Dear Mr Allen,

Regulation 28 Report – Wilfred Roy Breakell

Thank you for your letter of 21 May 2021 and the accompanying Regulation 28 Report, in connection with the Inquest on 12 May 2021 relating to the death of Mr Wilfred Roy Breakell that occurred at the Blackwater Traffic Signal Junction on 17 May 2020.

BCP Council has undertaken its own investigation into the circumstances of this unfortunate incident. We have reviewed the audio recording of the Inquest which your offices kindly supplied to us. We have also discussed the findings of the inquest and your Regulation 28 Report with senior officers of BCP Council, and would respond as follows.

The incident concerned is not recorded as a fatal road traffic accident on the Dorset Police collision database. It is appreciated that Police reports focus on the cause of the accident rather than the immediate cause of death but these reports hold information which is relevant to the Council’s reporting requirements and I have outlined this below.

The Dorset Police Data Team’s view that the cause of Mr Breakell’s fall into the storm drain could not be established. In arriving at this decision the Data Team considered the report of the Police Officer in Charge of investigating the incident who reported that “The working hypothesis was he (Mr Breakell) was taken ill on his bike, has mounted the verge, travelled a short distance before falling into the ditch. All available evidence pointed towards this being a medical episode”. This was based on the ambulance crew’s initial opinion expressed whilst the Police Officer was on the scene that the incident was as a result of a medical episode.

The Dorset Police Data Team therefore concluded that while the cause of death was injuries sustained in the fall, the cause of the collision was most likely a medical episode. Therefore this would not fall under the Stats 19 requirements to report the incident to the Department for Transport as a Road Traffic Accident. This means BCP Council are responding to a Regulation 28 Report for an incident which we do not have recorded as a fatal road traffic accident.

In addition to this it is not clear in which direction Mr Breakell was travelling before he fell into the ditch. In their statement read out at the Inquest the family of Mr Breakell indicated that he Mr Brendan J Allen Date 13 July 2021 HM Acting Area Coroner

The Coroner’s Office :

Bournemouth Town Hall

Bournemouth BH2 6DY

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was most likely negotiating the traffic signal Toucan facility across the mouth of the junction (i.e. cycling from east to west). They further indicated that Mr Breakell then failed to negotiate a 90 degree right turn when reaching the east side of the Toucan crossing, surmising that this was either because the pavement was too narrow here, causing him to end up in the ditch or there was no physical barrier to prevent him from doing so.

In PC statement given to the Inquest he reported that there was physical evidence indicating that Mr Breakell may have been riding up the ‘off’ slip road of the A338 Spur Road before leaving the road just short of the paved area of the shared footway/cycleway and then ending up in the storm drain which runs parallel with the off slip road. PC also confirmed that there was evidence of damage to Mr Breakell’s cycle helmet resulting from the crash and no evidence of another person or vehicle being involved in the incident.

I am aware that following what happened on the morning of Sunday 17 May 2020 you remain concerned that there is a risk that future deaths will occur, unless action is taken to extend the existing timber post and rail fencing along the slip road to prevent cyclists falling into the storm drain.

The A338 Blackwater Junction Improvements were completed in April 2020 and it was a project delivered jointly by Dorset and BCP Councils. The storm drain in question is designed to receive surface water runoff from the slip road through a series of road gullies situated against the kerb line. The scheme involved clearing the storm drain of vegetation and, to prevent surface water runoff from eroding its banks, concrete slabs were placed at intervals along the back of the storm drain, coinciding with each gully location.

The engineers involved in delivering the original scheme have indicated that the original design did not include for any fencing at this crossing point adjacent to the ditch. They have stated that following a reported safety concern here, a temporary barrier was initially erected and then a permanent timber post and rail fence was installed. The permanent timber post and rail fencing was completed by the 15 June 2020.

BCP Council acknowledges that someone has died here as a result of a tragic accident and would address the Coroner’s concerns and Regulation 28 Report as follows:

(i) There remains a low risk that a similar event will re-occur at this location. (ii) The small level difference from the slip road surfacing down into the ditch is in highway design terms deemed insufficient to require protection in the event of a vehicle leaving the carriageway. (iii) If the post and rail fencing is extended, it is as likely to cause injury to occupants of any vehicle that fails to negotiate the bends as to protect them from it. A known cause of injury and death to road users is from vehicles, including motorcycles and cyclists leaving the highway and striking posts, barriers or other obstructions that are not passively safe. There is a risk therefore that a timber barrier here could create an additional safety hazard. (iv) The concrete slabs in the storm drain are widely spaced and there is therefore a low risk that anyone would come into contact with them should they leave the road. (v) The ditch runs parallel with the carriageway and is on the inside of the bend. The geometry of the road is such that any vehicle losing control here is more likely to end up on the outside of the bend away from the ditch than end up in the ditch itself. (vi) The Council has reached these decisions in the context of a public highway which is a regulated environment and also in the context of professional judgement of experienced and qualified officers. This project was delivered in accordance with the national Standards for Highways including the essential document for the design, construction and maintenance of highways, the Design Manual for Roads and Bridges.

We would note that there is now a much improved crossing provision for both cyclists and pedestrians at this junction. This additional timber post and rail fencing would only be recommended if the accident record itself warranted it and there is no evidence of such a trend at the present time. There have been no recorded cyclist injuries here since October 2017. As

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highlighted above we would be in danger of potentially creating greater numbers of injuries than the measure might prevent were this work to be undertaken.

In light of the above, the Council does not believe it is appropriate to introduce additional fencing to the inside of the bend on the slip road. The Council will, however, continue to monitor this site and others like it in conjunction with the police.

I trust this is satisfactory but please feel free to contact me should you wish for any further information.