Steven Easdale
PFD Report
Partially Responded
Ref: 2023-0054Deceased
1 of 3 responded · Over 2 years old
Response Status
Responses
1 of 3
56-Day Deadline
10 Apr 2023
Over 2 years old — no identified published response
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) That the lack of working lights on the pedestrian refuge on the B197 Digswell Hill (near the Red Lion Public House) poses a danger to road users and pedestrians. Specifically that neither the illuminated bollard nor the streetlamp are in working order. (2) (3) (4)
Responses
Response received
View full response
Dear Sir Inquest Into the death of Stovon Eaedale Regulatlon 28 Roport to Prevent Future Deaths Response CORONER'S MATTERS OF CONCERN TheMATTER OF CONCERN i8 as follows: That the lack of worklng Ilghts on the pedestrian refuge on the B197 Digswell HIII (near the Red Lion Public House) poses a danger t0 road users and pedestrians. Specifically that neither the illuminated bollard nor the streetlamp are in working order: DETAILS OF ACTION TAKEN The Illumlnated bollards and refuge beacon on the same Island were confirmed to be in light on 13 January 2023. They have been checked every 20 since then, with no faults found, and the most recent check on 3rd March 2023 confimed that all lights were working as expected: [Please note the reference to streetlamp in the Report is Interpreted to mean refuge beacon on the same island as tho bollards: The refuge beacon is a low wattage unit with minlmal Ilght output in a downward direction to identlfy the Island for motorists from a distance. It is not deslgned to provide lighting for usors of the crossing] All other slgns and bollards on the B197 Digswell Hill have been checked and were confilned t0 be in light on 3rd March 2023 BACKGROUND: County of opportunlty days the
The island and associated assets were not logged on the Hertfordshire County Council (HCC) highways inventory at the time of the Road Trafiic Colllslon The content and quality of the highways inventory continually improves as assets are added to It In the last year 2,850 assets were added t0 the inventory which contains total of 1,297,947 assots. This means inspections and maintenance of the bollards and refuge beacon would not have been carried out. It is possible other malntenance works may have been caried out at this location; bollard cleaning for example, but these occur during daylight hours and s0 the lack of Illumlnation of the bollards and refuge beacon would be unnoticed: First knowledge of the existence of the assets as a location requlring maintenance by the highways lighting team was after a fault report was raised on 13th Decomber
2021. A hlghways crew visited the site on 12th January 2022 (achieving the 20 working target response for lightlng faults): On attendance on 12th January 2022 , It was found the beacon and bollards were not Iit, and this was caused by a UKPN (UK Power Networks) mains fault; This was notifed to UKPN on 13th January 2022. The site was checked on 31st January 2022 and the fault had not been repalred: It was re-ralsed with UKPN as a high priorty: By Ist February 2022, UKPN identified that the fault was positioned on the bridge over the A1: Before any excavations are carried out on a bridge the owner must provide their approval ' Inltlally UKPN checks were made with HCC to seek approval to excavate on the bridge. HCC confirmed that the structure was not our structure, rather It was Highways England/National Highways (NH): The outstanding fault at thls location was on the agenda at monthly meetings between UKPN and HCC and in June 2022, Ringway (the maintenance contractor working on behalf of HCC) requested that UKPN consider altornative options for electricity supply. Ringway attempted t0 help UKPN by logging an enquiry with National Highways in June 2022 on behalf of UKPN: Our understanding is that on 9th January 2023 UKPN received permission to excavate National Highways, and once that was received UKPN started work on tho fixing the mains fault on Ith January 2023. The HCC highways team were able to confimm all illuminations were in-Ilght on 13th January 2023. The location has been checked every 20-days since then and has been in-light each time. DETAILS QF FURTHER ACTION PROPOSED The slte is now included in the asset inventory and as such the bollards and beacon are inspected and maintained. will continue to be inspected every 20 by & day from site, They - days
Highways team and be attended t0 If necessary: If at any time the Ilghts are not working; that can also be reported by members of the public uslng the onllne Hertfordshire County Council Fault Reporting system. Yours slncorely dhio; Execudve
The island and associated assets were not logged on the Hertfordshire County Council (HCC) highways inventory at the time of the Road Trafiic Colllslon The content and quality of the highways inventory continually improves as assets are added to It In the last year 2,850 assets were added t0 the inventory which contains total of 1,297,947 assots. This means inspections and maintenance of the bollards and refuge beacon would not have been carried out. It is possible other malntenance works may have been caried out at this location; bollard cleaning for example, but these occur during daylight hours and s0 the lack of Illumlnation of the bollards and refuge beacon would be unnoticed: First knowledge of the existence of the assets as a location requlring maintenance by the highways lighting team was after a fault report was raised on 13th Decomber
2021. A hlghways crew visited the site on 12th January 2022 (achieving the 20 working target response for lightlng faults): On attendance on 12th January 2022 , It was found the beacon and bollards were not Iit, and this was caused by a UKPN (UK Power Networks) mains fault; This was notifed to UKPN on 13th January 2022. The site was checked on 31st January 2022 and the fault had not been repalred: It was re-ralsed with UKPN as a high priorty: By Ist February 2022, UKPN identified that the fault was positioned on the bridge over the A1: Before any excavations are carried out on a bridge the owner must provide their approval ' Inltlally UKPN checks were made with HCC to seek approval to excavate on the bridge. HCC confirmed that the structure was not our structure, rather It was Highways England/National Highways (NH): The outstanding fault at thls location was on the agenda at monthly meetings between UKPN and HCC and in June 2022, Ringway (the maintenance contractor working on behalf of HCC) requested that UKPN consider altornative options for electricity supply. Ringway attempted t0 help UKPN by logging an enquiry with National Highways in June 2022 on behalf of UKPN: Our understanding is that on 9th January 2023 UKPN received permission to excavate National Highways, and once that was received UKPN started work on tho fixing the mains fault on Ith January 2023. The HCC highways team were able to confimm all illuminations were in-Ilght on 13th January 2023. The location has been checked every 20-days since then and has been in-light each time. DETAILS QF FURTHER ACTION PROPOSED The slte is now included in the asset inventory and as such the bollards and beacon are inspected and maintained. will continue to be inspected every 20 by & day from site, They - days
Highways team and be attended t0 If necessary: If at any time the Ilghts are not working; that can also be reported by members of the public uslng the onllne Hertfordshire County Council Fault Reporting system. Yours slncorely dhio; Execudve
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and I believe you:
- Chief Executive of Hertfordshire County Council;
- Chief Executive of National Highways;
- UK Power Networks Holdings Ltd both individually and collectively have the power to take such action.
