Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0194, written 5 Aug 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Aug 2013 |
|---|---|
| Reference | 2013-0194 |
| Deceased | Joseph Burrell |
| Coroner | John Taylor |
| Coroner area | London (North) |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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Her Majesty's Coroner for the
Northern District of Greater London
(Harrow, Brent, Barnet, Haringey and Enfield)
North London Coroners Court,29 Wood Street, Barnet EN5 4BE
Telephone 0208 447 7680 Fax 0208 447 7689
Traffic and Highway Network Management Department
Civic Centre
Harrow Council
POX 39
Station Road
Harrow HA1 2XA
This report is sent to you under Rule 43 of The Coroners Rules 1984 (as amended by The Coroners
(Amendment) Rules 2008).
Rule 43 findings at the inquest
At the inquest touching the death of Joseph Burrell heard before H.M. Deputy Coroner John Taylor at
North London Coroners Court sitting at 29 Wood Street, Barnet ENS 4BE on 22 July 2013, the Deputy
Coroner found that {a) the evidence at the inquest gave rise to a concern that circumstances creating a
risk of other deaths would occur, or would continue to exist, in the future, and (b) in the Deputy Coroner’s
Opinion, action should be taken to prevent the occurrence or continuation of such circumstances, or to
eliminate or reduce the risk of death created by such circumstances.
This report is sent to you as a person who the Deputy Coroner believes may have power to take such
action.
The fatal collision
At 7:15 pm on Saturday 28 July 2012, Mr. Burrell attempted (as a pedestrian) to cross the two-lane
southern carriageway of The Broadway, in Stanmore, at its junction with Church Road and Stanmore Hill.
He was seen on the central reservation, next to the traffic lights, waiting to cross to the south side. At the
moment when he began to cross, the traffic in the right-hand lane of The Broadway (from where it would
turn into Stanmore Hill) was held on a red light, and the traffic in the left-hand lane (from where it would
bear left into Church Road) was permitted to proceed through the lights, by virtue of a green filter light.
As Mr. Burrell attempted to make his way across the left-hand lane, he was struck by a car proceeding
through the green filter light. He died from the multiple injuries which he sustained in that collision.
The circumstances
The evidence before the Deputy Coroner was:
1. a pedestrian on the central reservation has no clear view of the green filter light (particularly if
there is a high-sided vehicle held stationary in the right-hand lane)
2. there is no "second set” of lights beyond the lights (as there is at many junctions) - which would
be easier for a pedestrian to see
3. there is no "red man/green man" pedestrian light, or warning sound (which would indicate when
it was safe to cross)
4. there are no control buttons for pedestrians to use (in order to bring the lights in both lanes to
red)
5. for each and all of the above reasons, and when deciding his moment to cross, a pedestrian on
the reservation cannot easily be certain whether the lights for both lanes are on red (and hence
whether it is safe to cross)
Page 1 of 2
Her Majesty's Coroner for the
Northern District of Greater London
(Harrow, Brent, Bamet, Haringey and Enfield)
North London Coroners Court,29 Wood Street, Barnet EN5 4BE
Telephone 0208 447 7680 Fax 0208 447 7689
wee Oy
SO D Oey
ET MON,
6. the speed limit at the lights was (and is) 30mph
7. apedestrian waiting to cross may thus expose himself to risk of injury, or death, if he mistakenly
believes that both lights are on red, and so chooses to cross at the time when the light for the
left-hand lane is not on red, but instead on the green filter; and
8. there were references in the documentary evidence to “near misses” on earlier occasions
The Deputy Coroner accordingly invites you to consider these circumstances, and whether to take action
in relation to them.
Your response to this report
Your attention is drawn to the following provisions of Rule 43:
“434A. (1) A person to whom a coroner sends a report under rule 43(1) must give the coroner a written
response to the report containing—
(a) details of any action that has been taken or which it is proposed will be taken whether in
response to the report or otherwise; or
(b) an explanation as to why no action is proposed
within the period of 56 days beginning with the day on which the report is sent.
43B. A coroner may extend the period of 56 days mentioned in rule 43A (1) (even if an application for
extension is made after the time for compliance has expired).”
