Katherine Vanloo
PFD Report
All Responded
Ref: 2017-0493
All 1 response received
· Deadline: 23 Nov 2017
Coroner's Concerns (AI summary)
There was a severe 7-month delay in pothole repair, exacerbated by the County Council's lack of a system to track works orders or audit completion and quality, leading to the wrong repair being performed.
View full coroner's concerns
(1) The pothole was first identified on 23rd March 2015 as a category 2 defect with a target of 28 days within which such defects should be repaired.
(2) The works order to carry out the repair was only raised by Warwickshire County Council 3 months later on 5th June 2015. This was sent to Balfour Beatty Living Places who had entered into a contract with Warwickshire County Council to repair road surfaces in Warwickshire. They in turn subcontracted the road repair work, which included pothole repair work, to CR MacDonald. The works order was received by CR MacDonald on 19th June 2015.
(3) The work to repair the pothole was not undertaken by an employee of CR MacDonald until 2nd November 2015, albeit that the wrong pothole was repaired on that day.
(4) There was a delay of over 7 months between the identification of the pothole and the time it was supposedly repaired on 2nd November 2015.
(5) At the time of the incident Warwickshire County Council did not have a system in place to track with Balfour Beatty Living Places or CR MacDonald the progress of works orders, i.e. when outstanding works had been completed, nor any formal programme of auditing to check if the work has been done and to check the quality of the work.
(2) The works order to carry out the repair was only raised by Warwickshire County Council 3 months later on 5th June 2015. This was sent to Balfour Beatty Living Places who had entered into a contract with Warwickshire County Council to repair road surfaces in Warwickshire. They in turn subcontracted the road repair work, which included pothole repair work, to CR MacDonald. The works order was received by CR MacDonald on 19th June 2015.
(3) The work to repair the pothole was not undertaken by an employee of CR MacDonald until 2nd November 2015, albeit that the wrong pothole was repaired on that day.
(4) There was a delay of over 7 months between the identification of the pothole and the time it was supposedly repaired on 2nd November 2015.
(5) At the time of the incident Warwickshire County Council did not have a system in place to track with Balfour Beatty Living Places or CR MacDonald the progress of works orders, i.e. when outstanding works had been completed, nor any formal programme of auditing to check if the work has been done and to check the quality of the work.
Responses
Action Taken
The Highways Safety Inspectors now use handheld devices to upload pothole details directly into the County Council's database. The Highways team has direct access to Confirm which displays a dashboard for overdue works orders. (AI summary)
The Highways Safety Inspectors now use handheld devices to upload pothole details directly into the County Council's database. The Highways team has direct access to Confirm which displays a dashboard for overdue works orders. (AI summary)
View full response
Dear Mr Buckley, REPORT TO PREVENT FUTURE DEATHS: KATHERINE VANLOO INQUEST am writing in response to the report which you issued on 2 November 2017 to explain what action the County Council has taken and proposes to take in order to speed up the time it takes to repair potholes once they have been identified and to track the progress of works orders that have been sent to Balfour Beatty Living Places ("BBLP"): am the Joint Managing Director of the County Council and my responsibilities include the highways functions of the County Council: confirm that the County Council has no objection to this letter published in full by the Chief Coroner and being disclosed in full to the Interested Persons at the Inquest Our actions relate, firstly, to the period between pothole being identified by Safety Inspector and works order being issued to BBLP and, secondly, to the period after works order has been issued_ have not changed the target times for repairing potholes (and no criticism was made of them during the inquest) but have aimed our actions at ensuring that works orders are issued promptly and that any slippage by Balfour Beatty is quickly detected and pursued_ Ensuring Prompt Issue of a Works Order The Highways Safety Inspectors now use one of six handheld devices to create details of potholes that they find (co-ordinates, photographs, categorisation, etc ) and upload them directly into the County Council's database in the EXOR computer system: The database is known as the "defects pool"_ The defects pool contains records of all kinds of defects and so we have introduced measures to enable safety defects found by Inspectors to be readily distinguished from other defects that do not present an immediate safety concern_ This is done by assigning a letter to each of the handheld devices (A, B C, D, E or F) which prefixes the reference number of any safety defect when it is uploaded to EXOR (e.g: B9678). being We nldelry
