David Cox

PFD Report All Responded Ref: 2013-0355
Date of Report 15 November 2013
Coroner Sophie Cartwright
Response Deadline est. 10 January 2014
All 1 response received · Deadline: 10 Jan 2014
Coroner's Concerns (AI summary)
The narrow bridleway with acute, blind bends and no safety barrier poses a significant risk of vehicles leaving the track and falling into the river below.
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the course of the inquest the evidence revealed matters giving rise to concern In my opinion action should be taken to prevent those circumstances again Or to reduce the risk of death created by them: happening In the circumstances it is my statutory to report to you the Peak District National Park Authority: berednatters of concern are as follows and relate to the track at the point of the bend where the vehicles: left the track o 248h January 2013 narrow and acute, leaving no margin for error and inigkexf ether vehicles leaving the track and creating other down the river bank into the river below due to the absence ofany barrier: There is no barrier Or wall the length of the bridleway between the track and the river and had confirmed in evidence that there are in total three bends the length of the bridleway Tlefeserceaftwe ftoer blnd beliad the same track also causes me concern The concern is that circumstances creating a risk of further deaths will will continue to exist in the future relating to the risk of occur or vehicles the narrow bridleway at the blind bends and into the river due to the track bedthextrerelmarrow and the absence of any barrier between the bridleway and the river below.
Responses
Response
22 Jan 2014
Action Planned
The Authority installed further permanent signage at both ends of the track in December 2013. They are investigating possible funding streams to implement further measures. (AI summary)
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Dear Ms Cartwright Inquest touching_upon_the death of David Allen Cox Further to our letter of 30 December; we acknowledge receipt of your Prevention of Future Deaths Report, dated 15 November 2013. We note your observations within the Report and we are grateful for your acknowledgment of the safety measures implemented by the Authority since the accident: The Report outlines your concerns in relation to the nature of three bends along the track_ including the bend at which the two vehicles left the road on 24 January 2013,and the lack of physical barrier between the track and the river bank_ You expressed concern that there remains a risk of future deaths relating to other vehicles leaving the road and entering the water at one of three aforementioned bends along the track and you have recommended that the Authority take further action to prevent those circumstances happening again_ Report acknowledges that the Authority may potentially require the consent from the Environment Agency, Natural England_ Derbyshire County Council and Network Rail (hereinafter referred to as 'Partners') in connection to any works so determined_ You have kindly provided a copy of your Report to each of the Partners to facilitate such consent The Authority has carefully considered your Report;, which echoes your comments made during the inquest on 4 October 2013,and has undertaken the following actions: Actions Undertaken Post Inquest The Authority installed further permanent signage at both ends of the track in December 2013 The signage states 'Public Safety Notice. Narrow track Blind bends Cycle with care. Expect to meet authorised vehicles" photograph of this signage is attached. Member of the Association Of National Park Authorities Holder of Cauncil of Europe Diplorna Chief Executive: Jim Dixon Chair: Favell Deputy Chair: Geoff Nickolds Working together for the Peak District National Park: #A special environment -A welcoming place at the heart of the nation #Vibrant communities and a thriving economy information given to the Authority may be disclosed under the Freedom of Information Act 2000 have Your the Tony Any

b Notwithstanding that the Authority has no policy to grit its bridleways or roads, save for inside the Monsal trail tunnels; the Authority has provided (and initially filled) two grit bins along the track. These are located north of the first viaduct on the track (marked in the approximate position 'A' on Plan attached) and south of the second viaduct (marked in the approximate position B' on Plan 1 attached) respectively: The grit bins and initial grit were supplied by the Authority on week commencing 2 December 2013 on the basis that the residents of Blackwell Mill Cottages will apply the and subsequently re-fill the bins with the Authority providing a 25% contribution to the cost of such refills (with a cap of €100 per year) We understand that the residents have also arranged for a grit bin to be located at the residents car park. The Authority provided the residents on 20 December 2013 with 2 parking permits per household to enable them to free of charge at the Wyedale Car Park at the entrance to the track during winter months should they wish to do so. Further permits are available on request and the permits will be renewed annually: The Authority has continued its monthly inspections of the track: The Authority has continued to keep and update maintenance and inspection schedule of such inspections which have resulted in further pot hole repair works carried out on 27 September and 14 November 2013. The Authority made initial written contact with organisations, including the Partners, on 3 December 2013 to inform them of the issues identified during the inquest_ to them on notice of the impending PFD Report and your emphasis of the need for their input into the consideration and approval of any action taken by the Authority: The key organisations were notified before receipt of the PFD Report and the expert reports (outlined below) to facilitate the implementation of any identified actions as soon as possible. The organisations contacted in early December are as follows: Environment Agency Network Rail Natural England Derbyshire County Council ('DCC') Chatsworth Estate (they have been identified as owning the river bed adjoining the track) Buxton Fly Fishers Club who exercise fishing rights on the river adjoining the track (please see paragraph 'm' below)- Save for a meeting with representatives of DCC on 17 January 2014 (outlined further below) the Authority has not received a response from any of the organisations to date. Survey Report The River Wye Bank Stabilisation Works Site Assessment Report (the "Survey Report") was funded and commissioned by the Authority prior to the inquest The report, which addresses bank stability and wider hydrological issues along the entire length of the track, was prepared by Silkstone Environmental Ltd and SM Foster Associates Ltd further to their respective stability and hydrological assessments A copy is enclosed for your information. Although Silkstone carried out their initial on-site grit park key put

