Ellie Isaacs

Havering

imme LONDON BOROUGH London Borough of Havering
Highways
Town Hall
Main Road

East London Coroners Romford

Miss N Persuad RM1 3BB

Senior Coroner

Telephone: 01708 434894
Walthamstow Coroners’s Court
Queens Road
Walthamstow
E17 8QP

Date: 26% October 2020

REF:110991
Dear Miss Persuad,

Please find below our response to the Regulation 28 (Preventing Future Deaths) report sent to
us on 4" September 2020, reference

The incident location within the Regulation 28 (Preventing Future Deaths) report is on
Colchester Road, classified as the A12, approximately 65 metres north east of the Gallows

Corner roundabout.

The extract below taken from Havering Councils Highways Register overlay on Earthlight shows
that this location in black, along with the boundary of the adopted highway (red is footway, pink
is carriageway).

Boundary of the adopted highway taken from Haverings Hghways Register on Earthlight

While Colchester Road is part of the adopted highway network, Havering Council are not the
Highway Authority for this road, this responsibility falls to Transport for London (TfL). The plan
shown below shows the boundary of TfLs responsibility around Gallows Corner roundabout and
also the section of Colchester Road where the crossing point is situated.

2 Come Lop wt abn A nrc Se

TFL supplied boundary plan.

The TfL an shows a dotted line as the kerb line along the edge of the footway, whie the solid
blue line that runs almost pararell to this line at the rear of the footway shows the limits of TfLs
responsibility as the Highway Authority.

We have been advised ae the metropolitan police he Transport for
London will be liaising dire coroners’ officer.

A site inspection was undertaken on Thursday 17 September to look at the incident site so that
Havering could give responses to the points raised in the coroner's report. While these
comments are made by a Senior Engineer at Havering it must be stressed that TfL would need
to carry out their own investigation as they would be ultimately responsible for any action (or
inaction) carried out to the highway network at this location.

POINT 1. The Inquest heard that there are a number of items of street furniture that
obstruct the view that drivers should have of pedestrians waiting at the Pelican crossing
(signage, bus stand, safety camera and overhanging foliage/tree branches).

While the report does not state which side of the crossing point the incident occurred, the bus
stand and safety camera are on the south east footway so it is this location that has been
investigated.

The footway at this location is split into a cycle way at the rear of the footway with the pedestrian
side adjacent to the carriageway. The safety camera is located at the rear the footway
approximately 25 metres before the crossing, within the cycle way section, and would not cause
any sight line issues for car drivers approaching the controlled crossing point.

Safety camera located at the rear of the footway.

Upon insection on the 17 September 2020 all the trees that are contained within the grounds of
the Gallows Corner Retail Park were found to be well cut back, with no branches lower than six
foot overhanging the footway. There were no bracnches overhanging the carriageway at all. At
the crossing point itself there is a street light that illuminates the crossing point at night, and this
area was found to be completely clear of any over hanging branches so there would be no
shadows over pedestrians waiting to cross at this point on the footway.

Pies ee

# | Se ea 2:
Unobstructed lamp column at the controlled crossing point.

All the bushes and the trees at this location are within the Gallows Corner Retail Park and
appear well maintained, causing no obstruction to the highway. There are no highway trees or
Council maintained verges at this location.

The bus stand is located at approximatley 55m before the controlled crossing point. When a bus
is stopped within the bus stand it blocks the near side running lane of the dual carriageway
which would tend to then slow traffic down as vehciles manouvre around the stationary vehcile.
At this distance the bus stand its self does not cause any obstruction to for sight lines to the
crossing point, and once any stationary vehicle that was occupying the bus stand had been
passed there would still be at least 55m between the drivers positon and any pedestrian waitng
at the crossing.

With regard to signage, there is no signage blocking site lines at the crossing point, and there is
very little signage on the approach to the controlled crossing either (see photos below). The
large roundabout sign is some 140m prior to the crossing point, and the only other road sign is a
“no u turn” sign approximately 70m before the crossing, neither of which would obstruct drivers
sight lines.

Although not mentioned in the report, but worthy of note, is the fact that there is pedestrian
guard railing along the length of the footway for approximately 30m prior to the controlled
crossing. As can be seen from the photo below there is a clear viewing panel through the guard
railing to aid drivers to see whatever is on the footway or waiting at the crossing point.

2. The Pelican crossing is sited shortly following a bend in the road and the immediate
speed limit approaching the crossing is 30 miles per hour. Very shortly before the Pelican
crossing, the speed limit is 50mph.

