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Investigation and inquest
On 5th January 2016 I commenced an investigation into the death of Katherine Tracey Vanloo, then aged 52 years. The investigation concluded at the end of the inquest on 28th September 2017. The conclusion of the inquest was a narrative conclusion.
The medical cause of death was
a 1ung lacerations, splenic lacerations, fractured skull and left forearm
b road traffic collision
The pothole on Napton Holt Road in Warwickshire into which Mrs Vanloo fell when riding her bicycle was first indentified on 23rd March 2015 as a category 2 defect by a Safety Inspector employed by Balfour Beatty Living Places.
Under the terms of the Warwickshire County Council Highways Maintenance Safety Inspections Manual to which Balfour Beatty Living Places was working there was a target of 28 days within which such category 2 defects should be repaired.
The works order to carry out the repair was raised by Warwickshire County Council three months later on 5th June 2015 and received by Balfour Beatty Living Places on 10th June 2015.
The pothole was first identified on 23rd March 2015 and an employee of CR MacDonald Limited, to whom Balfour Beatty had subcontracted the road repair work, was sent out for the first time on 2nd November 2015 to repair the pothole, albeit that the wrong pothole was in fact repaired.
The pothole was never repaired before the death of Mrs Vanloo on 3rd January 2016.
Circumstances of the death
Katherine Tracey Vanloo died on 3rd January 2016 near to the entrance to Headlands farm on Napton Holt Road Warwickshire from catastrophic injuries she sustained in a collision with a Toyota Yaris car. Mrs Vanloo was cycling with a friend at the time and was thrown from her bicycle into the path of the car when her bicycle hit an unrepaired pothole in the road. She was pronounced dead at the scene at 1101am.
Coroner’s concerns
(1) The pothole was first identified on 23rd March 2015 as a category 2 defect with a target of 28 days within which such defects should be repaired.
(2) The works order to carry out the repair was only raised by Warwickshire County Council 3 months later on 5th June 2015. This was sent to Balfour Beatty Living Places who had entered into a contract with Warwickshire County Council to repair road surfaces in Warwickshire. They in turn subcontracted the road repair work, which included pothole repair work, to CR MacDonald. The works order was received by CR MacDonald on 19th June 2015.
(3) The work to repair the pothole was not undertaken by an employee of CR MacDonald until 2nd November 2015, albeit that the wrong pothole was repaired on that day.
(4) There was a delay of over 7 months between the identification of the pothole and the time it was supposedly repaired on 2nd November 2015.
(5) At the time of the incident Warwickshire County Council did not have a system in place to track with Balfour Beatty Living Places or CR MacDonald the progress of works orders, i.e. when outstanding works had been completed, nor any formal programme of auditing to check if the work has been done and to check the quality of the work.
Information checked against the published report and official responses