Prevention of Future Deaths reports · 2017

Thomas Unsworth

Regulation 28 report to prevent future deaths, reference 2017-0039, written 1 Mar 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report1 Mar 2017
Reference2017-0039
DeceasedThomas Unsworth
CoronerJennifer Leeming
Coroner areaManchester (West)
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 (1)

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

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

1. BE > incipar Engineer, Network Planning, Safety and Management,
Highways and Engineering Division, Department of Place, 3 Floor,
Paderborn House, Bolton BL1 1UA

2
[7 | CORONER |

IT am M Jennifer Leeming, HM Senior Coroner for the Coroner Area of
Manchester West.

2 | CORONER'S LEGAL POWERS

I 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.

L
3 a AND INQUEST

On the 19" of February 2016 I commenced an investigation into the death of
Thomas Moore Unsworth, aged 80 years. The investigation concluded at the
end of the inquest on the 9" February 2017. The conclusion of the inquest
was:-

e Thomas Moore Unsworth died as a consequence of a Road Traffic Accident.
* The medical cause of Thomas Moore Unsworth’s death was recorded as:-

_ la_Head Injury 4
CIRCUMSTANCES OF THE DEATH

On the 28" of January 2016 Thomas Moore Unsworth was a pedestrian crossing

Great Moor Street in Bolton when he was hit by a bus turning left into Great

Moor Street from Bradshawgate, Bolton.

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. During the Inquest evidence was heard that:-
The driver of the bus that came into collision with Mr Unsworth gave

evidence that the nature of the junction into which she was turning together
with the position into which pedestrians are guided to cross the road meant

that her view of such pedestrians was limited and in certain situations there |

was a “blind spot” in which she was unable to see pedestrians at all.

Police Officers likewise gave evidence that as vehicles were manoeuvring
round this junction their driver's views of pedestrians were limited by the
building line and then restricted by street furniture.

The area in question is presently under reconstruction giving an opportunity
for these issues to be reviewed and addressed.

' 6 SIerron SHOULD BE TAKEN

In my opinion urgent action should be taken to prevent future deaths and I
believe that you 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 Wednesday 26" April 2017. 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 ~]

T have sent a copy of my report to the Chief Coroner and to the following
Interested Persons:-

1. GMP Serious Collision Investigation Unit, Eccles Police Station
2. First Manchester Group, Wallshaw Street, Oldham OL1 3TR
3. C/o First Manchester Group

Tam 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.

i

Dated Signed [Cpr Pobr~g .
|__| 1* March, 2017 M Jennifer Leeming, HM Senior C er

NR

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 Bolton Council (PDF)
Date: 
Your Ref:
Our Ref: 

8 th May  2017

HE/NPSM/JF/107112

Prof J Leeming
Senior Coroner
Manchester West
HM Coroner's Court
Paderborn House
Bolton
BL1 1QY

R E C - t V E C

1 5 MAY 20V

Bolton
Council

Department of Place
Highways & Engineering
Division
Network Planning and Safety
Management
3lh Floor, Paderborn House
Bolton  BL1 1UA
Tel:
Mlnicom:

www.bolton.gov.uk

Dear Professor Leeming,

Regulation 28 Report*- Mr Thomas Moore Unsworth Deceased

I am in receipt of  your Regulation 28 Report  to Prevent Future Deaths Dated 1st
March 2017. As  the Principal Engineer for Traffic Management I am responding
to your report on behalf of the Chief Executive of Bolton Council.

I understand that the matters of concern, as set out in your report, are:

"1. During the inquest evidence was heard that:-

The driver  of  the  bus  that  came  into collision  with  Mr  Unsworth gave  evidence
that  the  nature  of  the  junction  into  which  she  was  turning  together  with  the
position  into  which  she  was  turning  together  with  the  position  into  which
pedestrians are guided to cross the road meant that her view of  such pedestrians
was  limited  and  in  certain  situations  there  was  a  blind  spot  in  which  she  was
unable to see pedestrians at all.

Police  officers  likewise  gave  evidence  that  as  the  vehicles  were  manoeuvring
round this  junction  their  drivers view of  pedestrians were  limited by  the building
line and then restricted by street furniture.

The  area  in  question  is  presently  under  reconstruction  giving  opportunity  for
these issues to be reviewed and addressed".

 To consider and address your concerns, a meeting was convened on 24lh March
2017  with  relevant  local  authority officers  and  Greater  Manchester  Police  Area
Traffic Manager from the Serious Collision Investigation Unit, at which a review of
the  CCTV  footage  from  the  time  of  the  collision  was  undertaken,  all  witness
statements  obtained for  the purpose of  the  Inquest  were  considered and  a  site
visit was undertaken.

The  information  shared  at  the  meeting  highlighted  that  there  are  primarily  two
areas of  concern (i) visibility when it is dark (ii)  visibility whilst large vehicles are
turning and the impact of ‘blind spots’.

To  address  these  concerns,  the  local  authority  has  considered  the  following
issues:

1.  Street Lighting

Bolton  Council’s  Principal  Street  Lighting  Engineer  has  undertaken  an
assessment of the street lighting and his comments are as follows:

“Attached is an A4 Plan showing the Street Lighting positions at lighting levels in
Lux.

I can confirm that  the lighting Brackets  Ref  1 and  2 on Great  Moor  Street  were
installed in 1979. The lighting units are at a height of 8m  and house a 250 Watt
High Pressure Sodium light source to which the colour rendering is around 2150
Kelvin.  The  same  applies  to 
the  lighting  Brackets  Ref  20  and  21  on
Bradshawgate were the lanterns were installed in 2008.

