Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016 – 0299, written 19 Aug 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Aug 2016 |
|---|---|
| Reference | 2016 – 0299 |
| Deceased | Amanda Coppen |
| Coroner | Philip Barlow |
| Coroner area | London Inner (South) |
| 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.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Chief Executive, Royal Borough of Greenwich, John Comber, Town Hall, Wellington Street, Woolwich, London SE18 6PW 2. Managing Director Surface Transport, Transport for London, Floor 11 R4, Palestra, 197 Blackfriars Road, London SE1 8NJ Senior Manager, Lands, Estates and Property, Housing and Land Directorate, Greater London Authority, City Hall, London SE1 2AA 1 | CORONER lam Philip Barlow, 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. [HYPERLINKS] 3 | INVESTIGATION and INQUEST On 8 January 2016 | commenced an investigation into the death of Amanda Coppen, age 44. The investigation concluded at the end of the inquest on 12 August 2016. The conclusion of the inquest was that Ms Coppen died of multiple injuries caused as a result of a road traffic collision. 4 | CIRCUMSTANCES OF THE DEATH At approximately 0704 on 4 January 2016 Ms Coppen suffered fatal injuries when she was struck by a bus as she was crossing Pilot Busway on the south side of the junction with John Harrison Way. 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) The evidence at the inquest was that Ms Coppen was crossing the busway ona signal controlled pedestrian crossing while the signal was red to pedestrians and green to traffic. However, the evidence also suggested that the layout of Pilot Busway and the neighbouring road (West Parkside) is unusual: they run side by side; West Parkside consists of a single carriageway in each direction; Pilot Busway consists of a single dedicated bus lane in each direction. The evidence was that this layout could mislead road users (pedestrians and motorists) into believing that this is a standard dual carriageway. Ordinary traffic has been seen in the dedicated busway, and pedestrians could be misled into looking the wrong way when crossing the road. (2) | understand that a new school is shortly to be built close to this junction. This may i increase the numbers of pedestrians using the junction and there is a potential risk to schoolchildren. (3) | understand that some discussion about the junction may already be underway between London Borough of Greenwich, Transport for London and the Greater London Authority. a | enciose a: of the reports of ED atec 15 February 2016 and dated 13 June 2016 which set out the circumstances in more detail. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you or your organisations 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 17 October 2016. |, 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 family as Interested Persons. | have also sent it to who may find it useful or of interest. 1 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. [DATE] [SIGNED BY CORONER] 7
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 Transport for London Leon Daniels Managing Director 17 October 2016 Surface Transport Mr Phillip Barlow, Her Majesty's Coroner Inner London South’s Coroner’s Court 197 Blackfriars Road a Tennis Street London SE1 8NJ Southwark SE11YD Transport for London 41th Floor, Zone R4 Palestra Dear Mr Barlow, We were all sorry to hear of the tragic accident that occurred on 4 January 2016 and wish to pass our condolences to the family of Amanda Coppen. We have reviewed your Regulation 28 report dated 19 August 2016 regarding the “unusual layout of West Parkside and Pilot Busway”, and the need to improve provision for a new school, close to the junction of John Harrison Way and West Parkside. This is in addition to the existing school in the same area. As the report assigns responsibilities to three parties, named as Greater London Authority (GLA), Transport for London (TfL) and Royal Borough of Greenwich (Greenwich), a joint response is provided. As stated in your report, following the fatality a site visit was held on 14 January 2016 and was attended by representatives of all three organisations and the Metropolitan Police. Since then, a number of actions have been undertaken to improve road safety at the junction and in the vicinity. A zebra crossing was installed on 15 March 2016, south of, but close to, the junction, to provide an additional crossing from the Millennium Village area to the existing primary school, and a safer crossing route between Pilot Busway and West Parkside. The crossing has been installed on a raised surface to improve visibility of pedestrians to drivers and encourage reduced speeds. A 20 mile per hour speed limit has been introduced, with appropriate road markings and signage, along the entire length of Pilot Busway and West Parkside to reduce the overall speed of buses and traffic. Further improvements to signage and road markings have also been made, at the junction of West Parkside and John Harrison Way, to increase pedestrian awareness of oncoming traffic. TfL and Greenwich are also reviewing pedestrian safety provisions, including footway and crossings, which are to be provided as expansion of the school takes place. Pilot Busway has an unusual layout for London, and complex ownership. Pilot Busway and West Parkside were originally built and operated by English Partnerships in preparation for the opening of the Millennium Exhibition, a structure now known as the O2 Arena. The original intention was for significant length of busway to be separated from general traffic. However, this project was not completed. gh Mog, ‘ 8fo7s & MAYOR OF LONDON CAG VAT number 756 2769 90 2OS%y, When English Partnerships were dissolved, their assets in London were transferred to the GLA on the 1 April 2022, under the Localism Act 2011. That transfer included Pilot Busway. West Parkside had previously been adopted by Greenwich on 1 April 2008. TfL and Greenwich have been working on developing a solution to address road safety concerns, arising from the unique nature of the road layout. We recognise that significant development is taking place in the area, including the construction of a new school, and that additional movements associated with those developments will increase concerns about road safety. This work has recognised that, as part of planning consent for an area to the north of Greenwich Peninsular, it is proposed to re-align a northerly section of the Pilot Busway and West Parkside at a future date. Accordingly it is recognised that any proposals to change the arrangements in the vicinity of the junction of West Parkside and John Harrison Way would need to be integral with changes further north. Feasibility work has identified that the conversion of the layout to a ‘traditional’ dual carriageway arrangement with bus lanes, that would operate at all times, would contribute to improved bus journey times and reliability whilst addressing concerns about road safety. It is the practice of both TfL and Greenwich to undertake local public consultation on significant changes to their road networks. Consistent with those practices, a joint public consultation exercise is underway to seek public and stakeholder opinion on the conversion of the existing arrangement to a dual carriageway with bus lane provision. ‘Notwithstanding the need to give consideration to responses to the public consultation, we shall seek to implement the proposed changes to the road layout at the earliest opportunity. We will write to you following the consultation to confirm the design and the proposed timetable to make changes. Yours sincerely, Zz Managing Director, Surface Transport, Transport for London . Chief Executive, Royal Borough of Greenwich Senior Manager, Lands, Estate and Property, Housing and Land Directorate, Greater London Authority
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