Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0024, written 28 Jan 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 28 Jan 2020 |
|---|---|
| Reference | 2020-0024 |
| Deceased | Beryl Fricker |
| Coroner | Brendan Allen |
| Coroner area | Dorset |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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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. Mr Graham Farrant, Chief Executive, BCP Council, Town Hall, Bournemouth 2. EE Street Lighting Engineer, Growth and Infrastructure, BCP Council, Civic Centre, Poole 1 | CORONER T am Brendan Joseph Allen, Assistant Coroner, for the Coroner Area of Dorset. 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 the 4" December 2018, an investigation was commenced into the death of Beryl Fricker, who was born on 4" March 1944. The investigation concluded at the end of the Inquest on the 14" January 2019. The Medical Cause of Death was: Ta Head Injury The conclusion of the Inquest was that Beryl Fricker died as a consequence of a road traffic collision. 4 | CIRCUMSTANCES OF THE DEATH At approximately 4.30 pm on 20th November 2018, Mrs Fricker was a pedestrian on Lake Road in Poole, walking towards Blandford Road. It was dusk, and the street lamps were illuminated. I heard evidence that the vehicles travelling along Lake Road had their headlights illuminated. As Mrs Fricker crossing Upwey Avenue, she was struck by a Toyota Yaris being driven b' a ,.; turning right into Upwey Avenue from Lake Road. Bystander CPR was commenced and paramedics attended. Mrs Fricker was taken to Southampton Hospital where she sadly died of her injuries on 30th November 2018. 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. During the inquest, the following evidence was heard: i, P| the driver of the Toyota Yaris, explained that she did not see Mrs Fricker as she turned into Upwey Avenue. She gave evidence that the street lighting at the junction is poor, which was reiterated to her by members of the public who spoke to her after the collision. In addition, I heard evidence from 2 further witnesses that the street lighting at the junction was poor. One of those witnesses was i 2 Royal Marine Medic, who was returning home from work and drove passed the collision site EM was one of the member of the public who was able to provide treatment to Mrs Fricker before the arrival of the paramedics. He was independent of all those directly involved in the collision. 2. I have concerns with regard to the following: i. Upwey Avenue is a wide junction, with the nearest street lamps some distance from the junction itself. As a consequence the middle of the junction appears to be the least well illuminated section of that stretch of road. The surrounding area is residential and there are a number of local schools, including infant and secondary schools, so there is likely a significant number of pedestrians, cyclists and other road users travelling along Lake Road. ii, I request that, to prevent future deaths, consideration is given to the street lighting at the junction of Lake Road and Upwey Avenue and whether improvements can be made to better illuminate the junction for all road users. ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I 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 25" March 2020. 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: oo | daughter of Mrs Fricker; (2 EES driver of the Toyota Yaris. Tam 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. Dated Signed 28" January 2020 Brendan J Allen
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.
Growth and Infrastructure - Transportation
Civic Centre
Poole, BH15 2RU
The Coroner’s Office for the County of
Dorset
Bournemouth Town Hall
Bournemouth
BH2 6DY
Date: 11th March 2020
Your Ref:
Our Ref:
Contact:
Email:
Tel: 01202 262073
For the attention of Mr Brendan J Allen HM Assistant Coroner for Dorset
Dear Mr Allen,
Re: Regulation 28 report – Inquest Touching the death of Beryl FRICKER
I refer to your letter dated 29th January 2020 to the BCP Council’s Chief Executive,
, and the Inquest touching the death of Beryl Fricker held on 14th January 2020.
I was very sorry to learn of this incident and I would like to pass on my sincere condolences to
family and friends with regards to their loss both personally, and on behalf of the Council.
With regards to your report to prevent future deaths under Regulation 28 of the Coroner’s
(Investigations) Regulations 2013 I would respond as follows.
Fatal Accident Investigation
The factual information available to BCP Council indicates that Beryl Fricker died as a result of
a head injury received as a consequence of a road traffic collision with a car in Upwey Avenue,
Hamworthy, Poole, at its junction with Lake Road, at 16.35hrs on Tuesday 20th November 2019.
BCP Council carries out joint investigations into all fatal road traffic collisions in conjunction with
the Dorset Police Road Casualty Reduction Officer. With regards to the incident on Upwey
Avenue, the site was visited by officers on Monday 10th December 2019 (see Appendix A).
The relevant observations to be highlighted as a consequence of this joint investigation included
noting that at the time of the incident, it was cloudy and fast approaching dusk; the streetlighting
present in the area was working at the time of the collision; the pedestrian was wearing dark
clothing; although the vehicle was moving at a low speed the pedestrian was not spotted
crossing by the driver of the car until it was too late to avoid a collision.
Investigation into Street Lighting Illumination Levels
‘BCP Council’ is the operational name for Bournemouth, Christchurch and Poole Council.
bcpcouncil.gov.uk
2
As I understand it, you have indicated in your report that during the course of the inquest the
evidence revealed matters giving rise to concern, namely that in your opinion there is a risk that
future deaths will occur unless action is taken to improve streetlighting levels at the middle of
the junction. You have therefore requested that consideration is given to better illuminating the
junction for all road users.
