Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0448, written 16 Oct 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Oct 2014 |
|---|---|
| Reference | 2014-0448 |
| Deceased | Roger de Klerk |
| Coroner | Selena Lynch |
| Coroner area | South London |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
In the South London Coroners Court Inquest touching the death of Roger William Maurice De Klerk REGULATION 28: REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: | Head of Highways, London Borough of Croydon CORONER | am Selena Lynch, senior coroner for the coroner area of South London CORONER’S LEGAL POWERS | 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. INVESTIGATION and INQUEST On 14th November 2013 | commenced an investigation into the death of Roger de Klerk The investigation concluded at the end of the inquest on 2"! October 2014. The conclusion of the inquest was road traffic collision CIRCUMSTANCES OF THE DEATH Some time just before noon on the 12'" November 2013 the deceased was riding his bicycle along Cherry Orchard Road. After stopping at the lights he turned left into Addiscombe Road travelling on the left hand side of moving traffic. The wheels of the bicycle came into contact with tramlines causing him to lose control and to fall sideways, landing on his right hand side, into the path of a bus travelling in the same direction. The bus driver had no time to take avoiding action or to stop before colliding with the deceased and his bicycle. 5 | CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. — (1) Tramlines present a significant danger for cyclists, either by being caught in the lines or slipping on the metal, particularly in the wet. (2) The design and appearance of the bicycle lane at the junction of Addiscombe Road and Cherry Orchard Road may cause confusion for cyclists who are apparently required to go on to the pavement before the junction in order to cross it safely. The cycle path continues into the junction so that cyclists turning left will be forced to parallel with the lines, rather than crossing at 90 degrees, which is safer. (3) For cyclists who do go onto the pavement, the intended route goes over two tactile paving areas and involves contact with pedestrians crossing at the junction. (4) The signage at the junction is confusing and appears to suggest that the tram route is a cycle route, yet the lines are frequently close to pavement at the junction and at other areas further along Addiscombe Road ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action by undertaking an urgent review of the provision for cyclists on or near tramlines both at this junction and generally. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 11 December 2014. |, 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: ee A: UK Bus. | have also sent it to Tramlink and Transport for London who may find it useful or of interest. | am also under a duty to send the Chief Coroner a copy of your response. 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. 16" October 2014
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.
Development and Environment Department 6th Floor Zone C Bernard Weatherill House 8 Mint Walk Croydon CR0 1EA Tel/Typetalk: 020 8726 6000 Ext. 52821 Minicom: 020 8760 5797 Please ask for/reply to Your Ref: Our Ref: DE/R28/HWAYS/001 Date: 10 December 2014 Selena Lynch Senior Coroner for South London Croydon Coroner’s Court Barclay Road Croydon CR9 3NE Dear Selena Lynch, Regulation 28 : Report to prevent further deaths Addiscombe Road / Cherry Orchard Road I refer to your regulation 28 report regarding the death of Roger William Morris De Klerk at the junction of Addiscombe Road / Cherry Orchard Road on the 12th November 2013. Following the findings of your Coroner’s inquest, the council has agreed to carry out a detailed review of the junction of Addiscombe Road / Cherry Orchard Road with the aim of finding any improvements that will assist cyclist and improve road safety at this site. To this end, the council is requesting TfL’s design team (with expertise employed on TfL’s cycling better junction review and central London cycle Superhighway design) to carry out this review and provide the council with a range of workable options. These will include both short term options that can be implemented quickly, and more extensive improvement. We are entering into discussions with TfL regarding cycling Quietway funding with a view to making such more extensive improvement by 2016. The remit of this review will be to cover the matters of major concern, as raised in your report, which were:- Tramlines present a significant danger for cyclists, either by being caught in the lines or slipping on the metal, particularly in the wet. The design and appearance of the bicycle lane at the junction of Addiscombe Road and Cherry Orchard Road may cause confusion for cyclists who are apparently required to go on to the pavement before the junction in order to cross it safely. The cycle path continues into the junction so that cyclists turning left will be forced to parallel with the lines, rather than crossing at 90 degrees, which is safer. For cyclists who do go onto the pavement, the intended route goes over two tactile paving areas and involves contact with pedestrians crossing at the junction. The signage at the junction is confusing and appears to suggest that the tram route is a cycle route, yet the lines are frequently close to pavement at the junction and at other areas further along Addiscombe Road. The review requires a clear and defined brief, which has been completed and provided to the TfL designers. The first site meeting with the designers is taking place on Friday 12th December 2014 thereafter we are looking to receive design proposals in April 2015 and at this stage it is not possible to confirm when any works will commence but it is our intention to implement during the 2015/16 financial year. The council also appreciates that the issues for cyclists when crossing the tram tracks may exist at other locations along the tram network. For this reason the Council has discussed with TfL Tramlink the possible application of proprietary products which fill the gap in but to date have not found anything that is suitable for in street application and that do not have a significant risk to the operation. However Tramlink are committed to researching other solutions and have meetings set up in the New Year with railway suppliers and plastic suppliers. We will review signing and markings at all other sites in Croydon where cyclists cross the tram tracks to check for and rectify any other potentially confusing signing and marking. All this work is to be carried out in partnership with TfL Tramlink, TfL Buses, TfL’s traffic signal unit, the Metropolitan Police, the Council’s Strategic Transport planners, the council’s Access Officer and representatives of the council’s facilitated Cycle Forum. This collaborative approach aims to ensure that any proposals put forward are carefully considered and provides a holistic solution that balances the needs all road users. TfL has proposed and is developing designs for a second tram ‘Loop Line’ within the town centre utilising Dingwall Road. Dingwall Road has also been designated one of London’s Quiteway cycle routes by TfL. We are clearly engaged with TfL in both these processes and will keep a constant focus on enabling cyclists, pedestrians and other road users safely share the public realm with trams. I hope that this provides sufficient assurance as to the council’s commitment to help cyclists and all other road users pass through and share this junction in the safest possible manner; and at other sites in Croydon where the paths of cyclists and trams cross. If there are any further points arising, please do not hesitate to contact me. Yours sincerely, Head of Highways and Parking Services Croydon Council 2
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