Prevention of Future Deaths reports · 2020

Liam Seager

Regulation 28 report to prevent future deaths, reference 2020-0029, written 17 Feb 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report17 Feb 2020
Reference2020-0029
DeceasedLiam Seager
CoronerMary Hassell
Coroner areaInner North London
CategoryRoad (Highways Safety) related deaths · Alcohol, drug and medication related deaths
Sourcejudiciary.uk record · original PDF
Responses published2

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

Regulation 28:  Prevention of Future Deaths report 

Liam Floyd SEAGER (died 01.01.19) 

THIS REPORT IS BEING SENT TO: 

1.  Mr Mike Brown 
Commisioner 
Transport for London 
5 Endeavour Square 
London E20 1JN 

2.  Mr Will Tuckley 
Chief Executive 
Tower Hamlets Council 
Mulberry Place 
Town Hall 
5 Clove Crescent 
London E14 2BG 

1 

CORONER 

I am:   Coroner ME Hassell 
           Senior Coroner  
           Inner North London 
           St Pancras Coroner’s Court 
           Camley Street 
           London  N1C 4PP 

2 

CORONER’S LEGAL POWERS 

I make this report under the Coroners and Justice Act 2009,  
paragraph 7, Schedule 5, and  
The Coroners (Investigations) Regulations 2013, 
regulations 28 and 29. 

3 

INVESTIGATION and INQUEST 

On 4 January 2019, I commenced an investigation into the death of Liam 
Floyd Seager, aged 24 years. The investigation concluded at the end of 
the inquest on 14 February 2020. I made a determination at inquest that 
death arose from a road traffic collision. 

4 

CIRCUMSTANCES OF THE DEATH 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Liam was knocked over and killed by a transit van at approximately 3am 
on  New  Year’s  Day  2019,  when  he  was  crossing  the  A12  southbound 
underpass  between  Old  Ford  Junction  and  Bow  Interchange.    His 
judgement  was  impaired  by  alcohol  and  drugs,  and  the  driver  was 
travelling in excess of 20mph above the speed limit of 40mph. 

The medical cause of death was: 
1a  multiple injuries 
1b  blunt force trauma 
2    ethanol and MDMA intoxication 

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 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.  

I heard at inquest that there is no pedestrian crossing on the A12 near 
the location of the collision. 

1.  Transport for London has indicated that it hopes to have a traffic 
management  order  in  place  by  June  2020,  which  will  prohibit 
pedestrians from crossing at this point.  I am concerned that we 
are still four months away from this. 

2.  Once  the  traffic  management  order  is  in  place,  a  pedestrian 
crossing is needed to make it easier for pedestrians to cross the 
top of the A12 at Wick Lane.  Even before this, Tower Hamlets 
could  undertake  useful  preparatory  work  to  enable  the  build  to 
proceed quickly following the TMO. 

6 

ACTION SHOULD BE TAKEN 

In  my  opinion,  action  should  be  taken  to  prevent  future  deaths  and  I 
believe that you 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 20 April 2020.  I, the coroner, may extend the 
period. 

2 

 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 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 following. 

  HHJ Mark Lucraft QC, the Chief Coroner of England & Wales 
 

, parents of Liam Seager 

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 Senior Coroner, at the time of your response, 
about  the  release  or  the  publication  of  your  response  by  the  Chief 
Coroner. 

9 

DATE                                                  SIGNED BY SENIOR CORONER 

17 February 2020 

3

Responses

2 responses 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.

Response from Tower Hamlets Council (PDF)
Coroner Mary Hassell 
Senior Coroner 
Inner North London 
St. Pancras Coroner’s Court 
Camley Street 
London   
N1C 4PP 

Also sent by email: 

10 March 2020 

Dear Coroner Mary Hassell, 

Re: Liam Floyd SEAGER 

Chief Executive’s Office 

Town Hall 
Mulberry Place 
5 Clove Crescent 
London 
E14 2BG 
Tel 
Fax 
Our ref  WT/CE/n:letters/letter to mary hassell snr 
coroner re liam floyd seager A12  10.03.2020  
Your ref   
Email   

020 7364 1363 
020 7364 3232 

  (P.A.) 

www.towerhamlets.gov.uk 

We refer to the Prevention of Future Deaths report in respect of Liam Floyd Seager dated 
17th February 2020.  