- Chief Executive of Hertfordshire County Council;
- Chief Executive of National Highways;
- UK Power Networks Holdings Ltd both individually and collectively have the power to take such action.
Report Sections
Investigation and Inquest
On the 12th December 2021 Steven Easdale died at Addenbrookes Hospital from injuries sustained in a road traffic collision. His death was reported to the Coroner and an investigation commenced. A post-mortem examination performed by Dr Martin Goddard on 21st December 2021 provided the following cause of death: 1a Purulent Bronchitis and Bronchopneumonia 1b Multiple Traumatic Injuries An inquest was opened on 9th March 2022 and the investigation concluded at the end of that inquest on the 8th February 2023, which found: Circumstances: On the 5th November 2021 Steven Easdale was struck by a car whilst crossing the B197 Digswell Hill. He sustained multiple injuries and was taken by ambulance to Addenbrookes Hospital. Despite treatment, Mr Easdale died on the 12th December 2021. There was a central pedestrian island near to where Mr Easdale crossed the road but he did not use it. It was dark at the time Mr Easdale crossed, he was wearing dark clothing and the driver did not have time to react to his presence in the road and avoid the collision. The central pedestrian island near to where Mr Easdale crossed the road should have been illuminated. It was not in working order, however, and was therefore unlit. A nearby streetlamp was also not working and was unlit. Had the pedestrian island and streetlamp been illuminated it may have helped the driver to see Mr Easdale earlier and avoid the collision. Conclusion of the Coroner as to the death: Road Traffic Collision
Circumstances of the Death
At the inquest I heard evidence from two police officers of the Bedfordshire, Cambridgeshire and Hertfordshire (BCH) Serious Collision Investigation Unit. They outlined that approximately 15 metres from where Mr Easdale crossed the road, there was a traffic island (or pedestrian refuge) with a bollard and streetlamp in place. The bollard on the island is made out of opaque white plastic and is designed to be illuminated from within. The time of the collision was around 5pm on a December afternoon meaning that this stretch of road was in deep darkness.
When the collision occurred on the 5th November 2021, neither the illuminated bollard nor the streetlamp were in working order and were therefore unlit. Both officers from the collision unit gave evidence that this situation presented a danger to road users and pedestrians.
A Traffic Management Officer has brought this situation to the attention of Hertfordshire County Council, Highways England (now National Highways) and National Power Networks (now UK Power Networks).
Despite this, I heard evidence at the inquest that both the bollard and the streetlamp have still not been repaired and remain unlit even in the hours of darkness.
I was not able to say on the balance of probabilities that the lack of lighting on the pedestrian island contributed to Mr Easdale’s death as he was not using the crossing itself when he was struck. He crossed nearby, however, and it is possible that had there been illumination at that island the driver of the car would have seen him earlier and potentially avoided the collision.
I am satisfied that the lack of working lights at this location on the B197 Digswell Hill poses a danger to road users and pedestrians. The location of the island is near to the Red Lion Public House and may be used by people going to and from the pub.
When the collision occurred on the 5th November 2021, neither the illuminated bollard nor the streetlamp were in working order and were therefore unlit. Both officers from the collision unit gave evidence that this situation presented a danger to road users and pedestrians.
A Traffic Management Officer has brought this situation to the attention of Hertfordshire County Council, Highways England (now National Highways) and National Power Networks (now UK Power Networks).
Despite this, I heard evidence at the inquest that both the bollard and the streetlamp have still not been repaired and remain unlit even in the hours of darkness.
I was not able to say on the balance of probabilities that the lack of lighting on the pedestrian island contributed to Mr Easdale’s death as he was not using the crossing itself when he was struck. He crossed nearby, however, and it is possible that had there been illumination at that island the driver of the car would have seen him earlier and potentially avoided the collision.
I am satisfied that the lack of working lights at this location on the B197 Digswell Hill poses a danger to road users and pedestrians. The location of the island is near to the Red Lion Public House and may be used by people going to and from the pub.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.