Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0109, written 22 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 | 22 Feb 2019 |
|---|---|
| Reference | 2019-0109 |
| Deceased | Doreen Fell |
| Coroner | Paul O’Donnell |
| Coroner area | Cumbria |
| 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Mr Jim O'Sullivan, Chief Executive, Highways England 1 | CORONER | am Paul O'Donnell, Assistant Coroner, for the coroner area of Cumbria 2 | 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. 3 | INVESTIGATION and INQUEST On 17" January 2018 an investigation was commenced into the death of Mrs Doreen Fell who died at the age of 76 years old. The investigation concluded at the end of the inquest on 20" February 2019. The conclusion of the inquest was accidental death. 4 | CIRCUMSTANCES OF THE DEATH Mrs Fell was a recently widowed lady living in the Cumbrian village of Backbarrow. She had lived in the area all her life. Mrs Fell had a strong social group in the village; attending friends, family and the community centre on a daily basis. She had been the caretaker of the local primary school for many years prior to retirement. The A590 bisects the village of Backbarrow. It is the only area of habitation along the 34 mile long A590 which contains a stretch of the road that maintains the national speed limit of 6Omph. The relevant areas of this village shall be referred to as the either the northbound side or the southbound side. On 17" January 2018, Mrs Fell had visited her friend who lives on the southbound side of the village, and was making her way home to her property which is located on the northbound side. The time was 5.00pm and it was dark. She walked down Brow Edge Road to its junction with the A590 and walked several meters to the north to a pedestrian crossing. The crossing has been designed to offer pedestrians crossing the A590 safe harbour in a railed off central traffic island which is located in the middle of the north and southbound carriageways. Mrs Fell crossed the southbound carriageway and made it on to central traffic island. She crossed the island to a dropped curb in order to negotiate crossing the northbound carriageway. The breadth of the northbound carriageway at this point was 3.8m wide. Mrs Fell allowed a white transit van to pass by and then commenced her crossing of the carriageway. She walked into the path of a black Honda Civic that was travelling at 50mph. She suffered catastrophic injuries and died at the scene. The inquest heard from Cumbria Constabulary Collision investigator, who had determined that: e the vehicle was a distance of 16 to 25m away when Mrs Fell attempted to cross e the vehicle was travelling at approximately 50mph which is the equivalent of 22.35 metres per second « there was approximately 0.8 seconds between Mrs Fell stepping out and being struck by the vehicle « the driver of the vehicle had no opportunity to react in such a period e it would have taken Mrs Fell (walking at an average speed for a lady aged 60+ of 1.25 metres per second) 3.04 second to have crossed the north bound carriageway e to ensure safe passage when crossing in front of a vehicle travelling at 50mph would require a safe gap of at least 67.94m (and indeed a distance of 81.47m if the car was lawfully travelling at 60mph) e it was highly likely that Mrs Fell had failed to see the black car which was following in convoy behind the white transit van e there is no artificial street lighting on the road (save for traffic warning lights on the traffic island itself to inform drivers of its presence) e Mrs Fell would have been wholly reliant on judging distance by gauging the speed of approaching vehicles from variations in the approaching headlights alone. e the lack of street lighting at this mid village crossing undoubtedly made it harder for any pedestrian to assess whether crossing the carriageway was safe to do so or not. Additional relevant factors regarding Mrs Fell were: a) she wore reactor tight glasses which affected her ability to assess rapid changes in light b) she had never passed a driving test or driven a car c) she was suffering from early onset Alzheimer's disease which family members asserted could have affected her spatial perception d) she crossed this carriageway daily to visit her friend Relevant factors concerning this section of the A590 were: a) it is a straight section of road sandwiched at either end by two dual carriageways: sustained speeds are regularly high in this area b) the village and road is located at the base of a valley which inhibits the level of natural light on the road c) the road at this point is bordered either side by continuous rows of very high trees further inhibiting the availability of natural light on the carriageway. The family of Mrs Fell were accordingly of the view that this section of road is naturally fast and very dark at night. 