Prevention of Future Deaths reports · 2023

Jean Hardy

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 report25 May 2023
Reference2023-0176
DeceasedJean Hardy
CoronerKaren Dilks
Coroner areaNewcastle upon Tyne and North Tyneside
CategoryRoad (Highways Safety) related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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

Responses

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.

Response from Sunderland City Council 1 (PDF)
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.   

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 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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