Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0128, written 17 Apr 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Apr 2019 |
|---|---|
| Reference | 2019-0128 |
| Deceased | June Russell |
| Coroner | Heidi Connor |
| Coroner area | Berkshire |
| 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.
Classification: OFFICIAL-SENSITIVE REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (b) THIS REPORT IS BEING SENT TO: The Chief Executive — Ms Josie Wragg: Slough Borough Council, St Martins Place, 51 Bath Road, Slough, Berkshire, SL1 3UF. 1. | CORONER Tam Mrs Heidi J. Connor, Senior Coroner for the coroner area of Berkshire. 2. | CORONER’S LEGAL POWERS I 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 T conducted an Inquest into the death of June Russell that was heard at Reading Town Hall on 2" April 2019. I recorded a conclusion of road traffic conclusion, 4. | CIRCUMSTANCES OF THE DEATH The family asked us to refer to the deceased as “June” at the inquest. I have reflected that request in this report. June was involved in a road traffic collision on the 2"4 May 2018. She was the passenger in a Kia Venga driven by her husband. His vehicle was in collision with a Ford Galaxy people carrier driven by a taxi driver. The Kia was being driven south on the B470 High Street, Langley, approaching a traffic light controlled junction with the A4 London Road. The Kia was in a left turn only lane at the junction, but drove straight ahead into the junction, colliding with the Ford Galaxy, which was continuing on the A4 across the junction towards Slough town centre. Classification: OFFICIAL-SENSITIVE Classification: OFFICIAL-SENSITIVE ‘The evidence was clear that there was little that the taxi driver could have done to | avoid this collision. Evidence from dashcam footage and from all of the key witnesses involved was consistent. The Crown Prosecution Service did not prosecute in this case, given the tragic | | outcome. It is appropriate to be clear from the outset that driver error has undoubtedly played a part in this collision. I have considered whether there were | | mitigating factors which make further incidents at this Junction likely, with the | | risk of future deaths occurring. | | concluded at the inquest that speed, weather conditions and the condition of the two vehicles involved played no part in this incident. During the inquest, I took evidence from a Traffic Management Officer with Thames Valley Police, J He has carried out some research into historical collisions which have occurred at this junction. This road layout was changed in July 2014. In the 5 years before this, there were 4 recorded collisions at this junction. Two of these involved similar circumstances to this collision. Since July 2014 (a less than 5 year period), there have been 13 reported incidents. Six of these involved similar circumstances. The number of incidents is undoubtedly much higher since July 2014. The evidence suggests that a high proportion of the collisions which have occurred at this junction fall into one of two categories namely where the left hand lane is treated as a straight on lane (in this case), or where vehicles have contravened red traffic lights whilst travelling on the B470 from lane 2, confusing the left turn filter arrow. Whilst driver error may well have played a part in many of the incidents, they can be categorised as driver error with common themes. I was made aware of ongoing work that Slough Borough Council has undertaken in early 2018 to improve safety at this junction. These followed concerns raised by police and neighbourhood groups in November 2017. This has included: (1) Changes to the positioning of the secondary traffic lights. These were moved away from the southbound secondary head so that drivers cannot become confused. This was completed on 2™ May 2018 (the day of the collision). (2) Drawing a left turn guidance line for southbound lane 1, left turn — completed 5“ February 2018. (3) Drawing a yellow box junction ~ although this was primarily to prevent the exit becoming blocked. This was completed on the 5" February 2018. A number of other matters are, I was told, being considered but have not yet been | -2- Classification: OPFICIAL-SENSITIVE Classification: OFFICIAL-SENSITIVE comp eted. These include: (1) Moving the southbound secondary head on pole 9 — to bring drivers’ attention to the stop line. | (2) Creating bigger lane designation signs before the junction. (3) Creating a regulatory blue left arrow to the southbound left turn-head to | reinforce what is allowed from that lane. T heard in evidence that the words “left turn” painted on the road had become very faded by the time of this incident. It was however accepted that, for the majority of the time, this sign would be covered by traffic using the lane. I also heard that there are a number of signs on the same pole as the left hand turn sign before the junction, creating distraction for drivers. In addition, Mr Edmond was of the view that, given the layout of this junction, the line of sight for drivers using the left hand only lane may give false reassurance to drivers considering going straight on, as the driver did in this case. 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 could occur unless this action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: — I consider that Slough Borough Council should take action to address the injury collision rate at this junction. Some work is ongoing, but this has been the case for over a year. This consideration should include: (a) Improvements to the signs at and before this junction. (b) Primary and secondary traffic light heads. (c) Layout and line of sight on the approach to this junction from the B470 High Street Langley. (d) It was not clear during the evidence whether the traffic lights in question are LED lights, which may assist in this respect as well. 6. | ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe your organisation has the power to take such action. 3+ Classification: OFFICIAL-SENSITIVE Classification: OFFICIAL-SENSITIVE Your response must contain details of action taken or proposed to be taken, OUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this | report, namely by 12" June 2019. I, the Coroner, may extend the period. setting out the timetable for action. Otherwise you must explain why no actions is | proposed. Given that these matters have been under consideration for some time, a lengthy extension will presumably not be required. 8. | COPIES and PUBLICATION | | Thave sent a copy of my report to the Chief Coroner and to June’s family. 1 have also sent a copy to the Road Traffic Team at Thames Valley Police. 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 Coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9. 117" April 2019 Mrs Heidi J. Connor Senior Coroner for Berkshire 4. Classification: OFFICIAL-SENSITIVE
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.
