Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0141, written 20 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 | 20 Feb 2015 |
|---|---|
| Reference | 2015-0141 |
| Deceased | Maria Nekrasova |
| Coroner | Paul Matthews |
| Coroner area | London Inner (South) |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
MARIA NEKRASOVA DECEASED _ REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Secretary of State for Transport 2. Transport for London 3. The City of Westminster 4. The London Borou h of Lambeth 1 CORONER am Paul Matthews, assistant coroner for the coroner area of Inner South London. 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 12 May 2014 an investigation was commenced into the death of Maria Nekrasova, aged 18 years. The investigation concluded at the end of the inquest held by me on 19 February 2015. The medical cause of death was: 1a Severe traumatic head injury. The conclusion of the inquest was: Accident. 4 CIRCUMSTANCES OF THE DEATFI At about 1.50 am on 4 May 2014, the deceased, who had been drinking, was whilst standing in the hatched area in the middle of the carriageway of Westminster Bridge, London SW1, hit by the front offside of a licensed taxi cab being driven by an experienced night-time driver across the bridge from the Lambeth end towards the Westminster end, so that she was thrown up onto the bonnet and her head hit the windscreen, sustaining the severe traumatic head injury from which she died. 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)There is nothing to prevent pedestrians crossing the carriageway of the bridge (such as a central fence) and neither is there any protection for pedestrians who have reached the middle of the carriageway (such as a central reservation); (2) At night the level of street lighting is low, the lamp standards producing pools of light which have the effect of leaving contrasting areas of the carriageway in relative darkness; (3) The glare of the headlights of oncoming vehicles makes it impossible for drivers of vehicles crossing the bridge to see pedestrians standing in the carriageway until it is too late to avoid hitting them. 6 ACTION SHOULD BE TAKEN 1 In my opinion action should be taken to prevent future deaths and I believe that one or more of you has or 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 10 April 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. 8 COPIES and PUBLICATION have sent a copy of my report to the Chief Coroner and to the following Interested Persons, namely the parents of Maria Nekrasova. 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 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. 9 Dated: 20 February 2015 ._./~
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.
Transport for London Mr Paul Matthews Transport for London Southwark Coroner's Court, Surface Transport 1 Tennis Street, Asset Management London 4" Floor, Palestra SE1 1YD 197 Blackfriars Road London, SE1 8NJ as wort. gov.uk 10" June 2015 Dear Mr Matthews, Maria Nekrasova — Regulation 28 Report My colleagues and | were very sorry to hear of the tragic accident which occurred on 4 May 2014 and would wish to pass our condolences to the family of Miss Nekrasova. Your Prevention of Future Deaths report was received by TfL on 16 April 2015 and | respond as follows: Introduction Westminster Bridge runs East to West across the River Thames and links Westminster Bridge Road in Lambeth to Bridge Street and the Victoria Embankment in Westminster. The Houses of Parliament, Portcullis House, Parliament Square and Westminster Underground station are located immediately to the west of the bridge (north side of the river). St Thomas’s Hospital, the old County Hall complex and Waterloo mainline station are located immediately to the east (south side of the river). TfL is the highway authority for the A302 as it crosses Westminster Bridge. The ‘Matters of Concern’ 1. There is nothing to prevent pedestrians crossing the carriageway of the bridge (such as a central fence) and neither is there any protection for pedestrians who have reached the middle of the carriageway (such as a central reservation). TfL’s policy is a presumption against the provision of pedestrian guardrail, except where there is a proven safety requirement. Having considered this location, and the possible physical segregation of pedestrians from vehicular traffic, the erection of a barrier could potentially create a safety hazard for pedestrians, joggers or cyclists who could become isolated on the wrong side of the barrier. For this reason, no barriers will be erected. Central reservations are usually provided to separate the flow of opposing high speed traffic, to prevent overtaking on the approaches to junctions or at designated pedestrian crossing points. Given that Westminster Bridge is subject to a 30mph speed limit and that there are no junctions or locations across the bridge which justify the provision of a pedestrian crossing, the provision of a central reserve would be inconsistent with other urban locations and TfL do not feel it would be appropriate to install one. Page 1 2. At night the level of street lighting is low, the lamp standards producing pools of light which have the effect of leaving contrasting areas of the carriageway in relative darkness; The light output from each of the ‘heritage’ lighting points on the bridge is similar to that provided from conventional street lights. However, TfL will be carrying out a detailed investigation of the lighting levels and the distribution of light over the bridge by August 2015. Following the outcome of the investigation, we will consider what alterations might be appropriate or possible, taking into account the physical constraints of providing additional lighting points across the bridge deck and in such a historic location. The glare of the headlights of oncoming vehicles makes it impossible for drivers of vehicles crossing the bridge to see pedestrians standing in the carriageway until it is too late to avoid hitting them. Glare from headlights is not a matter that TfL has any ability to influence or control, and no further comment is made in this respect. Further information We will be consulting the public in the summer of 2015 on the road layout across the bridge as part of TfL’s ‘Better Junctions’ works programme. More information can be found at https:/Avww. tfl. gov.uk/travel-information/improvements-and-projects/road-modernisation-plan In addition, the bridge will link two proposed cycling improvement schemes; the East-West Cycle Superhighway on the north side of the river and a junction improvement at Westminster Bridge Road/Addington Street on the south side which will result in some changes to the carriageway. Yours sincerely, Director of Asset Management TfL Legal Windsor House 42-50 Victoria Street London SW1H OTL Page 2
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