Travelling along the carriageway in a south westerly direction the boundary of the 50pmh/30mph
change is approximately 140m prior to the crossing point. Between the start of the 30mph zone
and the controlled crossing point is the speed camera which would encourage most vehicle
users to have reduced their speed prior to the crossing. It should be noted that it is TfLs
responsibility for setting the speed limits on the TLRN/SRN and the speeds currently set should
have taken into regard the current layout of the highway features at this location.

While on site there was no visible bend apparent in the carriageway along this length of the road
that would cause any sight line issues for drivers what so ever.

3. Arecent site visit noted a very high level of non-compliance with the automated traffic
signals. Vehicles were noted not to be stopping at the amber traffic light phase.

During the site visit on 17% September the non-compliance witnessed above was not seen. This
may well be down to the fact that someone standing near the crossing point dressed in black
wearing a high-viz jacket may have given the impression of a police presence in which case any
comment here is possibly flawed. In London it is the Metropolitan Polices role to enforce traffic
light control contraventions/speed offences etc. so it would fall to them to carry out any further
necessary investigation at this particular site.

While Havering Council are not the Highway Authority for this location they are responsible for
the cleanliness of the area as the Litter Authority. On inspection there area was clean, there was
no build-up of litter or detritus on the highway that would have had any input into this incident.

In conclusion we do not feel that there any actions Havering Council can take in relation to this
Regulation 28 (Preventing Future Deaths) report.

If you have any queries relating to any of these responses please do not hesitate to contact me
at a

Yours sincerely

Senior Engineer
Highways
L.B.Havering

Transport for London

Your ref: | |

Transport for London

Coroner N Persaud Legal
Senior Coroner

5 Endeavour Square
East London oe ny
Walthamstow Coroner's Court
Queens Road www.tfl.gov.uk
Walthamstow
E17 8QP

Dear Miss Persaud

Regulation 28 Prevention of Future Deaths Notice:
Ellie Jessalyn Isaacs (Inquest 01/09/2020)

| am personally very sorry to hear of the tragic death of Ms Ellie Isaacs and wish to
express my sincere condolences and those of Transport for London (TfL) to the
family and friends of Ms Isaacs.

We note that this Prevention of Future Deaths Notice is addressed to the London
Borough of Havering. The London Borough of Havering forwarded it to us on 15
September 2020 to respond to as TfL is the responsible Highway Authority for the
A12. Please accept this letter as TfL’s response to the Prevention of Future Deaths
(PFD) report dated 1 September 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.

TfL is a Highway Authority and is the responsible highway authority for the A12
Colchester Road for the section which is within London, that includes the location of
the collision and this letter outlines actions already taken and those that we intend to
take to improve safety along the A12 in the vicinity of the A12/A127 Gallows Comer
junction.

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 danger on our road network. These
documents outline the important first stages in a wide-ranging programme of actions
that we, as an organisation, are taking now and over the coming years.

Site Visits

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.
This is 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 collectively to 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 require enforcement by the
Metropolitan Police (MPS).

In this case, the initial site visit by TfL took place on 1 July 2019 and included traffic
officers from the MPS. No road user violation was noted during the site visit. This
section of the A12 is patrolled by the MPS. The MPS have not indicated any
additional concerns about this area which would result in increased enforcement
activity.

No immediate or urgent concerns were identified by the site visit. As part of this visit
the street furniture was reviewed and it was considered that it did not obstruct
drivers’ view of pedestrians in the area however issues with overgrown vegetation
were noted. A number of other minor action points were identified for follow up
(details of work then subsequently undertaken is provided below).

A further site inspection was undertaken by TfL Engineering's Traffic Control team
on 29 August 2019 following an enquiry from Ms Isaac's family which was forwarded
to us by the MPS regarding the location of the crossing facility. This inspection
determined that the design and operation of the pelican crossing met TfL’s current
design standards and this finding was communicated to the MPS. It additionally
determined that there was good visibility of the traffic signals which have five signal
heads on both approaches (with two positioned at 6m high and three at 4m high as
illustrated in the photos below).

>
Photo 1: A12 Colchester Road pelican crossing looking south-west towards Gallows
Corner (6m high signal heads highlighted blue; 4m high signal heads highlighted
red). Photo source: Google Streetview April 2018.

