Jeffery Matthews
PFD Report
All Responded
Ref: 2017-0230
All 1 response received
· Deadline: 1 Nov 2017
Coroner's Concerns (AI summary)
Inadequate warning signage and obstructed visibility at a hazardous crossroads, combined with a failure to implement previously recommended safety improvements due to resource issues, created a significant risk.
View full coroner's concerns
The C1021 is a minor country road that runs from the A595 at Orton Grange Roundabout in a north westerly direction and terminates when it joins the C2051 at Great Orton village. The road is generally unmarked and just wide enough for two vehicles to pass in opposite directions. The statutory speed limit is 60 mph. Approximately 220 metres prior to the scene of the collision on the C1021, is a left hand bend as you approach from the A595. The bend travels through an angle of approximately 16 degrees before the road straightens on the approach to the crossroads.
The C1021 is straight for approximately 196 metres from the bend to the crossroad and continues straight beyond the crossroads for approximately 159 metres before entering another left hand bend. The police collision investigation report dated 14th August 2017 identifies at paragraph 4.4 that at this point, the presence of the crossroad junction is not obvious to any approaching vehicle. The height of the roadside hedgerows and their close proximity cause a tunnel effect and as such obscure any sign of the crossroads. It is also noted that the presence of the ‘Give Way’ sign at the crossroad junction is lost in the background and therefore not obviously visible to approaching drivers from a distance.
Cumbria County Council is responsible for implementing measures on the county highway network that aim to reduce casualties and the risk of collisions. The C2051 Great Orton Crossroad was previously identified as having a sufficiently serious collision record during the period 1st October 2012 up to 30th September 2015. Capita were commissioned to carry out an independent investigation and inspection.
The finding in the police investigation report at paragraph 4.4 as set out above was not identified by Capita.
Evidence was heard at the inquest that the recommendations made by Capita in their report dated May 2016 were not implemented due to a lack of resources. The recommendations were;
1. The application of High Friction Surfacing on the north and southbound approached
2. Vegetation trimming – cutting back vegetation to the south-east, north-east and north-west quadrant verge areas
3. Additional Road markings on C1021 junction approaches – provide ‘SLOW’ markings on red patch on the C1021 approaches, adjacent to warning signs.
The MATTER OF CONCERN is as follows:
(1) The current warning signage on approach to the junction from a north westerly direction is inadequate.
(2) The height of the roadside hedgerows and their close proximity causes a tunnel effect obscuring any sign of the crossroads restricting visibility.
(3) Modifications to the junction on approach as recommended by Capita should be re-considered to minimise the risk of incidents and death in the future.
The C1021 is straight for approximately 196 metres from the bend to the crossroad and continues straight beyond the crossroads for approximately 159 metres before entering another left hand bend. The police collision investigation report dated 14th August 2017 identifies at paragraph 4.4 that at this point, the presence of the crossroad junction is not obvious to any approaching vehicle. The height of the roadside hedgerows and their close proximity cause a tunnel effect and as such obscure any sign of the crossroads. It is also noted that the presence of the ‘Give Way’ sign at the crossroad junction is lost in the background and therefore not obviously visible to approaching drivers from a distance.
Cumbria County Council is responsible for implementing measures on the county highway network that aim to reduce casualties and the risk of collisions. The C2051 Great Orton Crossroad was previously identified as having a sufficiently serious collision record during the period 1st October 2012 up to 30th September 2015. Capita were commissioned to carry out an independent investigation and inspection.
The finding in the police investigation report at paragraph 4.4 as set out above was not identified by Capita.
Evidence was heard at the inquest that the recommendations made by Capita in their report dated May 2016 were not implemented due to a lack of resources. The recommendations were;
1. The application of High Friction Surfacing on the north and southbound approached
2. Vegetation trimming – cutting back vegetation to the south-east, north-east and north-west quadrant verge areas
3. Additional Road markings on C1021 junction approaches – provide ‘SLOW’ markings on red patch on the C1021 approaches, adjacent to warning signs.
The MATTER OF CONCERN is as follows:
(1) The current warning signage on approach to the junction from a north westerly direction is inadequate.
(2) The height of the roadside hedgerows and their close proximity causes a tunnel effect obscuring any sign of the crossroads restricting visibility.
(3) Modifications to the junction on approach as recommended by Capita should be re-considered to minimise the risk of incidents and death in the future.
