UK Inquiry Tracker

Julia Peto

PFD Report All Responded Ref: 2019-0119

Date of Report 4 April 2019

Coroner Christopher Williams

Coroner Area London Inner (South)

Response Deadline est. 4 August 2019

Road (Highways Safety) related deaths

Judiciary.uk Report PDF

All 1 response received · Deadline: 4 Aug 2019

Sent To

Department for Transport

Response Status

Responses 1 of 1

56-Day Deadline 4 Aug 2019

All responses received

About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Coroners Concerns

From the evidence received, at the inquest; there are matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken: : recorded in section 3 of the Record of Inquest that it was not possible to establish, on the balance of probabilities, that Julia had been confused by & green pedestrian signal on the other side of the Westbound carriageway of a 'two stage' crossing: Nonetheless remain concerned that there is a strong possibility that she was distracted or confused by the green pedestrian light for the Westbound carriageway Transport for London (TfL) who are responsible for the signals_ on the junction in question, have subsequently taken remedial measures to minimise the possibility of a recurrence of the accident by modifying the green pedestrian signals with louvres to reduce the risk of 'see-through' for pedestrians on the staggered pedestrian crossing TfL informed me, at the inquest; that are putting in place "Look Left" and "Look Right" markings on the road to inform pedestrians on the direction of approaching traffic (A copy of the TfL report to me is appended for ease of reference. This contains a useful plan and photographs): From the evidence heard am satisfied that these particular changes would not have a wider impact on traffic flow but would improve the of pedestrians. was pleased to hear that TfL had taken proactive practical measures to reduce the risk at this particular junction but remain concerned that there are likely be other "two stage" pedestrian crossings throughout England and Wales which also do not currently have louvres t0 prevent pedestrian 'see-through' and road markings to warn pedestrians of traffic direction. am therefore of the view that am under a duty to report this wider concern to the Department of Transport to take appropriate action to reduce the risk of fatalities and serious injuries at two stage crossings throughout England and Wales

Responses

the Department for Transport

Response received

View full response

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Action Should Be Taken

In my opinion action should be taken to prevent future deaths and believe your organisations have the power to take the following action: The Department of Transport: Should use its available legal powers to introduce appropriate measures to reduce the above-identified risk at two stage pedestrian crossings throughout England and Wales_

Report Sections

Investigation and Inquest

An investigation into the death of Julia Luxmore Peto commenced on the 22 October 2018. The investigation concluded at the end of the inquest on 27 March 2019. The conclusion of the inquest was that the medical cause of death was 1(a) Head Injury. The conclusion was 'Road Traffic Accident"_

Circumstances of the Death

On Sunday 16 September 2018,at about 16.53 pm Julia was using a pedestrian crossing over the Eastbound carriageway of Deptford Broadway, SE8 (A2), when a bus collided with her causing a catastrophic head injury. She died in hospital the following She was aged 27 years and did not have significant health problems or disabilities. She was crossing from the Northside of Deptford Broadway to the Southside_ The three lanes of the Eastbound carriageway had split phasing of traffic light signals_ When crossing the first two lanes of the Eastbound carriageway the traffic had stopped at red traffic light signals When she entered the third lane of the Eastbound carriageway; which was a filter lane for vehicles turning right; the traffic light was in favour of the approaching bus when the collision occurred At the time she crossed the three lanes of the Eastbound carriageway the pedestrian signal was red. There was pedestrian island between the second and third lanes_ CCTV footage, from inside the bus, showed that she was looking to her left and when she stepped into the road she did not see the bus which was approaching from her right hand side The Eastbound carriageway consisting of three lanes was the first part of a 'two stage' crossing, the Westbound carriageway the second stage. At the time she was crossing the Eastbound carriageway a green pedestrian light was displayed on the far side of the Westbound carriageway: Based on the available evidence it was not possible to establish, on the balance of probabilities, that Julia had been confused by this particular green pedestrian signal day: green being

The CCTV footage from the bus showed Julia moving at a pace, which was faster than walking, but not running, across the first and second lanes and continuing into the third lane where the collision occurred_ The driver of the bus passed eyesight breath and drug tests at the scene. He was travelling well below the speed Iimit of 30 mph through a green light; in his favour; and had applied the brakes before the collision occurred The estimated speed of impact was below mph: There were no mechanical problems with the bus.