There are other possible explanations for the failure of the driver to see Beryl Fricker crossing
the road which are unrelated to lighting levels. For example, the driver's visibility of the
pedestrian could have been inhibited by the vehicle’s A-pillar rather than the lighting levels, and
changing the lighting would not have prevented it.
Another issue is that at the time of the collision (dusk), ambient lighting levels may
have been high enough that any street lighting would have been basically ineffectual depending
on the level of cloud cover (sunset was at 16:15hrs and civil twilight ended at 16:52hrs on
that day in Poole).
BCP Council’s policy is that it illuminates subsidiary roads and footpaths to lighting class P4 in
accordance with BS5489-1:2013 (Code of practice for the design of road lighting). The Council
Streetlighting Engineer has checked the current street lighting provision at the Upwey Avenue
Lake Road junction by way of producing a lighting report using specialist design software.
This report indicates that the existing lighting levels around the junction are standard and
appropriate for this location in terms of the recommended British Standard for the Lighting of
Subsidiary Roads & Footpaths (see Appendix B, Upwey Avenue Lighting Design for further
reference). This lighting class requires the following performance levels and alongside these are
the lighting levels being provided by the existing lighting:
Performance Requirement
Average illuminance over an area (in lux)
Minimum illuminance on an area (in lux)
Class P4
Levels
3.75 - 5.63
0.75
Existing
Lighting
4.95
0.75
The measurement of illuminance (in lux) basically refers to the level of brightness provided by
the lighting. The above shows that the current lighting around the junction is consistent with the
appropriate British Standard requirements for this situation, albeit meeting the minimum
illuminance level required of 0.75 lux.
For further reference, the street lights in the area use 19W LED lights that were installed in 2016
(Lake Road and Dean Close) and 2017 (Upwey Avenue). These emit a ‘white’ light to a CCT
(colour temperature) of 4000K. All of the lamp posts are 5 metres in height, apart from column
no. 3 on the western corner of Lake Road and Upwey Avenue which is 6 metres high.
In order to carry out a full and detailed assessment of the actual illumination levels on site using
light meters, we are required to visit the location during the day to measure and mark out several
light calculation points on the road and footway, and then follow up with a visit during the hours
of darkness. Unfortunately, the streetlighting team haven’t been able to carry out the required
site inspections due to the weather conditions. This is because the inclement conditions we
have experienced recently have meant the road surfaces were still fairly wet in the evenings,
and this factor can easily influence the ambient lighting levels we measure.
I can assure you that a site assessment will be carried out shortly when the weather conditions
are more suitable. The results of this survey will then determine our proposals for any potential
amendments or improvements, if considered necessary. BCP Council would not normally make
any improvements to the existing illumination levels at the junction unless this was specifically
recommended as part of any safety report.
Addressing Concerns/Action Plan
3
We do have a specific priority to reduce pedestrian casualties, particularly in our urban areas.
The Council regularly reviews all collisions that result in casualties across its whole road
network, and in the context of our objective of reducing casualties. We do this by focusing our
limited resources on ‘hotspot’ locations that have 7 or more casualties within a 5 year period
that also fall in a 50m radius.
Given this was only the second recorded injury road traffic collision at this location since May
1987, and the collision record for this location is very low, it appears unlikely that another serious
incident will occur here.
Irrespective of these observations however, the Council does take your concerns seriously.
Firstly, we will undertake to investigate whether any improvements to illumination levels can
sensibly be made at the junction once we have carried out a more detailed survey using a light
meter. This is provided that an improvement here would do no harm. For example, upgrading
lighting could be a disproportionate measure because it may potentially require upgrading all
similar junctions, and also it could possibly result in a mismatch of illumination provision along
Lake Road.
Secondly, in addition to the issue of illumination levels you would appear to raise concerns that
the road layout in some way has either contributed to or at least failed adequately to prevent the
collision, and that there is a potential for further similar collisions given how wide it is across the
Upwey junction with no central refuge.
As with all similar requests received for pedestrian improvements of this nature, the Council will
undertake an initial assessment of the pedestrian provision at the junction and determine
whether it is feasible to either provide a central refuge island or alternatively narrow down the
junction mouth to improve visibility as part of a road safety engineering intervention. The
assessment process includes recording measurable factors such as the number of pedestrians
crossing at peak times, the volume of traffic as well as judging the difficulty people have in
crossing the road.
Please be assured that BCP Council will do what it can to progress these potential options,
however, it is not possible to provide timescales at present. It should be noted that funding for
any schemes recommended as a result of these assessments is limited and there is already a
long waiting list of similar improvements across the authority.
I will also ensure that officers are aware of the need to progress relevant survey and prioritisation
work so that we can consider further and respond back to you with additional update information
in due course.
I trust that the above response is helpful but please feel free to contact me again if you require
further clarification about any point I have raised.
Yours sincerely
Service Director
Growth and Infrastructure
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