We are all saddened and shocked by this unfortunate incident and our thoughts are with his 
loved ones.  

Tower Hamlets Council has produced detailed plans for new pedestrian phases to be 
incorporated into the signalled junction of the A12 / Wick Lane to provide protected 
pedestrian crossing.  These have been discussed with the Police and TfL and it is 
recognised that the railings around the crossing landing points at the top of the slip roads 
provide an additional deterrent to pedestrians seeking to cross the A12. The railings will also 
provide space for additional signage indicating that pedestrians are not permitted to walk 
along the A12. 

These works will commence once approval is secured from TfL to close the A12 slip roads 
for 4 days to facilitate the necessary footway widening work. Those approvals are being 
sought as matter of urgency.  

Yours sincerely 

Chief Executive
Response from Transport for London (PDF)
Your ref:  2020-0029 

Coroner ME Hassell 
Senior Coroner 

Inner North London 
St Pancras Coroner’s Court 
Camley Street 
London N1C 4PP 

Transport for London 
Surface Transport 

11th Floor Palestra Building 
197 Blackfriars Road 
Southwark 
London SE1 8NJ 

Phone 020 3054 8196 
tfl.gov.uk 

27 April 2020 

Dear Ms Hassell, 

Regulation 28 Prevention of Future Deaths Notice:  
Liam Floyd SEAGER (Inquest 14/03/2020) 

I am personally, very sorry to hear of the tragic death of Mr Liam Seager and 
wish to express my sincere condolences and those of Transport for London 
(TfL) to the family and friends of Mr Liam Seager. 

Please accept this letter as TfL’s response to the Prevention of Future Deaths 
(PFD) report dated 17 February 2020 pursuant to regulation 28 of the Coroners 
(Investigations) Regulations 2013. The Commissioner and the Managing 
Director of Surface Transport have asked me to write to you.  This letter outlines 
actions already taken and those that we intend to take to improve safety along 
the A12.  

TfL is a Highway Authority and is the responsible highway authority for the A12 
by Wick Lane.  The London Borough of Tower Hamlets (LBTH) is the highway 
authority for Wick Lane adjacent to the A12. We have had discussions with 
LBTH regarding our joint approach to improve the pedestrian movement in the 
area. The A12 was designed and constructed originally as an urban motorway 
and therefore, without pedestrian facilities. The road did not require any signage 
prohibiting pedestrian access at the time of building (prior to TfL’s creation) due 
to its classification as a motorway (pedestrians are prohibited from motorways).  
It was reclassified as an ‘A’ road before TfL took over responsibility for it as 
highway authority in 2000 when TfL was created. 

Road safety, particularly the reduction of personal injuries, is core to our 
business at TfL. We actively seek to reduce collisions across the whole of 
London with initiatives detailed in the Mayor’s Transport Strategy (March 2018) 
and the Vision Zero Action Plan (July 2018). These policy documents set our 
vision to eliminate all deaths and serious injuries by 2041, as well as reduce the 
road danger on our road network. These documents outline the important first 

 
 
 
 
 
 
 
 
 
 
 
 
 
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stages in a wide-ranging programme of actions that we, as an organisation, are 
taking now and over the coming years. 

It is our standard practice and part of our wider commitment to Vision Zero to 
organise a visit to the site of every fatal incident that occurs on TfL’s road 
network. We aim to carry out a visit within 48 hours from when the incident 
occurs to identify any issues and actions that can be taken immediately to 
prevent future loss of life. 

These site visits involve TfL employees with different expertise within the 
organisation who review the site to collectively identify any inherent problems at 
the location that need to be addressed immediately. Also noted during the site 
visits are any other issues that may require a longer-term investigation of the 
highway conditions or any issues relating to the behaviour of road users, that 
may need to be addressed by TfL’s road safety education team and/or 
enforcement by the Metropolitan Police (MPS). In this case, the initial site visit 
by TfL took place on 3 January 2019. 

