Lesley Powell

REGULATION 28:  REPORT TO PREVENT FUTURE DEATHS 

REGULATION 28  REPORT TO PREVENT FUTURE DEATHS 

THIS  REPORT IS  BEING SENT TO: 

Gilva Tisshaw, Assistant Coroner, for the City of Brighton and Hove, The 
Coroner's Office, Woodvale,  Lewes Road, Brighton BN2 3QB  in  response to a 
Regulation  28 Report to  Prevent Future Deaths following an  inquest hearing  into the 
death of Lesley  Powell on  8 March 2021. 

EAST SUSSEX COUNTY COUNCIL 

I am 
County Council,  St Anne's Crescent,  Lewes,  BN7  1 UE 

, Director of Communities,  Economy and Transport,  East Sussex 

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CORONER'S MATTERS OF CONCERN 

The MATTERS OF CONCERN were identified as follows:  -

1.  There is  no safe crossing  point on  the A2100 Battle Hill,  Battle,  East Sussex in 

the vicinity  of the Essa/Tesco Express Garage and shop. 

2.  Between August 2016 and  December 2019 there have been  seven  incidents of 

which:-
i. 

ii. 
iii. 

Two were fatal  (in  one of which another person had  life changing 
injuries) 
Two included serious injury 
Three included slight injuries 

Four of the  incidents occurred  in  the vicinity of the section of road  between  St Mary's 
Villas and  the entrance to the filling station. 

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Background Information 

East Sussex County Council, as the  local  highway authority,  has a legal requirement 
under Section  39  of the Road Traffic Act 1988 to: 

•  Prepare and  carry out a programme of measures designed to  promote road 

safety. 

•  Carry out studies into crashes (accidents) arising out of the  use of vehicles,  and 

•  Take such  measures as appear appropriate to  prevent such crashes,  including 
the dissemination of information and  advice,  the giving  of practical training, the 
construction , improvement, maintenance or repair of roads and  other measures 
taken  in  the exercise of the authority's powers for controlling , protecting or 
assisting the  movement of traffic. 

To fulfil this statutory duty,  the  Road  Safety Team undertake an  annual  review of 
crashes on the  local road  network and  identify sites that display one or both of the 
following  criteria: 

• 

at least four personal injury crashes recorded within  the previous three-year 
period  (three years is considered  best practice, as  it represents a short enough 
time  period to be relevant, without there being  significant changes in  terms of 
traffic patterns and  flow).  A site  is  defined as within  a 25-metre radius for urban 
areas. This 25-metre radius  is calculated from the  moving point along the 
centreline of each road.  For rural  areas a site  is  defined as within  a 50-metre 

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 radius . This reflects the  more dispersed nature of crashes in  rural areas and 
ensures that sites within  urban  areas are locations where an  engineering  or 
traffic management solution is  likely to have an  impact. 

•  Routes that have a high  crash  severity (i.e. injury crashes per million vehicles) . 

The number of sites identified through this assessment process for the last ten  years 
(including Trunk Roads - a Trunk Road  is a major road  which  is the  recommended  route 
for long  distance traffic and  usually connects one or more cities) is: 

•  2011- 95 
•  2012 - 80 
•  2013-72 
•  2014 - 84 
•  2015-80 
•  2016 - 89 
•  2017 - 97 
•  2018-114 
•  2019-98 
•  2020 - 98 

Crash data is provided  by  Sussex Police and  is  recorded  in  line with the Department for 
Transport 'Stats 19' guidance for recording  personal  injury crashes on  the  public 
highway network. Analysis of the crashes is  used to  identify the  most appropriate 
site/route for intervention . 

Due to the  limited  level  of funding  that is  available for road  safety interventions, it is 
important that we ensure that they are directed to  locations that will  make the  biggest 
contribution to  casualty  reduction . 

Although every fatality  is of course a tragedy , due to  our limited  road  safety resources 
not all  crash  sites can  be  prioritised  for this funding. 

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Supporting Information 

At the conclusion of the inquest into a fatal  road  crash that occurred on the A2100  Battle 
Hill in  January 2020 the Coroner has raised concerns about the absence of a crossing 
point adjacent to the Esso/Tesco Express service station and  the history of crashes in 
the  local vicinity. 

