Investigation and inquest
On the 7 June 2021 I accepted the transfer of an investigation into the death of Albert Thomas Stafford Manley who was known to his family as “Jim”. I went on to open Jim’s Inquest on the 14 June 2021 and concluded both his and his late wife’s Inquest on the basis that their deaths arose out of the same incident on the 19 May 2021. I found that Jim’s medical cause of death was as follows:-
1a) Multiple Traumatic Injuries.
As regards how, when and where Jim came by his death I recorded as follows:-
Albert, known to his family as “Jim”, died at Southampton General Hospital, Tremona Road, Southampton, Hampshire on Monday 31 May 2021 from multiple traumatic injuries. Jim’s injuries were sustained when his Ford Mondeo collided on the opposite/northbound side of the highway with the front offside of an oncoming Land Rover Discovery on the morning of Sunday 30 May 2021 whilst both vehicles were travelling in opposite directions on the B3081 near Tollard Royal in Wiltshire at a bend and junction with a minor road leading to Tollard Green (OS Ref ST971831). It is unclear as to why Jim’s car crossed the centre of the highway and collided with the front of Land Rover Discovery as to whether he intended to exit the junction and head towards Tollard Green or misinterpreted the layout of the road at the junction.
As a conclusion I recorded Road Traffic Collision.
Circumstances of the death
Please see section 3 above in relation to the findings as to when, where and how (by what means Jim came by his death).
The published report provides this section by reference to another part of the report.
Coroner’s concerns
At the time of the incident and collision between Jim’s Mondeo and a Land Rover Discovery driven by ████████ travelling in the opposite direction from Tollard Royal, Jim was travelling in a south easterly direction along the B3081. As I indicated on the Record of Inquest although I found that the collision between the 2 vehicles at the junction with Tollard Green, occurred on ████████ side of the highway, I was unable to determine whether more likely than not Jim had been intending to leave the B3081, intending to travel in the direction of Tollard Green on his way to visit ████████ or whether he had misunderstood the layout of the road and had not realised the junction with Tollard Green was at that location on the highway.
Although I was unable to make a finding of fact in this case Jim more likely than not misunderstood the road lay out, I was satisfied that it was a possibility and I am concerned that a driver who is unfamiliar with that road section could read the road incorrectly taking into account what they physically see and having regard to the road signs approaching the junction, leading to such a misunderstanding. The national speed limit on this section of road is, of course, 60 mph and every driver have a duty to drive at a speed commensurate with road conditions and additionally owes a duty of care to other road users in terms of driving carefully and considerately. How is it possible to misread the road? In answering that question, see figure 1 below, is a photograph of the view using Google Earth cameras approaching the junction heading in the same south easterly direction that Jim would have been travelling.
Fig.1
At approximately 200 metres from the junction is a very clear sign (above) highlighting the junction with the main B3081 continuing left to Tollard Royal and the road leading off to Tollard Green. In the photograph in the road ahead depending on the type of vehicle being driven and its position you can see a left-hand bend ahead of you. The visible bend is in fact a left hand bend once you have left the B3081 and is part of the road heading towards Tollard Green. It is not the junction bend on careful analysis.
The next photograph at figure 2 shows a sign for tourist and information purposes which lies approximately 85 metres from the junction with Tollard Green. You can however see the bend ahead which again is the bend beyond the junction and is not the Tollard Green, Tollard Royal junction which is still hidden.
Fig2
In Fig3 below a chevron sign at the time of the collision was missing on the sign post to the right of the highway but this sign together with the road markings have now been replaced/refreshed. As a driver myself the chevron markings would be of more assistance to a driver at night time although, of course, they would be visible in the day time but due to size to a lesser degree. At night, the reflective paint differentiating between black and white in my personal view would make the sign more obvious especially when headlights would be unlikely to pick up he Tollard Green bend ahead.
Fig 3
In considering my duty to make a report to prevent future deaths I had a report prepared for ████████ from Wiltshire Police (copy attached) and in that report he documented a previous collision history in the last 5 years and in particular 2 incidents, 1 occurring in 2017 and the other in 2018, both of which involved vehicles turning right at the junction to Tollard Green. One incident involved a car and a motorcycle, the other involving a car and a van. I also heard evidence from ████████ who has lived in the area for a number of years that the route to via Tollard Green into Verwood and Bournemouth is used by many as a back road in respect of which he described it as “a rat run” and cars apparently do not necessarily slow to any great degree when exiting that junction from a south easterly direction. ████████ in his report makes 2 recommendations, one of which is to remove the hedgerow to the left to increase visibility around the bend. That recommendation, I have to say, is of some concern to me as I do not think that it would tempt drivers to slow down to any degree and they would be more likely in looking across to look for oncoming traffic and may not always pick up smaller vehicles such a cyclist and motorcycle users when looking to exit the junction heading towards Tollard Green. That recommendation is also of concern to me because Wiltshire at the end of the day is a rural county and its hedgerows and the wildlife contained within the hedgerows are an important feature of its character. I also heard evidence of one of our Coroners Officers, ████████, who commented that the hedgerows had an additional purpose in trying to prevent deer which are a feature in this particular area leaving the fields and crossing the roads. He acquired this information when he was a serving Police Officer and from speaking to one of the nearby landowners. Deer crossing road especially at night can pose a dangerous and unexpected hazard.
As regards the second recommendation from ████████, this maybe something that you might be willing to consider or whether there perhaps is a better way through the use of further signing to make it even clearer as regards the existence of the junction and the bend. In asking you to consider painting the word “SLOW” as you approach the bend in both directions as recommended by ████████, I am mindful of the fact that as the highway authority you are under no obligation to provide such warnings as was pointed out by the House of Lords in the 2003 Decision in “Gorringe”.
I am however concerned that there is a possibility that the road could be misread and that the bend having exited the junction heading towards Tollard Green could be mistaken by motorist unfamiliar with this section of the road, be confused with the bend and the junction on the B3081 heading towards Tollard Royal. The bend having exited the junction heading towards Tollard Green is very similar in shape to the bend heading towards Tollard Royal which is hidden until you get very close to it.
I can see the propensity for a mistake being made here even if it is a mistake that I myself, I hope, would not make and I would ask you to consider if there is anything further that could be done to warn of this junction and bend to further minimise the possibility of any misunderstanding being made by road users if you are minded not to adopt ████████ recommendation.