Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0498, written 9 Aug 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Aug 2019 |
|---|---|
| Reference | 2019-0498 |
| Deceased | Pauline Howell |
| Coroner | Karen Dilks |
| Coroner area | Newcastle Upon Tyne |
| 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.
Karen Dilks Senior Coroner for the City of Newcastle upon Tyne REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Newcastle upon Tyne City Council, Legal Services, 5" Floor Civic Centre, Newcastle upon Tyne, NE1 8QH (Ref: Tracy Quinn) CORONER | am Karen L Dilks, Senior Coroner, for the Coroner area of Newcastle upon Tyne. 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 8 February 2018 | commenced an investigation into the death of Pauline Howell, date of birth 30 May 1939, aged 78 years. The investigation concluded at the end of the inquest on 3 June 2019. The conclusion of the inquest was: Accidental Death Medical Cause of death: Head Injury. CIRCUMSTANCES OF THE DEATH On 5 February 2018 in Newcastle upon Tyne City Centre; Pauline Howell, a pedestrian, walked in an Easterly direction on the North pavement of Newbridge Street West towards the pedestrian crossing at the junction with John Dobson Street. She continued walking in an Easterly direction on to the pedestrian crossing at the junction, in contravention of the pedestrian phase of the traffic lights ahead of her. A single-decked bus travelling East on Newbridge Street West, at the junction with John Dobson Street turned left to travel North. The bus struck Pauline Howell causing injuries which resulted in her death. In the opinion of Collision Investigators the design/layout of the junction was a significant contributory factor in the events that occurred, in that: The proximity of the crossing to the junction, combined with the “tight” nature of the left-turn-manoeuvre, allowed no opportunity for the bus driver to identify the pedestrian hazard and/or take action to avoid a collision. The evidence confirmed a previous death from a similar collision at the said junction. 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 risk of pedestrian error at the John Dobson Street crossing is foreseeable. (2) The crossing is situated close to the junction. (3) The crossing is situated on a busy bus route. (4) The Junction is “tight” and challenging for public service vehicle drivers to negotiate. (5) The design/layout of the junction/crossing allow no margin for error by either or both pedestrian and driver. (6) The deaths of two pedestrians resulted from injuries sustained whilst crossing this junction in similar circumstances and the risk of future deaths continues. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and/or 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 30 September 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 | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: e Northumbria Police Collision Investigation Unit ° (daughter) | 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 | 9 August 2019 Signed by Karen Dilks, (Senior Coroner)
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.
Pat Ritchie Chief Executive Newcastle City Council Room 1.1, Civic Centre Barras Bridge Newcastle upon Tyne, NE1 8QH Phone: Fax: 0191 211 4980 Email: www.newcastle.gov.uk Mrs Karen Dilks HM Senior Coroner Civic Centre Barras Bridge Newcastle upon Tyne NE1 8QH 7 October 2019 Dear Mrs Dilks Re: Regulation 28 – Pauline Howell (Inquest held 3 June 2019) Thank you for your letter dated 15 August 2019 sent to relation to the above inquest, and enclosing a Regulation 28 Report To Prevent Future Deaths asking Newcastle City Council to take action. in Legal Services in First of all we again extend our sympathies to Pauline Howell’s family and friends. Whenever there is a tragedy the council looks at what lessons can be learned to try and avoid such accidents occurring again. In order to give full consideration to the issues you raised, we commissioned two independent Stage 4 Road Safety Audits by different experienced Civil Engineers to review the current junction layout and signal phasing. Should you wish to see copies of the independent road safety audits we will make them available to you. It should be noted the junction has been substantially re-modelled since the pedestrian fatality in 2015 and the Road Safety Audits undertaken assess only the current layout. Apart from some modifications to the green/red man signal boxes made in January 2019, the current layout is the same as that which would have been in place at the time of the second fatality that was the subject of the recent inquest. The Stage 4 Road Safety Audits included consideration of post scheme road traffic collision data, along with site visits to review physical layout and observe pedestrian and traffic movements at the junction. In response to the issues you have raised neither of the Road Safety Audits consider the locations of the pedestrian crossing points to be problematic. In fact, one of the independent consultants noted that: ‘Observations made on site suggest that the crossing points are on the desire line for pedestrians and that any movement of these points away from their current positions would unlikely affect the desire line.’ If you need this information in another format or language, please contact the person who sent it. It is also important that this is seen in the context of the Forensic Collision Investigation reconstruction report, which concluded that primary cause for the collision was the actions of Mrs Howell. The junction was designed as part of a wider scheme to improve cycling and incorporates a number of elements to reduce speed, such as a 20mph speed limit and a raised table across the junction to both slow traffic and provide an at grade crossing facility for pedestrians. The two Stage 4 Road Safety Audits have identified some minor issues with the junction layout and some potential remedial measures. One issue was raised as part of both consultants’ Stage 4 Road Safety Audits: Potential confusion over road layout as the segregated cycle lane could be mistaken as southbound carriageway – there had been an original suggestion to install text on the kerb edge at pedestrian crossing points to state ‘Look both ways’ which was discounted at the time as not permitted under the regulations. This is now permitted by the Traffic Signs Regulations and General Directions and will be installed. Other minor scheme improvements will include: 1. Amend the tactile paving on the north west corner of the junction outside the Central Library to improve consistency for blind and partially sighted users. 2. Revise the phasing of lights and install detection sensors. Amend the location of the primary traffic signal head and raise the level of the pedestrian repeaters. 3. Replace damage on splinter island between cycle lane and general traffic lane for west bound traffic on New Bridge Street West. We anticipate that the work highlighted above will be undertaken during late October 2019. I trust that this information is of assistance and addresses your concerns over the junction. Yours sincerely Pat Ritchie Chief Executive If you need this information in another format or language, please contact the person who sent it.
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