The area identified by  the Coroner is within  an  approximate 100-metre radius of the 
Tesco Express/Esso filling  Station on  Battle Hill  and the period  cited  by the Coroner of 
August 2016 to December 2019 covers a 41-month  period .  This area did  not fall  inside 
our parameters for the identification of a crash site because four or more crashes did  not 
occur within  a 25-metre radius within the  relevant three year period , which was  between 
1 January 2018 and  31  December 2020. 

In  addition , the site did  not have a high crash  severity (i.e. injury crashes per million 
vehicles) . 

The site did not therefore display the  necessary criteria for the  Road  Safety Team to 
undertake an annual review. 

Capital  Programme Transport Improvements 

Outside of the road  safety work the Council  has a Capital  Program of Transport 
Improvements.  Schemes are identified on  a priority/funding  basis.  A draft Capital 
Programme of Local Transport Improvements is considered  and  approved  by  the Lead 

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 Member for Transport and  Environment in  March each year.  The programme is funded 
from a range of sources including the County Council's own capital  allocation, 
development contributions (s106 monies and  Community Infrastructure Levy} , and 
external funding  secured  from Government or the South  East Local  Enterprise 
Partnership.  The  programme will  include schemes that are at various stages in  their 
design and  delivery cycle which will receive priority for the funding  available year on 
year.  Therefore,  the  number of new schemes entering the  programme on  an  annual 
basis will vary depending on the  remaining  levels of funding  available. 

A significant level of enquiries and  requests are received from the general public each 
year for engineered/traffic management interventions for areas of concern , that would 
not meet our crash  site identification criteria.  Limited  funding  is available to  develop local 
transport improvements and we therefore use a process to target our resources to 
schemes that will be of greatest benefit to our local communities. 

As  part of East Sussex County Council's current Local  Transport Plan  (L TP3},  an 
evidence based framework has been  developed to  prioritise the high  level of requests 
the County Council  receives and to  determine which  schemes should  be funded  through 
our capital  programme for local transport improvements. 

The assessment procedure consists of a two-stage process,  and  requests will  only 
progress through each stage if they meet with the criteria outlined below: 

1.  High Level Sift - a short assessment to establish  how the scheme fits with the 

transport objectives set out in  L TP3. 

2.  Detailed appraisal - a detailed assessment of how the scheme fits with the 
objectives of L TP3,  as well  as assessing value for money, risk and  equalities 
impacts.  Schemes that have undergone a detailed appraisal are then  prioritised 
for potential inclusion  in  the capital  programme of local transport improvements. 

The key  objectives against which  scheme requests are assessed  include the extent to 
which they will: 

• 
• 
• 
• 

• 

support sustainable economic growth 
Improve public safety and  health 
Tackle climate change 
Improve accessibility to  employment,  education , health facilities and 
other services 
Improve quality of life 

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DETAILS OF ACTION TAKEN 

In  response to the  Coroner raising  the above matters of concern,  the Council  has 
undertaken an analysis of incidents which  occurred within  a 25-metre radius since 2010, 
centred  on  the Tesco Express/Essa filling  station on  Battle Hill which forms  part of the 
A2100 (Plans are attached as Appendix 1): 

•  2010 to 2012 - 1 slight personal injury crash 
•  2011  to 2013 - 1 slight personal injury crash 
•  2012 to 2014 - 1 slight personal injury crash 
•  2013 to 2015 - No  personal  injury crashes 
•  2014 to 2016 - 1 fatal  and  1 serious personal injury crash 
•  2015 to 2017 - 1 fatal  and  1 serious personal injury crash 
•  2016 to 2018 - 1 fatal,  1 serious and  1 slight personal  injury crash 

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 •  2017 to 2019 - 1 fatal and 2 slight personal  injury crash 
•  2018 to 2020 - 1 fatal and 2  slight personal inj ury crash 

In  terms of the incident referred to by  the Coroner in  her report, the analysis of these 
incidents provided the following  (information: 

• 

• 

Pedestrian casualty walking westbound  up  Battle Hill on  north  pavement with 
friend . Friend  runs across road , pedestrian casualty follows [failed  to  look 
properly] a few seconds later and  is hit by V1  [impaired  by drugs] travelling 
westbound  up Battle Hill. V1  then fails to stop. 

