Prevention of Future Deaths reports · 2016

Aleeza Ahmed

Regulation 28 report to prevent future deaths, reference 2016-0089, written 3 Mar 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report3 Mar 2016
Reference2016-0089
DeceasedAleeza Ahmed
CoronerJohn Pollard
Coroner areaManchester South
CategoryRoad (Highways Safety) related deaths · Child Death (from 2015)
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, Stockport Metropolitan
Borough Council.

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

On 3 August 2015 | commenced an investigation into the death of Aleeza Ahmed dob
2™ March 2009. The investigation concluded on the 25" January 2016 and the
conclusion was one of Accidental Death. The medical cause of death was 1a Head

Injury.

4 | CIRCUMSTANCES OF THE DEATH

Aleeza was being carried in the car being driven by her father. She was not
restrained by a child seat or seat belt. The car left the carriageway and she was
thrown from the vehicle and received severe 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. This incident occurred at Crookilley Way, Stockport on the 26"" July 2015.
The vehicle had exited the M60 (clockwise section) at junction 25. As it left
the roundabout on to Crookilley Way, the driver lost control and the
vehicle mounted the offside kerb, crossed the central reservation and
overturned throwing the child from the car as this happened. The kerb
stones to the offside of the carriageway are of a chamfered design and it
would appear that this may have contributed to the vehicle overturning.
Questions were raised as to whether these kerbs should be replaced with
a more traditional 90 degree type.

2. There would appear to be no protective Armco type barrier on the central
reservation at this point. The evidence suggested that had such been
present the trajectory of the vehicle might have been different and less
danger caused to all road users.

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.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report,
namely by 29th April 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 following Interested
Persons namely father of the deceased). | have also sent it to The
Road Policing Unit, Greater Manchester Police and to The Highways Agency
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. jay send a copy of this report to any person who he believes may find it useful
or of/nterést. You may make representations to me, the coroner, at the time of your
respons¢, about 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 Stockport Borough Council (PDF)
STOCKPORT = sfeanmh
i ‘ Stopford House, Piccadilly, Stockport

METROPOLITAN BOROUGH COUNCIL SK1 3XE

HM Senior Coroner ee

Mr J Pollard Phone: nn
The Coroner's Court Ask for: is
Mount Tabor, Mottram Street

Stockport 28 April 2016

SK1 3AG

Dear Mr Pollard
Inquest into the death of Aleeza Ahmed

We acknowledge receipt of your report to prevent future deaths dated 3 March 2016. We note your
observations within the report that during the course of the inquest the evidence revealed matters giving
rise to concern and that in your opinion there is a risk that future deaths will occur unless action is taken.

The matters of concern relate to the type of kerb stones to the offside of the carriageway of Crookilley
Way, Stockport, and the absence of a protective Armco type barrier on the central reservation at this point.
You have recommended that action is taken to prevent future deaths and that you believe Stockport
Metropolitan Borough Council (“SMBC”) have the power to take such action.

SMBC has carefully considered your report and responds as follows.

Background

Crookilley Way AS60 is a’ carriageway that runs from the A6 Portwood roundabout via the Crookilley
roundabout to Ashton Road roundabout in Bredbury. The stretch of road on which this road traffic collision
occurred is a dual carriageway linking the two roundabouts. The speed limit on the carriageway is 50mph.
A survey conducted in September 2013 indicated a total day time flow in excess of 14,300 vehicles on the
south bound side of this carriageway.

SMBC is the highway authority for highways maintainable at public expense within Stockport. The network
consists of 944km of carriageway, 1,501km of pavement and 437km of footpaths, bridleways and byways.
The carriageway consists of a combination of A, B and C class and unclassified roads.

The design, construction and maintenance of roads in England is governed by Standards for Highways (the
Design Manual for Roads and Bridges (“DMRB”). Standards guidance is provided in manuals for each
specific element of designing, constructing and maintaining roads. Each standard has its own specifications

for implementation.

The standards which applied when the Crookilley Way carriageway was constructed would have been those
applicable at the time the road was designed. The design for Crookilley Way was approved in the mid-
1980s and was constructed by Highways England {as it now is) as part of the side roads works for the M63
(Portwood to Denton) extension. The road opened in April 1989.

