Prevention of Future Deaths reports · 2020

Millie Taylor-Noonan

Regulation 28 report to prevent future deaths, reference 2020-0097, written 15 Apr 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report15 Apr 2020
Reference2020-0097
DeceasedMillie Taylor-Noonan
CoronerTimothy Brennand
Coroner areaLincolnshire
CategoryRoad (Highways Safety) related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO:

1. Lincolnshire County Council Highways Department

1.

CORONER

I am Timothy BRENNAND HM Senior Coroner for the coroner area of Lincolnshire, 4
Lindum Road, Lincoln, Lincolnshire, LN2 1NN.

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.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made

3.

INVESTIGATION and INQUEST

On 12/12/2018 I commenced an investigation into the death of Millie TAYLOR-NOONAN,
aged 18. The investigation concluded at the end of the inquest on 25/09/2019. The
conclusion of the inquest was that Millie TAYLOR-NOONAN died as a result of Road
Traffic Collision, the medical cause of death being:

Head Injury Sustained in a Road Traffic Collision

1a.
1b.
1c.
2.

4.

CIRCUMSTANCES OF THE DEATH

On the afternoon of Tuesday 4th December 2018, whilst as a pedestrian crossing the A607
road adjacent to The Sir William Robertson School, Welbourn, Lincolnshire, the deceased
stepped into the road and was immediately struck by a car being driven in a lawful and
appropriate manner that the deceased had failed to appreciate being in close proximity to
her.
As a consequence of the collision, the deceased suffered a significant head injury and
cardiac arrest. She received active resuscitation at the scene and was transferred to the
Queen's Medical Centre, Nottingham. The nature and extent of the brain injury was such
that her condition was considered to be un-survivable. She was declared to be brain stem
dead at 14:42 on the 5th December 2018. Following organ donation procedures, active
support was withdrawn and she was formally to be pronounced as dead.

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

1. The location of the collision is in the immediate vicinity to the access and exit

entrances to a large secondary school;

2. Whilst motorists have the benefit of advanced warning triangles indicating to road

1

 users that there is a school 100 ahead along with a speed limit repeater the
location of the incident took place near a dropped kerb with a section of tactile
pavement on the footpaths either side of the road, there is no indication to road
users as to the imminence of what, was in reality a school crossing area and the
area is also unlit;

3. The evidence demonstrated that the deceased may have been distracted by other
road traffic users and in particular a school bus emerging from the school premises
in the immediacy of the collision that serves to demonstrate the vulnerability of
pedestrians in this location at such a time;

4. There are no other measures that exist to protect pedestrians such as:

a. Railings;
b. Street lighting;
c. An automated or zebra or other form of crossing to allow a priority to be given

to pedestrians;

d. A school crossing patrol officer;
e. A temporary reduction in the speed limit to 20 miles per hour at the beginning

and end of the school day;

6.

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and I believe 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 10/06/2020. 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.

8.

COPIES and PUBLICATION

I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons

(a)

(b)

(c) Lincolnshire Collision Investigation Unit

Witham Park House
Lincoln

(d)The
Chairman of the Board of Trustees
Aspire Schools Trust
Main Road
Welbourn
Lincoln
LN5 0PA

I am also under a duty to send the Chief Coroner a copy of your response.

2

 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.

Date: 15/04/2020

Timothy BRENNAND
HM Senior Coroner

3

Responses

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.

Response from Lincolnshire County Council (PDF)
Mr Timothy Brennand 
Lincoln Coroners' Court & Office 
4 Lindum Road 
Lincoln 
LN2 1NN 

Our ref: AG/AH 

08 October 2020 

Dear Mr Brennand 

Executive Director for Place 
Lincolnshire County Council 
County Offices 
Newland 
Lincoln  
LN1 1YL 

01522 782070 
cschighways@lincolnshire.gov.uk 

REGULATION 28 REPORT – MILLIE TAYLOR-NOONAN (DECEASED) 

Thank  you for your letter dated  20  April 2020  enclosing  your Regulation 28  Report 
following  the  inquest  investigating  the  death  of  the  late  Millie  Taylor-Noonan.    As 
required  under  Section  7  of  your  report,  I  have  now  considered  your  points  and 
respond accordingly. 

Your concerns listed in the report are: 

1. 

2. 

3. 

4. 

