Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0456, written 28 Dec 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 Dec 2017 |
|---|---|
| Reference | 2017-0456 |
| Deceased | Mark Welsh |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
Mark WELSH (died 06.07.17)
THIS REPORT IS BEING SENT TO:
1. Mr Mike Brown
Commissioner
Transport for London
Windsor House
50 Victoria Street
London
SW1H 0TL
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 17 July 2017, I commenced an investigation into the death of Mark
Nicholas Welsh, aged 55 years.
The investigation concluded at the end of the inquest on 18 December
2017. I made a determination of death by road traffic collision, when Mr
Welsh was knocked over by a lorry whilst crossing Duke’s Road at the
junction with Euston Road in London at approximately 9.30am on
Thursday, 6 July 2017.
The medical cause of death was:
1a multiple injuries.
1
4
CIRCUMSTANCES OF THE DEATH
Despite travelling at just 7 miles per hour, the lorry driver turning left into
Duke’s Road from Euston Road would only have had a second to see Mr
Welsh as a hazard, through the front passenger cab window, before the
pedestrian disappeared from his view.
The lorry would have been visible to Mr Welsh and it did have its indicator
on, but because it had to swing out to make the turn, it might have
appeared to him that the lorry was going to carry straight on along Euston
Road, falsely reassuring him that it was safe to cross.
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.
I heard at inquest that:
Transport for London (TfL) made a decision in 2007 that that it would
not undertake any consideration of pedestrian crossings at that
crossroads until after the completion of HS1;
£50,000 was paid to TfL in 2009 by UNISON as part of planning
permission to allow building on the opposite corner, £20,000 of which
was used on a feasibility study in 2013, but TfL decided that traffic
flow would be impeded by four pedestrian crossings, so none was
installed and use was not made of the remaining £30,000;
UNISON has made several complaints to Camden Council/TfL about
the dangers of this particular crossroads, but TfL’s best expectation
of delivery of any improvement is for the year 2020.
I appreciate that every decision about traffic control at one junction must
be taken in the context of the whole network, but 13 years after the issue
was first raised seems an inordinately long time to wait for some
improvement at such a busy crossroads (about which there had been
several complaints prior to this fatality).
Consideration of the junction was described to me as being based on
four new crossings or none, which I did not quite understand.
The statistics upon which TfL decisions about traffic control are based,
were described to me by TfL’s lead sponsor as only taking account of the
proportion of collisions/accidents that result in serious injury or death, not
taking into account the overall incidence of collisions/accidents (or even
taking into account reported near misses). This seems an omission.
2
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you have the power to take such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 27 February 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.
8
COPIES and PUBLICATION
I have sent a copy of my report to the following.
HHJ Mark Lucraft QC, the Chief Coroner of England & Wales
Camden Council
Department of Transport
, partner of Mark Welsh
, sister of Mark Welsh
, daughter of Mark Welsh
, UNISON
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 Senior Coroner, at the time of your response,
about the release or the publication of your response by the Chief
Coroner.
9
DATE SIGNED BY SENIOR CORONER
28.12.17
3
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.
