Prevention of Future Deaths reports · 2017

Aston Soulsby

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 report22 Jun 2017
Reference2017-0204
DeceasedAston Soulsby
CoronerZafar Siddique
Coroner areaBlack Country
CategoryChild Death (from 2015) · Road (Highways Safety) related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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]

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 Sandwell Metrolitan Borough Council (PDF)
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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