Prevention of Future Deaths reports · 2017

Nina Maggs

Regulation 28 report to prevent future deaths, reference 2017-0216, written 20 Jul 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report20 Jul 2017
Reference2017-0216
DeceasedNina Maggs
CoronerDavid Ridley
Coroner areaWiltshire and Swindon
CategoryRoad (Highways Safety) related deaths
Sourcejudiciary.uk record · original PDF
Responses published2

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

DAVID RIDLEY 
Senior Coroner for Wiltshire and Swindon 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO:   

. 

Head of Highways & Transport 
Swindon Borough Council 
Euclid Street 
Swindon 
SN1 2JH 

1 

CORONER 

I am DAVID RIDLEY, Senior Coroner for Wiltshire and Swindon                              

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. 
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 

3 

INVESTIGATION and INQUEST 

On the 1 March 2017 I commenced an investigation into the death of Nina MAGGS and an 
Inquest into her death was opened on the 8 March 2017.  On the 19 July 2017 I concluded 
Nina’s Inquest.  I found that the medical cause of death was 1a) Multiple Traumatic Injuries and 
under 1b) Road Traffic Collision.  In box 3 of the Record of Inquest I recorded how, when and 
where Nina came by her death the following:- 

Nina died from multiple traumatic injuries at the scene when she was struck by an Iveco 
road  sweeper  (left  hand  drive)  travelling  slowly  along  Hyde  Road  at  the  junction  with 
Ermin Street, Kingsdown Road and Beechcroft Road in Swindon.  Nina was attempting 
to  cross  the  road  close  to  a  dedicated  pedestrian  crossing  heading  northeast  from 
Beechcroft Road at about 1623 on 23 February 2017. It is more likely than not that Nina 
had not appreciated that the driver was sat on the nearside of the vehicle and due to the 
presence of the A pillar and her height, Nina’s actions went unnoticed by the driver even 
when  Nina  was  in  front  of  the  vehicle  due  to  the  height  of  Nina  relative  to  the 
windscreen.  

Consistent with what I recorded elsewhere on the record of Inquest as a conclusion I recorded – 
Road Traffic Collision 

4 

CIRCUMSTANCES OF THE DEATH 

See box 3 above 

Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP 
Tel 01722 438900    |    Fax 01722 332223 

 
 
 
 
 
 
 
 
 
 
      
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 5 

CORONER’S CONCERNS 

The MATTERS OF CONCERN are as follows.  – 

The  general  safety  of  pedestrians  crossing  this  junction  with  Ermin  Street,  Kingsdown 
Road and Beechcroft Road in Swindon. 

During  the  course  of  the  Inquest  I  was  satisfied  that  the  reason  Nina  was  not  using  the 
designated location pedestrian crossing across Hyde Road  was due to the fact that in crossing 
the road she would not have had a clear view of approaching vehicles up Beechcroft Road which 
could be turning left into Hyde Road.  It concerns me that whilst modifications had been carried 
out to the road to allow pedestrians to cross the road including those for example using disability 
scooters  having  regard  to  the  lowering  of  the  pavements  they  do  so  at  significant  risk  of  harm 
and even death.  Whilst the junction is controlled by traffic lights there is no assistance given to 
pedestrians, such as a “green man”, an active sound indicating that it is safe to cross or vibrating 
module  at  the  side  of  the  road  that  can  be  sensed  by  somebody  with  a  visual  and  hearing 
impairment.    In  fact  I  heard  evidence  during  the  course  of  the  hearing  that  whilst  there  was  a 
period of time when all the lights at the junction were red this lasted a matter of 4 seconds which 
is  totally  insufficient  in  my  view  in  giving  a  pedestrian  and  in  particular  one  that  may  have  a 
physical impairment time to safely cross any of the roads at the junction. 

My  concern  is  so  high  here  that  I  would  ask  you  to  treat  this  as  a  priority  in  considering  what 
action if any is to be taken as I believe this is a regularly used junction by pedestrians and their 
safety is my utmost concern in submitting this Regulation 28 Report. 

. 

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 to address the concern highlighted above. 

7 

YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, namely by                     
14 September 2017.  I, the Senior 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 Mr. 

 (husband) and 

 (driver of sweeper). 

I 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 Assistant Coroner, at the time of your response, about 
the release or the publication of your response by the Chief Coroner. 

