Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0033, written 2 Feb 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Feb 2015 |
|---|---|
| Reference | 2015-0033 |
| Deceased | Martha Seaward |
| Coroner | Jacqueline Lake |
| Coroner area | Norfolk |
| Category | Road (Highways Safety) related deaths · Child Death (from 2015) |
| 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Interim Director of Environment, Transport and Development County Hall Martineau Lane Norwich NR1 2SG 1 | CORONER tam JACQUELINE LAKE, Senior Coroner, for the coroner area of NORFOLK 2 | 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. 3 | INVESTIGATION and INQUEST On 15 January 2014 | commenced an investigation into the death of MARTHA ANNE SEAWARD, AGE 15 YEARS. The investigation concluded at the end of the inquest on 28 January 2015. The conclusion of the inquest was Medical Cause of Death: 1a) Extensive soft tissue and bone injuries b) Road traffic collision. Conclusion: on 10 January 2014 Martha Seaward alighted from a bus at Lodge Hill intending to cross the A148 to reach the village of West Beckham. As she crossed the A148 she was hit by a lorry and she died as a result of the injuries she sustained. 4 | CIRCUMSTANCES OF THE DEATH Martha Seaward got off a bus at Lodge Hill, at the junction of B1157 and A148. She was crossing the A148 intending to walk to West Beckham. As she crossed the road a Scania lorry drove along the A148 striking Miss Seaward. She died as a result of her injuries. : 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) The bus stop at Lodge Hill is regarded as busy by Norfolk County Council (NCC) with 778 passengers in 2014. There used to be an hourly service from this stop into West Beckham until 2006 when it was stopped due to it being too dangerous for the bus to travel across the A148. There is now a service 1 per day - 3 days per week. The bus stop services a local tourist attraction as well as the nearby village of West Beckham. Concerns have been raised with the NCC on two occasions in the past 2 years (unrelated to this incident) with regard to the dangers of this bus stop/stretch of toad. ~~: (2 (3) There has been communication between NCC and Norman Lamb MP regarding a feasibility study carried out for safety measures to be introduced in respect of this area. No action has been taken since May 2014. The outcome of this Inquest has been awaited before taking any further action. (4) Matters which have been considered but in respect of which no action has been taken include: 1. Affordable options to improve safety for pedestrians crossing the A148, such as a pedestrian refuge; 2. Improvements to visibility; 3. Bus stop arrangements such as a lay-by 4. Speed limit. In my opinion action should be taken to prevent future deaths and | believe your organisation has the power to take such action. YOUR RESPONSE You are under a duly to respond to this report within 56 days of the date of this report, namely by 30 March 20165, 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: BE (2211s) and to the LOCAL SAFEGUARDING BOARD (where the deceased was under 78)] | am also under a duty fo 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 ta 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. 2 February 2015 | ACTION SHOULD BE TAKEN Senior Coroner for Norfolk
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.
