Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0076, written 27 Feb 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 27 Feb 2019 |
|---|---|
| Reference | 2019-0076 |
| Deceased | Hoshi Naylor |
| Coroner | Oliver Longstaff |
| Coroner area | West Yorkshire (East) |
| Category | Child Death (from 2015) · 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 THIS REPORT IS BEING SENT TO: 1. PF Head of Highways Infrastructure, Leeds City Council, Middleton Complex, Middleton Ring Road, Leeds, LS10 4AX =y- CORONER | am Oliver Longstaff, Assistant Coroner, for the Coroner area of West Yorkshire (East) nl I 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 16 January 2018 an investigation was commenced into the death of Hoshi Jane Naylor, aged 12. The investigation concluded at the end of the Inquest on 15 February 2019. The conclusions of the Inquest were that Hoshi died on 11 January 2018 in Leeds General Infirmary from the effects of a severe traumatic brain injury sustained in a road traffic incident on 4 January 2018, and that this was a death due to a road traffic collision. CIRCUMSTANCES OF THE DEATH At around 1825 hours on 4 January 2018, Hoshi was crossing the A6120 Leeds outer ting road when she was struck at a point close to the A6120/A58 roundabout by a car travelling on the eastbound carriageway. She sustained unsurvivable injuries, and died a week later in Leeds General Infirmary. [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 point at which Hoshi started to cross the road is approximately opposite a bus stop and a shop which she was intending to visit to buy packed lunch provisions for a school trip the following day. It is a point where pedestrians can reasonably be anticipated to cross the road to and from the bus stop and the shop. (2) The nearest pedestrian refuge island to the scene of the collision is approximately 500 metres away from it, in an eastbound direction. (3) The nearest traffic signal controlled pedestrian crossing to the scene of the collision is approximately 940 metres away from it, in an eastbound direction. (4) In the opinion of a Forensic Collision Investigator called as an expert witness to the Inquest, the provision of facilitated pedestrian crossing points on this stretch of the A6120 (whether facilitated by refuge islands or pedestrian crossings) is sparse in comparison to such provision on similar stretches of the A6120 elsewhere along its length. (5) The street lighting at the collision site appears to offer little illumination of the grass verges to either side of the road. In dark conditions, motorists’ awareness of pedestrians intending to cross the road is likely to be restricted. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I 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 24 April 2019. |, 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 : Hoshi’s parents est Yorkshire Major Collision Enquiry Team; and to the Local Safeguarding Children Board at Leeds. ! 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. 27th February 2019 - f Oliver Longstaff Assistant Coroner West Yorkshire (Eastern)
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.
{2 APR 2019
Coroner's Office and Court Highways Services
71 Northgate St George House
Wakefield 3” Floor
WF1 3BS 40 Great George Street
Leeds LS1 3DL
Tel:
Case reference:
Date: 8 April 2019
Dear Mr Longstaff,
Subject:- Touching death of Hoshi Jane Naylor.
| refer to your letter dated 27th February 2019 in regards to the above.
| can confirm that officers have attended this location with the Police following the sad event
and whilst the road is straight and affords good forward visibility for both drivers and pedestrian,
officers concur with your observations in that the route from the grassed area of land is not
illuminated and also no formal crossing provisions is provided at this exact location.
As part of this onsite review the Police injury collisions record for this location have also been
analysed which identified that the location has a good safety record with only 1 recorded road
collisions recorded within the last 7 year period, prior to this sad event.
However given the circumstance behind the sad death of Ms Naylor and the continued desire
line to the shop for the residential area to the south of the Ring Road, a scheme has been
included in this year’s works program to widen the carriageway at this location to enable a
pedestrian refuge to be constructed. In addition to these proposed works it is also proposed to
provide lighting within the grassed area to illuminate the route and to highlight the presence of
any pedestrians walking towards the road to cross.
| trust the above is of assistance and subject to funding approval being granted the work will
commence on site in summer this year.
Yours Sincerely
Nicholas Hunt
Traffic Engineering Manager
CQ)
www.leeds.gov.uk switchboard 0113 234 8080 Highways Helpline 0113 2224407 INVESTOR IN PEOPLE
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