Assistant Coroner John Taylor
(formerly, H. M. Deputy Coroner)
5 August 2013
Page 2 of 2
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Best Achieving Council Mr John Taylor Assistant Coroner North London’s Coroners’ Court 29 Wood Street Barnet EN5 4BE Dear Mr Taylor Q % m 7 x t O U N C I L L O N D O N ---------------- Environment and Enterprise Directorate Corporate Director - Caroline Bruce Date: 29th August 2013 Inquest touching the death of Joseph Burrell - Rule 43 Report I refer to your letter of 5th August 2013 regarding the above and note the contents therein. In response to the points raised under rule 43 may I take this opportunity to explain what actions the council has already undertaken with regard to the junction of Stanmore Hill I The Broadway, Stanmore. The council is aware that this junction does not have a pedestrian phase built in to the signals and therefore we can appreciate that it can be difficult for pedestrians to cross at this location. From previous correspondence we are also aware that there is a perception from some local residents that the junction is dangerous. In fact until recently the accident record at this junction was extremely good with no personal injury accidents being recorded in the three years prior to 2012. There were, however, four accidents involving personal injury in 2012.Two of these accidents involved pedestrians. Three of the accidents were classed as slight and one was a fatal accident regrettably involving Mr Burrell. In our experience it is not practical to have a controlled crossing at all signalised junctions and the council in partnership with Transport for London (TfL) (who has responsibility for the maintenance and control of all traffic lights in London) works closely to strike a balance between the demands of pedestrians and motorists. In 2009 the signals unit at TfL modernised the traffic signals at the junction which included the removal of a secondary traffic signal pole which faced traffic approaching along Stanmore Broadway. As there was no dedicated pedestrian phase at the junction the TfL signal engineers considered the secondary pole was potentially dangerous because it could mislead pedestrians to think that it was safe to cross when traffic was still on green. Following representations and complaints about the removal of the secondary traffic signal pole, Harrow Council commissioned a study to look at the feasibility of incorporating a dedicated pedestrian phase into the signal timings. address Harrow Council, Civic Centre, Station Road, Harrow, HA1 2XF tel 020 8901 2600 web www.harrow.gov.uk The report concluded that the introduction of a dedicated pedestrian phase would significantly increase traffic delays and congestion with a consequent risk to safety, including surrounding residential roads being used as short cuts which already carried a significant volume of traffic. This view was supported by TfL's signals unit who confirmed that significant delays on all arms vould occur at the junction if a dedicated all-red phase was introduced. TfL would not support the introduction of a scheme which would cause more delays to this part of the strategic route network and consequently a scheme could not be taken forward. In order to pursue this issue further the council met with TfL to discuss other options for improving pedestrian facilities at the junction. TfL suggested linking the existing traffic signals at Church Road, Stanmore Hill junction, The Broadway (pelican crossing) and Marsh Lane junction so that they were synchronised in order to improve their performance. This approach would smooth traffic flows and give us the opportunity to see whether any improvements in traffic flow and capacity would make it possible to consider an all red pedestrian phase at the Stanmore Hill junction without the previously mentioned drawbacks. TfL agreed to fund the project as part of the council’s Local Implementation Plan and the installation of new the signal equipment and linking of the signals via SCOOT (Split Cycle Offset Optimisation Technique) was completed by the end of March 2013. SCOOT is a tool for managing and controlling traffic signals in urban areas. It is an adaptive system that responds automatically to fluctuations in traffic flow through the use of on-street detectors which are embedded in the road. Now that these works have been completed we are monitoring the performance of the signals and the impact on congestion and journey times. We will shortly be reviewing the Stanmore Hill junction again to see if introducing a dedicated pedestrian phase at the Stanmore Hill junction is feasible and acceptable to TfL. Since the receipt of your letter we have also opened up dialogue with TfL regarding the decision to remove the secondary signal and asked that a review of this decision is undertaken. However, the installation of a pedestrian phase is still the Council’s preferred method of resolving this matter. I trust you can appreciate that the council has been taking all necessary actions available to pursue the installation of a pedestrian phase at these signals over recent years and that we are continuing to pursue this matter with TfL to achieve a satisfactory resolution for the local community. Yours sincerely Environment and Enterprise Corporate Director of 2 c- RECEIVED 03 SEP 2013 SCANNED
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