Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0099, written 31 Mar 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 31 Mar 2017 |
|---|---|
| Reference | 2017-0099 |
| Deceased | Malcolm Langford |
| Coroner | Peter Bedford |
| Coroner area | Berkshire |
| 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.
oo Classification: OFFICIAL-SENSTTIVE
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (4)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
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| | THIS REPORT IS BEING SENT TO:
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| | Strategic Transport Manager
| | Reading Borough Council
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-1. | CORONER
‘la m Emma Jones, Assistant Coroner for Berkshire.
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CORONER’S LEGAL POWERS
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I make this report under the Coroners and Justice Act 2009, paragraph 7,
| Schedule 5, and The Coroners (Investigations) Regulations 2013, regulations 28
| and 29.
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3. | INVESTIGATION and INQUEST
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'On the 25" May 2016, the Senior Coroner, Peter Bedford, commenced an
Investigation into the death of Malcolm Langford. | concluded the investigation
by way of a one day inquest on the ond day of March 2017.
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I concluded that death was due to road traffic collision.
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CIRCUMSTANCES OF THE DEATH
| | On the 14 day of May 2016, at approximately 10:30am, Mr Langford was
walking along Albert Road, Caversham, Berkshire, with his wile.
I Albert Road is a residential road with two lanes, one in either direction, and is
subject to a statutory speed limit of 30mph.
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There are a number of roads leading off Albert Road, one of which is Highmoor
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The junction of Highmoor Road with Albert Road is marked by a stop sign, solid
i white lines and a section of red tarmac. The junction has restricted visibility due
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Classification: OFFICLAL-SENSIPIVE
Jassincation: ©
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r to houses on either side, fences and trees.
| Vehicle 1 was driving along Albert Road, in the direction of Mr Langford.
| | Vehicle 1 was driving within the speed limit.
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| Vehicle 2 approached the junction with Albert Road from Highmoor Road.
| | Vehicle 2 started to pull out of the junction and collided with vehicle 1, causing it
/ | to veer off course. |
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Vehicle 1 crossed the opposite carriageway. mounted the pavement and collided |
| with Mr Langford. knocking him into the road. He sustained a non-survivable |
_ head injury and died the same day. |
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5. CGRONER’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 could occur unless action
is taken. In the circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows: —
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| During the inquest, the court heard evidence — Cti‘C‘s*” Forensic
| Collision Investigator for Thames Valley Police. He attended the scene shortly
| after the collision and examined the junction. His evidence was that visibility at
_ the junction is restricted, particularly when looking to the right, due to a house
with a large fence and trees. The following four important points were elicited
| during the inquest:
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(1) a vehicle stopped at the stop line on Highmoor Road is first able to see the
front offside corner of a vehicle travelling north along Albert Road at a
distance of about 35 metres;
(2) a vehicle stopped at the stop line on Highmoor Road is first able to see the
full width of the front of a vehicle travelling north along Albert Road ata
distance of about 24 metres;
i (3) if'a vehicle is travelling at 30mph along Albert Road, it will take only 2.6
/ seconds from being completely out of view of drivers on Highmoor Road
| to reaching the junction. It will take only 1.8 seconds from the time that
the front of the vehicle is visible until it reaches the junction;
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(4) given a typical rate of acceleration, it is not possible for a ‘normal’ driver
| in a ‘normal’ car to pull safely out of Highmoor Road junction even when
i Albert Road appears to be clear. The only way to negotiate the junction
safely is to edge forward, maintaining a constant look-out. |
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Classification: OF FICIAL-SENSITIVE
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/ | likelihood of further collisions.
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6 | ACTION SHOULD BE TAKEN
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| 7. YOUR RESPONSE
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You are under a duty to respond to this report within 56 days of the date of this
| report, namely by 12'" June 2017. |, the coroner, may extend the period. |
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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. |
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| 8. | COPIES and PUBLICATION :
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I have sent a copy of my report to the following:
® ee of Malcolm Langford
I am also under a duty to send the Chief Ceroner a copy of your |
response.
e the Chief Coroner of England & Wales
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| 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 fo me, |
ithe Senior Coroner, at wef the your response, about the release or the
publication of your response/by the Chief Coroner. |
la a |
fo reh 2017
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| 9. | Dated this 31" day of
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Peter J. Bedford |
Senior Coroner for Berkshire
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\ _? Classification: GFFICIAL-SENSHITIVE
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.