(asa l(7/s¢ Transport for London Our ref: GP18-075 nS = HECEIVER (} 3 Mar Onin Managing Director Surface Transport Coroner ME Hassall Transport for London Senior Coroner | Ith Floor, Zone R4 Inner North London Palestra St Pancras Coroner’s Court 197 Blackfriars Road Camley Street London SE! 8NJ Ric a N1C 4PP 27 February 2018 Dear Coroner Hassell Euston Road Junction with Duke’s Road — Regulation 28 Prevention of Future Deaths Report | wish to pass my sincere condolences to the family of Mark Welsh after hearing of the tragic collision that occurred on 6 July 2017. We have carefully considered your Prevention of Future Deaths Report dated 28 December 2017, in which you raise concern over the length of time it has taken to provide improvements on the junction of Euston Road with Duke’s Road and Churchway and how we have considered our options; and TfL’s use of statistics upon which we take decisions about traffic control. | respond as follows: TfL’s use of statistics to drive improvement of traffic control at junctions | understand and share your concerns to ensure the decisions we take in this area are as far as possible taken on the best and most appropriate collision data sets. However, TfL’s collision statistics are based on police reports of collisions at which a casualty has occurred. These casualties are categorised by the police according to injury type, which is then allocated to an injury severity category (either fatal, serious or slight). Police reports are taken when either a police officer has been called to the scene of a collision at which a personal injury has occurred, or the injury has been reported to the police over the counter or via the new MPS online tool, which can be found here: https://www.met.police.uk/report/report-a-road-traffic-incident/ MAYOR OF LONDON da VAT number 756 2769 90 There is no consistent way of recording damage-only collisions, as the police don't routinely attend site or require those involved to report the incident. A damage-only collision may be relatively trivial (i.e. scraping a wing mirror), and may not even be taken into account by insurance companies (who would be the other potential source of data). There is also no reasonable way of recording near misses, and it would be impossible to ensure consistency throughout the reporting. Our decisions on traffic control and which locations to prioritise for improvement are therefore informed by analysis of where and how collisions have occurred, as these have the greatest impact on the well-being of Londoners. Annual priority lists for intervention are created’based upon collisions of all severity involving vulnerable road users. We also analyse the data collected to detect any patterns of accidents, and will prioritise further a junction for improvements if a pattern of types, modes or precise location of collisions can be detected. No such pattern has been detected in the collision data for the Duke's Road/Euston Road/Churchway junction. Where sites have been identified for investigation or investment, TfL might undertake further investigation to understand what damage-only or near-miss collisions regularly occur. Although no patterns have been identified, our intention is to provide a controlled pedestrian crossing on this junction in order to improve the provision for pedestrians and vulnerable road users to take account of the expected growth of pedestrians in the area. Consideration of improvements at the Euston Road/Duke’s Road/ Churchway Junction, including consideration of options. We have been working closely with Camden Council to deliver a design for this junction that improves the safety for pedestrians and other vulnerable road users, and a history of our work on this was submitted to you as part of our evidence to the inquest. However, our decisions about traffic control and the use of signals must be coordinated with the surrounding road network to prevent excessive congestion, which is likely to have impacts both on safety and air pollution. The roads in this area are currently operating at the maximum level of capacity, and it has proven very difficult to find a solution for this junction which is acceptable both to us and Camden Council given potential local and wider traffic impacts, and does not have significant negative impacts elsewhere. . nee When considering whether it is possible to introduce a new controlled crossing facility at a junction, it is necessary to consider how the junction currently operates. Currently, at the junction, all vehicle movements are permitted except for the right turn into Dukes Road. To introduce a signal controlled pedestrian crossing, we need to either e Bana further turning movement into Dukes Road to remove the pedestrian and vehicle conflict; or e Hold all the traffic on a red signal so that there is a period of time when traffic is not moving into or out of any of the approaches. This could provide crossings on all four arms and therefore deliver the greatest benefits to pedestrians in terms of safety and convenience. As set out in a previous report supplied in evidence to you at the inquest, the latter option would also enable TfL to put pedestrian crossings on the other arms of the junction providing the greatest benefits to pedestrians in terms of safety and convenience. However, our modelling analysis demonstrated that the introduction of pedestrian crossings and holding traffic would create severe congestion both in this area and more widely across the network, which would have negative impacts for pedestrians, other vulnerable road users and local air quality. Subject to Camden Council agreement, we intend to progress a banned turning movement in order to provide a signal controlled crossing on Dukes Road — to be implemented next year. We will continue working with Camden Council to develop a design for this junction and others in the near vicinity which will enable more and safer pedestrian and cycle facilities to be provided thereby encouraging people to walk, cycle or use public transport. Yours sincergly Managing Director — Surface Transport
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