Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0054, written 13 Feb 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Feb 2023 |
|---|---|
| Reference | 2023-0054 |
| Deceased | Steven Easdale |
| Coroner | Geoffrey Sullivan |
| Coroner area | Herefordshire |
| Category | Road (Highways Safety) 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.
Signed by Geoffrey Sullivan
Title
Jurisdiction Hertfordshire
HM Senior Coroner
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
- Chief Executive of Hertfordshire County Council
- Chief Executive of National Highways
- UK Power Networks Holdings Ltd
CORONER
I am Geoffrey Sullivan HM Senior Coroner for Hertfordshire
CORONER’S LEGAL POWERS
1
2
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 the 12th December 2021 Steven Easdale died at Addenbrookes Hospital from injuries sustained in a
road traffic collision. His death was reported to the Coroner and an investigation commenced. A post-
mortem examination performed by Dr Martin Goddard on 21st December 2021 provided the following
cause of death:
1a Purulent Bronchitis and Bronchopneumonia
1b Multiple Traumatic Injuries
An inquest was opened on 9th March 2022 and the investigation concluded at the end of that inquest on
the 8th February 2023, which found:
Circumstances:
On the 5th November 2021 Steven Easdale was struck by a car whilst crossing the B197 Digswell Hill. He
sustained multiple injuries and was taken by ambulance to Addenbrookes Hospital. Despite treatment,
Mr Easdale died on the 12th December 2021. There was a central pedestrian island near to where Mr
Easdale crossed the road but he did not use it. It was dark at the time Mr Easdale crossed, he was
wearing dark clothing and the driver did not have time to react to his presence in the road and avoid the
collision. The central pedestrian island near to where Mr Easdale crossed the road should have been
illuminated. It was not in working order, however, and was therefore unlit. A nearby streetlamp was also
not working and was unlit. Had the pedestrian island and streetlamp been illuminated it may have
helped the driver to see Mr Easdale earlier and avoid the collision.
Conclusion of the Coroner as to the death:
Road Traffic Collision
4
CIRCUMSTANCES OF THE DEATH
At the inquest I heard evidence from two police officers
Cambridgeshire and Hertfordshire (BCH) Serious Collision Investigation Unit. They outlined that
approximately 15 metres from where Mr Easdale crossed the road, there was a traffic island (or
pedestrian refuge) with a bollard and streetlamp in place. The bollard on the island is made out of
opaque white plastic and is designed to be illuminated from within. The time of the collision was around
5pm on a December afternoon meaning that this stretch of road was in deep darkness.
of the Bedfordshire,
When the collision occurred on the 5th November 2021, neither the illuminated bollard nor the
streetlamp were in working order and were therefore unlit. Both officers from the collision unit gave
evidence that this situation presented a danger to road users and pedestrians.
A Traffic Management Officer has brought this situation to the attention of Hertfordshire County Council,
Highways England (now National Highways) and National Power Networks (now UK Power Networks).
Despite this, I heard evidence at the inquest that both the bollard and the streetlamp have still not been
repaired and remain unlit even in the hours of darkness.
I was not able to say on the balance of probabilities that the lack of lighting on the pedestrian island
contributed to Mr Easdale’s death as he was not using the crossing itself when he was struck. He crossed
nearby, however, and it is possible that had there been illumination at that island the driver of the car
would have seen him earlier and potentially avoided the collision.
I am satisfied that the lack of working lights at this location on the B197 Digswell Hill poses a danger to
road users and pedestrians. The location of the island is near to the Red Lion Public House and may be
used by people going to and from the pub.
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. –
[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) That the lack of working lights on the pedestrian refuge on the B197 Digswell Hill (near the Red Lion
Public House) poses a danger to road users and pedestrians. Specifically that neither the illuminated
bollard nor the streetlamp are in working order.
(2)
(3)
(4)
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you:
Executive of Hertfordshire County Council;
- Chief Executive of National Highways;
- Chief
- UK Power Networks Holdings Ltd both individually and collectively 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 10th
April 2023. 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:
The family of Mr Steven Easdale.
