Doreen Turner
PFD Report
All Responded
Ref: 2025-0208
All 1 response received
· Deadline: 14 Jul 2025
Coroner's Concerns (AI summary)
A residential cul-de-sac lacks adequate barriers and standard height kerbing at its end, allowing vehicles to repeatedly enter an adjacent canal, posing a significant safety risk.
View full coroner's concerns
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.
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.
Responses
Action Planned
West Sussex County Council describes plans to install additional infrastructure at the end of South Bank, including replacing a missing wooden post with way-markers and installing bollards with reflectors. These works are expected to be completed by 31 July 2025. (AI summary)
West Sussex County Council describes plans to install additional infrastructure at the end of South Bank, including replacing a missing wooden post with way-markers and installing bollards with reflectors. These works are expected to be completed by 31 July 2025. (AI summary)
View full response
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.
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.
Sent To
- West Sussex County Council
Response Status
Linked responses
1 of 1
56-Day Deadline
14 Jul 2025
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
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.
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.
Similar PFD Reports
Reports sharing organisations, categories, or themes
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.