Department: Chief Executive Contact Name: Contact No: Email: Our Ref: Josie Wragg j 11 June 2019 By email Mrs H Connor Senior Coroner for Berkshire Coroner’s Office Reading Town Hall Dear Mrs Connor Following the Coroner’s inquest on 2nd April 2019 and the subsequent Regulation 28 report that was issued to Slough Borough Council on 17th April 2019, please find below how the Council intends to improve safety at the junction of High St, Langley and the A4. Immediately after the Inquest which took place on 2nd April 2019, the Service Lead for Major Infrastructure Projects at the Council commissioned an independent road safety engineer to carry out a full review of this junction in conjunction with a traffic signal engineer. Those professionals met on 29th May 2019 to discuss preliminary findings. Once the review has been fully carried out, including a detailed assessment of collision data, a detailed report will be provided with full proposals for any further improvements. It is envisaged that this report will be provided within approximately 6-8 weeks, following which recommendations for further action will be put forward for implementation. The report will identify options for the short, medium and long term, to address the road safety collisions at this junction. Matters of concern raised by the Coroner were fourfold and the response from the Council to each is set out below: (i) Improvements to signs at and before this junction Slough Borough Council (SBC) has undertaken an extensive programme of improvements to the road junction in question which began in December 2017. In direct response to observations and recommendations from Thames Valley Police (TVP), together with the Council's own road safety monitoring regime, several phases of work were undertaken to improve road safety at this particular junction with a view to improving signs at and before this junction. This programme of improvement was completed in May 2018; just less than six months after concerns were raised. As stated in the Collision Report from controlled crossroads between the A4 London Road linking the High Street from the north and Ditton Road to the south. The approach to the junction on the Slough bound carriageway consists of four wide lanes, split into two pairs. The off-side lanes are dedicated to vehicles wanting to turn right into the High Street, the near side lanes are for vehicles travelling straight along the London Road or those turning left into Ditton Road. The lane designation signs for High St, Langley are being reviewed by the independent engineer and will form part this junction is a multi phased traffic light of the final report and whether these are appropriate due to the number of signs leading to the junction. (ii) Primary and secondary traffic light heads As part of the recommendations from TVP, a decision was taken in November 2017 to split the two secondary traffic signals at the junction which served vehicles approaching the junction from High St, Langley. This work was completed in May 2018 – prior to that date these two traffic signal heads were directly opposite the junction on the pedestrian refuge area. In May 2018 work was completed to separate them out, one was moved to the left hand side of that part of the junction directing traffic to turn left and the other traffic signal head remaining in situ directing vehicles to make a straight on or right turn from the off-side lane. This work was carried out in a very short space of time between December 2017 and May 2018. Additional guidance markings were also put in at the junction to guide drivers safely round toward the motorway as part of the TVP recommendations. TVP were of the view that separating out the traffic signal heads would improve the situation of the primary and secondary traffic light heads at this junction and therefore Slough Borough Council acted on this recommendation very quickly. The independent report will look further at this change. SBC also carried out a full refreshing of the road markings from December 2017 to May 2018. The road markings on the approach to the junction from High St, Langley were all refreshed and the yellow box junction marking was also refreshed and made new over this timescale. (iii) Layout and line of sight on the approach to this junction from the B470 High Street Langley At this point in time, it is not possible to speculate on what improvements to the layout and line of sight can be introduced and therefore this point will be reviewed in line with the road safety report recommendations. There is a much larger programme of works already planned for this financial year where action will be taken to upgrade sections along this corridor which lead to the junction with the M4. All road safety measures depend upon drivers paying due care and attention to their own manoeuvres, to road safety signage and the conduct of other drivers (Highway Code). Measures will only be effective if drivers are strict in correctly obeying road signs and the improvements made so far. (iv) LED Traffic lights It has been established that the traffic lights at this junction are not LED but halogen light based. The change to LED is not considered a road safety improvement and where other junctions in the town have been upgraded this has been to reduce maintenance risks for traffic signal contractors. In terms of road safety, drivers are legally obliged to adhere to the phasing of traffic lights which they must always do whether the lights are LED or halogen based and it is considered that for the considerable cost of replacing all signal heads, cabling and the controller, there is not a significant enough difference between the two to warrant a wholesale change from one to the other at this junction. I hope the information contained in this letter sets out how serious the Council takes the safety of users on its highway network and the measures we have and will be taking to improve road safety at this junction. Yours sincerely Josie Wragg Chief Executive Slough Borough Council
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.