Gary Dunn: Prevention of Future Deaths Report
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Date of report: 03/12/2024
Ref: 2024-0666
Deceased name: Gary Dunn
Coroners name: Lorraine Harris
Coroners Area: East Riding of Yorkshire and City of Kingston Upon Hull
Category: Road (Highways Safety) related deaths
This report is being sent to: Hull City Council | National Highways
| REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: Traffic Services, Hull City Council National Highways – For area of Kingston Upon Hull | |
| 1 | CORONER Miss Lorraine Harris, Area Coroner, East Riding of Yorkshire and City of Kingston Upon Hull. |
| 2 | CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
| 3 | INVESTIGATION and INQUEST On 19th December 2023 I commenced an investigation into the death of Gary Stephen DUNN, aged 47 years. The investigation concluded at the end of the inquest on 2nd December, 2024. The conclusion of the inquest was: Road Traffic Incident The following findings of fact were made: Lorry White Volvo LGV registration H4 LGE Mr Dunn was riding a bicycle. Neither vehicle had any defects. No weather conditions were contributory to the incident. There was no defect in the road that was contributory to the incident. I do acknowledge that the road had changed it markings, this was a relatively recent change. I acknowledge that there was an alternative route for Mr Dunn to navigate the busy roundabout, however Mr Dunn was within his rights to use the road. The issue of whether Mr DUNN was visible at any time was an issue at inquest. The driver of the LGV could not recall specifics about his mirror checks but stated a number of times that it was instinctive, constant thing, something that he does all the time. He was open about the fact that he did not see Mr DUNN at any time. I do find his evidence credible. When Mr Dunn is in a position where he could be started to be regarded as visible, he is approximately 70 metres from the roundabout. I accept there was an opportunity for the LGV to see Mr Dunn and recognise him as a road user, but I also recognise that for the majority of the time Mr DUNN was in the inside lane, there were other vehicles on the road and the driver of the LGV would have also been looking to negotiate the roundabout. Mr Dunn did have lights on his bike but he was not wearing any clothing that would make him more visible. As stated previously, the driver of the LGV reported that at no time did he see him. At the time that the presence of Mr DUNN would have indicated a risk, he would have been in the blind spot of the LGV, high visibility clothing at that stage not have made a difference. This is relevant when at the give way line, albeit for a short period of time, Mr Dunn was positioned in the LGV driver’s blind spot before both move to negotiate the roundabout. The 1st lane of the roundabout is marked for those to leave the roundabout at the first junction. The 2nd lane of the roundabout allows users to both leave the roundabout at the 1st junction and also continue travelling forward on the roundabout. As the vehicles leave the give way line, the LGV is indicating to take the first junction. Mr Dunn was positioned very close to the cab. It would not be possible to say whether he noticed the indicator. As both the LGV and Mr Dunn leave the roundabout, they are both positioned in lanes that allow exit via the first junction. Mr Dunn is, however, not visible to the LGV driver. Mr Dunn is straddling both the 1st and 2nd lane and is going to travel straight over the roundabout. CCTV shows that as the LGV manoeuvres to take it’s exit, Mr Dunn rides across its front directly in its path. I note that the lorry does not cross the bicycles path, it does not leave it’s lane. It is evident that Mr Dunn does not appreciate that the vehicle was indicating to turn left at the 1st junction. At the time that the LGV takes its junction Mr Dunn may have been trying either to cycle quickly to out-manoeuvre the vehicle, or attempting to cut across the front of the LGV to reach the next junction, however the CCTV seems to indicate he simply does not appreciate the lorry is turning left and he carries on his route which takes him in front of the LGV. It was a quick misjudgement, with very tragic consequences. At the time the bicycle crosses his path, there was nothing that the driver of the LGV could do to avoid the collision. I find the LGV stopped appropriately. For the avoidance of doubt, I accept the evidence that the tachograph did not show that this slowing was in an attempt to avoid the accident. I do note that Mr DUNN was not wearing a cycling helmet, however given the gravity of his injuries, this piece of equipment would not have saved his life. Mr DUNN’s death was instantaneous. Toxicology revealed previous exposure to cocaine and tramadol in his system, but no evidence of acute toxicity. I note that the dashcam was not seized immediately, and then there was a discrepancy over who seized it. I accept that one officer seized the LGV and the dashcam together but another then seized the dashcam itself. I note that the override on the dashcam was continuous even when the engine was running, and as such there was no dashcam footage. I appreciate that when officers attend these scenes there are many tasks and priorities, but it is regrettable that this footage was not seized immediately. This is something that could have given comfort to the family. However we do have the CCTV footage and while it does not give a view from the cab it does provide a record of the incident. I will be making a RPFD to highlight the officers concerns over signage. Box 3 of the record of inquest read: On 8th December 2023 Gary Stephen DUNN was riding his pedal cycle to college. At the Stoneferry Road/Ferry Lane roundabout, Kingston Upon Hull Mr DUNN’s bicycle collided with a Light Goods Vehicle. Mr DUNN was killed instantly. His medical cause of death was recorded as: 1a Severe Head Injuries 1b Road Traffic Incident |
| 4 | CIRCUMSTANCES OF THE DEATH Gary Stephen DUNN, aged 47 years, was cycling to college. En route he had to negotiate the Stoneferry Road/Ferry Lane roundabout in Kingston Upon Hull. Evidence was heard that the layout of the road had changed recently, whereby the centre lane could now also be utilised to turn left. An LGV was in this lane and indicating to turn left. Mr DUNN was intending to travel over the roundabout and was on the nearside of the LGV. The driver of the LGV said at no time did he see Mr DUNN. Mr DUNN attempted to travel towards his exit but rode into the path of the LGV as it turned left. He died instantly. |
| 5 | CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – I appreciate it has been almost a year before this inquest was concluded so the change in road layout may now be more known to regular drivers, however people unfamiliar with the road may also need to navigate the roundabout. The Officer in the Case, an experienced Serious Collision Investigation Officer, raised concerns regarding the signage of 2 aspects of this area of road: Firstly, although the road markings which indicate the centre lane can also be used for left hand turning vehicles was regarded as clear, the officer felt there was insufficient actual road signage to assist road users in how the roundabout can be navigated. This was of particular concern as this is a busy roundabout with a build up of traffic and so markings on the road are often obscured. Secondly, there is a dual use path for both pedestrians and cyclists as well as the availability of a Toucan Crossing. This provides cyclists with an alternative to using the road. Again, evidence was heard that there was inappropriate signage to instruct cyclists that this route was available. |
| 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your department/organisation have the power to take such action. |
| 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 28th January 2024. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. |
| 8 | COPIES and PUBLICATION I have sent a copy of my report to: The family of Mr Gary Stephen DUNN via counsel [REDACTED] Counsel for 2nd Driver – [REDACTED] Serious Collision Investigation Unit – Humberside Police I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response. |
| 9 | [DATE] [SIGNED BY CORONER] 3rd December 2024 Lorraine Harris |