Readinci W ScJ'n"y Working better with you r L Peter J Bedford Senior Coroner for Berkshire Reading Borough Council Reading Town Hall Blagrave Street Reading RG1 1QH Director of Environment and Neighbourhood Services n Civic Centre Reading RG1 2LU Our Ref: Your Ref: Direct: ... J Date 9th June 2017 Your contact is: Network and Parking Manager Dear Peter Bedford Thank you for your email of 3rd April 2017 and your issue of a Regulation 28 report to prevent future deaths in relation to the death of Mr Malcolm Langford on 14tn May 2016. There have been a number of changes at this junction with the aim to improve road safety over a number of years. These changes have been implemented both before and after the fatality of Mr Langford and there remains an ongoing commitment to keep this junction under review. Local concern was first raised following an accident on 14th November 2013 and a petition (for road safety improvements) was submitted to the Council’s Traffic Management Sub-committee on 16th January 2014. Since that time there have been a series of reports to the Traffic Management Sub-committee exploring the cause of accidents, possible options for improvements and recommending changes to be considered. On 11th September 2014 the Sub-committee considered restricting the eastbound Highmoor Road general traffic movement across the junction to reduce the risk of collisions. As a result of significant local objection supported by the local MP this proposal was deferred with a further review of the options. On 15th January 2015 the Sub-committee considered this review of options but in the meantime a large tree overhanging the junction had been removed. The result of the removal of the tree was such that the junction became much more visible (as opposed to always being cast in shadow). The Sub-committee again deferred any other changes at the junction in consideration of further local representation. The next report to the Sub-committee was on 15th June 2016 and after the death of Mr Langford. As a. result of this report the Sub-committee agreed to changes in road markings on the Highmoor Road eastbound approach and to meet with two local campaign groups, Highmoor and Albert Road Campaign (HARC) and Caversham and District Residents Association (CADRA). Further reports have followed and further lining changes have been carried out at the junction. www.reading.gov.uk DX 40124 Reading (Castle Street.) Classification: OFFICIAL-SENSITIVE The latest report on works carried out and further commitments to improving road safety at this is being presented to the next meeting of the Sub-committee on 14tn June 2017. This details woi debate on improving road safety at the junction of Highmoor Road with Albert Road since 2013. AU of these reports are publically available on-line (within the Council’s website) but can be made available to you if you so wish. However, it is important to express that the junction is presented with STOP signs on both Highmoor Road approaches coupled with contrasting coloured road surfaces and associated signing. Prior to the accident on 14th November 2013 the junction had no significant casualty record that justified road safety improvements. The position of the STOP line and central hatching on Albert Road through the junction was in response to a previous casualty reduction scheme involving right turning vehicles. During the period from 14th November 2013 (as detailed within the Traffic Management Sub-committee cepactoLthere has been gathering of evidence as to what the collision risk is at the junction. The evidence of drivers failing to stop at the stop line on the eastbound Highmoor Road approach is overwhelming hence the original recommendation to restrict vehicle movements on this approach. Whilst the views expressed by Police are appreciated they do not reflect the evidence provided by the police to Reading Borough Council and that collected (by us) through CCTV video surveys. , Forensic Collision Investigator for Thames Valley As you may be aware, the local highway authority is often asked to attend a site meeting following a road death to establish any highway related issues that may need to be considered. In response to the death of Mr Langford a site meeting was held between representatives of the council and Thames Valley Police. At this site meeting it was clearly indicated that the death of Mr Langford was as a result of the driver failing to stop at the eastbound Highmoor Road approach. This, as already indicated, is consistent with other collisions at the junction resulting in casualties and the CCTV gathered evidence. On this point the two local campaign groups (HARC & CADRA) also agree although they continue to campaign for additional traffic calming measures. The visibility restrictions at the junction are obvious hence the reason for the regulatory STOP requirement and the other associated measures. It is the professional view of officers that once a driver has stopped, by slowly edging forward to gain improved visibility, it is irrelevant as to where the STOP line is positioned. This point is made by the Forensic Collision Investigator in 5(4) of the regulation 28 report. Therefore, regardless of the exact position of the STOP line drivers will still have to ‘nudge out’ slowly to gain sufficient visibility before crossing the junction. As it is believed by us that Mr Langford died as a result of a failure to stop there appears to be conflicting evidence. For us, as the local highway authority, to properly ensure that we meet our duty as highway authority I request absolute clarity on the circumstances of this collision. If you require further information, evidence and/or copies of the Traffic Management Subcommittee reports please do not hesitate to contact me either by email or telephone. Yours sincerely Network and Parking Manager www.reading.gov.uk DX 40124 Reading (Castle Street) C l a s s i f i c a t i o n : OFFICIAL-SENSITIVE
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