V1  travelling  northwest on  main road,  V2 travelling  southeast.  Drivers of 
vehicles know each other and are in current dispute. Driver V1  intentionally 
crosses carriageway [aggressive driving] on  seeing driver of V2,  colliding with 
front offside wheel , wing , and driver's door. Driver V1  then fails to  stop making 
off to location  unknown leaving driver V2 injured at roadside. 

•  Male pedestrian crossing  road  by  petrol station, pedestrian steps out into path  of 

pedal cyclist travelling  north towards battle. Cyclist avoids collision with 
pedestrian , loses control , falls from cycle suffers serious head  injuries. [loss of 
control] [other] 

• 

(V1) motorcycle with  learner driver [inexperience] traveling too close behind 
motorcar (V2) which braked causing  motorcycle to  brake heavily [failed to judge 
other person's path  or speed] losing traction to front wheel causing  rider to fall  to 
ground slightly injuring knee . No contact with motor car. 

•  Pedestrians crossing from  offside of V1  [failed to judge vehicles path  or speed] 

[impaired by  alcohol] . V1  travelling towards Battle strikes pedestrians in 
northbound carriageway causing serious injuries to  one pedestrian and fatal 
injuries to the other [failed  to  look properly] . 

•  V2 travelling  northwest on  main  road when approaching junction . V1  failed to 

see V2  [failed to look properly] and turned across his path causing serious injury 
to the pedal cyclist V2. 

•  V2 for unknown reason  has come to an  abrupt stop, V1  [following too close] 

went into rear of V2.  [nervous/uncertain/panic/other]. 

The most common contributory factors relate to failure to look properly (CF405 & 802) or 
failure to judge another road  user's speed (CF 406 & 803),  which were recorded  in 4 of 
the 7 crashes (57%) . 

The contributory factors indicate that the two crashes which  resulted  in  pedestrian 
casualties (1  fatal and 2 serious injuries) were due to 'failure to  look properly' on the part 
of the pedestrians. In  both  crashes,  the pedestrians were crossing from the footway on 
the northern side of the road , towards either the petrol station or to the commencement 
of the southern footway  on  the northwest side of the rail  bridge,  and were struck by  north 
westbound vehicles travelling  downhill on  Battle Hill.  Impairment by drugs was listed as 
a possible cause on the part of the driver in  one of the crashes and  impairment by 
alcohol on  the part of the pedestrian casualties was listed as  a possible cause in the 
other. 

The two cyclist casualties were both travelling  north westbound along  Battle  Hill, on the 

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 downhill section of road,  although in  both  instances, the crashes occurred due to 
another road  user's actions. The cyclist fatality occurred because of loss of control,  after 
the cyclist swerved to  avoid  a pedestrian who had  stepped out into the carriageway 
(presumably from the south  side) . 

2 of the 7 crashes involved  rear end  shunts  by  south  eastbound vehicles travelling uphill 
on  Battle  Hill. 

The crash analysis did  not indicate that there is  any clear causation factor or consistent 
manoeuvre involved  in  the crashes occurring at this location that could  be  solely 
addressed  by  an  engineered intervention. 

The Coroner raises the  issue of a lack of a safe crossing  point.  However,  only two of the 
crashes in  the  Esso/Tesco Express Garage area identified  relate to  pedestrians, and  in 
those two instances, there were other factors  responsible for the crash. 

The  County Council  previously received  requests in  August 2015 and  February 2017 
(from  Battle Town  Council and the  local elected  Member) for a pedestrian crossing 
facility  in  the vicinity of the Tesco Express/Esso filling  station  on  Battle Hill. 

The request was assessed  under the Capital  Program of Transport Improvements in 
2017 /18 and  scored  sufficiently to  progress to  the detailed appraisal stage. However, it 
was ranked  32nd  out of the 67 detailed scheme appraisals that were assessed. 
Therefore,  it initially did  not rank high enough for inclusion  in  the 2018/19 programme,  as 
the available funding  meant we were able to only include the 23 highest ranked 
schemes. 

However, following a serious pedestrian-related crash on  Battle Hill , a petition was 
presented to the County Council on  15  May 2018. The petition was considered  by the 
then  Lead  Member for Transport and  Environment at their decision  making  meeting on 
16 July 2018,  where it was resolved that, after liaising with  Sussex Police,  the County 
Council would commission  their term contractor  'East Sussex Highways' to conduct a 
feasibility study to determine whether some form of pedestrian crossing facility could  be 
introduced at this location and  potentially funded through  a future capital programme for 
local transport improvements. 