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 coroner, at the time of your response, about the release or the publication of
your response by the Chief Coroner.
9
Date: 13th February 2023
Signature
Geoffrey Sullivan HM Senior Coroner for Hertfordshire
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.
Chief Executive: i ief Executive Hertfordshire HM Senlor Coroner Geoffrey Sullivan Hertfordshire County Councll The Old Courthouse CH 0238, County Hall St Albans Road East, Hatfleld Hertford, Herts, SG13 8DE AL10 OES Contact: Your ref: 9903512 Date: 27 March 2023 Dear Sir Inquest Into the death of Steven Easdale Regulation 28 Report to Prevent Future Deaths Response CORONER'S MATTERS OF CONCERN The MATTER OF CONCERN is as follows: — That the lack of working lights on the pedestrian refuge on the B197 Digswell Hill (near the Red Lion Public House) poses a danger to road users and pedestrians. Specifically that neither the illuminated bollard nor the streetlamp are in working order. DETAILS OF ACTION TAKEN The illuminated bollards and refuge beacon on the same Island were confirmed to be in light on 13 January 2023. They have been checked every 20 days since then, with no faults found, and the most recent check on 3rd March 2023 confirmed that all lights were working as expected. [Please note the reference to streetlamp in the Report is interpreted to mean the refuge beacon on the same island as the bollards. The refuge beacon is a low wattage unit with minimal light output in a downward direction to identify the Island for motorists from a distance. It is not designed to provide lighting for users of the crossing] All other signs and bollards on the B197 Digswell Hill have been checked and were confirmed to be in light on 3rd March 2023 BACKGROUND: County of opportunity The island and associated assets were not logged on the Hertfordshire County Council (HCC) highways inventory at the time of the Road Traffic Collision. The content and quality of the highways inventory continually improves as assets are added to It. In the last year 2,850 assets were added to the inventory which contains a total of 1,297,947 assets. This means inspections and maintenance of the bollards and refuge beacon would not have been carried out. it is possible other maintenance works may have been carried out at this location, bollard cleaning for example, but these occur during daylight hours and so the lack of illumination of the bollards and refuge beacon would be unnoticed. First knowledge of the existence of the assets as a location requiring maintenance by the highways lighting team was after a fault report was raised on 13th December 2021. A highways crew visited the site on 12th January 2022 (achieving the 20 working day target response for lighting faults). On attendance on 12th January 2022, It was found the beacon and bollards were not lit, and this was caused by a UKPN (UK Power Networks) mains fault. This was notified to UKPN on 13th January 2022. The site was checked on 31st January 2022 and the fault had not been repaired. It was re-raised with UKPN as a high priority. By 1st February 2022, UKPN identified that the fault was positioned on the bridge over the A1. Before any excavations are carried out on a bridge the owner must provide their approval. Initially UKPN checks were made with HCC to seek approval to excavate on the bridge. HCC confirmed that the structure was not our structure, rather it was Highways England/National Highways (NH). The outstanding fault at this location was on the agenda at monthly meetings between UKPN and HCC and in June 2022, Ringway (the maintenance contractor working on behalf of HCC) requested that UKPN consider alternative options for electricity supply. Ringway attempted to help UKPN by logging an enquiry with National Highways in June 2022 on behalf of UKPN. Our understanding is that on 9th January 2023 UKPN received permission to excavate from National Highways, and once that was received UKPN started work on the site, fixing the mains fault on 11th January 2023. The HCC highways team were able to confirm all illuminations were in-light on 13th January 2023. The location has been checked every 20-days since then and has been in-light each time. DETAILS OF FURTHER ACTION PROPOSED The site is now included in the asset inventory and as such the bollards and beacon are inspected and maintained. They will continue to be inspected every 20 days by a Highways team and be attended to if necessary. If at any time the lights are not working, that can also be reported by members of the public using the online Hertfordshire County Council Fault Reporting system. Yours sincerely
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