Responses
Action Planned
Funding was allocated to implement recommendations from a 2016 road traffic collision study, including high friction surfacing, improved road marking and signage, which is currently out for consultation. The highways department immediately improved the white lining after a fatal collision in March 2017. (AI summary)
Funding was allocated to implement recommendations from a 2016 road traffic collision study, including high friction surfacing, improved road marking and signage, which is currently out for consultation. The highways department immediately improved the white lining after a fatal collision in March 2017. (AI summary)
View full response
Dear Miss Cheema RE: Jeffrey Matthews (Deceased) refer to your letter dated 6 Ih September containing a copy of the Regulation 28 Report: As you state in your report a study into road traffic collisions over the 3 year period, October 2012 to September 2015, was carried out by Capita and the report was published in
2016. As consequence of this report funding was allocated to implement the recommendations in the current financial year, 2017/18 This is standard practice in allocating funds for safety improvements the study is carried in one financial year and depending on priorities the recommendations are implemented in the following financial year: The scheme to introduce the high friction surfacing, improved road marking and signage is curtently out to consultation with the police, the Parish Council and the local County Councillor and subject to agreement; the measures will be introduced as soon as practicable. The vegetation has already been reduced by the local landowners, presumably as a result of the media coverage of the inquest. Once all measures have been installed a further site visit will be held with the police to see if any amendments need to be made or if any further improvements are required. A statement is made in your letter that the Capita recommendations were not installed due to a lack of resources but they were not installed as by May 2016 the funding had already been allocated for the 2016/17 financial and funding was allocated for the following year; as explained previously Following the fatal collision in March 2017 , a site visit was carried out by staff from the highways department and immediately actioned the improvement of the white lining: This is in agreement with the police that any defect should be rectified as soon as possible and should not be delayed awaiting the outcome of an investigation or inquest: Serving the people of Cumbria ME cumbria gov.uk RK May
i.e: out they
2 hope this provides a satisfactory response to the Regulation 28 Report but if you require any more information or clarification do not hesitate to contact me_
2016. As consequence of this report funding was allocated to implement the recommendations in the current financial year, 2017/18 This is standard practice in allocating funds for safety improvements the study is carried in one financial year and depending on priorities the recommendations are implemented in the following financial year: The scheme to introduce the high friction surfacing, improved road marking and signage is curtently out to consultation with the police, the Parish Council and the local County Councillor and subject to agreement; the measures will be introduced as soon as practicable. The vegetation has already been reduced by the local landowners, presumably as a result of the media coverage of the inquest. Once all measures have been installed a further site visit will be held with the police to see if any amendments need to be made or if any further improvements are required. A statement is made in your letter that the Capita recommendations were not installed due to a lack of resources but they were not installed as by May 2016 the funding had already been allocated for the 2016/17 financial and funding was allocated for the following year; as explained previously Following the fatal collision in March 2017 , a site visit was carried out by staff from the highways department and immediately actioned the improvement of the white lining: This is in agreement with the police that any defect should be rectified as soon as possible and should not be delayed awaiting the outcome of an investigation or inquest: Serving the people of Cumbria ME cumbria gov.uk RK May
i.e: out they
2 hope this provides a satisfactory response to the Regulation 28 Report but if you require any more information or clarification do not hesitate to contact me_
Sent To
- Cumbria County Council
Response Status
Linked responses
1 of 1
56-Day Deadline
1 Nov 2017
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 20/04/2017 I commenced an investigation into the death of Jeffrey William Matthews born 19th April 1988. The investigation concluded at the end of the inquest 31st August 2017. The conclusion of the inquest was that the deceased Jeffrey William Matthews died as a result of a road traffic collision.
Circumstances of the Death
On Sunday 26th March 2017 at about 13.35 hours, the deceased had been riding his motorcycle in a north westerly direction along the C1021 heading towards Great Orton village from the A595, when he collided with the offside of a Nissan Juke travelling in a north easterly direction towards Carlisle along the C2051. The deceased suffered fatal injuries as a result of the collision and was pronounced life extinct at the scene at 14.19 hours.
The medical cause of death was recorded as: 1a. Multiple Injuries inconsistent with life 1b. Trauma
The medical cause of death was recorded as: 1a. Multiple Injuries inconsistent with life 1b. Trauma
Copies Sent To
Cumbria Constabulary Collision Investigation Unit
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Revise signal sighting standard to explicitly consider signal readability
Ladbroke Grove Inquiry
Hazardous road design
Define additional time required for reading gantry-mounted and complex signals
Ladbroke Grove Inquiry
Hazardous road design
Clarify "very short duration" definition within the signal sighting standard
Ladbroke Grove Inquiry
Hazardous road design
Identify and retrospectively review locations affected by "very short duration" ambiguity
Ladbroke Grove Inquiry
Hazardous road design
Clarify "overhead line equipment" in signal sighting standard to mean wires and droppers
Ladbroke Grove Inquiry
Hazardous road design
Define acceptable limits for temporary signal obscuration in sighting standards
Ladbroke Grove Inquiry
Hazardous road design
Explicitly define cab sight lines for signal positioning based on driver's eye
Ladbroke Grove Inquiry
Hazardous road design
Railtrack to conduct safety examination of Paddington station layout and operations.
Ladbroke Grove Inquiry
Hazardous road design
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.