Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0262, written 1 Dec 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Dec 2020 |
|---|---|
| Reference | 2020-0262 |
| Deceased | Ibrahima Yahaia |
| Coroner | Emma Whitting |
| Coroner area | Bedfordshire and Luton |
| Category | Road (Highways Safety) related deaths, Community health care and emergency services related deaths and Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Senior Coroner - Emma Whitting Bedfordshire & Luton REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: , Chief Executive of Luton Borough Council Mr Town Hall George Street Luton Bedfordshire LU1 2BQ CORONER 1 I am Emma WHITTING, Senior Coroner for the area of Bedfordshire and Luton Coroner Service 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 Seventeenth January 2020 I commenced an Investigation into the death of Ibrahima YAHAIA aged 69. The investigation concluded at the end of the inquest on Fourth November 2020. The conclusion of the inquest was Accident. Ia Multiple Severe Injuries Ib Ic II Road Traffic Collision 4 CIRCUMSTANCES OF THE DEATH At around 17.55 hours on 15 January 2020, the Deceased was struck by a single decker bus whilst he was walking along the designated busway, instead of using the adjacent pedestrian footpath, close to Jeans Way, Luton. The bus was travelling between 50 and 52 miles per hour and the Deceased suffered fatal injuries; his death being confirmed by attending paramedics at 18.15 hours. Approximately one hour prior to the incident, the Deceased, a French non-English speaking national, had arrived by plane from Lyon, France, and, although family members believed they had arranged for him to have assistance so that he would be met by them at arrivals, the Deceased who suffered with memory issues, had left the airport alone. 5 CORONER’S CONCERNS ##DW<<corAddress>> Tel ##DW<<corTel>> | Fax ##DW<<corFax>> 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) There is a pedestrian footway which runs parallel to the Busway in places and pedestrians have access to the Busway at bus stops. Pedestrians may cross the Busway at the bus stops and there is no physical prevention for pedestrians to enter the Busway lanes. There is no signage on the Busway, itself stating pedestrians should not enter and only a small sign on a post by the footpath which states pedestrians should not trespass on the Busway. Although the footpaths which run parallel to the Busway are separated by fences, there are a number of places where pedestrians may freely enter the Busway. Hatters Way, Luton has many gaps in the fence, with no gate, giving pedestrians free access to roam in and out of the Busway lanes. There are no signs of bus stops near these gaps in the fences and, at the Bury Park end of Hatters Way, there is no fencing which again means pedestrians are free to enter the Busway lanes. Unlike train tracks, where the only way to get access is via a station, the Busway is easily accessed, yet it is just as dangerous; (2) There have been at least two other incidents on the Busway (involving serious injury/death) in the period from 9 February 2019 and 15 January 2020; (3) Evidence from the local Forensic Collision Investigation Unit suggests there are clear and evident design flaws with this Busway; (4) The local Forensic Collision Unit has seen no evidence of any steps being taken to prevent further vulnerable people from being injured/killed in incidents on this Busway. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you, Mr , have the power to take such action. 6 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 25 January 2021. 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: Mr (Deceased’s son) and the Forensic Collision Investigation Unit at Stevenage Police Station. 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 Bedfordshire and Luton Coroner Service Tel 0300 300 8383 | FAX 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 Emma WHITTING Senior Coroner for Bedfordshire and Luton Coroner Service Dated: 01 December 2020 Bedfordshire and Luton Coroner Service Tel 0300 300 8383 | FAX
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.
Luton Council Town Hall Upper George Street Luton LU1 2BQ www.luton.gov.uk 9th February 2021 Dear Ms. Whitting, On behalf of Luton Borough Council, I am responding to your PFD report dated 1st December 2020. I note that the Council were not invited to attend the inquest to assist you with your investigation into the tragic accident that resulted in the death of Mr. Yahaia on 15th January 2020. I understand that following his arrival on a flight at Luton Airport, Mr. Yahaia was provided with assistance by airport contractors, CCS, to meet him at the plane and escort him to his family who were to collect him at the arrivals area. However, he was left at the duty free exit to arrivals and then seems to have made his way out of the terminal building then boarding a bus from which he alighted at some point on its journey along the Busway in the Jeans Way area, in Central Bedfordshire. Background to the Busway The Busway was built on a disused railway track and opened in September 2013 following detailed consultation with experts as to the layout and safety measures required on the track, at crossing points and at stops. The Busway was developed as part of LBC’s and CBCs commitment to an integrated transport system. At no stage has LBC or CBC been advised that the Busway should be fenced along its entire length and indeed to do so would be prohibitively expensive. I understand that no busways are fenced in the same way as a railway and the two should not be seen as comparable. The Busway has made a significant contribution to the local economy and benefitted the environment by reducing congestion. The design of the Busway and the adjoining pathway was subject to rigorous statutory scrutiny and therefore it is of concern that you feel this design is in some way flawed. The busway has carried an estimated 23.8 million passengers with an estimated 784,000 journeys completed by the specially adapted buses. There is no evidence of pedestrians regularly straying onto the live Busway and the three incidents in the view of LBC and CBC constitute a very small risk profile when compared with the number of journeys completed. Previous incidents Whilst there have been two other accidents on the Luton / Dunstable Guided Busway, they both occurred in the hours of darkness and both of them involved persons has entering the live carriageway, intended for bus traffic only. I note that PC provided details so I do not repeat them here. On both occasions, Luton Council reported the incidents to the Health and Safety Executive as the relevant regulatory authority. The Busway is deemed a work place, not a highway, designed for bus operations only and not road, or pedestrian traffic. It is in fact a criminal offence to trespass on the busway. The Police attended both the accidents and we co-operated with them to review the circumstances leading to the deaths. Luton Council were represented, at the first inquest during which the safety of the Busway was not questioned by the Police. I must respectfully disagree with the conclusions of PC that there are clear and evident design flaws with this busway. in his report to you For the reasons already set out in this letter, it cannot be correct to ascribe those criticisms to the Luton Dunstable Busway. It may be thought that street lighting would improve safety but that is not possible in the area where the accident involving Mr. Yahaia occurred as it is an area designated as occupied by bats so we cannot install street lighting at this location. Steps to be taken to prevent future deaths Luton Council has continued to engage with the Bedfordshire, Hertfordshire and Cambridgeshire Constabulary Roads Policing team to determine what lessons might be learnt from these tragic occurrences. We are in the process of completing an updated Memorandum of Understanding with the police in relation to operations, traffic regulation and investigation of incidents and to keep safety under review through regular meetings. We have also included the Health & Safety Executive in the process of reviewing safety measures for the Busway. On the section at Hatters Way any faded or missing signs have been replaced and the rest of the Busway is in the process of being reviewed for upgrading of signage at emergency access points and any other locations, including Jeans Way, where additional signage may be thought to assist in emphasizing that access to the Busway is not permitted. I feel that I must nonetheless point out that it is impossible to prevent unauthorised access to the Busway along its 8.3 mile length of which 4.6 miles is guided. It is perhaps stating the obvious to note that Bus Lanes in urban environments are in the main not fenced. I hope you find this response addresses your concerns. Yours sincerely, Chief Executive
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