Prevention of Future Deaths reports · 2015

Valerie Walton

Regulation 28 report to prevent future deaths, reference 2015-0107, written 19 Mar 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report19 Mar 2015
Reference2015-0107
DeceasedValerie Walton
CoronerSean McGovern
Coroner areaCoventry
CategoryRoad (Highways Safety) related deaths
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)

NOTE: This form is to be used after an inquest.

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:

Chief Executive — Coventry City Council

4 | CORONER

lam S McGovern, Senior Coroner, for the coroner area of Coventry

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

| opened an investigation on 10 October 2014 into the death of Valerie WALTON, late
lof | concluded the inquest on 19 March
2015 and returned a conclusion that her death was due to a road traffic collision .

4 | CIRCUMSTANCES OF THE DEATH
Ms Walton was struck by a bus while using a Zebra crossing on Remembrance Road,
Coventry on 29 September 2014.

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. —

| heard evidence from PC a: the Regional Collision Investigation Unit that the
positioning of the crossing on the apex of a sharp bend was contributory to this death.
He opined that had the crossing been on the straight section of the road the death may
not have occurred or alternatively whether the crossing should be controlled by traffic
lights.

6 | 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.

7 | YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report,
namely by 14 May 2015 . 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

[| have sent et the Chief Coroner and to the following Interested
Persons (a) (brothers of Ms Walton)

lam 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.

19" March 2015
Senior Coroner S McGovern aS WL yer

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 Coventry City Council (PDF)
-

ia

Coventry City Council Chief Executive's Office

Martin Reeves
Chief Executive

Mr Sean McGovern
Council House

HM Coroner for Coventry and Warwickshire Fal Bhrast
The Coroner's Office a, ne
a oventry
Little park Street CV1 5RR
Coventry
CV1 2J5X DX 18868 Coventry 2

www.coventry.gov.uk
minicom 024 7683 1093

13 May 2015 Diosst line
|

Dear Mr McGovern
Re: The late Valerie Walton

| refer to your letter of 23" March, sent to me under Regulation 28 of the Coroners Rules
Act of the Coroners (Investigations) Regulations 2013 to prevent future deaths.

| would like, at the start of this letter, to offer the Council's sincere condolences to the
family of Valerie Walton on their sad loss.

Appended to your letter was your report and in particular your statement of concerns
following the inquest, which were:-

‘T heard evidence from | of the Regional Collision Investigation Unit that the positioning
of the crossing on the apex of a sharp bend was contributory to this death. He opined that had the
crossing been on the straight section of the road the death may not have occurred or alternately
whether the crossing should be controlled by traffic lights.’

In response, please be assured that Coventry City Council takes its responsibility to
promote the safety of all road users in the city very seriously. As such, the zebra crossing
in question was introduced at this location following a local petition about concerns over
road safety, in particular relating to pedestrians crossing the road in the vicinity of the
crossing to use the various local facilities.

In terms of the process we follow, all traffic and road safety schemes implemented by the
Council are subject to a road safety audit by a team of engineers who are independent of
the design team. The Road Safety Audit procedure has been developed “to ensure that
operational road safety experience is applied during the design and construction process
in order that the number and severity of collisions is kept to a minimum” (Department for
Transport Design Manual for Roads and Bridges HD 19/15).

As a result, as part of the process of installing the Zebra Crossing in 2006, three stages of
safety audit were undertaken:-

e Combined Stage 1 & 2 — Completion of Design
« Stage 3-— Completion of Construction
e Stage 4 — Monitoring of recorded injury accidents after completion

At both the combined Stage 1 & 2 and Stage 3 the auditors were happy with the visibility
of the zebra crossing, other than with an issue observed after completion when buses
were seen parking slightly on the crossing which was subsequently resolved. The stage 4
part of the process is reviewing the accidents at 1 and 3 years after implementation to see
what problems develop from the change in the road. The Police recorded injury accident
database is used for this. In the eight years from the installation of the zebra crossing until
the unfortunate accident there are none recorded which involved injury to a pedestrian
crossing on the zebra. The only other accident was a car on car, tail shunt, indicating that
a driver had stopped for a pedestrian.