9 

Dated  20 July 2017 

Signature_________________________ 
HM Senior Coroner for Wiltshire and Swindon 

Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP 
Tel 01722 438900    |    Fax 01722 332223

Responses

2 responses 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 Department for Transport (PDF)
ae Great Minster House
33 Horseferry Road

Department SWiP 40R

for Transport

Tel: 020 7944 2080
E-Mail:

Web site: www.gov.uk/dft
Mr David Ridley
Senior Coroner Our Ref: ID 202614
Wiltshire & Swindon Coroner's Court
28 Endless Street 26 October 2017
Salisbury
Wiltshire
SP1 1DP

Dear Mr Ridley

Thank you for your letter of 20 July, addressed to Jesse Norman MP, enclosing a
Regulation 28 Report on the investigation into the death of Nina Angela Maggs. The
circumstances of this accident are that Nina Angela Maggs had crossed the road in front of
a left hand drive road sweeper, in such a manner that she would not have been visible to
the lorry driver.

On conclusion of the inquest your concerns are —

1. The vehicle involved in the incident was a left hand drive commercial road sweeper.
She would have been travelling from right to left. A combination of the deceased's
height and being hidden by the vehicle’s offside “A pillar” more likely than not were a
contributory factor in the collision occurring.

2. You were told in evidence that the vehicle signs indicating that the vehicle was left
hand drive were displayed at the rear of the vehicle and that there are no regulations
governing the position of warning signage.

3. Your concern relates to left hand UK registered commercial vehicles. If signage is
not considered appropriate then there is a risk of future deaths occurring in your view.

| am replying as Head of the International Vehicle Standards Division of the Department
for Transport (DfT) as this division has responsibility for road vehicle safety standards.

| apologise for the delay in responding to your letter and Regulation 28 Report to prevent
future deaths dated 20 July 2017. | understand that the date for reply has been changed to
31 October 2017.

We have checked collision statistics for similar incidents of this type involving left hand
drive vehicles and have not identified any cases.

We have consulted colleagues in the department's road safety division and they do not
hold any evidence that signage indicating thé vehicle to be left hand drive displayed on the
front or side of such vehicles, would have any effect in alerting pedestrians of the risks
posed by being a left hand drive vehicle.

Nonetheless, we have consulted the Freight Transport Association, Road Haulage
Association and the Local Government Association for their opinion on whether signage
such as you suggest would be beneficial in preventing future collisions. Although there is
no evidence that such signage would be effective, they recognise that this would be a
relatively inexpensive intervention as there are so few UK registered left hand drive
commercial vehicles. Whilst they would not be supportive of further regulation, they
indicated that they could support advice to operators of these vehicles, to encourage such
signage to be displayed.

| should like to assure you of our best endeavours to taking this matter forward and we will
be considering how this might be done, with the trade associations in the coming months.

Yours sincerely

Head International Vehicle Standards Division
Response from Swindon Borough Council (PDF)
Highways and 
Transport Delivery 
Services 

Civic Offices 
Wat Tyler West 4 
Beckhampton Street 
Swindon SN1 2JG 

Tel:  01793 463000 

Website: www.swindon.gov.uk 

David W.G.Ridley 
H.M. Senior Coroner for Wiltshire and Swindon 
Wiltshire & Swindon Coroner’s Court 
26 Endless Street 
Salisbury 
Wiltshire 
SP1 1DP 

Please ask for: 

 Direct Dial No: 

Email: 

  Date 13th September 2017 

Dear Mr David Ridley 

Regulation 28 report - inquest into the death of Nina Maggs 

I have received your Regulation 28 Report to Prevent Future Deaths, dated 20th July 2017, 
detailing the issues arising from the investigation and inquest into the death of Nina Maggs.  The 
following letter details the Council’s formal response, as Highway Authority, to that report and the 
matters of concern raised by you. 

As part of my response I would like to place on record the Council’s condolences to Ms Maggs’s 
family.  Fatalities across Swindon’s highway network remain relatively rare however the Council do 
recognise the tragic impact that these have on families and communities across Swindon. 

Historical position 

The current accident record at the junction is generally good, despite high levels of traffic using the 
junction.  There are no particular historical issues or trends relating to pedestrian or vulnerable 
users, however it is clear that crossing the junction creates a number of difficulties for pedestrians. 

Pedestrian demand and desire lines exist across all of the arms of the junction.  In recognition of 
this, pedestrian dropped kerbs were previously installed at the traffic signal stop lines to serve the 
needs of pedestrians, using these established desire lines, rather than these being installed as a 
facility to corral or encourage pedestrians to cross at this location. 

The ‘all red’ phase of the signals that exists at present is predominantly a phase that helps to 
prevent vehicular conflict between different arms and to allow right turning traffic to safely clear the 
safely junction, rather than a provision to directly assist pedestrians to cross. 

Council’s actions 

Following the fatal accident an analysis of the current operation of the traffic signals at Kingsdown 
Crossroads was carried out, including an analysis of the current traffic levels. A scheme to  

 
                                                                                        
                                            
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 potentially modify the signals to include a signal phase for pedestrians (with a ‘green man’ and 
audible signal) on all four arms of the junction has been developed. 

