Prevention of Future Deaths reports · 2020
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 report | 17 Feb 2020 |
|---|---|
| Reference | 2020-0029 |
| Deceased | Liam Seager |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Road (Highways Safety) related deaths · Alcohol, drug and medication related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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
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.
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
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 Page 2 of 6 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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