Prevention of Future Deaths reports · 2019

Jamil Ahmed

Regulation 28 report to prevent future deaths, written 15 Nov 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report15 Nov 2019
DeceasedJamil Ahmed
CoronerJames Bennett
Coroner areaBirmingham and Solihull
CategoryRoad (Highways Safety) related deaths
Sourcejudiciary.uk record · original PDF
Responses publishednone published

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Highways England
1 CORONER
I am James Bennett Assistant Coroner for Birmingham and Solihull.
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 24/08/2017 I commenced an investigation into the death of Jamil Ahmed. The investigation
concluded at the end of an inquest on 22nd January 2018. The conclusion of the inquest was Road Traffic
Collision.
4 CIRCUMSTANCES OF THE DEATH
On the morning of 18 August 2017 the M6 motorway section passing through the northerly outskirts of
Birmingham City Centre was congested and the automated ‘smart’ motorway system permitted vehicles
to use the hard shoulder as a temporary running lane. There were intermittent Emergency Refuge Areas.
Mr Ahmed was travelling in his low‐loader lorry along the hard shoulder on the southbound section
between junctions 6 and 5 which are 1.6 miles apart. To the nearside of this section of the hard shoulder
was a barrier and significant drop. At around 09.13hrs his vehicle came to a stop. The nearest Emergency
Refuge Area was 300 meters further forward. Mr Ahmed activated his hazard lights, exited his lorry,
opened the bonnet and stood looking into the engine. The maximum speed limit was 60mph and 135
seconds after stopping, a lorry travelling at 55mph, drove into the rear of Mr Ahmed’s lorry causing him
fatal injuries. This preceded a number of approaching vehicles, including large lorries, narrowly avoided a
similar collision by veering into lane 1, which was busy with other vehicles. A post‐mortem examination
revealed the cause of death was multiple injuries from blunt force trauma. Toxicology revealed he has
recently consumed cannabis.
5 CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to concern when a hard
shoulder is used as a running lane.
Whilst any vehicle may break down on any road, in relation to motorways: (1) drivers do not expect to
come across a stationary vehicle in a running lane, (2) the speed of traffic is high, (3) the volume of
traffic is high increasing the number of people affected by a stationary vehicle, (4) the options for the
occupants of a stationary vehicle to escape the road are more limited, and (5) not all stretches of
motorway are necessarily appropriate for use as ‘smart’ motorways ; For example, the stretch of
motorway in question was raised with a significant drop next to the hard shoulder, as opposed to a
stretch of hard shoulder adjacent to a bank or field. All five matters mean it is less likely other drivers will
be able to take evasive action when confronted with a stationary vehicle.
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.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you 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 10
January 2020. 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.
I have sent a copy of my report to the following Interested Persons: (1) Mr Ahmed’s next of kin, (2)
and (3) West Midlands Police.
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 15/11/2019
Signature_________________________
James Bennett Assistant Coroner Birmingham and Solihull

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