Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0197, written 1 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 | 1 Apr 2019 |
|---|---|
| Reference | 2019-0197 |
| Deceased | Ozan Allen |
| Coroner | Sarah Bourke |
| Coroner area | Inner North London |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Coroner ME Hassell HM Senior Coroner Inner North London REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Transport for London 1 CORONER I am: Assistant Coroner Sarah Bourke Inner North London Poplar Coroner’s Court 127 Poplar High Street London E14 0AE 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 On 20 August 2018 I commenced an investigation into the death of Ozan Allen (aged 40 years). The investigation concluded at the end of the inquest on 28 March 2019. The conclusion of the inquest was that: Mr Allen was hit by a car on 16 August 2018 as he was crossing the road at the junction between Mile End Road and Burdett Road. He died in hospital on 20 August 2018. The medical cause of his death was: 1a traumatic brain injury 1b road traffic collision I recorded a short‐form conclusion that Mr Allen’s death was due to a road traffic collision. 4 CIRCUMSTANCES OF THE DEATH Mr Allen was walking along the north side of Mile End Road from Stepney Green Underground Station to Thames Magistrates’ Court. At the junction with Burdett Road, he walked across Mile End Road to the central traffic island. He then ran diagonally in the direction of the central traffic island in Burdett Road. Whilst he was crossing the junction, he was hit by a red Suzuki car that was travelling north up Burdett Road. Mr Allen sustained head injuries in the collision and died in hospital a few days later. The witness evidence, investigation report and CCTV established that there were a number of vehicles seeking to turn into the westbound section of Mile End Road at the time. In addition, the evidence established that the driver of the Suzuki would not have been able to prevent the collision. 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 action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – (1) The junction is a busy crossroads involving multiple traffic lanes with filters, segregated cycle lanes and multiple pedestrian and cycle crossings (2) There is no pedestrian guard railing at the junction (3) Visibility of the junction can be impaired by vehicles waiting to turn. (4) There are staggered two‐stage crossings in place to enable pedestrians to cross the road. The investigator from the Metropolitan Police’s Road Engineering Unit, observed that pedestrians often do not use the crossings as intended. (5) evidence was that in the three years to the end of 2017, there have been 36 reported personal injury collisions within 50 metres of the junction – 17 of which involved pedestrians. (6) In addition, informed me that a collision study undertaken by TfL has identified that whilst collisions involving cyclists had decreased since the introduction of Cycle Superhighway 2, the proportion of collisions involving pedestrians had increased. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 27 May 2019. 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (mother), (driver). I have also sent it to the Metropolitan Police’s Serious Collision Investigation Unit. 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. Sarah Bourke Assistant Coroner 1 April 2019
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.
Your ref: Our ref: Sarah Bourke Assistant Coroner Inner North London Poplar Coroner’s Court 127 Poplar High Street London 06 August 2019 Dear Mrs Bourke, Transport for London Surface Transport 4th Floor Palestra Building 197 Blackfriars Road Southwark London SE1 8NJ Phone 020 3054 0803 tfl.gov.uk Mile End Road junction with Grove Road and Burdett Road – Regulation 28 Prevent Future Death Report We were sorry to hear of the tragic collision that occurred on 16 August 2018 and wish to pass our sincere condolences to the family of Mr Ozan Allen. We have reviewed your Regulation 28 report and matters of concern dated 1 April 2019. We note your request to prevent future deaths and this letter outlines actions we intend to take. TfL seeks to reduce collisions across London with initiatives stated in the Mayor’s Transport Strategy (March 2018) and the Vision Zero Action Plan (July 2018). As part of the upgrade of Cycle Superhighway 2 completed in 2016, changes were made at the junction including installing segregated cycle lanes on the Mile End Road approaches, and introducing a right turn ban from Mile End Road (western arm) into Burdett Road (southern arm) and a right turn ban from Burdett Road (southern arm) into Mile End Road (eastern arm). Prior to finalising this design, we considered straight-across crossing design options, but they were not feasible due to adverse impacts which included longer wait times for pedestrians, increased queue lengths for vehicles, and re-routing of traffic on local roads leading to ‘rat-running’. Our implemented design used pedestrian islands to manage a high level of demand by all road users and assist pedestrians crossing due to the junction’s size and complexity. Pedestrian