Prevention of Future Deaths reports · 2018

Jacqueline Jordan

Regulation 28 report to prevent future deaths, reference 2018-0263, written 24 Aug 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report24 Aug 2018
Reference2018-0263
DeceasedJacqueline Jordan
CoronerMaria Voisin
Coroner areaAvon
CategoryRoad (Highways Safety) related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

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.

M. E. Voisin
Her Majesty’s Senior Coroner
Area of Avon

24th August 2018 REF: 8564

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO:

Transport Department
Bristol City Council

CORONER

lam M E Voisin Senior Coroner for Area of Avon

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.

http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7

http://www. legislation.gov.uk/uksi/2013/1629/part/7/made

INVESTIGATION and INQUEST

On 14/12/2017 | commenced an investigation into the death of Jacqueline Dympna JORDAN. The
investigation concluded at the end of the inquest. The conclusion of the inquest was: Road Traffic
Collision

CIRCUMSTANCES OF THE DEATH

Mrs Jordan died on 18th November 2017 at Passage Road, Brentry, Bristol. At around 6pm she had
walked across the dual carriageway and central reservation which was a shortcut known to be used by
pedestrians but which was not a designated crossing. She was struck by a car as she stepped into the
path of the car, she was pronounced dead at the scene.

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:

| was told by the police officer and the family that a barrier exists throughout part of the central
reservation along this dual carriageway but is absent throughout this short stretch. If there was a barrier

Telephone 01275 461920
Email AvonCoronersTeam @bristol.gov.uk Website www.avon-coroner.com
The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL

throughout this central reservation that it would potentially deter certain members of the public using
this shortcut. | was told that there are 2 pedestrian crossings nearby

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 234
October. |, 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 — family of
the 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.

24/08/2018

Signature 7. =

M E Voisin Senior Coroner Area of Avon

Telephone 01275 461920
Email AvonCoronersTeam@bristol.gov.uk Website www.avon-coroner.com
The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL

Responses

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.

Response from Bristol City Council
(“1

The Coroner’s Court,
Old Weston Road,
Flax Bourton
BS48 1UL

Date

1 st October 2018

Dear Ms Voisin,

Re: Regulation 28 fetter - Jacqueline Jordan, 18°’ November 2017

Bristol City Council has considered the requested course of action laid out in the
Regulation 28 letter following the death of Jacqueline Jordan on the 18th November
2017 on A4018 Passage Road, Bristol.

Your request is to extend the pedestrian guard railing along the A4018 to reduce the
risk of pedestrians attempting to cross the road using the central reservation and
guide them to the nearest formal crossing points.  The City Council understands why
this course of action has been proposed, particularly as this has been identified as a
place where pedestrians cross due to the presence of the bus stops and the distance
between the existing crossings.

However, whilst we sympathise with the family following this tragic incident, the City
Council is not currently proposing to install any additional pedestrian guard railing in
this location as suggested.

Rather than install further guard railing along this road, which has a local history of
being climbed over by pedestrians or damaged by vehicle impact, the City Council is
proposing an alternative approach.  As part of the mitigation measures for the Cribbs
Patchway New Neighbourhood development, a comprehensive scheme is currently
being developed to improve the A4018 from the boundary with South Gloucestershire
Council to Redland Hill.  Funding has already been secured for delivery of these
improvements by March 2021, and as such the initial designs are due to go to public
consultation in November this year.

This proposal includes new inbound and outbound bus lanes, a reduction in the
speed limit to 30mph and the provision of a formal crossing in the immediate vicinity
of this incident. The proposal also includes physical changes to the existing junctions
to reduce traffic speeds in support of the lower speed limit and improvements to the
existing street lighting. As this comprehensive scheme would significantly reduce the
risks to pedestrians the current proposal also includes the removal of the majority of
the existing guardrail.

Growth & Regeneration 
Transport 
100 Temple Street 

Service Director
Transport

Website
www.biistol.qov.uk

ISO
1 0 0 0 2
Customer
SiHstallaa

 As the City Council is about to consult on this proposal, we would propose that no
immediate action is undertaken to install additional guardrail and that this wider
design is progressed to public consultation.  This is in line with the City Council’s
Safe Systems approach as it will be looking to change the whole environment and
feel of this road and as a result reduce the road safety risks to all road users
including the local community.

I trust that this approachis deemed acceptable as a considered response

Yours sincerely,

Area Manager -  Local and Sustainable Transport

Growth & Regeneration 
Transport 
100 Temple Street 

' 

Service Director
Transport

Website
www.bristol.qov.uk

I5O
1 0 0 0 2
Coslrnrr
Satiifattica
M;n35'n’tn|

Related reports

Other reports by Maria Voisin

See all →

More reports categorised “Road (Highways Safety) related deaths”

See all →

Track Road (Highways Safety) related deaths

See every Prevention of Future Deaths report matching Road (Highways Safety) related deaths, and how often a new one appears.

What would an alert for this have sent me? Search the full text

Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.

These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.