Prevention of Future Deaths reports · 2015

Anais Thouvenot

Regulation 28 report to prevent future deaths, reference 2015-0110, written 18 Mar 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report18 Mar 2015
Reference2015-0110
DeceasedAnais Thouvenot
CoronerChristina Swann
Coroner areaLeicester (City & South)
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.

for Leicester (City and South)

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO: The Chief Coroner
Leicester City Council,
The family of Miss Thouvenot
Leicester Campaign Cycling Group.

CORONER

lam Dr Christina Swann ,Assistant Coroner for Leicester (City and South)

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.

http://www. leqislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www. legislation.gov.uk/uksi/2013/1629/part/7/made

INVESTIGATION and INQUEST

On 17/11/2014 | commenced an investigation into the death of Anais Chantal Thouvenot, who
was 22 years of age, at the time of her death. The investigation concluded at the end of the
inquest on 17 March 2015. The conclusion of the inquest was Road Traffic Collision. Miss
Thouvenot suffered a traumatic brain injury following a road traffic collision whilst riding her
bicycle and died on 16th November 2014 at Queens Medical Centre, Nottingham despite
supportive measures. The cause of death was given as cerebral Infarction due to traumatic brain

injury.

CIRCUMSTANCES OF THE DEATH

Miss Thouvenot was involved in a road traffic collision at the junction of Upper Kings Street and
Regent Road in Leicester on 9/11/14 when she was knocked from her pedal cycle by a passing
vehicle sustaining a serious head injury. She was taken to QMC, Nottingham, where she died on
16/11/14.

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 may occur unless action is taken. In the circumstances it
is my statutory duty to report to you.

The MATTERS OF CONCERN are as follows. —

During the course of the investigation | was made aware of specific concerns regarding the
safety of the road traffic junction at Upper Kings Street and Regent Road, Leicester. These
concerns were highlighted to me by the Leicester Cycling Campaign Group (LCCG) and a
member of the public Iso raised these concerns for the attention of

Councillors and

The LCCG have informed me that they believe the junction to be inherently dangerous quoting a
number of ‘near misses’ as experienced by their cycling group.

The specific concerns relate to visibility at the junction and absent or inadequate filter lanes,
exacerbated by heavy traffic and the contour of the road at this junction. It is also known to be on
a major cycle route into the city.

Town Hall Square, Leicester, LE1 9BG
Tel 0116 4541030 | Fax 0116 225 2537

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. | would appreciate if you would kindly review the inherent safety of this
junction in the course of preventing future deaths.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report, namely by
29 April 2015. |, 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
namely the family of Miss Thouvenot. | have also sent it to the Leicester Cycling Campaign
Group 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, 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,

Dated 18 March 2015

Signature.
for Leicester (City and South)

‘Town Hall Square, Leicester, LEL 9BG
Tel O116 4541030 | Fax 0116 225 2537

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 Leicester City Council (PDF)
Please ask for: cc ry
Direct line:

Email: O

Our ref: ( ] \ )
Your ref: CEM/GA/031 10-2014

Date: 23" April 2015 Leicester
City Council

FAO Dr C Swann

H M Coroner for Leicester City and South

Leicestershire, |
The Town Hall,

Town Hall Square,

Leicester.

LE1 9BG

Dear Dr Swann,
Re: Anais Chantal Thouvenot.

Thank you for your letter dated 24" March 2015 enclosing the Regulation 28 Report resulting from
the Inquest of Miss Anais Chantal Thouvenot. Firstly may | take the opportunity to express our
deepest sympathy to the bereaved family and friends of Miss Thouvenot following her tragic fatal
accident.

The Council takes its duty to maintain the public highway in a safe and serviceable condition very
seriously and | have taken time to carefully review the concerns you have outlined in your report
concerning the safety of the highway junction layout at Regent Road/King Street/Upper King
Street.

| have examined recorded personal injury accidents information relating to accidents that have
occurred over the past 25 years at the junction. In that time there have been five such accidents,
including the tragic event of 9" November 2014. The five accidents resulted in six casualties —
one fatal and five slight. The five slight casualties consisted of; two vehicle drivers, one vehicle
passenger, one motorcyclist and one pedestrian. Detailed examination of the circumstances of
each accident has demonstrated no common traits to which a pattern could be attributed.

