Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0175, written 6 Jun 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Jun 2018 |
|---|---|
| Reference | 2018-0175 |
| Deceased | Carol Metcalfe |
| Coroner | Kevin McLoughlin |
| Coroner area | West Yorkshire (East) |
| 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.
ANNEX A 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 7 THIS REPORT IS BEING SENT TO: Leeds City Council Highways Department, Selectapoint 6, Ring Road, 1 | CORONER | am Kevin McLoughlin, Senior Coroner for the coroner area of West Yorkshire (Eastern) 2 | CORONER'S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and reguiations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 | INVESTIGATION and INQUEST On 1* November 2016 an investigation was commenced into the death of Carol Metcalfe, aged 41. The investigation concluded at the end of the inquest on 6" June 2018. The conclusion of the inquest was a Narrative indicating that she died from chest and abdominal injuries after being struck by a heavy goods vehicle. | 4 | CIRCUMSTANCES OF THE DEATH The location of the fatal road traffic collision involved in the Inquest was on the A63 Selby Road opposite a low secure psychiatric unit called Waterloo Manor Hospital. The patients treated there have typically been compulsorily detained (“sectioned”) under the Mental Health Act 1983 due to their complex mental illnesses. Many are prescribed medication which may leave them drowsy. An integral feature of the rehabilitation of such patients is to undertake escorted (or unescorted) leave from the hospital. It is, therefore, likely that patients subject to medication will be crossing the busy A63 Selby Road dual carriageway, which is subject to a 50 miles per hour speed limit. The situation described gives rise to a concern that deaths may occur as people such as patients seek to cross the dual carriageway to get to the bus stop. | 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. — The need for measures to be taken to protect pedestrians crossing the A63 dual carriageway in the vicinity of Waterloo Manor Hospital. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you 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 1** August 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 Coro: ing Interested Persons: (1) The family of Ms Carol Metcalfe c/o 2) bec Johnson, Hospital Director of Waterloo Manor H . , arforuy, 7 LS25 1NA. | have also sent a copy to Alec Shelbrooke MP, House of Commons, London, SW1A OAA. | 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 compiete 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. 6" June 2018 Signed "Ke Coroner | _ Kev iiorki—-_|
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.
21 SEP 20g
woe CITY COUNCIL
Coroner's Office and Court Highways Services
71 Northgate Selectapost 6
Wakefield Ring Road
WF1 3BS Middleton
Leeds LS10 4AX
Contact: Nicholas Hunt
Tel:
Email: is
Case reference:
Date: 26" June 2018
Dear Mr McLoughlin, 3464, Taliden Saq- 6-6 18
RE: Inquest touching the Death of Carole Metcalfe (deceased) FS
| refer to your letter dated 7 June 2018 in regards to the above sad incident.
| have been requested to investigate your concern relating to the measures required to protect
pedestrian when crossing the A63 Selby Road in the vicinity of the low security psychiatric unit
(Waterloo Manor Hospital).
| visited the location on the 21 June 2018 to undertake an onsite visual assessment.
The A63 Selby Road at this location is a dual carriageway, ‘A’ classified principal route which is
governed by a speed limit of 50mph. There is a system of street lighting along it route and the condition
of the carriageway is good.
On the day of my visit | observed that there was already an existing informal pedestrian crossing across
both directions of the dual carriageway which | concluded was introduced to access the bus stops on
either side of the A63 Selby. These bus stops in my opinion appear to have been provide to offer a
public transport serve to the Waterloo Manor Hospital itself. These informal pedestrian crossing points
provide a safe location to cross the A63 Selby Road from Waterloo Manor Hospital, across the central
grassed reservation and onto the pavement on the opposing side.
These crossing points have tactile paving provided to assist and guide our blind/ partially sighted road
users where to cross safety. The location of the crossing points are located on the straight section of the
A63 Selby Road, which offers the greatest forward visibility from both direction, not only for pedestrians
but also for the approaching drivers. (See Appendix A — Photographs 1 to 4).
Onsite observations identified that there were gaps within the traffic to safely cross this road, even for
our most vulnerable road users. A further site visit was conducted during the morning and evening peak
periods (08:30 to 09:30 and 16:00 to 17:00hrs) on the 25" June 2018 to see if this observation changed.
| found that that whilst the waiting time to cross was marginally greater, | had good opportunity and gaps
within the oncoming traffic to safely cross this road.
In addition to the provision of dropped kerbs and tactile paving to assist pedestrians to cross the A63
Selby Road, there is also present on site highly visible advanced warning signs from both directions.
C)
www.leeds.gov.uk switchboard 0113 234 8080 Highways Helpline 0113 2224407 INVESTOR IN PEOPLE
These signs are very prominent and give advanced warning to approaching drivers of the potential risk
of ‘pedestrians in the road ahead’. These are also placed on yellow backing boards to highlight and
emphasize the message to approaching drivers. (See Appendix A — Photographs 5 and 6).
i have as part of this investigation assessed the site for a formal pedestrian crossing based on the
national assessment criteria based the LTN 1/95 “The assessment of pedestrian crossings”. This
assessment process considered the site characteristics, vehicular and pedestrian usage, forward
visibility, road environment, speed of road and previous road safety history. My conclusion after this
review was that informal measures which have already been provided are the most appropriate
provision for this location.
As part of this investigation | have also reviewed the Police injury collisions data for this location from
2010. This has identified that there has only been one recorded pedestrian injury collision in this period
which is the sad incident this report refers to. There were two other recorded injury collisions, both
resulted in an injury collision rating of slight and one was attributed to debris on the highway and poor
driver maneuvering for the second.
In light of the above findings | am unable to offer any further highway intervention to assist pedestrians
to across this section of the A63 Selby Road from an engineering perspective. However, if the Coroner
feels it would be beneficial | will ask my colleagues from our Influencing Travei Behaviour Team (Road
Safety) to visit Waterloo Manor Hospital to offer some road safety advice and crossing training.
{am sorry | cannot be more positive to this request but trust the above explains my reasoning.
Yours Sincerely,
Traffic Engineering Manager
www.Jeeds.cov.uk switchboard 0113 234 8080 Highways Helpline 0113 2224407
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