Prevention of Future Deaths reports · 2017
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 report | 20 Jul 2017 |
|---|---|
| Reference | 2017-0216 |
| Deceased | Nina Maggs |
| Coroner | David Ridley |
| Coroner area | Wiltshire and Swindon |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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
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.
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
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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