Yogalakshmi Sinnaiah

ANNEX A

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS

NOTE: This form is to be used after an inquest.

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:

Highways Department
Hampshire County Council
The Castle

Winchester SO23 8UJ

4 | CORONER

lam David Clark Horsley, senior Coroner for the Coroner area of Portsmouth and South
East Hampshire.

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 1“ February 2016 | commenced an investigation into the death of Yogalakshmi
Sinnaiah, aged 58. The investigation concluded at the end of the inquest on 7* July
2016. The conclusion of the inquest was:

1. Medical Cause of Death: Multiple injuries.

2. Circumstances of Death: At about 13.55 hours on 26" January 2016,
Yogalakshmi Sinnaiah was struck by a lorry whilst crossing Dragon Street in
Petersfield. She sustained injuries that were instantly fatal.

3. Coroner's Conclusion as to Death: Death due to an Accident.

4 | CIRCUMSTANCES OF THE DEATH

See 3 above.

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. Ms Sinnaiah crossed Dragon Street using the pelican crossing and | was told in

evidence that she started to cross the road from the "wrong side” of the traffic
light at the crossing, “cutting the corner".

2. | was also told in evidence that using the crossing in this manner is a common

occurrence and that there have been a number of near misses of pedestrians in
consequence.

3. It occurs to me that provision of railings at this crossing either side of the actual
crossing would prevent this happening and would thereby reduce the potential
for future incidents of the type involving Ms Sinnaiah.

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe your
organisation 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 1g" September 2016. 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.

COPIES and PUBLICATION

| have sent a copy of my report to the Chief Coroner and to the following Interested
Persons:
- Representatives of the deceased's family,

- Hampshire Constabulary, Collision Investigation Unit and Road Policing Unit.
| 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.

25™ July 2016

Enquiries to

Direct line

Date

ey Hampshire

Hampshire

Services

Hampshire Legal Services
Hampshire County Council

David C Horsley LLB, Solicitor The Castle, Winchester

H M Coroner Hampshire, SO23 8UJ
The Coroner's Court Telephone 0300 555 1375
1 Guildhall Square Fax 01962 840215
Portsmouth Minicom 0300 555 2510
PO1 2GJ DX Winchester 2510

www.hants.gov.uk

P| My reference fF

Dear Mr Horsley
Inquest into the death of Sinnaiah YOGALAKSHMI

| am writing in response to your Regulation 28 Report and the concerns within,
namely that:

e Ms Sinnaiah crossed Dragon Street using the pelican crossing from the ‘wrong
side’ of the traffic light ‘cutting the corner’

e Using the crossing in this manner is a common occurrence and there have been
a number of near misses

e Provision of railings either side of the crossing would prevent this happening and
thereby reduce the potential for future incidents of this type.

On the 7" of September Hampshire County Council's Casualty Reduction
Partnership (CRP) held a meeting at the site of the collision to consider your
concerns. The CRP is a Programme run by the County Council's Safety Engineering
Team which consists of officers from the County Council who specialise in various
fields, the relevant Borough/District/Town Council and Hampshire Constabulary. As
part of the partnership we consider the circumstances of each fatal and potentially
fatal accident site and, in this instance, issues raised within the Regulation 28
Report.

Attendees at the site visit included the Highway Manager for Traffic Systems and
Street Lighting, a Principal Engineer from Highways Maintenance, a Principal
Engineer from HCC Traffic Management, an East Hants District Council Traffic
Management Engineer, the Team Leader from HCC Safety Engineering, the
Hampshire Constabulary Traffic Management Officer and the Senior Investigating

Officer from Hampshire Constabulary’s Serious Collision Investigation Unit.
Barbara Beardwell MA Solicitor
Head of Law and Govermance and Monitoring Officer

| John Coughlan CBE
Cou nty Co uncil Lex Cel Chiet Executive

Whilst on site we examined our entire database of personal injury accident history at
the crossing and found no recorded personal injury accidents involving pedestrians
between January 1990 and 30" November 2015. Our Traffic Management, Highway
Maintenance and East Hants District Council colleagues confirmed no history of
complaints or concerns from members of the public concerning the crossing.

National research data shows that the majority of accidents that occur at pedestrian
crossings do occur on the approaches. Approximately 50% of pedestrians use
crossings correctly where there are no barriers on the approach, compared to 75%
where there are barriers. Therefore the installation of barriers does not guarantee
total compliance with proper crossing procedure. There are strict guidelines for
highway works and measures are designed using the guidance provided by the
Department for Transport such as the Design Manual for Roads and Bridges,
Manual for Streets, the Traffic Signs Regulations and General Directions 2016,
Traffic Signs Manuals or various Transport Notes or Traffic Advisory Leaflets. The
most important advice for this situation would be LTN 2/09 Pedestrian Guard railing.

In recent years National best practice has been to encourage a reduction in the
dominance of motor vehicles in inappropriate places by reducing the amount of
street clutter, barriers and obstructions and placing the emphasis on freedom of
pedestrian movements. The area of Petersfield in question is part of a Shared
Space scheme, there are limited road markings, extensive decorative road surfaces
and it is within close proximity to the 20mph zone. The installation of pedestrian
guard railing could potentially increase the speed of vehicles as the addition of
street furniture reduces the effect of the shared space area. The area surrounding
the crossing has been carefully designed to limit the ability of pedestrians to cut
across, with bike racks and planters in place on the eastern side.

A significant concern for members of CRP was the potential for people to shortcut
around the proposed barriers and whether introducing barriers at this location would
encourage people to cross closer to the Heath Road and High Street junctions
resulting in a potential for increased conflict with vehicle movements. It is also a
fairly common practice for pedestrians trying to avoid the barriered area to stand
between the barrier and the road edge. An additional concern should a barrier be
placed on the approach to the crossing, would be the potential for planters to be
placed on the railings limiting the intervisibility between pedestrians and vehicles on
the approach.

The current pedestrian crossing is a ‘Pelican’ type and, as we are aware you
understand from your investigations, these crossings have a high level ‘flashing
green figure’ for pedestrians on the opposite side of the crossing which initially
operates concurrently with the flashing amber for waiting vehicles. As shown by the
Police evidence within the transcript of the inquest Ms Sinnaiah attempted to cross
on a flashing green figure when she approached the crossing at the same time that
the Mercedes lorry driver had the flashing amber light and no sight of Ms Sinnaiah.
Due to significant reservations about the safety of installing pedestrian guard railing
at this location and the lack of previous personal injury accidents at the location, the
County Council proposes to bring forward the upgrading of the Pelican crossing by 3

years to a new style Puffin crossing instead, removing the potential uncertainty that
comes with a concurrent flashing amber signal and flashing green figure. The Puffin
crossing does not utilize an offside flashing green figure but has the pedestrian
signal located on the nearside pole ensuring pedestrians have to be in the correct
position on the crossing to see their signal. This also ensures the pedestrians are
stood facing towards any oncoming traffic. The crossing will have a minimum ‘all
red’ period of 3 seconds which can be extended by on-crossing pedestrian detectors
providing an additional all-red of up to 8 seconds, a total of up to 11 seconds to
allow pedestrians to clear the crossing after the green figure has been extinguished.
If this is acceptable we estimate works will be complete by the end of the financial
year.

In addition to these works the crown on the trees on the northbound approach to the
crossing will be raised to improve the visibility of the signals, intervisibility between
pedestrians and oncoming vehicles and overall conspicuity of the crossing.

| trust the above is of assistance.

Yours sincerely

S Richardy

Legal Team Leader — Highways Litigation & Insurance
For Head of Law and Governance and Monitoring Officer