Norfolk County Council Community and Environmental Services Martineau Lane . Norwich 3.0 MAR 2015 NR1 2SG Via email and post NCC contact number: 0344 800 8020 ‘Ms Jacqueline Lake Textphone: 0344.800 8011 _ Senior Coroner Email: Coroner's Office — : 69-75 Thorpe Road 26 March 2015 ‘Norwich ; NRi 1UA Dear Ms Lake Further to your Regulation 28 report to prevent future deaths, served following the inquest into the death of Martha Seaward, we set out below the response from Norfolk County Council. To assist, we set out the legal duties owed by Norfolk County Council in respect of the road in question, the A148, where Martha Seaward tragically died. Legal Duties of Norfolk County Council The Highways Act 1980 ; The Highways Act 1980 imposes a statutory duty on Norfolk County Council,.as the highway authority, to maintain the highway. The duty to maintain is absolute, although the roads do not have to be perfect. The duty is to put the’ highway in such good repair as renders it reasonably passable for the ordinary traffic of the neighbourhood at all seasons of the year without danger caused by its physical condition. The duty imposed by the Highways Act does not extend to maintaining any land other than the highway, the painting of markings upon the surface of the highway or the erection of traffic signs, nor does it apply to street furniture. The Traffic Act 1985 The Traffic Act sets out a number of regulations for the creation, registration and running " of a ‘local service’. : The Traffic Act imposes a duty on Norfolk County Council, as the local authority, to secure the provision of public transport services to meet the requirements within the county. The Act also grants powers to councils to maintain'a bus station: However, the Act does not require the counell to take steps in the planning of bus routes or where the bus stops. The tragic: death of Martha Seaward was not a result of any breach of legal duty by Norfolk County Council. Areas of concern Turning now to the areas of concern, which we will address in turn below. “4) The bus stop at Lodge Hill is regarded as busy by Norfolk County Council (NCC) with 778 passengers in 2014. There used to be an hourly service form this stop into West Beckham until 2006 when it was stopped due to it being too dangerous for the bus to travel across the A148. There is now a service 1 per day — 3 days per week. The bus stop services a local tourist attraction as well as the nearby village of West Beckham.” . ; - The bus service in this area is operated by Sanders Limited, a bus operating company, who are independent from the County Council. Sanders have operated the routes in this area for over 10 years. Bus routes, frequency of routes and locations of bus stops are the responsibility of the bus operating company. Bus operating companies are free to decide where and when to stop their buses along the route. Sanders historically operated a service into the village of West Beckham, however this service.ceased in 2006. Norfolk County Council understand there to be a number of reasons behind.this decision. The first was a commercial reason due to lack of demand for the service. The bus operator also reported that roads through West Beckham were difficult to negotiate for larger buses and had visibility issues. There was also difficulty with the junction at Lodge Hill crossing from West Beckham. The operator decided that the combination of these factors meant they could not continue with that level of service. Since 2006 West Beckham has been served three days a week, with shopping time services to Sheringham and Holt. These services are commensurate with demand. Norfolk County Council is able to access data on bus usage via the electronic ticket machines. The figures quoted in your report of 778 passengers using the bus stop at Lodge Hill do not match the data held by Norfolk County Council. Our data shows that 778 passengers use buses on the route. This is different to the number of bus passengers who use the bus stop. The data on the Lodge Hill bus stop shows the number of passengers using this stop to be: : O16 in the week beginning 17 August 2014 O 8 in the week beginning 25 January 2014 Assuming the same number of passengers get off as got on, indicative user numbers would be around: ; 32 users per week in summer Q 16 users per week in winter Norfolk County Council does not classify a bus stop used by 32 passengers each week as a busy bus stop. Whilst Norfolk County Council cannot dictate where a bus operating company stops their bus, we are of the view that similar accidents could be avoided in the future by changes being made to the location of bus stops‘at the Lodge Hill junction. Currently buses stop at Lodge Hill to allow passengers to alight before turning right onto the A148. If the bus stop were to be moved from Lodge Hill onto the A148 this would prevent passengers having to cross the A148 road should they wish to continue their journey into West Beckham. Norfolk County Council have no power to enforce such a change, however we have written to the bus operating company making this recommendation. Norfolk County Council are committed to improving road safety and set out below the steps we have taken to prevent similar accidents occurring in the future: \ 1 We have shared the Coroner's Prevent Future Death’s report with