Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0594, written 4 Nov 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Nov 2024 |
|---|---|
| Reference | 2024-0594 |
| Deceased | Polly Friedhoff |
| Coroner | Darren Salter |
| Coroner area | Oxfordshire |
| Category | 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.
Polly Mary Margeret Friedhoff REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Director of Highways and Operations Oxfordshire County Council 1 CORONER I am Mr Darren Salter, Senior coroner, for the coroner area of Oxfordshire 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. 3 INVESTIGATION and INQUEST On 24 October 2024 at Oxfordshire Coroner’s Court I conducted the inquest into the sad death of Polly Friedhoff, aged 81, who died at the John Radcliffe Hospital on 2 December 2022 from injuries sustained in a collision with a pedal cyclist on 20 November 2022. It occurred on the path beside the River Thames at Iffley Lock, Oxford. I returned a conclusion of Accident and I attach a copy of the Record of Inquest for your information. I heard oral evidence from the cyclist, investigating police officers’, and, helpfully, from , Operations Manager, Countryside Access and Tree Service, Oxfordshire County Council (OCC). I was grateful to witness statement at relatively short notice. I note the towpath is recorded as a public footpath and it forms part of the Thames Path National Trail. I understand OCC are responsible for managing the footpath although Iffley Lock itself, through which it passes, is owned by the Environment Agency. /OCC for providing a 4 CIRCUMSTANCES OF THE DEATH The brief circumstances are set out in the Record of Inquest but I also attach the investigating police officer’s report, that of aforementioned statement of for your information. It will be seen that , and also the raises some safety issues about the path at the end of his report and outlines at paragraphs 2.6 and 2.7 that OCC and local Councillors have given considerable thought to the issue of safety. Mrs Friedhoff’s two son’s have also raised significant concerns which I share (see below). 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 could occur unless action is taken. In the circumstances it is my statutory duty to report to you. 1 The concern relates to the safety of users, particularly pedestrians who appear to at greatest risk of injury as was the case with Mrs Friedhoff. Indeed, the speed of the cyclist was not excessive in this case but the injuries caused in the subsequent fall were serious. I understand this part of the path at the lock is popular with pedestrians and cyclists. It is a shared space, albeit strictly speaking it is a footpath and cyclists are not permitted to use it unless they have permission. In reality it is heavily used by cyclists for leisure and commuting and some cyclists travel at significant speed in close proximity to pedestrians. One of the main problems is that the path at the location of Mrs Friedhoff’s accident is only about 2 metres wide. A short distance before this the path is only 1.6 that national guidance for such a path is 3.5 metres wide. I understand from metres. Mrs Friedhoff’s sons are very familiar with the location and describe it as normal pavement width but with cyclists permitted to cycle on it, thereby creating an obvious accident risk. It is also noteworthy that the surface of the path has been upgraded in recent years which, in all probability, has encouraged its use by cyclists and enabled them to cycle faster. I appreciate that OCC, and perhaps the Environment Agency, have given considerable thought to the safety issue and have not found a clear solution. It is not for me to make recommendations but I do request a further review to see if there are any mitigating measures, not least with clear signage reminding users, particularly cyclists, of the need to take care and slow down around pedestrians. At inquest, there was some evidence and discussion in relation to the following; -A communications package, perhaps with a public consultation element. -Stronger enforcement ( I understand the Environment Agency do not permit cyclists to cycle through locks and there are signs about this but they do so nevertheless). I appreciate it is difficult to enforce this and the focus may necessarily be on speed. -Gates or similar to slow cyclists. -Segregation lines but the narrow width of the path no doubt makes this problematic. -Reconfiguring so that the path is redirected through the small woods that are present at the location. This may afford the opportunity to have 2 separate paths at the location, one that is gated for pedestrians and one for cyclists. In short, given my concern that accidents may continue to occur that could result in death, OCC are asked to carry out a safety review in conjunction with the Environment Agency and other stakeholders where appropriate. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you Oxfordshire County Council 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 31 December2024. 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 The Family of Mrs Polly Friedhoff Solicitors I am also under a duty to send a copy of your response to the Chief Coroner and all 2 interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. 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. 9 [DATE] [SIGNED BY CORONER] 4th November 2024 3
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.
Reference: Mr DM Salter Oxfordshire Coroner’s Office The Oxford Register Office 2nd Floor 1 Tidmarsh Lane Oxford OX1 1NS Dear Mr Salter Paul Fermer Director of Environment & Highways Oxfordshire County Council New Road Oxford OX1 1ND 27th December 2024 Re: Response to coroner report Thames towpath at Iffley Lock Thank you for your letter dated 4th November 2024 and the coroner’s report relating to the death of Polly Friedhoff on the Thames Towpath at Iffley Lock on 2nd December 2022. We note your request for a response on what action the county council will look to take and a timetable for this action in response to the inquest, else an explanation for why we would consider no action is appropriate. In response to your letter, I can confirm that county council representatives have met on site with representatives from the Environment Agency (EA) who are landowners at Iffley lock to discuss potential actions and next steps. Both parties agree with the principle that a set of follow up actions is appropriate but that these need to be proportionate and effective. Following discussions and an assessment on site we propose to take the following action; (1) Improved understanding– Whilst both the county council and EA have a solid understanding of the area and user behaviour, we consider it beneficial to undertake some surveying of people cycling and pedestrian use in the Iffley lock area. This will enable us to better quantify the volumes / type of pedestrian and cycle users in the area as well as details on speed. As usage is affected by seasonality and wider events, we plan to carry out this monitoring spring/ summer 2025. Early assessment of potential monitoring methods suggests there could be a number of different approaches used. This could include the use of cameras and / or detection tubes. Further engagement with user groups would be considered beneficial to informing further details on the type and duration of monitoring which would be necessary both before and after any intervention measures. (2) Vegetation clearance – Whilst it is noted that the fatality took place in December when typically, overgrown trees/ vegetation may be less of a factor, both organisations appreciate that especially during summer months vegetation growth can restrict user space and visibility increasing the likelihood of conflict. Both the county council and EA will undertake volunteer clearance work around the Iffley lock site and plan to undertake this winter/ early 2025. (3) Signage and promotion – It is noted that there is already various signage in the vicinity of the site and along the towpath. This said, a review of signage will be undertaken to give consideration for whether additional signage would be beneficial including at key entrance points along the towpath. We aim to carry out an audit of signage in winter/ early 2025 with implementation of any appropriate measures expected for the summer 2025. Additionally, we are proposing to organise with partners and user groups a series of promotional events spread throughout the year would highlight safe and responsible use of the towpath. As an example, there are several high-profile rowing events along the river in the spring / summer period resulting in increased usage. It is proposed that promotional activity at events like these could provide a meaningful impact with a potentially large catchment of users. Similar events focussing on the councils Vision Zero programme have been held in Oxford over recent years and have had positive feedback. We consider this measure would have a beneficial relevance and reach to the wider towpath route including the Iffley lock site. We plan to commence this from spring 2025. The above committed action is subject to engagement with local councillors and key stakeholders in the development and implementation of the above measures in early 2025. I trust that this note provides the reassurance required, however please do not hesitate to contact should you wish to discuss further. I am happy to provide you with an update of the planned action outlined by end August 2025 if desired. Yours sincerely Director Environment and Highways www.oxfordshire.gov.uk 2
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