inspection on 16 October 2013, input from their sub-contractor and staff changes unfortunately resulted in the draft report not produced until 21 November and the final report on 20 December 2013. The Survey Report indicates that the river bank is unstable at several locations along the Ikm track due to water erosion, including at the incident bend. The report identifies the potential issues and solutions for bank stabilisation as well as the feasibility for track widening The Survey Report confirms that the options for stabilisinglwidening works are complicated by the fact that the track is the sole egress for the residents of Blackwell Mill cottages &nd so any works must allow for short term closures only and track must be capable of opened in an emergency The track's width, construction and proximity to the river indicate that there will be continual issues with erosion and maintenance and it is suggested that engineering measures are necessary to improve the safety of the track for the residents_ Three sites are identified as requiring such measures The sites are shown on the attached Plan and correspond to the aforementioned bends_ The Survey Report recommends gabions (stones inside metal mesh cage) as the most appropriate stabilisation method at each site , including the incident bend (Site 1) Potential for track widening (2.46m to 2.63m) at the incident bend and at Site 2 have been considered. The experts also suggest that suggested bank stabilisation works will provide the track with sufficient stability to incorporate & fencelbarrier along the embankment edge at Sites and 2- A further gabion is recommended at the site of the existing gabion protection (SitelPriority 3) The report also appraises other possible engineering options, however, is the intention of Authority to pursue (subject to necessary consents and funding) the installation of gabion walls as recommended: g The Survey Report was forwarded to the residents and the organisations listed above within paragraph 'e' on 16 and 17 January for comment by no later 14 February 2014 You will recall from the inquest that the Authority consulted with DCC nd Natural England, and required consent from the Environment Agency and Network Rail; in respect of previous minor bank repair works carried out in April 2013. This previous process took 2 months and did not entail the extent of preparatory work or technical input required in respect of the works proposed within the Survey Report_ In light of the much larger scale of the proposed works the Authority has requested consent from all of the Partners . Present Position and Next Steps The following paragraphs set out actions currently undertaken by the Authority together with an outline of the next steps; Specification for Works Whilst commentslconsents are awaited from the residents, Partners and organisations referred to above, the Authority has been in on-going discussions with Silkstone regarding the next phase of the regeneration works, that is the commissioning of Specification for the proposed works The Specification is a detailed document which sets out the design, materials and methodology for the completion of the proposed works. being the being the the the the being

The consultants have indicated that; due to the complexity of the requirements of the preferred engineering solution, they require further input from safety consultant, specialist gabion supplier and detailed design consultant and have advised that going forward the project should be led by a specialist engineering firm. Unfortunately, Silkstone advised the Authority last week that due to the complexity of the proposed works do not have the capacity or relevant insurance in order to complete the Specification. The Authority has therefore requested that Silkstone nominate and provide all relevant details of specialist engineering firms capable of compiling the Specification, managing the tendering process and taking the project forward_ The Authority is currently actively chasing details of these nominated experts Upon instruction of a suitable replacement of Silkstone the Authority will work with that expert firm in identifying the relevant safety consultant; gabion supplier and detailed design consultant with a view to ensuring the Specification is compiled appropriately and as soon as possible. This additional input will necessitate a variation of the original cost and timeframe for production of the Specification: Silkstone had initially intimated that the Specification could be prepared within month of receipt of purchase order, however;, in light of the additional expert input now identified the process is likely to take considerably longer. The Authority will forward copy of the draft Specification to the Partners and organisations listed above together with the residents upon receipt for further comments and input All relevant input will be referred to the instructed specialists for incorporation (if necessary) into a final draft of the Specification: The Authority can confirm that internal funds have been ring-fenced to pay for the development of the detailed Specification. Communication with Residents As above, the Authority has been in regular contact with the residents of Blackwell Mill Cottages regarding the track. Given the possible impact any engineering solution may have on the track, and access to the cottages during the works, the Authority will_in addition to requesting comments, invite the residents to attend meeting with Property Development Officer for the Authority, to discuss the proposals_ meeting will be arranged upon receipt and distribution of the initial draft of the detailed Specification. The residents will not be asked to contribute to the cost of such works_ Tendering Process Upon finalisation of the Specification for the works the expert engineering company instructed to replace Silkstone will be commissioned to prepare the technical tender documents and a minimum of three appropriately qualified contractors will be invited to bid for the works in accordance with the Authority's standing orders_ In addition to finalising the length of the works programme, the tender process will also quantify the costs of the proposed works_ The tender process will take approximately 3 months from finalisation of the Specification_ The Authority has also ring-fenced internal funds for the tender process, however, a contract for the works will only be awarded upon receipt of sufficient funding and any necessary consents_ they they the any

