Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0013, written 9 Jan 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Jan 2025 |
|---|---|
| Reference | 2025-0013 |
| Deceased | Anthony Paine |
| Coroner | Nicholas Graham |
| Coroner area | Oxfordshire |
| 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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Oxfordshire County Council Highways Department 1 CORONER I am Mr N Graham, Area 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 12th April 2023 I commenced an investigation into the death of Anthony John PAINE, a 75 year old male. The investigation concluded at the end of the inquest on 7 January 2025 and my conclusion as to the death was one of Road Traffic Collision. 4 CIRCUMSTANCES OF THE DEATH At approximately 22:45 hours on Friday 24th March 2023, a fatal road traffic collision occurred on the A361 North Bar Street, Banbury, Oxfordshire. A red Nissan Pixo collided with a pedestrian, Anthony Paine on the A361 North Bar Street, Banbury. Mr. Paine was crossing the carriageway on a pedestrian crossing from right to left as viewed by the driver of the Nissan. The pedestrian crossing was controlled by traffic signals. Mr Paine did not wait to use the pedestrian controlled lights having considered the that the road was clear. He was struck by the vehicle and sadly died at the scene. 5 CORONER’S CONCERNS During the course of the Inquest the evidence revealed matters giving rise to concerns. 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 make this report to you. The MATTERS OF CONCERN are in relation to the following: • The speed limit on the A361 North Bar Street at the location of the collision is 30 mph. There was a concern expressed at the Inquest that this speed limit may be too high, given the characteristics of the road and the volume of pedestrian traffic in the area. 1 • The A361 at this location is a long, straight, single carriageway with one lane in each direction. Traveling southbound, the pedestrian crossing is approached from a gradual rise in the road from Banbury Cross Roundabout, some 150 meters away. The rise in the road obscures the view of the pedestrian crossing to approaching vehicles. • There are a number of pubs and restaurants on both sides of the road and a number of pedestrians in the area late into the evening. • The Forensic Collision Investigator concluded that in the short window of time in which Mr. Paine was likely visible to the driver, they failed to see him. The Investigator’s evidence was that even if the driver had seen Mr. Paine, there would have been insufficient time to react and avoid the collision. However, the Investigator’s evidence also stated that if the vehicle had been traveling at a slower speed, this may have provided the driver with sufficient time to react and either avoid the collision or reduce the severity of the impact. In the opinion of the Forensic Collision Investigator, the speed of the driver’s vehicle was 32.6 mph ± 3.6 mph and was a contributing factor to the severity of the collision and that, as a general point, the slower the vehicle is travelling the less severe the effects of any impact. It was further noted that other nearby town/city centres (eg Oxford) have introduced 20 mph speed limits on roads in the city centre. • • 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 6th March 2025. I may extend the period on request. 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 Anthony Paine - Thames Valley Police 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. 2 9 Signed Date 9th January 2025 Mr N. Graham HM Area Coroner for Oxfordshire 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.
Oxfordshire Coroner's Office The Oxford Register Office 2nd Floor 1 Tidmarsh Lane Oxford OX1 1NS Dear Mr N Graham, Director of Environment & Highways Oxfordshire County Council New Road Oxford OX1 1ND Date 14th March 2025 Thank you for your letter of 9 January and Regulation 28 Report to Prevent Future Deaths. In response to the matters of concern raised, I can confirm that the current speed limit (30mph), is in line with current national guidance and standards. That said, it should also be noted that following a community consultation, in line with our 20mph policy, an allocation has been made in the 2025/26 Vision Zero road safety programme for the design and implementation of improvement measures including (subject to consultation and subsequent approval) a 20mph speed limit at the location of the traffic collision resulting in the death of Mr Paine. If approved, the intention is that the scheme will be completed by the end of the 2025/26 financial year. Until this scheme is implemented there is no plan to change to the current and appropriate speed limit of 30mph. If helpful I would be happy to provide an update in 6 months’ time as to the progress of the 20mph scheme mentioned. Yours sincerely Director of Environment & Highways Direct line: Email: www.oxfordshire.gov.uk
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