Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0204, written 22 Jun 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Jun 2017 |
|---|---|
| Reference | 2017-0204 |
| Deceased | Aston Soulsby |
| Coroner | Zafar Siddique |
| Coroner area | Black Country |
| Category | Child Death (from 2015) · Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. 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: 1. Highways and Planning Department, Sandwell Local Authority. 1 CORONER I am Zafar Siddique, Senior Coroner, for the coroner area of the Black Country. 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. 3 INVESTIGATION and INQUEST On the 16 November 2016, I commenced an investigation into the death of the child, Aston Soulsby. The investigation concluded at the end of the inquest on 26 May 2017. The conclusion of the inquest was a conclusion of: Road Traffic Collision. The cause of death was: 1a Hypoxic Brain Injury b Cardiac Arrest as a consequence of Road Traffic Collision 4 CIRCUMSTANCES OF THE DEATH i) At around 15:50 hours on the 1 November 2016 on Crankhall Lane, Wednesbury, schoolboy Aston Soulsby was involved in a collision with a bus. ii) The road in question is subject to a 30mph speed limit and at the time of the collision there were parked vehicles in the Walsall bound carriageway commencing from the island, and on West Bromwich bound carriageway they commence just after the collision point. iii) Between the two carriageways there is a central hatch marking area. iv) The bus was being driven along Crankhall Lane towards the general direction of West Bromwich and a second vehicle (Vauxhall Corsa) was being driven along the same road towards Walsall. v) Aston was in company with a group of school friends and were making their way home. One of his friends crossed the road but Aston who ran across the road narrowly missed the Vauxhall Corsa car but sadly was struck by the bus. vi) He sustained serious traumatic injuries and despite medical treatment he died on the 7 November 2016 in hospital. vii) The bus was travelling at a speed of 25mph on the approach to the collision 1 [IL1: PROTECT] scene and the bus driver appears to have had insufficient time to react to Aston in the road and avoid the collision. viii) The average speed of the Corsa vehicle was estimated to be around 34mph and was in the hatch markings. This vehicle was fitted with a particularly loud exhaust system and may have distracted Aston giving the perception the vehicle may have been travelling faster. 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. Evidence emerged during the inquest that pedestrians frequently wait in the hatch area whilst crossing the road and vehicles also pass parked vehicles in the road in the hatched area. This may lead to confusion and pose a risk for pedestrians and motorists. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 1. You may wish to consider reviewing the traffic calming measures in place at the collision site on Crankhall Lane and whether anything can be done to minimise risks to pedestrians with appropriate signs/warnings or consideration of pedestrian crossings. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 17 August 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons; Family. 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. 9 22 June 2017 Mr Zafar Siddique Senior Coroner Black Country Area 2 [IL1: PROTECT]
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.
Margaret Collins Black Country Coroners Court Jack Judge Halesowen Street Oldbury West Midlands B69 2AJ My Ref: Your Ref: Please ask for: Telephone No. 0121 569 4052 E-mail: Date: 16th August 2017 Dear Ms Collins Regulation 28 Report – Aston Soulsby Following the fatality on Crankhall Lane, Wednesbury in November 2016 a road safety investigation has been carried out by Sandwell MBC, Highways Department. A 12 hour pedestrian count was undertaken on the 7th February 2017 along Crankhall, Lane between the junction of Hall Green Road and property number 17 Crankhall Lane, split into 3 areas, (plan attached). The results showed a total of 377 pedestrians crossed the carriageway in both directions. During the morning school journey hour of 8-9am, 66 pedestrians crossed the carriageway in both directions, 18 of which were children. During the afternoon school journey hour of 3-4pm, 46 pedestrians crossed the carriageway in both directions, 8 of which were children. When we consider the locations of the schools and the direction of crossing movements for school children the counts indicate that all the 18 children crossed the carriageway in a westbound direction during 8- 9am and all 8 children crossed the carriageway in an eastbound direction between 3-4pm. Upon site visits undertaken by highways at this location the pedestrian movement was observed as very low. In addition there was little evidence to suggest that pedestrians frequently waited in the central hatched area of the carriageway whilst they cross Crankhall Lane. [IL0: UNCLASSIFIED] Regeneration and Planning Sandwell Council House, Freeth Street, Oldbury, West Midlands. B69 3DE www.sandwell.gov.uk 2 Although, due to the lack of controlled crossing points in this vicinity, we do understand that this could be suppressing pedestrian movement. A five year road traffic injury accident analysis shows there has not been any other recorded casualties along Crankhall Lane, from the junction of Hall Green Road to the junction with Eldalade Way during this period. Nonetheless, it is accepted that it is not an ideal location for pedestrians to cross and as such to assist pedestrian movement, Sandwell MBC are considering the possibility of installing a formalised crossing point along this section of Crankhall Lane. It should be noted, however that this will be dependent upon a suitable location being identified with consideration given to desire lines, existing footway crossings, business accesses, parking bays, servicing to shops and usability. In addition it has been noted the existing carriageway markings at this location are now considered to be an outdated layout and consequently these will be altered and road space re-appropriated as necessary. It is hoped all the work will be completed by 31st March 2018. Yours sincerely Engineer [IL0: UNCLASSIFIED] Regeneration and Planning Sandwell Council House, Freeth Street, Oldbury, West Midlands. B69 3DE www.sandwell.gov.uk
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