Prevention of Future Deaths reports · 2015

Karen Clayton

Regulation 28 report to prevent future deaths, reference 2015-0388, written 15 Sep 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report15 Sep 2015
Reference2015-0388
DeceasedKaren Clayton
CoronerJohn Pollard
Coroner areaManchester 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.

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO: The Chief Executive, Trafford Metropolitan
Borough Council: Secretary of State for Transport

1 | CORONER

| am John Pollard, senior coroner, for the coroner area of South Manchester

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

Ons" January 2015 | commenced an investigation into the death of Karen Clayton dob
10" January 1965.The investigation concluded on the 30" June 2015 and the
conclusion was one of Accidental death. The medical cause of death was 1a Traumatic
subdural haematoma .

4 CIRCUMSTANCES OF THE DEATH

On the 2"? January 2015 at Moss Lane, Altrincham, Mrs Clayton was riding her
bicycle in a designated cycle lane. As she traversed the brow of the railway
overbridge, she was confronted by a group of youths walking in the cycle lane.
The youths made efforts to step off the cycle lane but were prevented from doing
so by the narrowness of the lane; a collision then took place between the cyclist
and one of the pedestrians. The cyclist fell to the ground and sustained what
proved to be fatal head 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. At this location there is mixed traffic, being pedestrian, bicycle and motor.
There is insufficient room for all these different forms of traffic to be
effectively segregated.(Trafford)

2. Although this is a “one way” route for most traffic, the cycle lane allows
for bicycles to travel in a contra flow. This is inherently confusing and
dangerous for the cyclists and other road users.(Trafford)

3. The signage in the immediate area is unclear and possibly
confusing(Trafford)

4. Because of the location of the Supermarket and the lay out of the toad,
there is an obvious crossing-place via the cycle path. Not to use this route

by pedestrians intending to walk to the railway station would involve them
in crossing the road twice.(Trafford)

5. The guidance in the “Highway Code” and elsewhere relating to the fact
that pedestrians should not walk in a cycle path, is weak and needs to be
re-written and reinforced. (Secretary of State for Transport)

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.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report,
namely by 11"" November 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 Tara) MM shan of the deceased). | have also sent it to
Greater Manchester Police (Road Policing department) 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 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

, abput the release or the publication of your response by the Chief Coroner.

John Pollard, HM Senior Coroner

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 Trafford Council (PDF)
C6 /7OD me)

% TRAFFORD
’ COUNCIL
Helen Jones
Deputy Chief Executive

Mr J. S. Pollard t _ :

Coroner’s Court i i Trafford Council
1 Mount Tabor Street i Trafford Town Hall, Talbot Road
Stockport | Stretford, Manchester, M32 0TH
ee ; Telephone 0161 912 1915

SK1 3AG
www.trafford.gov.uk

Date: 17" November 2015

Dear Mr Pollard

Moss Lane, Altrincham
Ref: Regulation 28 Report to Prevent Future Deaths following the inquest of Karen

Clayton (Deceased)

| refer to your letter dated 23 September 2015 regarding the above matter and would
comment as follows in relation to items 1 to 4 of your concerns. | apologise for the delay to

this response.

The current layout of the section of Moss Lane between Manor Road and Stamford New
Road was designed in accordance with the Department of Transport guidance, namely
‘Traffic Advisory Leaflet 6/98 September 1998’ for Contraflow cycling and was constructed in
November 2002. Physical segregation of cyclists and vehicular traffic was provided at the
entry and exit from the one way street because there was sufficient room to do so and the
route is lined and signed in accordance with this document. This layout also corresponds
with Transport for Greater Manchester's current 'Greater Manchester Cycling Design
Guidance’ document. The Council does not concur that there is insufficient room for the
three forms of traffic to be effectively segregated on this road.

Following its introduction no recorded injury accidents had taken place on this link until the
accident in question and there haven't been any recorded accidents to date since. It is the
Councils opinion that the current layout is not confusing and pedestrians who walk along the
mandatory cycle lane do so knowingly to shorten their journey...

There are controlled crossings on Moss Lane at the traffic signals junctions at either end of
its one way section and the Council does not consider that pedestrians travelling between
the railway station and the Tesco Supermarket have to cross the road twice to reach their

destination.
The Council takes Road Safety seriously and whilst this is an extremely unfortunate incident

and Trafford Council regrets the tragic road traffic accident that led to the fatal injuries
sustained by Mrs Clayton the Council does not consider that there are any improvements

required in this instance for the reasons stated above.

| hope that the information above provides an assurance that the findings of your report have
been considered but if you have any specific enquires please do not hesitate to contact me.

Yours sincerely

Waern mes

Helen Jones
Deputy Chief Executive

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