Jennifer and Marion Bunyan: Prevention of Future Deaths Report
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Date of report: 26/07/2024
Ref: 2024-0406
Deceased name: Jennifer Bunyan and Marion Bunyan
Coroner name: David Heming
Coroner Area: Cambridgeshire and Peterborough
Category: Road (Highways Safety) related deaths
This report is being sent to: Cambridgeshire County Council | Secretary of State Department of Transport
| REGULATION 28 REPORT TO PREVENT DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: 1 [REDACTED], Chief Executive, Cambridgeshire County Council, New Shire Hall, Alconbury Weald, Cambridgeshire 2 Secretary of State, Department of Transport, Great Minster House, 33 Horseferry Road, London, SW1 4DR | |
| 1 | CORONER I am David Heming, Senior Coroner for the coroner area of Cambridgeshire and Peterborough |
| 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 the 8th June 2020, I commenced investigations into the deaths of Jennifer BUNYAN, aged 24 years and her mother, Marion BUNYAN aged 54 years. The investigations concluded at the end of an inquest on the 25th May 2023. The Conclusion of the inquest was Road Traffic Collision. |
| 4 | CIRCUMSTANCES OF THE DEATH Jennifer and Marion Bunyan, the driver of, and a passenger in a motor car respectively, died on the 7th June 2020 in a waterway known as Crease Drain, adjacent to the C117, Puddock Road, Warboys. The cause of their deaths was from drowning when their motor car left the carriageway and travelled over the eastern grass verge where it then descended into the said waterway. The motor car rolled on to its roof. They were unable to extricate themselves from the vehicle and died as a result of the vehicle being partially submerged in water. At the time of her death, Jennifer was pregnant (circa 30 weeks gestation), and her unborn daughter, subsequently named Erin Marion Chatten, died in utero. |
| 5 | CORONER’S CONCERNS During the course of the investigation my inquiries 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: (brief summary of matters of concern) CAMBRIDGESHIRE COUNTY COUNCIL A. SPEED LIMIT The designated speed for this section of road was 60 mph. The charity BRAKE have stated that the default speed limit on rural roads is 60 mph, a speed at which it is rarely safe to travel. They stated the approach should be based on the design of roads. This road has an uneven road surface and it was within local knowledge that the designated speed limit was dangerous and could lead to a loss of control whilst driving in the upper speed range. The need for a reduction in the limit as a safety measure does not appear to have been raised during inspections/debriefs following a series of fatalities that have led to a number of drowning incidents along this section of road. It raises a concern that the speed limit should be reduced significantly as a risk reduction measure – some areas have adopted 20 mph on some sections of road. B. INSPECTIONS OF THE ROAD I have a concern that inspections of the road have not been sufficiently rigorous given a recurring issue of highway degradation from ‘rutting’ at the carriageway edge which can be a contributory factor causing loss of control of a vehicle. It is unclear if the council have carried out audits to review the quality of inspections and whether there have been examples of substandard inspections. C. LENGTH OF TIME TO EFFECT REMEDIAL ACTION These deaths occurred on the 7th June 2020 and there had been previous fatalities along this road which had led to fatalities caused by drowning when vehicles left the road. A barrier to prevent entry to the waterway would be one effective measure that has been deployed in many other places to prevent a vehicle leaving the road and yet, I understand no final solution is in place. D. HIGHWAY DEGRADATION This has been an issue and I have a concern about prompt repairs being effected to the road and also the weight of vehicles which is a factor in damage to the verge adjacent to the road itself. E. LOCAL SAFETY GROUP The Fenland Road Safety Campaign (Charlotte’s Way) have undertaken outstanding work as a charity in raising awareness of the dangers of Fenland roads given the unique environmental factors involved. It is not clear whether there has been prompt action taken following representations from them on safety matters. SECRETARY OF STATE FOR TRANSPORT A. CLUSTER SITES Councils have a number of roads that feature on a cluster site analysis. By their nature, these will carry an obvious and serious risk of death or significant injury. Funding pressures in recent years have delayed prompt action in risk reduction at these sites. It raises a question of whether there should be a central government fund as a special measure to release capital for such sites as this would lead to enhanced risk reduction repairs being deployed more quickly. B. GPS On the facts of this investigation, this road had seen a number of fatalities which would not be known to those unfamiliar with the area (as here). It raises a question of whether there could be collaboration with software companies to flag roads on satellite navigation programming for providing verbal/visual prompts that a particular road carries high risk as an accident site. |
| 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your 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 September 20, 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 Chief Coroner and to the following Interested Persons [REDACTED] I have also sent it to Fenland Road Safety Campaign (Charlottes way) BRAKE ROSPA who may find it useful or of interest. 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 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 by the Chief Coroner. |
| 9 | Dated: 26/07/2024 David HEMING Senior Coroner for Cambridgeshire and Peterborough |