Joanne Constable: Prevention of future deaths report
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Date of report: 20/12/2023
Ref: 2023-0536
Deceased name: Joanne Constable
Coroner name: Caroline Jones
Coroner Area: Cambridgeshire and Peterborough
Category: Road (Highways Safety) related deaths
This report is being sent to: Cambridgeshire County Council
| REGULATION 28 REPORT TO PREVENT DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: 1. Cambridgeshire County Council | |
| 1 | CORONER I am Caroline Jones, Assistant 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 10 August 2020 I commenced an investigation into the death of Joanne Comstable aged 52 years. The investigation concluded at the end of the inquest on 30 October 2020. The conclusion of the inquest was that: Joanne died from multiple unsurvivable injuries sustained in a road traffic collision on the A141 Isle of Ely Way in Cambridgeshire when the motorcycle on which she was a passenger was in collision with a tractor whose view of the road was obscured by overhanging trees and vegetation. |
| 4 | CIRCUMSTANCES OF THE DEATH On 2 August 2020, Joanne Constable was the passenger on a motorbike which collided with a trailer being pulled by a tractor as it turned right out of a field onto the A141 Isle of Ely Way near Wimblington, Cambridgeshire. Due to vegetation growth of trees and bushes on the verge of the public highway, the tractor driver’s line of sight was obstructed, making it impossible to assess whether there was adequate time and distance to safely exit the junction. Consequently, the motorbike’s path was blocked by the trailer and the rider could not take evasive action in time to avoid the collision. Mrs Constable was thrown from the motorbike in the collision, sustaining multiple injuries and she was pronounced deceased at 1150 hours. |
| 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: In the course of evidence from the local authority’s highway maintenance manager, I heard concerning testimony as to the apparent lack of systems and processes in place to record complaints or reports of hazards or defects with the highway. Consequently, there seemed to be no way of identifying which reports had been actioned or inspected and even when the system indicated that an inspection had taken place and led to a recommendation for work to be carried out within a statutory timeframe, there was no information available on the system to show if or when any work was carried out, much less to what specification. On the evidence I heard, the circumstances prevailing at the entrance to Bypass Field onto the A141 Isle of Ely Way are replicated at many points across the county and therefore, should those with a statutory responsibility to maintain the highways, including verges, at public cost be unaware of the status of reported hazards or defects, there is a clear risk of future deaths occurring due to those with the responsibility not taking steps to remedy the problem and more fatal road traffic collisions occurring. |
| 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 14 February 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 Family of Joanne Constable 2. [REDACTED] The insurers for [REDACTED] as landowner and tractor driver respectively Cambridgeshire County Council. I have also sent it to Cambridgeshire Constabulary who investigated the road traffic collision and therefore 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: 20/12/2023 Caroline JONES Assistant Coroner for Cambridgeshire and Peterborough |