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 application of the national speed limit for this short section of trunk road whilst it passes through the village of Backbarrow directly impacts on: a) reaction times for pedestrians b) reaction times for drivers c) the size of gap in traffic required to execute a safe pedestrian crossing 2. The low levels of natural light on this section accentuates the present lack of any street lighting on this section of road which may otherwise assist pedestrians with executing a safe crossing during the hours of darkness. 3. There is a village hall on the southbound side and a primary school on the northbound | side of Backbarrow. It is foreseeable that children: the elderly or those with a physical or | mental impairment will have occasion to cross this section of road This aspect has a direct impact on the risk analysis applicable to points 1 & 2 above. It is recommended that an urgent review of traffic safety for this section of the A590 which bisects the village of Backbarrow is undertaken, including particular analysis from a pedestrian’s perspective. As a footnote, it would seem that there are no signs indicating to residents, or visitors to the village, that there is an alternative route across the A590 via an underpass some 500m to the south of this accident. A review of applicable signage along this section of road is also suggested. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and 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 24th July 2018. |, 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: hii. daughter of Mrs Fell i have also sent it to Chief Constable. Cumbria Constabulary Chief Executive, Cumbria County Council .— Chief Executive, South Lakeland District Council who may find it useful or of interest. wn lam 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. Signed: Paul O'Donnell Dated: 22" February 2019 [es
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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS RESPONSE IS BEING SENT TO: 1. The Assistant Coroner for Cumbria, Mr Paul O’Donnell of 65 Duke Street, Barrow-in-Furness, Cumbria LA14 1RW in response toa ‘Regulation 28 Report to Prevent Future Deaths’ received following an inquest hearing into the death of Doreen Fell, that concluded on 20 February 2019. HIGHWAYS ENGLAND 1am MEE, Regional Director (North West Region), responding on behalf of Jim O'Sullivan, Chief Executive of Highways England Company Limited of Bridge House, 1 Walnut Tree Close, Guildford, SURREY, GU1 4LZ. CORONER’S MATTERS OF CONCERN The MATTERS OF CONCERN are as follows:— a. The application of the national speed limit (60mph) for this single carriageway section of the A590 Trunk road as it passes through the village of Backbarrow and how it impacts on: i. Reaction times for pedestrians ii. | Reaction times for drivers iii. The size of gap in traffic required to execute a safe pedestrian crossing; The lack of street lighting on this section of the A590 Trunk road; The safety of pedestrians crossing this section of the A590 Trunk road with particular emphasis on users of the Backbarrow village hall and primary school; and The lack of signage in the vicinity of this section of the A590, and the village of Backbarrow, to advise pedestrians of an alternative route across the A590 Trunk road via an underpass 500m to the south of the accident location. DETAILS OF ACTION TAKEN OR PROPOSED TO BE TAKEN, OR AN EXPLANATION AS TO WHY NO ACTION IS PROPOSED As requested by the Coroner in his Regulation 28 Report dated 22 February 2019, Highways England have reviewed the speed limit, the street lighting, the safety of pedestrians and the provision of signing to the underpass at the location of the accident on 17 January 2018. a. National speed limit The Department for Transport Circular 01/2013 Setting Local Speed Limits advises that speed limits should reflect the function of the road and its environment. They should also reinforce people’s assessment of what is a safe speed to travel. The A590 is part of the Strategic Road Network and as such its primary function is to cater for through traffic between the M6 motorway and Barrow-in Furness. Whilst the A590 trunk road bisects the village of Backbarrow into two distinct sections, practically none of the village itself fronts directly onto the road. The western and eastern sides of the village are accessed via two junctions situated to the north and south of the pedestrian refuge island. Much of the village is screened from the A590 by trees and the only frontage development is a small parking area to the rear of Brow Edge Road and the driveway to South Lakes Boarding Kennels. We therefore consider that the national speed limit of 6omph is appropriate for this stretch of the A5go and is consistent with current guidance. The circumstances of death recorded in the Regulation 28 Report state that it would take a pedestrian, walking at an average speed for a lady aged 60+ of 1.25 metres per second, 3.04 seconds to cross the northbound carriageway. The A590 is a high standard single carriageway road which runs from north to south through the valley on a relatively straight alignment and gentle gradients for approximately 1 kilometre. There is at least goo metres clear visibility in each direction at the pedestrian refuge, a distance which would take approximately 11 seconds for a vehicle travelling at the speed