islands minimise clearance times on controlled crossings (the time between one movement losing priority and a conflicting movement gaining priority), allow more time to be allocated to effectively move people and minimise waiting times to cross, provide a protected space for Page 2 of 3 cyclists to wait and turn, and provide a suitable location to position signal heads to inform road user decisions. The banned turns have been contentious with some local residents. The London Borough of Tower Hamlets has asked for these to be reviewed. In addition, as per your report, we acknowledge that monitoring of the changes made in 2016 shows that they have reduced the number of collisions affecting cyclists, but the number of collisions involving pedestrians has increased. This impact was not intended as part of that design. We sought to analyse reasons for this and commissioned a collision study that was completed in July 2018, prior to the death of Mr Allen, which involved a review of the recent recorded collision history. This informed a package of further proposals of cycling and walking improvements at this junction. We undertook a public consultation on our proposals which stretched between Hackney and the Isle of Dogs, including this junction, between the 9 May and 21 found on our website at can be this https://consultations.tfl.gov.uk/cycling/hackney-to-isle-of-dogs/ June 2019 and As outlined in our consultation, we are proposing to re-introduce the right turn from Burdett Road (southern arm) to Mile End Road (eastern arm) but ban the corresponding left turn from Mile End Road (eastern arm) to Burdett Road (southern arm). This will allow us to decrease the overall wait times at the pedestrian crossings on all arms of the junction, as well as the adjacent staggered (two-part) crossing outside Mile End station that is co-ordinated with the operation of the junction. A full sequence of the traffic signals currently takes two minutes (120 seconds) at the busiest times and with the proposed changes it is intended to be reduced to just under a minute and a half (88 seconds). On average at this junction, pedestrians currently wait well over a minute and a half (104 seconds) to cross the road (on a ‘green man’) during the busiest periods, and our proposals would reduce this to under a minute (51 seconds). The reduction in pedestrian wait times will increase the probability of pedestrians arriving to cross on a green through providing more opportunities to cross per hour, and is expected to improve compliance with crossing only during ‘green man’ stages. We are proposing to re-introduce pedestrian guard railing on north-west corner of the junction to direct pedestrians to use the formal crossings provided. We are also investigating signal louvres on green pedestrian signals to reduce the risk of ‘see-through’ problems (where two or more signals are close together and there are risks that road users look at the wrong set of signals), and removal of street furniture such as telephone kiosks to improve pedestrian visibility (subject to discussions with third parties). Our proposals do not remove the use of internal islands, and pedestrians will still be required to cross in two or more movements. A design with no internal islands and straight across and/or diagonal crossings would appear simpler but would reduce overall capacity resulting in greater congestion, as the amount of clearance time would need to be increased. An increase in congestion may result in worse air quality, and increase the risk of some traffic migrating to less Page 3 of 3 suitable routes to maintain journey times. It would also be a longer distance for people with impaired mobility to cross in a single movement. Our design seeks to limit the occurrence of vehicles being unable to complete a turn due to their exits being blocked though co-ordinated signal control with adjacent junctions, so that visibility will be improved through less stationary or slow moving traffic in the centre of the junction due to exits being blocked. We are currently analysing the consultation feedback for this exercise and we are considering adjustments to the design in light of comments received. We are planning to publish our consultation report by October 2019 which will outline our next steps, and subject to the consultation outcome, funding and other approvals, construction could start in winter 2019/20 and complete by summer 2020. We will then continue to monitor the performance of this junction. We are also proposing to introduce a reduced speed limit of 20mph on the A11 corridor between Bow and Aldgate through the junction, and we are investigating measures on the A11 Mile End Road approaches such as changes to bus stop facilities and relocating the crossing outside Mile End station to reduce the risk of traffic queuing and blocking back into the junction. We have yet to consult on these additional proposals but plan to complete both further projects by 2024 subject to funding, resources, consultation, roadspace co-ordination for build, and due process. Yours sincerely Director, Investment Delivery Planning Copy to:
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