Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0428, written 28 Nov 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 28 Nov 2017 |
|---|---|
| Reference | 2017-0428 |
| Deceased | Sonia Stante |
| Coroner | Jacqueline Devonish |
| Coroner area | Inner North London |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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 (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Transport for London Transport for London 1 | CORONER fam Jacqueline Devonish, assistant coroner, for the coroner area of Inner North London 2 T 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 31 July 2017] | commenced an investigation into the death of Sonia Elvira Stante, aged 69. The investigation concluded at the end of the inquest on 28 November 2017. The conclusion of the inquest was Road Traffic Collision and a cause of death of multi organ failure due to ischaemic bowel (operated) as a direct result of multiple injuries. CIRCUMSTANCES OF THE DEATH On 10 July 2017 Sonia Stante arrived in London for a three day trip as a part of multi country European trip which she had commenced on 30 May 2017. Ms Stante was evidenced on CCTV footage stepping off the pavement just east of the junction along Pentonville Road from Kings Cross Road into the path of a double decker bus without looking in the direction of the bus, but appearing to look across the road, not left, but diagonally. The bus had a green light signal and was travelling in the bus lane at a speed of between 18 and 22mph, in a 30moh zone. Upon seeing Ms Stante step into the road the bus driver applied the brakes reducing his speed to 16-9mph. She made contact with the front nearside of the bus and was thrown back onto the pavement along the kerb. She was transferred to hospital in a conscious state and had been able to tell the London Ambulance Service paramedic that she had checked the road in the wrong direction. She deteriorated and died from her injuries on 21 July 2017 at the Royal London hospital. 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. — Following the incident i! Traffic Management Officer undertook a review of the road traffic layout at the scene. He met with TfL on site on 16 August 2017 anda number of findings were made: (1) No road markings indicating the direction pedestrians should look when crossing (2) Two separate junctions at that location make that crossing confusing for pedestrians (3) The phasing of the green man operates for each carriageway independently so causing confusion for pedestrians who may look at the wrong phasing (4) Missing louvre on the green man on the north side of the crossing making the green man more visible to pedestrians crossing from the south (5) With the location being close to the Eurostar Terminal there are several hotels nearby and foreign visitors may not have a full understanding if the junction. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe 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 4 January 2018. 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the Interested Person. | have also sent it to ho may find it useful or of interest. ! 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. 28 November 2017 (pegretie howons U
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.
Dear Ms Jacqueline Devonish, My colleagues and | were very sorry to hear of the death of Ms Sonia Stante and we pass on our sincere condolences to her family. We acknowledge receipt of your Prevention of Future Deaths report on the 30 November 2017 and respond as follows. Junction design and layout (‘matters of concern’ points 2 and 3) The junction of Pentonville Road and King’s Cross Road operates as a single junction with two separately signalled pedestrian crossings. The crossing of King’s Cross Road is known as a ‘straight across’ crossing and the crossing on Pentonville Road as a ‘staggered’ crossing. This is a common arrangement and used throughout London. At a staggered crossing, a pedestrian must cross the road in two stages as each green figure light aspect will display independently of the other. Each green figure light aspect is sufficiently far apart to discourage pedestrians from looking at the other. This arrangement allows the junction to operate in the most efficient manner overall, reducing the time that pedestrians must wait before they are able to cross the road as well as delays to other road users. J OFFICES & b EISURE ig L | é B\ pancras's KING|: Ot. CROs | | endurys 4 Figure 1: Location of junction within wider area Green figure ‘louvres’ on pedestrian signals (‘matters of concern’ point 4) At the time of the collision, pedestrian signals at both crossings were functioning normally. This included louvres (a slatted cover designed to prevent confusion between the green figure light aspects of the separate crossings) on two of the green figure light aspects at the pedestrian crossings. These louvres were in place at the time of the site visit with the Metropolitan Police on 16 August 2017. We inspected the crossings again on 11 September 2017 to review the layout and consider whether any changes could be made to assist pedestrians further. Subsequent to this visit, additional louvres were fitted on 13 October 2017 to two further green figure light aspects on the Pentonville Road crossing, including on the north side of the crossing (see Figure 2), to reduce the likelihood of pedestrians crossing when they were not invited to do so. Road markings (‘matters of concern’ point 1) The provision of ‘Look left, Look right’ markings is assessed by TfL on a site-by-site basis, in line with the national guidance. Following your report, these have been installed at each of the pedestrian crossings at this junction. Understanding of the junction by foreign visitors (‘matters of concern’ point 5) We take the safety of our highway extremely seriously and adopt an approach of continual improvement to reducing road danger. The measures we have undertaken at this junction will further enhance pedestrian safety at this location. There are hotels and tourists in the area, including those from outside the UK. This type of location, however, is not atypical in London and we design and operate the highway so that it is clear and understandable for all users, regardless of their origins and familiarity of the area. Yours sincerely, TfL - Head of Network Sponsorship Figure 2: Location of louvres on green figure light aspects and additional ‘look left, look right’ markings = Pentonville Road / King’s Cross Road junction Vs W ost
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