Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0208, written 30 Apr 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 30 Apr 2025 |
|---|---|
| Reference | 2025-0208 |
| Deceased | Doreen Turner |
| Coroner | Joanne Andrews |
| Coroner area | West Sussex, Brighton and Hove |
| 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 REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: West Sussex County Council 1 CORONER I am Joanne ANDREWS, Area Coroner for the coroner area of West Sussex, Brighton and Hove 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 02 November 2024 I commenced an investigation into the death of Doreen TURNER aged 91. The investigation concluded at the end of the inquest on 30 April 2025. The conclusion of the inquest was that: Doreen Turner died on 1 November 2024 having been found in her car in the canal at the of South Bank, Chichester, West Sussex. She died as a result of drowning having entered the water. 4 CIRCUMSTANCES OF THE DEATH Mrs Turner drove her car into the canal at the end of Canal Bank, Chichester, West Sussex on 1 November 2024 at around 2130hrs. It is not clear why the car ended up in the canal but there was no evidence of mechanical failure or impairment of Mrs Turner being contributory to events. 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: The inquest was told that South Bank is a residential cul de sac. At the end of the road, there is a footpath which is perpendicular to the road which also runs alongside the canal. The end of the road has kerbing, a 5ft foot grass section and then the canal. The inquest heard that the kerbing is less than standard height and there are no Regulation 28 – After Inquest Template Updated 15/10//2024 TG devices present to prevent a vehicle which passes over the kerbstones from entering the canal. The evidence was that Mrs Turner was the second driver to have entered the canal in a vehicle in the last 5 years at that location. 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. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by June 25, 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 Family of Mrs Turner 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. She 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: 30/04/2025 Joanne ANDREWS Area Coroner for West Sussex, Brighton and Hove Regulation 28 – After Inquest Template Updated 15/10//2024 TG Regulation 28 – After Inquest Template Updated 15/10//2024 TG
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.
Assistant Director (Highways, Transport & Planning) www.westsussex.gov.uk County Hall West Street Chichester West Sussex PO19 1RQ Private and Confidential Parkside Chart Way Horsham RH12 1XH 13th June 2025 Dear Inquest into the death of Doreen Turner (Your ref: 03075-2024) Thank you for your covering letter and Regulation 28: Report to Prevent Future Deaths issued by Joanne Andrews, Area Coroner, dated 30th April 2025 (ref 03075-2024), the County Council would like to respond with the comments and actions detailed below. Following the police notification of Mrs Turner’s crash the authority began its own well - established investigation procedure. This included undertaking a site visit and discussing the incident with Sussex Police. As a result, proposals have been designed to install additional infrastructure at the end of South Bank. These works consist of: • Replacing a missing wooden post with way-markers on the canal towpath to the • north side. Installing bollards with reflectors on the canal bank within the gap between an existing traffic sign post and the northern end of the turning head. It is considered the above works will provide clear indication of the end of the road and mitigate the risk of a similar incident to that of Mrs Turner occurring in the future. With regard to the Matters of Concern raised: As noted, South Bank is a residential cul de sac. Traffic speeds approaching the end of the road are very low as drivers approach with caution influenced by the narrow confines of the road due to on-street parking. It is appreciated that the kerb height in the turning head at the end of South Bank is lower than many kerbs at the edge of a public highway, although it does still provide sufficient physical separation between the road edge and the grass bank of the canal to give a physical and audible warning to a driver. Raising the height of the kerbs would not necessarily offer any additional prevention of a vehicle overrunning onto the bank, unless they were of such a height as to fully stop a vehicle – this type of kerbing would be a significant visual intrusion and disruption to the canal bank. It is acknowledged there are no devices present for a section of the canal bank. It is believed the proposed works to install bollards with reflectors will provide approaching drivers with a clearer visual indication of the end of the road. An order has been placed for the works and they are expected to be completed by 31 July 2025. Yours sincerely Assistant Director (Highways, Transport & Planning)
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