This study , undertaken  in  2018/19,  investigated options for providing a form of 
pedestrian crossing facility  in  the vicinity of the Tesco Express/Esso filling  station and 
utilised data including  pedestrian  movement surveys and  traffic speed  surveys,  to 
identify the most appropriate type and  location of facility.  The study  also considered the 
appropriateness of additional interventions on the wider extent of Battle Hill to  reinforce 
the  prevailing 30mph speed  limit. 

The study identified a light-controlled pedestrian (Puffin) crossing  as being  the  most 
appropriate intervention and that,  due to  site constraints,  it would  need  to  be  located on 
the A2100 between the vehicular entry and exit points of the Esso filling station 
forecourt.  Options were also provided for additional engineering  measures on  the 
northbound approaches to the proposed crossing  location (a  plan  of the crossing 
location is attached as Append ix 2). 

The study also considered options for the onward safe movement of pedestrians from 
the crossing  point to the Tesco Express shop entrance. As there are no existing onward 
pedestrian footway facilities on  the southern  side of the A2100  in  the vicinity of the Esso 
filling  station , the crossing facility would  effectively solely serve the Tesco Express store 
and  pedestrians would  have to  navigate the  busy filling  station forecourt to access the 
store entrance. 

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 Whilst limited  informal internal footways and  pedestrian markings were already  provided 
within  the filling  station forecourt area,  these were located some distance from what the 
desire line of pedestrians using the  proposed crossing  facility on  the A2100 .  This also 
presented difficulties to  pedestrians of limited , or restricted  mobility and specifically 
those using wheelchairs/mobility scooters,  due to the gradients on  the wider curtilage  of 
the forecourt.  The forecourt is  privately owned and not under the control of the Highway 
Authority (East Sussex County Council) . The County Council was concerned that,  in 
addressing the issue of safe passage across the A2100 through the introduction of a 
formal controlled crossing facility,  pedestrians could  be placed in  danger through 
uncontrolled movement across a  busy forecourt on  which  drivers are not focused  on 
pedestrian  movement. 

In  2020,  further discussions and  meetings were carried  out with  Esso and Tesco on 
alternative options for a pedestrian  route across the filling  station forecourt and these 
have resulted  in  a more direct and  level  route  being  identified from  the edge of the 
proposed crossing on  the A2100 to  the Tesco Express entrance. A  preliminary design 
has now been  completed for both  the pedestrian crossing  and the forecourt pedestrian 
route. This design  has been subject to a Stage 1 Road  Safety Audit and the County 
Council has allocated further funding  in  its 2021 /22 Capital  Programme of Local 
Transport Improvements to  progress the scheme through  statutory/local stakeholder 
consultation,  and subject to the outcome of this process,  progress to detailed design and 
possible implementation in  a future year's capftal  programme. 

Delivery of a crossing scheme will be dependent on  securing  legal agreements between 
the County Council and  the owner/operators of the  Esso filling  station/Tesco Express 
store and  securing funding  in  a future capital programme for construction . 

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DETAILS OF FURTHER ACTION  PROPOSED 

A potential  pedestrian crossing scheme is currently  being  developed in  2021/22 through 
the County Council's Capital  Programme of Local Transport Improvements. Whilst we 
are unable to confirm precisely the actions that will  be taken at this location (or a 
timeframe for any works to be  completed) due to the limited availability of funding  and 
our approved process for agreeing capital expenditure, we consider that the actions 
outlined above are appropriate and  proportionate to the issues raised and  have due 
regard to the priority that this site has,  in  terms of all other identified and  prioritised 
commitments. 

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SAFETY OF ROAD  USERS 

Every road  death is a tragic loss of life. The Council is committed to improving 
communication with  road  users and  improving the safety of the roads . 

The death  of Lesley  Powell  is tragic,  as are the serious injuries sustained  by  her partner, 

sincerely  hopes for a full  recovery 

.  The Council offers its'  condolences to  Ms. Powell 's afl4-family and 
. 

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XYJXX.'XXXX26/05l2021 

Signed: _  ________ 

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  Director of Communities, Economy and Transport 

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