The location of the collision is in the immediate vicinity to the access and exit 
entrances to a large secondary school. 
Whilst motorists have the  benefit  of advanced  warning  triangles  indicating  to 
road  users  that  there  is  a  school  100yds  ahead  along  with  a  speed  limit 
repeater  the  location  of  the  incident  took  place  near  a  dropped  kerb  with  a 
section of tactile pavement on the footpaths either side of the road, there is no 
indication to road users as to the imminence of what, was in reality a school 
crossing area and the area is also unlit. 
The evidence demonstrated that the deceased may have been distracted by 
other  road  traffic  users  and  in  particular  a  school  bus  emerging  from  the 
school premises in the immediacy of the collision that serves to demonstrate 
the vulnerability of pedestrians in this location at such a time. 
There are no other measures that exist to protect pedestrians such as 
a.  Railings: 
b.  Streetlighting 
c.  An  automated  or  zebra  or  other  form  of  crossing  to  allow  priority  to  be 

given to pedestrians 

d.  A school crossing patrol officer 
e.  A  temporary  reduction  in  the  speed  limit  to  20  mph  at  the  beginning  and 

end of the school day 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 The  incident  occurred  on  the  A607  Cliff  Road  between  Leadenham  and  Welbourn 
adjacent to  the  Sir William  Robertson Academy.  Lincolnshire  County  Council  is the 
relevant Highways Authority. The Academy is a large secondary school which is part 
of the Aspire School Trust.  

As the deceased was a student at the Academy we have worked with the school to 
look at enhancing road safety around the entrance to the school grounds as well as 
the highway itself, details of which are set out below.  

With  regard  to  your  second  point,  the  school  entrance  benefits  from  both  advance 
warning triangles and a 30mph speed limit. There is no School Safety Zone present 
in  the  vicinity  as  these  are  largely  designed  for  primary  schools  where  pupils  will 
generally  have  less  road  safety  awareness  and  where  parking  around  school 
entrances may be an issue. These factors do not apply to this location. Further, we 
confirm  that  we  have  no  record  of  any  other  incident  involving  a  pedestrian  at  this 
location within the last 20 years.  

However, it is agreed that the conspicuity of the school entrance could be enhanced 
and I shall outline our proposed measures below. 

With regard to your third point, a joint examination with the Academy of the school's 
vehicular  access  arrangements,  which  currently  operate  as  a  one-way  system 
utilising the northern access and southern exit, was carried out at school exit times. 
For  the  internal  operation  within  the  school  premises,  of  children  boarding  and 
exiting  buses,  this  is  the  safest  option.  An  option  to  reverse  this  arrangement  was 
considered  but  it  was  agreed  this  would  create  queuing  vehicles  on  the  highway 
which would obscure pedestrian and vehicle visibility and, at worst, actually prevent 
crossing of the road.  

Your fourth and final concern relates to a request that a number of individual control 
measures are considered. 

a.  At this location the width of the footway is such that the installation of guardrail 
would require significant widening works and affect underground utility services. 
Safety  concerns  would  also  be  created  due  to  reduced  highway  visibility  for 
properties  opposite  the  school;  and  also  the  risk  that  pedestrians  may  be 
tempted  to  walk  outside  the  barrier  if  the  footpath  was  occupied  by  other 
waiting pedestrians. It is not considered to be reasonably practicable to provide 
guardrail taking into account the above issues.  

b.  The provision of Streetlighting at this location does not meet the requirements 
of the County Council's Streetlighting Policy. However, the school feel that this 
request  would  have  the  most  significant  benefit  and  the  Executive  Councillor 
has authorised its installation as an exceptional case. 

c.  Unusually for a large academy the vast majority of pupils access this school by 
coach/bus.  The school roll shows that only 15 children live in Leadenham and 
16 children live in Welbourn and physical counts at exit time showed less than 
50  pupils  cross  the  road.  As  such  this  location  does  not  meet  the  minimum 
criteria  to  provide  a  light  controlled  crossing.  However,  the  school  has  now 
provided a teacher to effectively marshal and hold students at the school gate 
until it is safe to cross the road; effectively providing a safe method of crossing. 

 
 
 
 
 
 
 d.  Similarly, whilst a School Crossing Patrol does not meet the necessary criteria 
in  terms  of  numbers  of  pupils  who  would  use  that  patrol,  as  the  school  have 
volunteered  the  services  of  their  staff  at  the  pedestrian  exit  this  provides  a 
suitable alternative that ameliorates the risk. 

e.  The  benefits  of  a  temporary  speed  limit  are  a  matter  of  debate  nationally  as 
evidence  suggests  such  a  measure  may  not  have  the  effect  of  reducing 
average  speeds.  The  County  Council  does  not  therefore  have  a  policy  of 
implementing  temporary  speed  limits  of  20  mph  in  place.  However,  as 
mentioned above it is agreed that the conspicuity of the school entrance can be 
enhanced.  Therefore,  we  will  carry  out  works  this  year  to  place  improved 
roadmarkings including SLOW and yellow SCHOOL zig-zag markings adjacent 
to the entrance. We will also install additional school warning signs and finally 
we  will  provide  school  amber  flashing  lights  to  raise  awareness  at  start  and 
finish times. 

I trust the above addresses your concerns and outlines our plans for this section of 
highway. 

Yours sincerely 

Executive Director for Place

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