limit to cover. This would allow plenty of time for a waiting pedestrian to make a decision and then cross the road safely. Furthermore, this provides more than adequate visibility for an approaching driver travelling at the speed limit to react safely and appropriately to a pedestrian crossing the road. b. Street lighting The A590 is unlit throughout the National Park area with the exception of the major roundabout junctions at Meathop, Newby Bridge and Greenodd. The pedestrian refuge itself contains a base lit bollard and high-level beacon on either side which highlights the refuge to approaching motorists. The Design Manual for Roads and Bridges document TA 49/07 which covers the appraisal of new lighting on the trunk road network states that the role of road lighting as a safety benefit has limitations and should be considered alongside measures with less adverse environmental impact. It should not be used to mitigate a high darkness collision record unless an investigation carried out by a qualified Road Safety Engineer indicates this would be the best solution. In this case there are a low proportion of collisions in the dark (section c. below) which does not support the installation of street lighting at this location. c. Safety of pedestrians crossing A590 We have reviewed the safety record for this stretch of the A590 through Backbarrow including particular analysis from a pedestrian’s perspective. Over the previous 10 years, up to the accident on 17 January 2018, there have been seven personal injury collisions over the ikm section. All of the previous collisions were classified as ‘slight injuries’. None of the previous collisions involved pedestrians and none were directly attributed to excessive speed. Only one of the seven collisions occurred during the hours of darkness where a single vehicle lost control and left the carriageway in the middle of the night for no documented reason. Most of the collisions have occurred at the junctions on either side of the refuge and involved turning vehicles or shunt type collisions in slow moving traffic. Our analysis found that the current speed limit and lack of street lighting have not been detrimental to road safety as the A59o passes through Backbarrow. Combined with the lack of frontage development mentioned above, and the low number of collisions in the hours of darkness, our review has concluded that lighting this stretch of the A590 would not be appropriate or beneficial. d. Signage of the pedestrian underpass The presence of local facilities on both sides of the village means that there is likely to be significant pedestrian demand to cross the A590 and there are two available options for this; the pedestrian refuge in question and an alternative underpass to the south. There are continuous footways on both sides of the A590 between the refuge and the underpass. The footpaths to the underpass are signed from both bus laybys on the A590 and on both sides of the village where connecting footpaths meet local roads. We have identified that one of the signposts at the southbound bus layby is currently missing its sign. Although our records show that these public footpath signs are not Highways England’s, we are investigating their ownership to have the missing sign replaced at the earliest opportunity. Furthermore, it is worth noting that the ramps leading to the underpass are lit where they run away from the carriageway, and the lighting in the underpass itself was upgraded last year to modern standards. The most direct pedestrian route between the eastern side of the village and the primary school is via the pedestrian underpass. With reference to signing the underpass from the pedestrian refuge as an alternative crossing int, the distance there and back would involve walking approximately half a mile and we do not consider that pedestrians would realistically walk this distance rather than use the refuge. Both the refuge and underpass are likely to be used primarily by local people who would already be aware of the established routes to either crossing point. We therefore do not feel any additional signing to the underpass would be justified. TIMETABLE FOR ACTION Date Action Ongoing Investigate the ownership of the public footpath signs at the bus laybys. Tbe Arrange for the reinstatement the missing sign at the southbound bus layby. SAFETY OF ROAD USERS The safety of our road users is an imperative for our business in what we set out to achieve, and a core value of our organisation in how we go about it. Our company vision for safety is that “no one should be harmed when travelling or working on the strategic road network”. Any improvements we make must be done in a considered and controlled fashion so that the consequences of any improvements are fully understood, and any | safety risks linked to proposed changes are eliminated or reduced as far as possible. Highways England’s review of this location has not identified any action, other than the reinstatement of a missing sign, as necessary at this time. 25 May 2019 Signed: Regional Director on behalf of Jim O'Sullivan
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