After speaking to both our street lighting maintenance team and Streetcare, I can
confirm that at the time of the collision (January 28*' 2016) that all  the lighting at
the  junction  of  Great  Moor  Street  and  Bradshawgate  was  operational  and  in
working order.

The lighting installation was designed in 1979 to the BS5489 to which the lighting
level  designs for  City  and Town  Centre  Part  9/1/1  Primary  Vehicular  as  shown
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The  attached  is  an  A4  Plan  showing  the  Street  Lighting  levels  in  lux,  the
Luminance  level  for  this  type  of road  will be  around 1.5  Cd/m  equates  to  1.5  *
10.76 = 16.40 lux  to which  the lighting levels today are far greater, this is due to
the  fact  that  the original  SOX  (Yellow) light  source has  been  replaced  by  SON
(White) light source.

In relation to your request of making the junction safer to prevent future deaths, I
can confirm  that  that  there  was  an  improvement  scheme  under  278  works  to
improve Great Moor Street (Sept 2016), to which street lighting is associated to.

I  can  confirm  that  the  existing lanterns within the  vicinity of  the  accident will  be
replaced with LED lighting units (Holophane 114’s) to which the lighting levels will
be the same but the difference will be the colour rendering being 4000K and the
light  source  being  Natural  White  which provide  an increase of  40%  visibility  of
both pedestrian and vehicle movement.

2.  Review of Accident Data

Bolton  Council  has  reviewed  the  injury  accident  data  for  the  junction  and  can
confirm that there have been 6 injury accidents during the past 5 years which has
resulted  in  6  casualties.  The  causation  factors  attributed  to  the  collisions  are
different across each incident, with no common theme being evident. None of the
other 5 collisions occurred at the same location on the junction or under the same
circumstances.

 3.  Vehicle Blind Spots and Re-construction works

I  can  confirm  that  there  are  reconstruction  works  currently  on-going  on  Great
Moor Street as part of the Interchange public realm works. However, these works
do  not  include  the  crossing  area  at  the  junction  of  Great  Moor  Street  and
Bradshawgate. On this basis there is no scope to extend the works further to the
site investigation.

There  is  little  street  furniture at  the  junction  which  could  be  re-located.  In  the
Regulation 28 report the bus driver refers to a “blind spot” and the Police Officer
statement refers to  the driver’s  view of  pedestrians being limited by the  building
line and then restricted by street furniture. It is evident from our site visit that the
visibility  from  the  driver’s  position  towards  pedestrians  waiting  to  cross  Great
Moor Street from south to north is obstructed by  the building line. The statement
does  not  specify  which item  of  street  furniture restricts  the  view  and  it  was  not
evident from the site visit. It is possible that the CCTV cabinet causes an element
of  limited  visibility given  the orientation  of  the driver’s position in  relation  to  the
pedestrian  waiting  to  cross.  From  our  observations  it  would  appear  that  the
restricted visibility is for a short duration and is prior to the  vehicle beginning the
turn into the junction.

Consideration  has  been  given  as  to  whether  any  risks  would  be  reduced  by
alterations or relocation of the pedestrian crossing. Following investigation, I can
confirm that the position of  the  crossing In relation  to the junction is  determined
by  position  of  the  stop  line,  which  in  turn  is  determined  by  the  swept  path  of
vehicles  turning  into  the  junction.  The  distance  between  the  stop  line  and  the
crossing must be between 2.0 -  3.0m and in this case the crossing could be re-
located  by  approximately  1.0m  towards  Bradshawgate.  However,  this  would
have  no  benefit in  terms  of  visibility  between motorists  and  pedestrians  as  the
building  line  would  still  obstruct  the  line  of  sight.  It  would  not  be  beneficial  to
relocate  the  crossing further  away  from  the junction with  Bradshawgate  due  to
the  close  proximity  of  Back  Bradshawgate  and  the  likelihood  that  pedestrians
would  walk  around  the  pedestrian  guardrail  as  this  would  not  be  on  the
pedestrian desire line.

Following  investigation, I  can confirm that  the  pedestrian  stage  of  the  crossing
cycle is indicated to pedestrians by  a  far  side indicator.  The  local authority will
request that Transport for Greater Manchester undertake a review, with a request
to replace the far side indicator with a near side indicator. This has the advantage
that  pedestrians  waiting  to  cross  will  look  towards  the  oncoming  traffic  when
seeking confirmation from the indicator to cross.

I can advise that the traffic using this junction will change once the public realm
works  are  completed  and  the  Transport  Interchange  opens  later  this  year.
General  traffic  will  be  able  to  enter  the  junction  of  Great  Moor  Street  from
Bradshawgate and  travel in  a  westbound  direction,  with  buses/taxis/cycles only

 being able to travel in an eastbound direction. This forms part of  the town centre
transport strategy in  which there will be a bus gyratory system in place where-by
buses  will  generally  travel  in  an  anti-clockwise  direction and  general  traffic  will
travel in a clockwise direction. As a result there will be fewer buses undertaking
the left turn manoeuvre from Bradshawgate onto Great Moor Street.

In summary:

(a) There  is  no  scope  to  amend  the  highway  layout  at  the  junction  of

Bradshawgate and Great Moor Street.

(b) The  lighting  levels  will  increase  as  part  of  the  ongoing  public  realm

works.

(c) There  will  be  fewer  bus  turning movements  at  this  junction  once  the

Interchange is operational later this year.

(d) A  request  will  be  made  to  TfGM  to  review  the  pedestrian  stage
indicators with a view to changing from far side to nearside indicators.

If you require any further information please do not hesitate to contact me.

Yours sincerely

Principal Engineer
Network, Planning and Safety Management
Highways and Engineering Division
Department of Place
3rd Floor
Paderborn House
Bolton
Lancs
BL1 1UA

Office Tel:
Office e-mail:

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