William McCourt
PFD Report
All Responded
Ref: 2013-0383
All 1 response received
· Deadline: 6 Feb 2014
Coroner's Concerns (AI summary)
Local residents' reports of flooding were not recorded or acted upon, and maintenance staff failed to correctly identify land ownership, leading to significant delays in addressing a safety hazard.
View full coroner's concerns
1) No record was found of the reports made by local residents prior to June, 2012, of flooding at this location either via the Highways website or by telephone on two occasions and, therefore, no action taken.
2) The maintenance manager who visited the site in June, 2012, formed the opinion that the land in question was owned by the Ministry of Defence. There is no note of the conversation which led to this conclusion, neither did the maintenance manager visit the occupier of the land from which the water was flowing.
3) Over a three month period nothing was done to address the issue other than to telephone the Ministry of Defence. The Ministry of Defence did not provide an answer to the question of ownership of the land until after this accident when they confirmed that they were not responsible for the land in question.
4) Nothing was ever put in writing to the Ministry of Defence requiring them to notify the Highways Authority within a reasonable time scale as to whether they owned the land and if so what action would be taken and by when.
5) This situation was allowed to ‘drift’ over at least a 3 month period prior to the accident.
6) Inspectors should have reported all potential hazards and actions taken to address them.
2) The maintenance manager who visited the site in June, 2012, formed the opinion that the land in question was owned by the Ministry of Defence. There is no note of the conversation which led to this conclusion, neither did the maintenance manager visit the occupier of the land from which the water was flowing.
3) Over a three month period nothing was done to address the issue other than to telephone the Ministry of Defence. The Ministry of Defence did not provide an answer to the question of ownership of the land until after this accident when they confirmed that they were not responsible for the land in question.
4) Nothing was ever put in writing to the Ministry of Defence requiring them to notify the Highways Authority within a reasonable time scale as to whether they owned the land and if so what action would be taken and by when.
5) This situation was allowed to ‘drift’ over at least a 3 month period prior to the accident.
6) Inspectors should have reported all potential hazards and actions taken to address them.
Responses
Action Taken
North Yorkshire County Council acknowledged concerns, clarified the context of some decisions, and circulated further advice to highways officers regarding recording of actionable defects and warning signs. (AI summary)
North Yorkshire County Council acknowledged concerns, clarified the context of some decisions, and circulated further advice to highways officers regarding recording of actionable defects and warning signs. (AI summary)
View full response
Dear Mr Turnbull Regulation 28 _ Report to prevent future deaths Inquest touching the death of Mr McCourt write further to receipt of the above Regulation 28 report, and set out Authority' s below which address the points raised in section 5 of the above report response (1) It is acknowledged by North Yorkshire County Council that no records of the alleged customer contacts could be found, the inquest it was identified that the customers were unable to provide evidence of these contacts s0 any further investigation; by the County Counciltisaoe possible; North Yorkshire County Council systems have been reviewed in the past and found to be robust: In addition, training has been provided to minimise the potential for human error to occUr, resulting in an enquiry not logged and recorded correctly. (2) It was acknowledged at the inquest that on this occasion more detailed notes should have been taken and clearer direction is now given to staff to ensure better records exist in the future The Maintenance Manager, in this instance; was given every indication by the representative of the Ministry of Defence that they were responsible for the land in question and hence no further enquiries were made_ It appeared that the farm buildings were unoccupied at time the flooding event occurred _ (3)ad (4) - in relation to both of these point, it is acknowledged by North Yorkshire County Council that it would have been appropriate to the position in and to confirm the expected remedial action and a timescale (5) As set above, it is acknowledged that advising of the original approach in writing to the Ministry %f Defence would have been of greater assistance in seeking an agreed resolution to the issue of flooding_ Lexcel Aiaceice inagelnen SLendard responsive County Council providing excellent and efficient Iocal services Law Society Accredited HR / 106393 129936 County the During being being the put writing out
North Yorkshire County Council Central Services (6) North Yorkshire County Councils highway officers record actionable defects (i.e those defects where work is intended) when carrying out inspections of the highway network If temporary warning signs are in place to alleviate a hazard, the defectlwarning signs should still be recorded until it has been resolved. Further advice has now been circulated to relevant highways officers through their managers to assert that this process is followed in future. trust that the above points assist the Coroner in response to the report dated 14 January 2014. If can be of any further assistance, please do not hesitate to contact me on the details set out above_ Yours sincerelv for Assistant Chief Executive (Legal and Democratic Services) Lexcel Praclice #anagcmci Standard A responsive County Council providing excellent and efficient local services Law Society Accredited HR 106393 129936
North Yorkshire County Council Central Services (6) North Yorkshire County Councils highway officers record actionable defects (i.e those defects where work is intended) when carrying out inspections of the highway network If temporary warning signs are in place to alleviate a hazard, the defectlwarning signs should still be recorded until it has been resolved. Further advice has now been circulated to relevant highways officers through their managers to assert that this process is followed in future. trust that the above points assist the Coroner in response to the report dated 14 January 2014. If can be of any further assistance, please do not hesitate to contact me on the details set out above_ Yours sincerelv for Assistant Chief Executive (Legal and Democratic Services) Lexcel Praclice #anagcmci Standard A responsive County Council providing excellent and efficient local services Law Society Accredited HR 106393 129936
Sent To
Response Status
Linked responses
1 of 1
56-Day Deadline
6 Feb 2014
All responses received
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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 18th September, 2012, I opened an inquest touching the death of William David McCourt, then aged 52 years. The inquest was concluded on 12th December, 2013. The conclusion of the inquest was that Mr McCourt died from injuries sustained in a road traffic collision, the medical cause of death being severe head injuries.
