Sonia Stante
PFD Report
All Responded
Ref: 2017-0428
All 1 response received
· Deadline: 4 Jan 2018
Sent To
Response Status
Responses
1 of 1
56-Day Deadline
4 Jan 2018
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
Duringthe course of the inquest the evidence revealed matters giving rise to concern: In my opinion there is a risk that future deaths will occur unless action is takeno Iote circumstances it is my statutory duty to report to you: _ To the The The day May from the the July The
Following the incident_ Traffic Management Officer undertook a review of the road traffic layout at the scene_ He met with TfL on site on 16 August 2017 and a number of findings were made:
1) No road markings indicating the direction pedestrians should look when crossing
2) Two separate junctions at that location make that crossing confusing for pedestrians (3) The phasing of the green man operates for each carriageway independently so causing confusion for pedestrians who may look at the wrong phasing (4) Missing louvre on the green man on the north side of the crossing making the green man more visible to pedestrians crossing from the south (5) With the location being close to the Eurostar Terminal there are several hotels nearby and foreign visitors may not have a full understanding if the junction
Following the incident_ Traffic Management Officer undertook a review of the road traffic layout at the scene_ He met with TfL on site on 16 August 2017 and a number of findings were made:
1) No road markings indicating the direction pedestrians should look when crossing
2) Two separate junctions at that location make that crossing confusing for pedestrians (3) The phasing of the green man operates for each carriageway independently so causing confusion for pedestrians who may look at the wrong phasing (4) Missing louvre on the green man on the north side of the crossing making the green man more visible to pedestrians crossing from the south (5) With the location being close to the Eurostar Terminal there are several hotels nearby and foreign visitors may not have a full understanding if the junction
Responses
Response received
View full response
Dear Ms Jacqueline Devonish My colleagues and were very to hear of the death of Ms Sonia Stante and we pass on our sincere condolences to her family_ We acknowledge receipt of your Prevention of Future Deaths report on the 30 November 2017 and respond as follows Junction design and layout (matters of concern' points 2 and 3) The junction of Pentonville Road and King's Cross Road operates as single junction with two separately signalled pedestrian crossings_ The crossing of King's Cross Road is known as a 'straight across' crossing and the crossing on Pentonville Road as 'staggered' crossing: This is a common arrangement and used throughout London. At a staggered crossing, pedestrian must cross the road in two stages as each green figure light aspect will display independently of the other. Each green figure light aspect is sufficiently far apart to discourage pedestrians from looking at the other: This arrangement allows the junction to operate in the most efficient manner overall; reducing the time that pedestrians must wait before they are able to cross the road as well as delays to other road users_ WY Place FiFE 3 S Mus z AlL SALNTSS) TER ST RC 7 COUNCIL COL Cll OFFICES & WYNFORD ROAD LEISURE 1 Health CEN 2 3 Sec 8 ~Po PANCRAS Zking $ WHARFDALE RD " PRIORY Sch + 4 SO CROSS 6 EGREEN ST7223 8 ZRSTWAN 12 EST Youth Cen ST 6 Sch ST ANCRAS Public Jurys KING'S CALE;/ Carr Off % P NT 3 CROSS DONIA Halls 0f RD ST ST Res G2 Gt. Northern PANCRAS PE & HOLFORD Hotelc 8 GDNS Transport 40 Comm 2 Pol PO 9 Gee Cen 2 ST St Pancras 3t 5 Uni St Renaissance 8 6 ST R PERCY PO VHA ToWN S 8 2 St Travelodge 44 HALL $ HOSP 4 Thea Sch Comm ST ST U St 50 {A ST Ccem ST S1 Comm Sch Cen PANCRAS 5 4 4# ST 2 8 G ST EASTMAN 8 s1 Coll DENIT RD Pl Du Vab Vc PL Athye Ji Jioilua % Figure 1: Location of junction within wider area sorry 1 'GOODS_ 1 MAYG ~dEwe TOLPudD" Cent 1 0 ~SquiH , TRISING HIL 8 STREET 'DONEGAL 5 COLLIER A5O1 NTONVILLE 8 L KJNG $ CruiKS CROSS I 1 9 LBRITANNA VER PERCY 5 WckloW CHad s E 3 5 SWINTON 8 Filovd ACTON WHARTON JBOROUGH " 1 erEdERICK 'GRANV 8 HastINGS 0 8 CROSS AMPTON 0 HARRISON MARGERY 8 1 SIDMOUTH REGENT 6 2 ~SQUARE 'EIGH