Kerb stones
Road kerbs serve a number of purposes:

Retaining the carriageway edge to prevent ‘spreading’ and loss of structural integrity
Acting as a barrier or demarcation between road traffic and pedestrians or verges
Providing a physical check to prevent vehicles leaving the carriageway

Forming a channel along which surface water can be drained

A splayed kerb is used on Crookilley Way, which is the type of kerb used on dual carriageways and
motorways and where there are no adjacent footpaths. Whilst one of the purposes of a kerb is to provide a
physical check to prevent vehicles leading the carriageway, the design of the splayed kerb used on such a
carriageway has an angled face which presents an inclination. This is designed to allow a vehicle to mount
the verge in an emergency and keep the carriageway clear, which is of critical importance on a dual

carriageway or motorway.

A 90 degree square kerb or half battered kerb more commonly used on roads with a lower speed limit
could prevent vehicles clearing the carriageway and cause them to remain in the carriageway, potentially
creating a hazard. This is not appropriate for a dual carriageway such as Crookilley Way. A high
containment kerb is designed to prevent traffic leaving the carriageway at potentially vulnerable or
sensitive areas to protect those areas from vehicle incursion. However, these can create an additional risk
of injury to vehicle occupants and other vehicles by blocking the carriageway so are not suitable for use on

dual carriageways or motorways.

The relevant guidance which applies to kerbs on carriageways is TA57/87.

Central barrier

Current design standards are contained within the Standards for Highways Design Manual for Roads and
Bridges, Volume 2: Highway Structures: Design (Substructures and Special Structures) Materials, Section 2:
Special Structures, Part 8 TD19/06 Criteria and Guidance for the Provision of Permanent Safety Barriers.
This specifies that a safety barrier must be provided on dual carriageway roads where the width of the
central reserve measured between opposing edges of carriageway road markings is 10 metres or less.

It is not known why it was deemed that there was no requirement for a protective safety barrier to be
erected on the central reservation at the time of the design of Crookilley Way.

The current design standard need only be implemented on trunk roads with speeds of 50mph or more
where that road is new or where the highway cross section is being altered permanently. Consideration of
the standard must only be given when upgrading the existing road restraint system or installing a new
system where an existing one does not exist when other works (excluding routine maintenance) are being
carried out near a hazard that is currently without provision for which the road restraint risk assessment

process indicates provision is required.

Following the establishment of Transport for Greater Manchester (“TFGM”) from the former Greater
Manchester Passenger Transport Executive (“GMPTE”) in April 2011 the remit of the new organisation was
expanded to include, among other things, joint highway responsibility with the local authorities over a
network of strategic roads known as the key route network (“KRN”). Parts of the A560 within Stockport are
identified as being part of the KRN, including Crookilley Way.

It is the responsibility of TfGM to identify and initiate potential improvements to the KRN. As part of this
responsibility TfGM asked the local highway authorities, including SMBC, to identify possible improvements
on the KRN that the authorities might consider beneficial in the next five years. This request was made in
December 2015 and SMBC responded by supplying a list of possible improvements sent to TfGM on 24
December 2015.

Among the schemes proposed for consideration was inclusion of a possible central barrier on Crookilley
Way. No details of the form of the barrier were known or detailed on the list. This was proposed on the
basis that at the time of the review there was no such barrier in place on Crookitley Way and installing such
a barrier would potentially avoid cross over type collisions and bring the road up to modern standards.

As Crookilley Way is part of the KRN any installation or amendments to the carriageway would need the
support of TfTGM. No response has been received from TIGM to the submitted list of potential
improvements to the KRN and no funding has been received from TFGM for this installation. It is estimated
that the cost of such a barrier would be in excess of £50,000. SMBC has extremely limited finding for road
safety improvements and the budget for 2016/2017 is already committed so funding will have to come
from some other source for this installation to be made. There is potential for a bid to be made to the
Greater Manchester Casualty Reduction Partnership (“GMCRP”) and we anticipate making such a bid during

the course of 2016/2017.

SMBC is also planning to undertake a review of the speed limit on this part of Crookilley Way. We
anticipate that the speed limit will be reduced from SOmph to 40mph between Ashton Road and the
southern side of the M60 junction 25 southern roundabout. This will assist with safety on both this road
and on the large roundabout itself and consideration of the installation of a barrier cannot be considered in

isolation.

SMEBC fully appreciate the recommendations of the report and is committed to ensuring the necessary
actions are progressed as a priority. This goal, however, is one which will require the active involvement,
consent and funding from a range of parties including TTGM.

Yours sincerely

\

OA

Corporate Director, Place

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