We undertook a further site visit on 4 February 2019 once the Police Serious 
Collision Investigation Unit (SCIU) had conducted the collision investigation.  
This site visit involved a drive through the area organised by the MPS (who 
were in attendance) where we undertook a more detailed review of the A12. We 
identified precautionary actions that could be taken along the route to reduce 
risk, especially at the key locations of Wick Lane, Bow Roundabout and 
Hackney Wick, where pedestrians are more likely to access the A12.  

Following these site visits, we set up and held a series of joint TfL/MPS 
meetings. These meetings led to coordinated activities and we collectively 
drafted an Action Plan with safety improvement recommendations that were 
quickly put forward for development and implementation. The meetings were 
held on 8 March, 15 April and 6 September 2019, along with key progress 
updates via email on 12 December 2019 and 30 March 2020. 

A summary of the interventions that were identified in the Action Plan included: 

•  Measures to prohibit pedestrian access to the A12; 
•  Renewing the road markings and cats’ eyes along this section of the 

A12; 

•  Reconfiguring the road safety cameras; 
•  Adjusting the luminosity of the digital advertising boards; 
•  Trialling a speed reduction campaign;   
•  Meeting with the LBTH to coordinate our joint measures including 
improved better pedestrian routing with wayfinding and signalised 
crossings at Wick Lane; 

•  Setting timeframes to review the decision to remove the street lighting;  
•  Considering a longer-term plan to work with the adjacent local authorities 
to seek out opportunities to construct new and additional pedestrian 
crossings over the A12. 

 
 
 
 
 
 
 
 
 Page 3 of 6 

Prohibiting pedestrian access to the A12 

We have physically inspected and identified over 20 locations between Bow 
Roundabout and George Green Tunnel where pedestrians can access the A12. 
We are in the process of implementing a Traffic Regulation Order (TRO) at 
these locations with appropriate signage to prohibit and deter pedestrian 
access. Once in place, the TRO will provide the Police with the authority to take 
enforcement action if anyone attempts to walk along the slip road to access the 
A12.  

There is a statutory process set out in the Road Traffic Regulation Act 1984 and 
Local Authorities Traffic Orders (Procedure) (England and Wales) Regulations 
1996 (The ‘Regulations’) that we and all Highway Authorities must follow to 
implement a TRO. In brief, the statutory process requires a process of informal 
and formal consultation, publication of statutory notices and a requirement to 
make TRO documents/plans available to view by the public.  Following the 
consultations, TfL, after considering any responses received from any 
interested parties will then decide whether to proceed with implementing the 
TRO.   

Once we have undertaken the necessary statutory steps, the final stage of this 
process is to erect the necessary signage and any other supplementary 
interventions such as road markings. These signs (item 22 diagram 651.1, item 
21 diagram 951 and item 24 diagram 622.6 referenced in Table 1) must adhere 
to the Traffic Signs and General Directions 2016 (UK Statutory Instruments 
2016 No. 362 Schedule 3 Part 2). Without these signs, the TRO is not 
enforceable by the MPS.   

Table 1 Signs to be erected in accordance with TSRGD 2016  

Item 22 
Diagram 625.1 
Pedestrians prohibited 

Item 21 
Diagram 951 
Riding of pedal cycles prohibited 

Item 24 
Diagram 622.6 
Ridden or accompanied horses prohibited 

At the date of the Inquest, works were proceeding well, and it was planned to 
publish a Notice of Proposal for the TRO by May 2020 and then subject to any 
objections which may impact the TRO as proposed, a decision would be taken.  
If the decision was taken to proceed with the TRO, the plan was to install 
signage on-site during June 2020. 

 
 
 
 
 
  
 
 
 
 
 
 
 Page 4 of 6 

However, due to the current health crisis caused by COVID-19 pandemic, we 
are following Government guidance in respect of the operations we can 
continue whilst following social distancing. As such and considering the 
pandemic, we may be unable to carry out the remaining activities to put in place 
the TRO.  When it is safe to undertake necessary works in respect of the TRO 
(and in accordance with guidance from the Department of Transport), this work 
will be a priority.  

Reducing road danger along the A12 

In addition to measures to prohibit pedestrian access to the A12, additional 
complementary measures were identified in the Action Plan to reduce road 
danger along the route of the A12. These measures are outlined below to 
demonstrate TfL’s commitment to accident prevention. 

