Prevention of Future Deaths reports · 2015

Martha Seaward

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 report2 Feb 2015
Reference2015-0033
DeceasedMartha Seaward
CoronerJacqueline Lake
Coroner areaNorfolk
CategoryRoad (Highways Safety) related deaths · Child Death (from 2015)
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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

Responses

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.

Response from Norfolk County Council (PDF)
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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