RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

To the Chief Coroner

We write in response to the regulation 28 report dated 9th April 2019, from Mr Simon Jones, an Assistant Coroner for Lancashire & Blackburn with Darwin. Mr Jones having investigated the death of Freda Odette Mason, aged 67, concluded on 9th April 2019 that she died an accidental death.

The Coroner found that the circumstances of death were as follows:- Freda Mason had suffered from a number of underlying conditions including chronic obstructive pulmonary disease and osteoporosis and had sustained a number of fragility fractured including fractures to her left humerus and to her vertebrae in 2017. On 26th July 2018 at approximately 1145hrs, while sitting at a bus stop at the junction of Burnley Road and Victoria Street Padiham, she fell through the back of the bus shelter where a panel of glass was missing ( and on the evidence had been missing for approximately three months). She was admitted to RBH at approximately 2325hrs where she was found to have sustained multiple rib fractures. Surgical intervention and invasive ventilation could not be provided , due to her underlying conditions, and her respiratory function was severely compromised. She died in hospital on the 29th July 2018 at approximately 1945hrs.

The MATTERS OF CONCERN raised by the Coroner were as follows

1. LCC has a duty to maintain bus shelters within its area, an does so using a process whereby complaints are made to LCC by third parties- members of the public, councillors, employees of LCC and bus companies
2. LCC assesses the complaint and responds, effecting repairs where necessary.
3. LCC does not operate an inspection system where it views the bus shelters, therefore unless a third party notifies LCC of a problem, to has no knowledge go to and cannot respond/repair.
4. The Learned Coroner was of the opinion that a more pro-active system of anticipating necessary repairs could prevent future deaths; and LCC has the power to take further additional steps to ensure that problems requiring repair are brought to its attention immediately-whether by implementing a regime of inspection or by ensuring that those who use/visit the shelters (including bus drivers and inspectors) are required (or Encouraged, where LCC does not have the authority to require it) to notify LCC of any problem which needs attention.

LCC RESPONSE

In Lancashire, there are approximately 2,000 bus shelters situated at bus stops across the county.

Approximately one third of these are owned and maintained by the County Council. A further third are directly owned and maintained by district or parish councils with the final third owned and maintained by a number of advertising companies, under contract to either the county or district councils.

We are currently in the process of tendering a contract for a service provider to install, maintain, monitor and repair our bus shelter stock as part of a comprehensive overhaul and upgrade programme throughout the county.

This contract will allow us to provide a consistent monitoring regime, where every shelter is to be checked every six weeks for any damage, with a structural assessment every twelve months.

It is expected that this contract will be in operation from 1st October 2019.

In addition to, and prior to the commencement of this contract, we have put in place a number of measures to ensure that any damage to/or issues with any of our bus shelters that require repair, are brought to our attention as soon as practically possible.

We have instructed our staff, who may be visiting shelters to update timetable information or for any other reason, to carry out an inspection and to report any damage to a manager with sufficient detail so that a determination can be made as to whether an urgent repair is required.

We have written to all bus operators requesting they that they instruct their drivers to also report any shelter damage they observe during the course of their daily duties.

We are introducing a more prominently situated 'Report It' notice for members of the public detailing where and how to easily communicate any shelter damage they may find in between the regular checks being undertaken by our own staff or contractors. This 'Report It' process will be managed through the corporate reporting system to ensure the whole process is consistent and information is communicated in the most efficient way.

We are responsible for displaying timetable information at bus stops, and the 'Report it' notice will also be displayed on all timetable cases of those bus shelters that are not owned or managed by the county council. This will enable the county council to centrally coordinate any damage reports and ensure the handover of information to the applicable organisation for them to take the appropriate action.

We will write to our contacts in district councils and to the shelter owning advertising agencies advising them of our arrangements to mitigate the risk of injury to users of bus shelters following damage and suggest that they may wish to consider their own arrangements and seek their cooperation in ensuring an efficient reporting process.

Whilst it's not possible to be aware of shelter damage the moment it occurs, we do expect the measures put in place will bring them to our attention as speedily as reasonably possible and enable any safety critical repairs to be undertaken as a matter of urgency.