Green figure 'louvres' on pedestrian signals (matters of concern' point 4) At the time f the collision, pedestrian signals at both crossings were functioning normally: This included louvres (a slatted cover designed to prevent confusion between the green figure light aspects of the separate crossings) on two of the green figure light aspects at the pedestrian crossings_ These louvres were in place at the time of the site visit with the Metropolitan Police on 16 August 2017_ We inspected the crossings again on 11 September 2017 to review the layout and consider whether any changes could be made to assist pedestrians further: Subsequent to this visit; additional louvres were fitted on 13 October 2017 to two further green figure light aspects on the Pentonville Road crossing, including on the north side of the crossing (see Figure 2) , to reduce the likelihood of pedestrians crossing when they were not invited to do so. Road markings ('matters of concern' point 1) The provision of 'Look left; Look right' markings is assessed by TfL on a site-by-site basis, in line with the national guidance. Following your report, these have been installed at each of the pedestrian crossings at this junction_ Understanding of the junction by foreign visitors ('matters of concern' point 5) We take the safety of our highway extremely seriously and adopt an approach of continual improvement to reducing road danger: The measures we have undertaken at this junction will further enhance pedestrian safety at this location. There are hotels and tourists in the area, including those from outside the UK This type of location, however, is not atypical in London and we design and operate the highway so that it is clear and understandable for all users, regardless of their origins and familiarity of the area.
Green figure 'louvres' on pedestrian signals (matters of concern' point 4) At the time f the collision, pedestrian signals at both crossings were functioning normally: This included louvres (a slatted cover designed to prevent confusion between the green figure light aspects of the separate crossings) on two of the green figure light aspects at the pedestrian crossings_ These louvres were in place at the time of the site visit with the Metropolitan Police on 16 August 2017_ We inspected the crossings again on 11 September 2017 to review the layout and consider whether any changes could be made to assist pedestrians further: Subsequent to this visit; additional louvres were fitted on 13 October 2017 to two further green figure light aspects on the Pentonville Road crossing, including on the north side of the crossing (see Figure 2) , to reduce the likelihood of pedestrians crossing when they were not invited to do so. Road markings ('matters of concern' point 1) The provision of 'Look left; Look right' markings is assessed by TfL on a site-by-site basis, in line with the national guidance. Following your report, these have been installed at each of the pedestrian crossings at this junction_ Understanding of the junction by foreign visitors ('matters of concern' point 5) We take the safety of our highway extremely seriously and adopt an approach of continual improvement to reducing road danger: The measures we have undertaken at this junction will further enhance pedestrian safety at this location. There are hotels and tourists in the area, including those from outside the UK This type of location, however, is not atypical in London and we design and operate the highway so that it is clear and understandable for all users, regardless of their origins and familiarity of the area.
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe your organisation have the power to take such action.
Report Sections
Investigation and Inquest
On 31 July 2017] ! commenced an investigation into death of Sonia Elvira Stante aged 69. investigation concluded at the end of the inquest on 28 ovember207 . conclusion of the inquest was Road Traffic Collision and a cause of death of multi organ failure due to ischaemic bowel (operated) as a direct result of multiple injuries
Circumstances of the Death
On 10 July 2017 Sonia Stante arrived in London for a three trip as a part of multi country European trip Which she had commenced on 30 2017. Ms Stante was Peidenced ORocdtr footage stepping %ff the Pavementjust east of the junction aiong Pentonville Road Kings Cross Road into the path of a double decker bus without looking in the direction of the bus, but appearing to look across the road, not left; bot diagonally: The bus had a green light signal and was travelling in bus lane at a speed of between 18 and 22mph, in a 3Omoh zone Upon seeing Ms Stante step into the road the bus driver applied brakes reducing his speed to 16-9mph. She made contact with the front nearside of the bus and was thrown back onto the pavement along thenkect ' She was transferred to hospital in a conscious state and had been able to tell the London Ambulance Service paramedic that she had checked the road in the direction. wrong She deteriorated and died from her injuries on 21 2017 at the Royal London hospital.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.