Sanders, the bus operating company responsible for the bus service. Sanders. have the power to take action and implement changes to the location of the bus stops in order to prevent passengers having to cross the A148. A copy of Norfolk County Council's correspondence to Sanders is attached to this response. A review has been conducted of accident patterns near bus stops on the A road network. The A road network within the county spans 480 miles. Our review has shown that in the last 10 years, 83 pedestrians were killed or seriously injured in collisions which occurred on the rural 5S0mph+ network in Norfolk. This accounts _ for 2.3% of the killed and serious injury accidents. in the county. Of these, 20 ~ occurred within 100m of a bus stop; however, this does not indicate whether the | bus stop was implicated in the cause ofthe accident or not. With over 2,000 rural bus stops in Norfolk, only 4 have more than 1 pedestrian collision within 100m over the past 10 years. This does not suggest a significant safety problem at any particular site or across Norfolk as a whole. Nevertheless, we have now developed an internal procedure to risk assess each new application for a formal bus stop to manage down risk as far as practicable, along with existing guidance for designers regarding provision of formalised bus stops on high speed (50mph+) A class roads. We will inplement a localised road safety campaign to raise awareness of safety issues for bus users, in particular regarding crossing the road. We provide specialist education from road safety experts in both primary and secondary schools to promote awareness of the risks in crossing roads, and measures to stay safe. We continually monitor and evaluate this programme to reflect best practice and latest research to provide the best possible opportunity for Road Safety education. * Legislation allows bus operators to establish stopping points at any location they choose. Where a commercial service exists, operators are not required to consult Norfolk County Council or involve the County Council in their decision making. However, we will seek to engage with operators to discuss current practices for bus stop determination with a view to standardise the approach across all operators. “2) Concerns have been raised with the NCC on two occasions in the past2 years (unrelated to this incident) with regard to the dangers of this bus stop/stretch of road.” - Norfolk Country Council has received some correspondence regarding concerns linked to the bus stops since the tragic accident. There have been previous discussions with the focal residents. and the parish council regarding improvements that can:'be made to the junction and this section of road. Local Safety Scheme improvements were implemented in October 2009: ’ Vegetation east of the junction cut back to improve sideways visibility from the West Beckham approach. Advance direction signs moved further back to improve drivers’ view. ‘SLOW’ road markings and wider hatch markings: placed on the A148, give way lines refreshed. Oo Following a site meeting between NCC highways officers, and Upper Sheringham and West Beckham Parish Councils in July 2011, the West Beckham side of the junction was _ highlighted for increased verge maintenance with our North Area office. The possibility of a Vehicle Activated Sign (VAS) to highlight the crossroads to drivers was discussed and the possibility of providing a VAS through our “Parish Partnership” initiative (which delivers low cost highway improvements across Norfolk, jointly funded with parish / town councils) was discussed. This would have required a bid and funding from the relevant parish councils, and was not progressed. “3) There has been communication between NCC and Norman Lamb MP regarding a _ feasibility study carried out for safety measures to be introduced in respect of this area. No action has been taken since May 2014. The outcome of this Inquest has been awaited before taking any further action.” Since May 2014, the “SLOW” markings on the carriageway have been refreshed. It is regrettable that the timespan has lengthened linked to the delay in holding the inquest. A copy of the feasibility study is appended to this response. “4) Matters which have been considered but in respect of which no action has been taken include: 1. Affordable options t to improve safety for pedestrians crossing the A148, such as a pedestrian refuge; . 2. Improvements to visibility; 3. Bus stop arrangements such as a lay-by; 4. Speed limit.” Context The County Council as Highway Authority has a duty. of care to manage and maintain the highway network, but no duty to improve it. Our Local Transport Plan (LTP) has six main aims which are: ‘4. Managing and maintaining the transport network; 2. Delivering sustainable growth; 3. Enhancing strategic connections; 4. Improving accessibility; 5. Reducing transport emissions; 6. Improving road safety The extent to which we can deliver improvements is governed by available funding. Following government funding reductions in 2010/11, we do not receive enough funding to maintain the highway network to current standards. Although we prioritise funding toward maintenance work, we still have a £72.5m backlog of such work. . Consequently, we currently allocate £2million to highway improvements. This budget has been