BBLP have agreed that the Inspectors should upload from their handheld devices at the end of every inspection day- This reduces any delays in defects entering the pool and ensures that safety defects do not accumulate into clusters that become backlog_ senior Inspector at BBLP is also taking responsibility for checking with our Highways teams at the end of every day that each Inspector has successfully uploaded their data for that day: We have introduced target to issue a works order within no more than five days from a safety defect being uploaded to EXOR The letter prefix means that safety defects in the defects pool can be easily collected and organised for review within database. Our Delivery Teams in Highways are now required to review the defects pool on a daily basis and the review includes the following objectives: to check whether there is any reason why a Category 2 delect cannot be repaired within 28 days and, if there is such reason, to arrange for an emergency temporary repair; (ii) to identify any safety defects that were uploaded more than five days ago and prioritise them for an immediate works order. The introduction of a letter prefix also means that it is quicker to find and attach the correct photograph to the job pack that is issued to BBLP with the works order and the risk of error is reduced Action has also been taken to speed up the preparation of job packs by agreeing with BBLP that it deliver all traffic management forms to one central Highways office o Mondays, Wednesdays and Fridays_ The traffic management forms set out any arrangements for managing traffic that will be necessary whilst defects are being repaired and they are an essential part of each job pack Although this was not mentioned at the inquest; discussions with BBLP about improving processes identified that traffic management forms were being delivered to either the northern sector office Or the southern sector office where they were scanned and into either a northern sector or a southern sector file_ This caused delays if forms were dellvered to the wrong office or length of road straddled the boundaries between the sectors_ The responsible team at the central office now scan the forms into single countywide computer file which can be accessed by both the northern and southern offices_ Although it is not mentioned in the Regulation 28 Report, whilst giving your narrative verdict you expressed the hope that Inspectors would in: future record depth of potholes at the fime of inspection. An instruction to do so has been issued to BBLP to be implemented from the start of January 2018 When a works order is raised and a jobs pack is sent to BBLP by the County Council, it is entered into BBLPs Confirm computer system: Itis the intention of the County Council and BBLP to develop their systems further s0 that safety defects in the defects pool can be automatically transferred to Confirm: However, am afraid that we are unable to timescale on achieving that: Monitoring Works Orders The County Council did have a system for checking the paperwork returned by BBLP after it had carried out works orders and also system for carrying out quality audits on proportion of randomly selected completed repairs (see paragraphs 61-62 of the Statement of However; the inquest heard evidence that systen was overwhelmed when the number of repairs carried out quadrupled following the introduction of the Find and Fix programme and records of repairs completed were being returned by BBLP intermittently in massive batches_ the will put the put the being
The inquest also heard evidence from our Programmes and Delivery Manager, and the Head of Operational Improvement for BBLP that the Find and Fix programme has now been discontinued and about the introduction of the Confirm system in the first half of 2017 (see in particular paragraphs 27-28 of Statement of 30 June): The leader of a team sent by BBLP or its sub-contractor to carry out works orders is now issued with GPS linked handheld device which carries all the information in the pack, including GPS co-ordinates When the repair has been completed, and photographed, records of that can be uploaded directly into the Confirm system from the site (if there is no 3G coverage at the site the data is uploaded when 3G connectivity is available). No system can wholly eliminate the potential for human error or deception but this system very substantially eliminates the possibility of correct location not being found by the repair team and of any miscommunication about what work has been carried out and where_ Ouir Highways team have direct access to Confirm as well as BBLP (at the moment only Highways has access but access will be provided to all the relevant team Teaders in January 2018) Confirm displays a "dashboard' which automatically displays details of any works orders which have gone "red" , meaning that they have not been carried out within 23 days of the date of the works order. Allowing up to five days for the works order to be issued after inspection, this effectively sounds an alert that the 28 target is at risk of being missed. These works orders are then prioritised for urgent completion. At present, the County Council are working co-operatively with BBLP to target overdue works orders and will