Modelling the impact of a pedestrian crossing phase and therefore an “all red” phase for traffic, has 
identified that there will be a considerable increase in peak time delays to vehicles using this 
junction. 

Consideration has been given to the morning peak hour delay to traffic which co-incides with the 
pedestrian morning peak, as school and general commuter peaks tend to occur at similar times in 
the morning. 

In the evening the school travel peak is at a different time to the general travel peak.  Hence 
analysis has considered that a pedestrian phase would be called less frequently as pedestrian 
demand is lower at non-school times. 

Alternative options 

A range of alternative options have been considered for the junction.  These have included a do 
nothing option, zebra crossings, different pedestrian phasing arrangements and the potential to 
significantly widen or expand the junction itself. The junction is however very constrained in relation 
to sight lines and pavement space and each of these options have been ruled out on either benefit 
or deliverability grounds when compared to the current proposed way forward 

Wider considerations 

Pedestrian safety at the junction was raised in the Regulation 28 report as of ‘upmost concern’ and 
this reflects the Highway Authority’s current considerations and statutory requirements.  Historical 
analysis and professional experience requires us to also consider safety across the wider network 
for all users, including pedestrians, on a holistic basis.   

Additional delays will impact on traffic and this has the potential to influence driver behaviour.  This 
may influence drivers to change their route and divert their journeys onto smaller less suitable 
roads in order to avoid these delays, effectively ‘rat-running’ through neighbouring areas; there is 
potential for speeds to increase as a result of driver frustrations caused by long delays either on 
the adjoining network or on roads used as ‘rat-runs’; and there is a potential for an increase in red 
light running at the junction as a result of driver frustration with the length of time taken to progress 
through the signals. 

As such the balance of benefits to be achieved for pedestrians at this location (by introducing a 
pedestrian phase at the signals) needs to be considered against the potential for these changes to 
introduce other risks to pedestrians and all network users at this location and in the surrounding 
areas likely to be impacted by anticipated changes in driver behaviour. 

Current progress 

Initial analysis and design options had been undertaken whilst the Coroner’s inquest and 
investigation was in progress.  Initial design has been carried out in respect of the technology 
elements (the traffic signal equipment) and the civil engineering elements (the ducting, cabling and 
tactile paving). This has included carrying out checks on the presence of service utilities in the 
footway and carriageway.  

This means that much of the preliminary work to understand the deliverability of the proposal has 
been completed, should the current proposal be taken forward for implementation.  It was of 
course felt to be appropriate to await the Coroner’s report, informing some of these considerations, 
before programming any potential next steps. 

 
 
 
 Since receipt of the Regulation 28 notice, further work has included the preparation and sign off of 
a briefing note for the Council’s Cabinet Member for Communities and Place and sign off by myself 
as Head of Highways and Transport. This has recommended and approved a proposal to take the 
proposed scheme forward to further investigation and consultation with stakeholders and the 
public. 

Whilst delegated powers would effectively allow the Highway Authority, under certain 
circumstances, to effectively progress the implementation of highway works without stakeholder 
consultation; the significant impact on traffic delays and safety implications across a wider network, 
combined with the otherwise good safety record for the junction does indicate that the Council 
should seek stakeholder views before progressing further. 

The next stage is therefore for the Council to undertake stakeholder consultation with regard to the 
proposals and the balance between those aspects of safety and impact noted above. 

Proposed actions 

Consultation will commence on 18th September 2017 and will include Ward Councillors, Stratton 
Parish Council, major employers and public institutions (e.g. schools) as well as the wider public 
(via an on-line survey). Comments within the Regulation 28 report will also be considered 
alongside this feedback. 

The proposed timeline is: 

  Commence stakeholder consultation - 18th September 2017 

  End of stakeholder consultation - 9th October 2017 

  Analysis of consultation results and feedback – by end of October 2017. 

The level and content of feedback will provide an indication with regard to the next steps in the 
process after October 2017 and an indication of the decision making mechanisms that could be 
used.  I would anticipate decisions related to future steps to be taken in November 2017. 

I am not able to pre-judge the outcome of any consultation or indeed the next steps that may be 
required, however to reflect the comments within the Regulation 28 report and to ensure that any 
scheme (if supported) could be taken forward expediently, I have provisionally arranged for 
resources to be assigned this financial year (ending March 2018) to progress with the design of the 
scheme, if required.  I have further provisionally arranged for resources to be made available for 
the potential delivery on site of the works, if required, during next financial year (April 2018 - March 
2019). 

Given the requirement to consult and take due regard of wider stakeholder feedback on the 
proposal, I would intend to update yourself as Senior Coroner on the outcome of the consultation 
and associated decisions during November 2017. 

If you do require further information at this stage then please do not hesitate to contact me. 

Yours Sincerely 

Head of Highways and Transport Delivery Services 

Board Director  
Communities and Housing

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