Photo 2: A12 Colchester Road pelican crossing looking north-east away from
Gallows Corner (6m high signal heads highlighted blue; 4m high signal heads
highlighted red). Photo source: Google Streetview July 2019.

Technical information about the crossing

The controlled pedestrian crossing facility in question was modemised in 2005 and it
was converted to a ‘ped-x’ type crossing in 2015. A ‘ped-x’ type crossing is a
standalone signal-controlled pedestrian facility using pedestrian signals which are
operated with push buttons. The traffic signal sequence is the same as at a junction
with a steady amber period for traffic (rather than flashing). Pedestrians receive a
steady green pedestrian symbol (rather than flashing) indicating that it is safe to
cross, followed by a black out period where no pedestrian signal is displayed,
followed by a red pedestrian signal (details of the timings of the crossing are
provided below).

The revised design was implemented in accordance with the TfL design standard at
the time (Reference TTS6). The implemented facility was fully compliant with this
standard at the time of modernisation.

In the intervening period TTS6 has been updated and a new set of TfL design
standards has been developed, including the following:

a) SQA-0643: Design for Signalised Junctions
b) SQA-0644: Design for Signalised Crossings
c) SQA-0645: Traffic Signal Timings

We have not provided copies of these design standards due to their detailed and
technical nature, however please let us know if the Coroner would like to see copies.
The above design standards outline the parameters for the design and operation of
traffic control facilities in London. The layout implemented on the A12 Colchester
Road is shown in TfL standard SQA-0644: Design for Signalised Crossings
Appendix E and is a “H2” layout (diagram replicated below in Figure 1), albeit with
the mast arm modified to two 6m poles on both sides of the crossing in accordance
with current best practice.

Figure 1: SQA-0644: Controlled Crossing Layout “H2”.

In accordance with the TfL standard SQA-0643: Design for Signalised Junctions, a
triangular warming sign is in place on the approach to the controlled crossing facility
at this location. The aim of the advance warning sign is to provide advance notice to
road users of the presence of the controlled crossing facility ahead.

The controlled crossing facility is programmed to show 6 seconds of the ‘green’
pedestrian signal (the green man), 6 seconds of signal black-out time and 5 seconds
of the ‘red’ pedestrian signal, there is then a 1 second ‘all red’ (pedestrian signals
and traffic signals showing red) followed by a 2 second starting amber signal for
traffic. This gives adequate opportunity for pedestrians to cross unopposed by

general traffic and is compliant with the relevant standards (TfL standard SQA-0645:
Traffic Signal Timings).

Speed limits and signage at Gallows Corner roundabout

Below is an aerial photo of the crossing. The speed limit for the Gallows Corner
roundabout is 30mph and remains so through the pedestrian crossing location for
traffic exiting the roundabout to travel north-east along the A12.

There is a speed limit change between 30/50mph which occurs on the other side of
the pedestrian crossing (approximately 130m to the north east) for traffic
approaching the roundabout. This road layout with the change of speed limit is in line
with relevant highway regulations.

a ¢

Y —-See travel times, traffic and nearby places

Work undertaken

Following the site visits referred to above a number of additional minor works have
been undertaken by TfL’s Asset Operations team in the vicinity of the pedestrian
crossing. These include:

a) liaison with the management team of the Gallows Corner Retail Park to request
regular maintenance and cutting of vegetation and trees within their property
boundary;

b) it was noted during the site visit that the 30mph signs were different sizes, the
sign in the central reservation and farside of the road were smaller than the sign

on the nearside. These signs were renewed and are now the same size; and

c) resurfacing of the Gallows Comer roundabout including both lanes of the A12
Colchester Road up to the junction with Bryant Avenue. This includes renewal of
the surfacing on the approaches to the pedestrian crossing, white lines and
markings (including 30mph warning markings), and the renewal of the bus stop
cage lining and red surfacing.

Conclusion

TfL will undertake a further safety review by the end of November 2020 to ensure
that the actions already taken address the matters of concern. As part of this review
we will also again consider the positioning of street furniture and whether it is safe. If
any further actions are identified through this review, TfL will address these by 31
March 2021.

In addition to the measures outlined above, TfL is preparing to submit a bid to the
Department for Transport (DfT) in late 2020 for Major Roads Network (MRN) funding
to deliver further improvements to the A12/A127 Gallows Comer junction.

Please do let me know if you require further information or { can be of direct
assistance to you in some way.

Yours sincerely,

Director, Investment Delivery Planning
Surface Transport