significantly cut from previous years when the budget was around £10million. Norfolk County Council received a number of requests for a wide range of highway improvements to the roads within the county. Within the constraints of a reduced budget Norfolk County Council has to allocate funds to those areas which present the greatest risk. Under the heading of "Inter-urban links" (mostly junction improvements), potential A/B road schemes are ranked, based on accident (total within the preceding 5 years) and traffic flow data (based on a 24 hour count). This ranking is used as a guide — other factors such as the strategic importance of a route, practicality of construction, and cost of improvements also determine whether a scheme progresses. : For the A148 section between Bodham and the A1082 Holway Road, there have been 11.8 personal injury accidents per 100 million vehicle kms. This is well below the national average for rural A roads of 17.7. In the last three years, two injury accidents have been recorded by Norfolk Constabulary, including the recent tragic fatality. Although this is a lower accident record than before the 2009 improvements, we recognise that a fatality of this nature is still distressing for the community. Our Road Safety Team monitors injury accidents to identify accident ‘cluster sites’. For rural locations like Lodge Hill, this means five injury accidents within 50m over the past three years. This would trigger investigations which may result in a ‘Local Safety Scheme’. Our evidence-based approach to casualty reduction helps target investment at the most hazardous locations first. The accident record at this junction would not normally trigger the implementation of either a road crossing scheme or Local Safety Scheme, even taking - account of this tragic fatality. A roundabout has been requested and added to the pending longlist of requested schemes. This could cost between £500,000 (compact roundabout) and £1m (full sized roundabout). A mini-roundabout would not be suitable at this rural location. It is not likely to be considered in the medium term in the present context of a £2m annual highways improvement programme, nor could it be justified when there are still many other sites in Norfolk with worse accident records. Our study reviewed the four points identified above. The key conclusions of the report are: 1. A “D-shaped” pedestrian refuge (with limited main road widening to accommodate it) was considered and discounted because a) the need to accommodate vehicular turning movements mean it would be placed too far from the junction to be practicable and b) the risk of vehicles colliding with the refuge on a high-speed road would create an unacceptable risk for pedestrians and drivers, and is not recommended by the applicable design standards. The recommended proposal to improve safety for pedestrians is summarised in the final section of this response. 2. Whilst visibility does not fully meet DMRB (Design Manual for Roads and Bridges) standards (which were developed for trunk roads), it is in line with similar junctions on the A road network. Some localised verge lowering to enhance visibility is considered to be beneficial. 3. Lay-bys were considered but discounted as visibility requirements would place them too far from the junction to be practicable. 4. In line with our agreed Speed Management Strategy, the lack of frontage development on the A148 makes it difficult to justify a lower speed limit, given that limits should appear self-evident based on the characteristics of the road. Speed readings at this site demonstrate a good level of driver compliance. Proposed action: On 28 January 2013, the County Council's Cabinet “agreed proposals for using £8m in one-off funding to support Norfolk's most vuinerable people, while investing in key projects that are priorities in local communities.” From this £8m it was agreed to allocate £2m to highways, divided equally between: * £1m for parish partnerships * £1m for other highway improvements to support communities and businesses Given the concerns raised by local community via their elected representatives, savings within the latter programme of additional schemes mean some of the remaining one-off funding can be applied to deliver the above improvements at Lodge Hill junction. It is proposed to implement an improvement as soon as possible within the financial year 2015/16 comprising: e Ashort section of “trod” (an open textured footpath suitable for rural areas) on the north side of the A148 from the bus stops, directing pedestrians to a suitable crossing point. e Ashort section of “trod” on the south side between the crossing point and Sheringham Road. — e Some localised verge lowering to enhance visibility, with an appropriate low- growing seed mix to reduce maintenance requirements ‘@ Information signs to remind bus users to take care when crossing the main road. These measures will help improve safety for pedestrians, providing a clearer direction to a suitable point to cross the A148. The County Council is arranging a meeting with the local member, parish council and bus company representatives to discuss its response to the coroner and the proposed action. Yours sincerely . Executive Director of Community and Environmental Services
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