keep under review whether joint monitoring and action on collaborative basis is proving sufficient to ensure that repairs are being effected on time or, in a small number of cases very shortly thereafter. However, inspection of the Confirm dashboard on 19 December 2017 showed that only 14 safety defects were at or beyond the 28 target across the whole county- Conclusion hope that this letter, which mainly describes actions that have already been taken, provides reassurance, most especially to family of Ms Vanloo, of how seriously the County Council takes the safety of people on our roads and that the processes which we and BBLP operate have been significantly improved in practical and effective ways for the future_ If you would like further detail or information, please do let me know and will do what can to
BBLP have agreed that the Inspectors should upload from their handheld devices at the end of every inspection day- This reduces any delays in defects entering the pool and ensures that safety defects do not accumulate into clusters that become backlog_ senior Inspector at BBLP is also taking responsibility for checking with our Highways teams at the end of every day that each Inspector has successfully uploaded their data for that day: We have introduced target to issue a works order within no more than five days from a safety defect being uploaded to EXOR The letter prefix means that safety defects in the defects pool can be easily collected and organised for review within database. Our Delivery Teams in Highways are now required to review the defects pool on a daily basis and the review includes the following objectives: to check whether there is any reason why a Category 2 delect cannot be repaired within 28 days and, if there is such reason, to arrange for an emergency temporary repair; (ii) to identify any safety defects that were uploaded more than five days ago and prioritise them for an immediate works order. The introduction of a letter prefix also means that it is quicker to find and attach the correct photograph to the job pack that is issued to BBLP with the works order and the risk of error is reduced Action has also been taken to speed up the preparation of job packs by agreeing with BBLP that it deliver all traffic management forms to one central Highways office o Mondays, Wednesdays and Fridays_ The traffic management forms set out any arrangements for managing traffic that will be necessary whilst defects are being repaired and they are an essential part of each job pack Although this was not mentioned at the inquest; discussions with BBLP about improving processes identified that traffic management forms were being delivered to either the northern sector office Or the southern sector office where they were scanned and into either a northern sector or a southern sector file_ This caused delays if forms were dellvered to the wrong office or length of road straddled the boundaries between the sectors_ The responsible team at the central office now scan the forms into single countywide computer file which can be accessed by both the northern and southern offices_ Although it is not mentioned in the Regulation 28 Report, whilst giving your narrative verdict you expressed the hope that Inspectors would in: future record depth of potholes at the fime of inspection. An instruction to do so has been issued to BBLP to be implemented from the start of January 2018 When a works order is raised and a jobs pack is sent to BBLP by the County Council, it is entered into BBLPs Confirm computer system: Itis the intention of the County Council and BBLP to develop their systems further s0 that safety defects in the defects pool can be automatically transferred to Confirm: However, am afraid that we are unable to timescale on achieving that: Monitoring Works Orders The County Council did have a system for checking the paperwork returned by BBLP after it had carried out works orders and also system for carrying out quality audits on proportion of randomly selected completed repairs (see paragraphs 61-62 of the Statement of However; the inquest heard evidence that systen was overwhelmed when the number of repairs carried out quadrupled following the introduction of the Find and Fix programme and records of repairs completed were being returned by BBLP intermittently in massive batches_ the will put the put the being
The inquest also heard evidence from our Programmes and Delivery Manager, and the Head of Operational Improvement for BBLP that the Find and Fix programme has now been discontinued and about the introduction of the Confirm system in the first half of 2017 (see in particular paragraphs 27-28 of Statement of 30 June): The leader of a team sent by BBLP or its sub-contractor to carry out works orders is now issued with GPS linked handheld device which carries all the information in the pack, including GPS co-ordinates When the repair has been completed, and photographed, records of that can be uploaded directly into the Confirm system from the site (if there is no 3G coverage at the site the data is uploaded when 3G connectivity is available). No system can wholly eliminate the potential for human error or deception but this system