Road markings and cats’ eyes 

As part of the management of our road assets, we conducted a review of the 
road markings along the A12 and decided to renew/replace them to encourage 
better lane discipline by making the demarcation of the lanes more visible. By 
the end of March 2020, we have replaced over 70% of the road studs and cats’ 
eyes. 

Safety cameras 

TfL provides the safety cameras on the road network in London and they are 
operated by the MPS for enforcement. Not every camera is operational all the 
time and neither TfL nor the MPS identify to the public which cameras are 
operational or non-operational as they both can provide a deterrent to speeding. 
As part of the Action Plan, four safety cameras along this section of the A12 
were re-calibrated, upgraded and site tested against the relevant standards and 
subsequently handed over to the MPS for the enforcement of the speed 
restrictions.  

Digital advertising screens 

There are four digital advertising screens located on or near the A12 near Wick 
Lane. All four signs were erected after receiving planning permission and are 
operated and maintained in accordance with the relevant standards. Two of 
these digital signs are owned by TfL and we have control over the operation of 
the signs and advertisements shown. We have no jurisdiction or control over the 
two screens which are on private land.  

The signs are extremely large and display both static advertisements and short 
videos. The two sites owned by TfL span over the A12, and we reviewed the 
luminosity of these signs during the hours of darkness and confirmed that their 
operation was within permitted technical standards. However, we decided to 

 
 
 
 
 
 
 
 
 
 
 
 Page 5 of 6 

further reduce their illumination to the lowest possible level to reduce the 
possibility of glare to passing motorists. 

On the two digital advertising boards that span the A12 near Leytonstone 
Station, we displayed speed reduction messages for a trial two-week period 
from 9 December to 22 December 2019.  The message operated on a rolling 
programme and continually rotated between other advertisements. The 
message was designed as part of the speed reduction awareness campaign 
promoted by TfL throughout London over the Christmas period as part of our 
Vision Zero Action Plan. 

Street lighting 

When the Blackwall Tunnel Northern Approach Road was constructed, it had 
around 200 street lighting columns in this section. During the winter of 2016/17, 
two of these columns structurally failed; one of them fell away from the 
carriageway, the second fell into the A12 carriageway causing no damage or 
injury. The assets were 30 years old with a projected design life of 40 years. In 
accordance with the management of all our assets, the columns had an 
inspection and testing regime for the age and location. However, following 
these two structural failures (in high winds) 10 years before the end of their 
design life, the failures raised concerns and triggered more in-depth testing: this 
identified more advanced corrosion than expected for their age. 

There is no technical requirement for street lighting to be provided in this road 
section and resulted in the decision to remove all the lighting columns on safety 
grounds for a trial two-year period.  

The trial period ended in April 2020 and will be reviewed over the coming 
months using information from the latest technical standards. Then a decision 
will be made if this section of the A12 will continue to be unlit or if the lamp 
columns should be replaced.   

Joint work between TfL and LBTH 

We met with senior Tower Hamlets Council officers and representatives from 
the MPS on 29 October 2019 to plan and coordinate our proposals for this 
location and jointly agree on timescales for implementation.  

The planned measures include action by TfL to prohibit pedestrian access to 
the A12 and for the LBTH to design and construct a new pedestrian crossing at 
the mouth of the junction and to provide new wayfinding signs to direct 
pedestrians over the A12 via a safe crossing point.  

In addition, we have been working with the other London boroughs along the 
route to develop improved wayfinding signs at other locations to provide 
positive advice and direction to pedestrians on where to cross the A12.  

 
 
 
 
 
 
 
 
 
 
 
 
 Page 6 of 6 

As part of our longer-term strategic plans, we will continue working with the 
relevant London boroughs to identify and establish new and improved 
pedestrian crossing opportunities across the A12. These plans may include 
long term development proposals and are dependent on both the private and 
public sectors, as well as the use of land outside the highway boundary. 

We would be happy to provide you with an update in respect of the timings for 
implementing the TRO as discussed above.  

Yours sincerely, 

Director, Investment Delivery Planning 
Surface Transport 

Email:

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