At signal controlled junctions in Leicester, there has been an average of 1.1 accidents per annum
(using the last 10 years for which data is available). The junction of Regent Road/King
Street/Upper King Street has an average of 0.2 accidents per annum. Therefore it is considered
that this junction is significantly safer than similar junctions in the city.

Your report specifically includes the following detailed matters of concern which | address below:
e Visibility at the junction;
e Absent or inadequate filter lanes;

« The contour of the road at this junction.

LEICESTER CITY COUNCIL
City Hall, 115 Charles Street, Leicester, LE1 1FZ
www. leicester.gov.uk

The junction design and signalling arrangements have taken account of the Design Manual for
Roads and Bridges (Volume 6, Section 2, Part 3 - TD 50/04 The Geometric Layout of Signal
Controlled Junction and Signalised Roundabouts). As such, constraints such as existing road
geometry, buildings and availability of land have been considered in accordance with TD50/04 and
junction inter-visibility has been maximised.

The existing road geometry at the junction renders the provision of both cycle and all-vehicle lanes
difficult. In addition, loss of the right turn lane into King Street may not be of any benefit to cyclists,
but could cause problems with traffic flow through the junction, adding to congestion. It may also
result in inappropriate driver behaviour which could have a detrimental effect on the safety of
cyclists through the junction.

The gradient through the junction is estimated to be around 1 in 45. This equates to a gradient of
2.2%. The Design Manual for Roads and Bridges (Volume 6, Section 1, Part 1 — TD 9/93
Amendment No. 1 Highway Link Design) states that the desirable maximum gradient for all-
purpose single carriageway roads is 6%. The gradient through the junction of Regent Road/King
Street/Upper King Street falls well within the design requirements of TD 9/93.

The record of road safety at the junction of Regent Road/King Street/Upper King Street is
considerably better than most of the 204 traffic signal controlled junctions in Leicester. The design
of the junction has been reviewed with regards to its inherent safety and it performs well against
the requirements of the Design Manual for Roads and Bridges. In view of the existing record of
safety at the junction, any changes would have to be very carefully considered to ensure they
would not have an adverse effect on road safety at the site.

However, during the review of the junction and in the interest of improving general amenity,
reducing road danger for cyclists and other road users and in line with current best practice
guidance, several potential actions have been identified for investigation:

(i) Provision of Advanced Cycle Stop lines in both directions on Regent Road and removal of
the right-turn lane markings into King Street,

(ii) Adding road markings to define the cycle crossing route between Upper King Street and King
Street

(iii) Extra road markings to discourage car drivers from queueing across the junction.

(iv) Parking and loading restrictions along the whole of Regent Road and the introduction of
cycle lanes or maintenance of on-street parking and removal of this part of Regent Road as a
strategic through road.

(v) The Leicester Cycling Campaign Group has made comments since the accident have been
about their concerns relating to vehicles turning right out of King Street without giving way or
having any regard to cyclists coming out of Upper King Street. Both approaches currently run
in the same stage. Each approach could run in different signal stages, thus removing this
potential conflict, with the cycle approach from Upper King Street only appearing if a cycle is
present.

This work to carry out investigation of potential improvements will be carried out over the next few
months with a view to including any identified improvements in future highways and transport
improvement works programmes.

LEICESTER CITY COUNCIL
City Hall, 115 Charles Street, Leicester, LE1 1FZ
www.leicester.gov.uk

A briefing paper on the tragic accident involving Miss Thouvenot, which included the Regulation 28
Report, was considered by the City Mayor at a meeting on 22™ April 2015. At the meeting, the
City Mayor agreed this response to the Regulation 28 Report

| trust that this letter provides an acceptable response to the points raised in the Regulation 28
report

Yours sincerely,

Director of Planning, Transportation & Economic Development

“LEICESTER CITY COUNCIL
City Hall, 115 Charles Street, Leicester, LE Z

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