Consent and Liaison with the Partners Whilst the Authority has invited comments and requested consent from the Partners by 14 February 2014 it is likely that the Partners will not be in a position to confirm their consent fo the proposed works until receipt of the finalised Specification and the conclusion of the tendering process. The Authority will continue to pursue consents during the Specification and tendering process_ It should also be noted, however, that any variations to the Specification required by the Partners, Chatsworth Estates, Buxton Flyfishers Club or the residents may have an adverse impact on timescales: Funding As stated at the Inquest; the Authority does not have the available resources to fund the proposed works_ The Authority must therefore seek funding from external bodies_ Although the Authority cannot bid for specific funding until the cost of the proposed works are known the Authority is in the meantime_ investigating possible funding streams. In particular, the Authority is liaising closely with DCC as lead partners in the Pedal Peak Il programme to discuss the feasibility of incorporating proposed works into its scheme meeting was held with DCC on 17 January during which DCC expressed their agreement that the safety of all users of the track is paramount Whilst DCC were not able to promise funds, it was agreed that they would consider the Specification to see how the proposed works would fit into their wider aims for the Pedal Peak Scheme_ Further discussions are planned upon receipt of the Specification_
m. Liaison with Other Organisations In addition to the above, the Authority has also been liaising with the Buxton Flying Fishers Club which is investigating the possibility of carrying out soft engineering works (in the form of installing willow hurdles) to parts of the bank adjoining the track_ It is estimated that; subject to the Club securing its own funding, such works may take between January and March 2015. Although the areas the Club is concerned with do not include the Sites identified in the PFD report or the Survey Report; and will not impact on these, the Authority is working with the Club to ensure that funding streams are not duplicated and, where possible_ solutions can be found that are mutually beneficial to both parties. The Authority fully embraces the recommendations within the Prevention of Future Deaths Report and is committed to ensuring the recommended actions are progressed as priority _ This goal, however, is one which will require the active involvement; consent and funding from range of parties including the Environment Agency, Natural England, Derbyshire County Council and the residents of Blackwell Mill cottages_ We hope that this letter demonstrates the Authority's commitment to improving the safety of the track for all users_ Kind regards
Sent To
  • The Peak District National Park Authority
Response Status
Linked responses 1 of 1
56-Day Deadline 10 Jan 2014
All responses received
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Source: Courts and Tribunals Judiciary

Report Sections
Investigation and Inquest
On the 28th January 2013 an investigation was commenced into the death of David Allan Cox The investigation concluded at the end of the inquest which took place on the 4th October 2013. The conclusion ofthe inquest was accidental death: The medical cause of death was la Death due to immersion;
Circumstances of the Death
Shortly after 8.30am on 24th January 2013 David Allan Cox was his Toyota vehicle registration Ifrom his home an unclassified single track bridleway at Blackwell Mill, Derbyshire between Blackwell Mill Cottages and Wye Dale Car Park at Topley Head. Driving conditions were poor; the bridleway being covered in compacted snow and ice David Allan Cox was driving at a slow speed as he approached the second over bridge as the bridleway bends 90 degrees sharply to the left At the bend the vehicle ran wide onto the steep riverbank to the offside sliding down and onto its roof into the river below. David Allan Cox was trapped in his vehicle for some 45 minutes and was subsequently pronounced extinct at Stepping hill Hospital Present in Mr Coxs vehicle was also his daughter who managed to escape heard evidence at inquest that shortly after Mr Coxs vehicle entered the water; vehicle which was being used to drive their son to school also left the bridleway at the same location on the bend and her vehicle also slipped down the steep slope of the river bank and overturned into the river below: My investigation revealed that the track at the point of the bend where the two vehicles left the road is ninety degrees to the left and is extremely narrow and acute with no margin error: driving Aygo along rolling life for

Tothe offside is a steep shale covered bank which falls 1.4 metres to the surface of the river atan angle ofapproximately 40 degrees: The forensic collision investigator PC Igave evidence that it would appear that Cox misjudged his speed on the approach to this bend possibly by only a slightamountand this has resulted in the vehicle sliding on the surface and onto the river bank where it would have been impossible to regain control:
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe the Peak District National Park Authority have the you power to take such action:
Copies Sent To
1. Derbyshire County Council 2, Environment Agency 3. Natural England Network Rail During duty being sliding along along along leaving rolling days Your
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.