Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0176, written 25 May 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 May 2023 |
|---|---|
| Reference | 2023-0176 |
| Deceased | Jean Hardy |
| Coroner | Karen Dilks |
| Coroner area | Newcastle upon Tyne and North Tyneside |
| 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.
Newcastle and North Tyneside Ms Georgina Nolan SENIOR CORONER Civic Centre, Barras Bridge, Newcastle Upon Tyne , NE1 8QH Date: 25 May 2023 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Sunderland City Council CORONER I am Karen Dilks Assistant Coroner for Newcastle and North Tyneside 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 INVESTIGATION and INQUEST On 14 February 2020 I commenced an investigation into the death of Jean HARDY. The investigation concluded at the end of the inquest on 24th April 2023. The conclusion of the inquest was Road Traffic Collision 1a Multi-Organ Failure 1b Head, Chest and Pelvic Injuries 1c II CIRCUMSTANCES OF THE DEATH On 4th February 2020 Jean Hardy (JH), a 71-year-old lady (generally fit and well), crossed the B1286 Doxford Parkway Sunderland from the Southside to the Westbound carriageway. She did so, at a point where there was no designated pedestrian crossing, when it was dark and when the carriageway was illuminated by street lighting. JH was struck by a motor vehicle and sustained multiple Injuries that led to her death within RVI Newcastle Upon Tyne on 8th February 2020. 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 B1286 Doxford Parkway is bordered by Multiple housing estates and the evidence confirmed that local practice of crossing at non designated crossing points which are more easily accessible and convenient is common and well known. (2) Access to the carriageway is not restricted by fencing (save for limited fencing at designated crossing points) and there is no signage prohibiting crossing at non designated crossing points or warning of the risks to the public of doing so. (3) There is a risk of further deaths occurring in this location and in similar circumstances. To prevent future deaths there should be a comprehensive review of current pedestrian crossing provision on B1286 Doxford Parkway. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you Dave Smith CEO Sunderland City Council have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 21st July 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested (Driver of the Motor Persons: Vehicle). I have also sent it to PC (Independent Collision Investigator) who may find it useful or of interest. (Northumbria Police) and (Daughter of JH) and 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. 25 May 2023 for Newcastle and North Tyneside
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.
Newcastle and North Tyneside Coroner’s Office Civic Centre Barras Bridge Newcastle Upon Tyne NE1 8QH For the attention of Karen Dilks, Assistant Deputy Coroner City Development Directorate City Hall Plater Way Sunderland SR1 3AA Date: 29th August 2023 This matter is being dealt with by: Development Group Engineer, Transportation Dear Madam, Thank you for your letter and report dated 25th May 2023 with the case reference number 308348. This matter is in relation to the death of Jean Hardy who unfortunately passed away following a road traffic collision which occurred on Doxford Park Way in Sunderland. Following the conclusion of the inquest in April 2023, the Council received your Regulation 28 report detailing the following concerns: (1) The B1286 Doxford Parkway is bordered by Multiple housing estates and the evidence confirmed that local practice of crossing at non designated crossing points which are more easily accessible and convenient is common and well known. (2) Access to the carriageway is not restricted by fencing (save for limited fencing at designated crossing points) and there is no signage prohibiting crossing at non designated crossing points or warning of the risks to the public of doing so. (3) There is a risk of further deaths occurring in this location and in similar circumstances. To prevent future deaths there should be a comprehensive review of current pedestrian crossing provision on B1286 Doxford Parkway. Northumbria Police generally contact the Council’s Local Highway Authority road safety representatives to request a site meeting following a road traffic collision resulting in a fatality. This only happens if the Police investigating officer is of the view that the highway layout or highway condition at the time was a potential contributory factor. There were no requests received from the Police to undertake a site meeting. However, following your request, the Council arranged and met on site with the investigating officers from Northumbria Police to help understand the circumstances and any contributory factors in relation to this fatality. This took place at the collision location on 15th August 2023. It is unknown why Mrs Hardy chose to cross at the location where the collision occurred; however, it should be noted that there is an existing footway following the northern side of Doxford Park Way and appropriately located pedestrian crossing points nearby to this location. These are found at the roundabout junction with Moorside Road / Noirmont Way approximately 120 metres to the west, and a controlled crossing approximately 180 metres to the east near Morrison’s and the local shopping centre. C o m m e r c i a l D e v e l o p m e n t C B S T i i v c C e n t r e u r d o n R o a d u n d e r l a n d , S R 2 7 D N e l The investigating officers from Northumbria Police were of the view that the tragic accident would not have been prevented by additional road safety measures due to the circumstances involved. A suggestion made by the Police is to install warning or advisory signs. In response to your concerns and request for action, the Council has undertaken a road safety review of the location concerned; and has also investigated the suitability of the existing pedestrian crossing point locations on Doxford Park Way. The issues you have raised around provision of fencing within a central grassed reservation and signing has been considered. This was discussed on site, and the view of the Police is that this would encourage barrier hopping by more agile pedestrians and would not be supported by them. As an action, the Council are proposing to install signing on both sides of Doxford Parkway to direct pedestrians to nearby crossing points. I trust this satisfactorily addresses the concerns and actions identified within your report. Yours sincerely Assistant Director of Transport and Infrastructure
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