 A REPORT TO PREVENT FUTURE DEATHS THIS RESPONSE IS BEING SENT TO: 1. The Senior Coroner for the coroner area of Northamptonshire, Anne Pember, of The Guildhall, St Giles’ Square, Northampton NN1 1DE in response to a ‘Regulation 28 Report to Prevent Future Deaths’ issued after an inquest into the death of Jane Bennett. 1 NATIONAL HIGHWAYS I am , Regional Director, Midlands region, Operations Directorate, responding on behalf of National Highways Limited, Bridge House, 1 Walnut Tree Close, Guildford, SURREY, GU1 4LZ. 2 CORONER’S MATTERS OF CONCERN The MATTERS OF CONCERN are as follows:– “The junction of St John’s Road, Tiffield, and the A43 Northamptonshire is very difficult to manoeuvre. Witnesses who attended at the inquest gave evidence to the effect that unless some changes are made there are likely to be further accidents/or fatalities. I concur with this view.” 3 DETAILS OF ACTION TAKEN i. Difficulty in manoeuvring at junction National Highways undertakes regular maintenance activities on the road network to ensure the road network is as safe as possible for all road users. The Midlands trunk and motorway network managed by National Highways is assessed on an annual basis using the latest 5 years personal injury collision data collated by the Police and verified by DfT. This assessment is used to identify those locations with the highest incidents of personal injury collisions (PIC) so they can be prioritised for further detailed investigations and potential safety improvements. The latest assessment of the PIC data has recently been completed using the most up-to-date 5 years of data available (2019-2023). Following the fatal incident National Highways has referred to this assessment list and the junction of the A43 / St John’s Road does not appear within the top 100 sites in the Midlands. Although this data does not include the recent fatality it does reveal that this junction has a relatively good safety record in relation to the Midlands trunk and motorway network, with only two ‘slight’ injury collisions recorded here within that 5 year period. Based on this, the junction of the A43 and St John’s Road does not rank highly as a safety problem location, and for this reason we have not prioritised this junction as a location to undertake detailed investigations for a potential safety improvement scheme. 1 National Highways currently have a renewals scheme programmed for 2026/2027 which includes resurfacing, road markings, road studs, vegetation clearance, and drainage for sections of the A43 including St John’s junction. 4 DETAILS OF FURTHER ACTION PROPOSED i. Difficulty in manoeuvring at junction In advance of the 2026/2027 planned carriageway renewals scheme, National Highways is planning minor surfacing works for Summer 2025. This will include refreshing road markings and reflective road studs on the A43 eastbound mainline through the junction. We are currently investigating the possibility of including the vegetation clearance in these works. The vegetation clearance works should improve manoeuvrability at the junction by increasing visibility which will make it easier for drivers exiting St John’s Road to identify gaps in the traffic on the A43 to safely negotiate the junction. ii. Future Planned Works The A43 renewals scheme is currently being developed and scheduled for construction in the later part of 2026. This scheme involves resurfacing of the A43 eastbound and westbound carriageway, repainting of the line markings and replacing the reflective road studs from the M1 motorway through to St John’s Road junction. While the physical layout of the junction will not change, as part of our scoping we are investigating potential improvements for the junction of St John’s Road, such as signage. 5 TIMETABLE FOR ACTION DATE ACTION Planned for Summer 2025 Planned for Late 2026 Minor carriageway repair works. Vegetation clearing in A43 central reserve. Vegetation clearing in A43 verge adjacent St John’s Road junction Northbound and southbound carriageway resurfacing works from M1 motorway to St John’s Road junction. 6 SAFETY OF ROAD USERS The safety of everyone on our road network matters; it is an imperative for our business in what we set out to achieve and a core value of our organisation in how we go about it. The action taken and planned on the A43 is designed to ensure we maintain the road network to ensure efficient and safe movement for all road users and should help to prevent future deaths at this location. 2 7 Date: 31 03 2025 Signed: , Regional Director, Midlands region 3
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