Prevention of Future Deaths reports · 2017

Frederick Dudley

Regulation 28 report to prevent future deaths, reference 2017-0272, written 16 Aug 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report16 Aug 2017
Reference2017-0272
DeceasedFrederick Dudley
CoronerMargaret Jones
Coroner areaStaffordshire (South)
CategoryRoad (Highways Safety) related deaths
Sourcejudiciary.uk record · original PDF
Responses publishednone published

The report

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.

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:

1. Highways Agency:
Mr J O’Sullivan CEO
Highways England
Bridge House
1 Walnut Tree Close
Guildford GU1 4LZ

CORONER

| am Margaret Joy Jones Senior Assistant Coroner for the coroner area of
Staffordshire South

CORONER’S LEGAL POWERS

| 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.

INVESTIGATION and INQUEST

On 26.11.2016 | commenced an investigation into the death of Frederick George
DUDLEY The investigation concluded at the end of the inquest on 15.8.2017 The
conclusion of the inquest was:

The deceased was an elderly pedestrian crossing a dual carriageway at an
uncontrolled pedestrian crossing point when he was struck by a vehicle which
failed to stop at the scene.

CIRCUMSTANCES OF THE DEATH

The deceased was 90 years of age. He mobilised well but was slow when
walking and needed to turn his upper body when looking left or right due to
neuralgia. . On the 25" November 2016 he had been to visit family and was
returning home on the bus. At about 17.15 hours he alighted from the bus at
the bus stop near to the Miller and Carter Public House on the A449
Stourbridge Road, Penn. He had with him a shopping trolley which he used as
a walking aid and a walking stick . He had started to cross over the two lane
dual carriageway at an uncontrolled pedestrian crossing point. He was
probably at a point in the centre of the two lane carriageway when he when he
was struck by a Volkswagen Scirocco motor vehicle registered number PJ59
WFO which was travelling along the A449 in the offside lane approaching
from his right and from the general direction of Wolverhampton. This vehicle
was overtaking other vehicles which were travelling in the nearside lane
which may have obstructed the drivers view of the deceased. The driver of
the vehicle failed to stop at the scene. There is a pedestrian crossing warning

sign at the approach to the crossing. The speed limit at the scene of the
collision is 60 mph the estimated speed of the vehicle involved was 75-85
mph. It was dark but the road was well illuminated. The deceased was wearing
non reflective clothing. The weather was dry.

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)The deceased had alighted from a bus and was crossing the very busy
A449 dual carriageway at an uncontrolled pedestrian crossing point. The
crossing is :

1. Ona bend
2. Obscured by a brick wall in the centre of the carriageway.
3. The speed limit changes from 40 mph to 60 mph 260m prior to the crossing.
4. Uncontrolled.
5. Adjacent or very near to a public house, an elderly care home, a housing
estate,

a bus layby and a road junction.

In this case the view of the pedestrian was obscured by vehicles travelling in
the nearside lane. The deceased was elderly, another young female passenger
had also alighted from the bus and crossed the road at the same point. She
needed to hurry to avoid the approaching vehicles. The inquest was given to
understand from police that there had been other incidents ( not necessarily
fatal) at this location.

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe you and
your organisation have the power to take such action.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this
report, namely by 11" October 2017. |, 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.

COPIES and PUBLICATION

| have sent a copy of my report to the Chief Coroner and to the following Interested
Persons:
1. Chief Executive Wolverhampton Borough Council:

Mr K Ireland —Chief Executive

Civic Centre

Ring Road

St Peters Square

Wolverhampton WV1 1SH

2. Jesse Norman MP
Penn House
9-10 Broad Street
Hereford HR4 9AP

3. Staffordshire Police Officers | and | |

4. Family of deceased

| 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 coroner, at the time
of your response, about the release or the publication of your response by the Chief
Coroner.

Date: 16" August 2017

Margaret J Jones
Senior Assistant Coroner
Staffordshire (South)

Coroner's Office

No 1 Staffordshire Place
Stafford

ST16 2LP

Tel No: 01785 276127
Fax No: 01785 276128

www.staffordshire.gov.uk
sscor@staffordshire.gov.uk

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