very substantially eliminates the possibility of correct location not being found by the repair team and of any miscommunication about what work has been carried out and where_ Ouir Highways team have direct access to Confirm as well as BBLP (at the moment only Highways has access but access will be provided to all the relevant team Teaders in January 2018) Confirm displays a "dashboard' which automatically displays details of any works orders which have gone "red" , meaning that they have not been carried out within 23 days of the date of the works order. Allowing up to five days for the works order to be issued after inspection, this effectively sounds an alert that the 28 target is at risk of being missed. These works orders are then prioritised for urgent completion. At present, the County Council are working co-operatively with BBLP to target overdue works orders and will keep under review whether joint monitoring and action on collaborative basis is proving sufficient to ensure that repairs are being effected on time or, in a small number of cases very shortly thereafter. However, inspection of the Confirm dashboard on 19 December 2017 showed that only 14 safety defects were at or beyond the 28 target across the whole county- Conclusion hope that this letter, which mainly describes actions that have already been taken, provides reassurance, most especially to family of Ms Vanloo, of how seriously the County Council takes the safety of people on our roads and that the processes which we and BBLP operate have been significantly improved in practical and effective ways for the future_ If you would like further detail or information, please do let me know and will do what can to
Sent To
- Warwickshire County Council
Response Status
Linked responses
1 of 1
56-Day Deadline
23 Nov 2017
All responses received
About PFD responses
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 5th January 2016 I commenced an investigation into the death of Katherine Tracey Vanloo, then aged 52 years. The investigation concluded at the end of the inquest on 28th September 2017. The conclusion of the inquest was a narrative conclusion.
The medical cause of death was 1a lung lacerations, splenic lacerations, fractured skull and left forearm b road traffic collision
The pothole on Napton Holt Road in Warwickshire into which Mrs Vanloo fell when riding her bicycle was first indentified on 23rd March 2015 as a category 2 defect by a Safety Inspector employed by Balfour Beatty Living Places.
Under the terms of the Warwickshire County Council Highways Maintenance Safety Inspections Manual to which Balfour Beatty Living Places was working there was a target of 28 days within which such category 2 defects should be repaired.
The works order to carry out the repair was raised by Warwickshire County Council three months later on 5th June 2015 and received by Balfour Beatty Living Places on 10th June 2015.
The pothole was first identified on 23rd March 2015 and an employee of CR MacDonald Limited, to whom Balfour Beatty had subcontracted the road repair work, was sent out for the first time on 2nd November 2015 to repair the pothole, albeit that the wrong pothole was in fact repaired.
The pothole was never repaired before the death of Mrs Vanloo on 3rd January 2016.
The medical cause of death was 1a lung lacerations, splenic lacerations, fractured skull and left forearm b road traffic collision
The pothole on Napton Holt Road in Warwickshire into which Mrs Vanloo fell when riding her bicycle was first indentified on 23rd March 2015 as a category 2 defect by a Safety Inspector employed by Balfour Beatty Living Places.
Under the terms of the Warwickshire County Council Highways Maintenance Safety Inspections Manual to which Balfour Beatty Living Places was working there was a target of 28 days within which such category 2 defects should be repaired.
The works order to carry out the repair was raised by Warwickshire County Council three months later on 5th June 2015 and received by Balfour Beatty Living Places on 10th June 2015.
The pothole was first identified on 23rd March 2015 and an employee of CR MacDonald Limited, to whom Balfour Beatty had subcontracted the road repair work, was sent out for the first time on 2nd November 2015 to repair the pothole, albeit that the wrong pothole was in fact repaired.
The pothole was never repaired before the death of Mrs Vanloo on 3rd January 2016.
Circumstances of the Death
Katherine Tracey Vanloo died on 3rd January 2016 near to the entrance to Headlands farm on Napton Holt Road Warwickshire from catastrophic injuries she sustained in a collision with a Toyota Yaris car. Mrs Vanloo was cycling with a friend at the time and was thrown from her bicycle into the path of the car when her bicycle hit an unrepaired pothole in the road. She was pronounced dead at the scene at 1101am.
Action Should Be Taken
The action should include an explanation of the steps you have taken to speed up the time it takes to repair potholes once they have been identified and what steps you have taken to track the progress of work orders that have been sent to Balfour Beatty Living places for action.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.