Prevention of Future Deaths reports · 2015
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 report | 19 Mar 2015 |
|---|---|
| Reference | 2015-0107 |
| Deceased | Valerie Walton |
| Coroner | Sean McGovern |
| Coroner area | Coventry |
| 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.
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
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.
- 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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