It is impossible to make a highway where vehicles and pedestrians mix completely safe;
we can only make it safer. In view of your recent comments we have reviewed again the
site to consider what measures might be implemented to improve the safety. Four options
have been considered:-

1. Upgrade the facility to a signalised Puffin Crossing.

Whilst this would increase the conspicuity of the crossing and encourage drivers to stop,
observations of the use of the existing Zebra crossing by pedestrians suggests that this
may be less safe. This is because we would anticipate that most pedestrians would not
push the button and wait, as there are plenty of gaps in the traffic, and visibility is good
enough to tempt people to cross. Even if they did push the button they may not wait the
10 to 45 seconds for a green man given the low flows and cross when traffic had a green
light and drivers did not anticipate stopping.

Therefore the Council at this moment in time does not proposed to upgrade the Zebra to a
Puffin Crossing as it does not consider that it is likely to improve the safety of the crossing
facility and may actually have a detrimental effect.

2. Relocate the crossing.

The problem with relocating the crossing is that, looking at each option in turn, if we move
it to the:-

e Middle of the straight from Robin Hoods Road to the bend. To do this we would
have to remove most of the on street parking. ‘Due to the current level of demand
for on-street parking in the local vicinity it is considered that under this option it
would increase the likelihood that drivers would park illegally, including on the zig
zag markings, thus restricting visibility between drivers and pedestrians using the
crossing.

« East side of the existing crossing. To do this we lose the bus stops which are well
used and an important timing point for services. These would have to be relocated
into the on street car parking bays which in our opinion, would produce problems of
cars persistently parking in the bus stops or we would have to relocate the stops
away from the shops.

The other consideration is pedestrian ‘desire’ lines. These are the natural routes taken by
pedestrians to get to their chosen destination usually based on the quickest or most
convenient route to walk along. Site observations would suggest that pedestrians see the
existing crossing to be on their desire line to the entrance of the Co Op food centre. So
relocating significantly away from this desire line may reduce the use of the crossing
facility and encourage more pedestrians to cross the road without ‘protection’ of the Zebra.

Consequently, the Council at this moment in time does not propose to relocate the
crossing as it does not consider that it is likely to improve the safety of the crossing facility
and the area around it.

3. Remove the Zebra Crossing

There is a strand of professional opinion that in some situations where low traffic and/or
pedestrian flows occur that removing a Zebra or Puffin crossing facility can improve road
safety at a location. However site observations show the crossing to be well used and
therefore this has been dismissed as an option.

4. Enhance the existing zebra crossing conspicuity

Subsequent site observation identified that based on the nature of the accident various
measures could be undertaken to enhance the conspicuity of the crossing for drivers:-

a) Reduce the under-hanging branches from the trees to the south of the crossing
which can in full leaf partially conceal the southern Belisha beacon and
approaching pedestrians.

b) Re-align the crossing by moving it more onto the centre of the bend, to enhance
the visibility of the surface of the crossing as well as pedestrians already on the
crossing for drivers approaching from the south.

c) Remove the guard rail from the inside of the bend to reduce any masking effect it
might create for drivers of pedestrians.

d) Reduce the height and number of bollards on the right hand side of Remembrance
Road as drivers approach from Robin Hood Road to reduce any masking effect it
might create for drivers of pedestrians.

e) Make use of more intensely illuminated Belisha beacon heads. The conversion
from conventional heads to the Zeebrite type head. This will also require the
installation of an additional two poles and heads as the Zeebrite type heads are
highly directional so that each set of two is aligned along the approach direction.

f) Include on all poles with Belisha beacons on, illuminated poles whereby the white
parts of the pole is illuminated.

Having considered the options it is proposed that option 4, to enhance the conspicuity of
the Zebra crossing is implemented. It is anticipated that these works will be undertaken

over the next three to six months.

Please note that the City Council has not received a copy of the detailed Police
investigation of the accident that was provided to you. Therefore our engineers’
assessment of how the crossing might be improved to prevent a similar accident is based
on a number of elements: information gleaned from a site meeting with the Police on the
day of the accident; your comments in your Regulation 28 notice; site observations; and
their professional opinion based on the information available to them.

| trust that as a result of our proposed actions the safety of potentially vulnerable road
users such as pedestrians can be enhanced with a view to preventing a further death and
that this letter provides sufficient response to your questions and assurance.

Yours sincerely

Martin Reeves
Chief Executive

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