Circumstances of the Death
1) On the afternoon of the 15th September, 2012, Mr McCourt was riding his motorcycle on the A6108 Reeth to Richmond road. It was a fine day with good visibility. The motorcycle was being ridden at a speed appropriate to the road conditions and within the speed limit.
2) On approaching a location known as Lowenthwaite Bridge Mr McCourt was confronted with a patch of running water which was running across the road from adjacent land. He lost control of his motorcycle and was thrown from it sustaining injuries from which he died at the scene.
3) There had been a flood warning sign erected to warn motorists of the presence of the water. However, the sign had fallen over some time previously and would not have signalled a warning to Mr McCourt.
4) Evidence at the inquest established that the hazard created by this running water was a long standing problem and had been present almost continuously since December, 2011. In February, 2012, it was reported by a local resident to the Highways authority via their website. Another resident had contacted the Highways authority by telephone on two occasions, on the second occasion, in May, 2012, he was told that somebody would come out to investigate but heard nothing more.
5) In June, 2012, a two car accident occurred at the same location. On this occasion a Highways Maintenance Manager attended and spoke to people at the scene. Flood signs were erected and enquiries commenced to establish who owned the land and to require action to be taken to resolve the matter. It appears that the maintenance manager believed that the land in question was under the control of the Ministry of Defence. There was no written record of what had been said on that occasion.
6) Between June, 2012, and the date of this accident there were numerous telephone contacts between the maintenance manager and representatives of the Ministry of Defence but nothing was resolved. It was after this accident on 15th September, 2012, that the Ministry of Defence finally stated that they did not own the land in question. Over that period nothing had been sent to the Ministry of Defence in writing requiring them to confirm ownership. This water continued to run across the road, even in dry periods, between June and September, 2012, with no action taken to resolve the problem other than the erection of signs.
7) This road was subject to monthly inspections. The inspection reports did not mention the water on the road.
8) The matter was finally resolved following the accident when a police officer visited the owner of the land and action was taken to clear a blocked drain.
2) On approaching a location known as Lowenthwaite Bridge Mr McCourt was confronted with a patch of running water which was running across the road from adjacent land. He lost control of his motorcycle and was thrown from it sustaining injuries from which he died at the scene.
3) There had been a flood warning sign erected to warn motorists of the presence of the water. However, the sign had fallen over some time previously and would not have signalled a warning to Mr McCourt.
4) Evidence at the inquest established that the hazard created by this running water was a long standing problem and had been present almost continuously since December, 2011. In February, 2012, it was reported by a local resident to the Highways authority via their website. Another resident had contacted the Highways authority by telephone on two occasions, on the second occasion, in May, 2012, he was told that somebody would come out to investigate but heard nothing more.
5) In June, 2012, a two car accident occurred at the same location. On this occasion a Highways Maintenance Manager attended and spoke to people at the scene. Flood signs were erected and enquiries commenced to establish who owned the land and to require action to be taken to resolve the matter. It appears that the maintenance manager believed that the land in question was under the control of the Ministry of Defence. There was no written record of what had been said on that occasion.
6) Between June, 2012, and the date of this accident there were numerous telephone contacts between the maintenance manager and representatives of the Ministry of Defence but nothing was resolved. It was after this accident on 15th September, 2012, that the Ministry of Defence finally stated that they did not own the land in question. Over that period nothing had been sent to the Ministry of Defence in writing requiring them to confirm ownership. This water continued to run across the road, even in dry periods, between June and September, 2012, with no action taken to resolve the problem other than the erection of signs.
7) This road was subject to monthly inspections. The inspection reports did not mention the water on the road.
8) The matter was finally resolved following the accident when a police officer visited the owner of the land and action was taken to clear a blocked drain.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.