Millie Taylor-Noonan

PFD Report All Responded Ref: 2020-0097
Date of Report 15 April 2020
Coroner Timothy Brennand
Coroner Area Lincolnshire
Response Deadline est. 13 July 2020
All 1 response received · Deadline: 13 Jul 2020
Response Status
Responses 1 of 1
56-Day Deadline 13 Jul 2020
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

Coroner’s Concerns
1. The location of the collision is in the immediate vicinity to the access and exit entrances to a large secondary school;
2. Whilst motorists have the benefit of advanced warning triangles indicating to road users that there is a school 100 ahead along with a speed limit repeater the location of the incident took place near a dropped kerb with a section of tactile pavement on the footpaths either side of the road, there is no indication to road users as to the imminence of what, was in reality a school crossing area and the area is also unlit;
3. The evidence demonstrated that the deceased may have been distracted by other road traffic users and in particular a school bus emerging from the school premises in the immediacy of the collision that serves to demonstrate the vulnerability of pedestrians in this location at such a time;
4. There are no other measures that exist to protect pedestrians such as:
a. Railings;
b. Street lighting;
c. An automated or zebra or other form of crossing to allow a priority to be given to pedestrians;
d. A school crossing patrol officer;
e. A temporary reduction in the speed limit to 20 miles per hour at the beginning and end of the school day;
Responses
Lincolnshire County Council
20 Apr 2020
Response received
View full response
Dear Mr Brennand

REGULATION 28 REPORT – MILLIE TAYLOR-NOONAN (DECEASED)

Thank you for your letter dated 20 April 2020 enclosing your Regulation 28 Report following the inquest investigating the death of the late Millie Taylor-Noonan. As required under Section 7 of your report, I have now considered your points and respond accordingly.

Your concerns listed in the report are:

1. The location of the collision is in the immediate vicinity to the access and exit entrances to a large secondary school.
2. Whilst motorists have the benefit of advanced warning triangles indicating to road users that there is a school 100yds ahead along with a speed limit repeater the location of the incident took place near a dropped kerb with a section of tactile pavement on the footpaths either side of the road, there is no indication to road users as to the imminence of what, was in reality a school crossing area and the area is also unlit.
3. The evidence demonstrated that the deceased may have been distracted by other road traffic users and in particular a school bus emerging from the school premises in the immediacy of the collision that serves to demonstrate the vulnerability of pedestrians in this location at such a time.
4. There are no other measures that exist to protect pedestrians such as
a. Railings:
b. Streetlighting
c. An automated or zebra or other form of crossing to allow priority to be given to pedestrians
d. A school crossing patrol officer
e. A temporary reduction in the speed limit to 20 mph at the beginning and end of the school day

Mr Timothy Brennand Lincoln Coroners' Court & Office 4 Lindum Road Lincoln LN2 1NN

Our ref: AG/AH

08 October 2020

Executive Director for Place Lincolnshire County Council County Offices Newland Lincoln LN1 1YL

01522 782070 cschighways@lincolnshire.gov.uk

The incident occurred on the A607 Cliff Road between Leadenham and Welbourn adjacent to the Sir William Robertson Academy. Lincolnshire County Council is the relevant Highways Authority. The Academy is a large secondary school which is part of the Aspire School Trust.

As the deceased was a student at the Academy we have worked with the school to look at enhancing road safety around the entrance to the school grounds as well as the highway itself, details of which are set out below.

With regard to your second point, the school entrance benefits from both advance warning triangles and a 30mph speed limit. There is no School Safety Zone present in the vicinity as these are largely designed for primary schools where pupils will generally have less road safety awareness and where parking around school entrances may be an issue. These factors do not apply to this location. Further, we confirm that we have no record of any other incident involving a pedestrian at this location within the last 20 years.

However, it is agreed that the conspicuity of the school entrance could be enhanced and I shall outline our proposed measures below.

With regard to your third point, a joint examination with the Academy of the school's vehicular access arrangements, which currently operate as a one-way system utilising the northern access and southern exit, was carried out at school exit times. For the internal operation within the school premises, of children boarding and exiting buses, this is the safest option. An option to reverse this arrangement was considered but it was agreed this would create queuing vehicles on the highway which would obscure pedestrian and vehicle visibility and, at worst, actually prevent crossing of the road.

Your fourth and final concern relates to a request that a number of individual control measures are considered.

a. At this location the width of the footway is such that the installation of guardrail would require significant widening works and affect underground utility services. Safety concerns would also be created due to reduced highway visibility for properties opposite the school; and also the risk that pedestrians may be tempted to walk outside the barrier if the footpath was occupied by other waiting pedestrians. It is not considered to be reasonably practicable to provide guardrail taking into account the above issues.
b. The provision of Streetlighting at this location does not meet the requirements of the County Council's Streetlighting Policy. However, the school feel that this request would have the most significant benefit and the Executive Councillor has authorised its installation as an exceptional case.
c. Unusually for a large academy the vast majority of pupils access this school by coach/bus. The school roll shows that only 15 children live in Leadenham and 16 children live in Welbourn and physical counts at exit time showed less than 50 pupils cross the road. As such this location does not meet the minimum criteria to provide a light controlled crossing. However, the school has now provided a teacher to effectively marshal and hold students at the school gate until it is safe to cross the road; effectively providing a safe method of crossing.

d. Similarly, whilst a School Crossing Patrol does not meet the necessary criteria in terms of numbers of pupils who would use that patrol, as the school have volunteered the services of their staff at the pedestrian exit this provides a suitable alternative that ameliorates the risk.
e. The benefits of a temporary speed limit are a matter of debate nationally as evidence suggests such a measure may not have the effect of reducing average speeds. The County Council does not therefore have a policy of implementing temporary speed limits of 20 mph in place. However, as mentioned above it is agreed that the conspicuity of the school entrance can be enhanced. Therefore, we will carry out works this year to place improved roadmarkings including SLOW and yellow SCHOOL zig-zag markings adjacent to the entrance. We will also install additional school warning signs and finally we will provide school amber flashing lights to raise awareness at start and finish times.

I trust the above addresses your concerns and outlines our plans for this section of highway.
Report Sections
Investigation and Inquest
On 12/12/2018 I commenced an investigation into the death of Millie TAYLOR-NOONAN, aged 18. The investigation concluded at the end of the inquest on 25/09/2019. The conclusion of the inquest was that Millie TAYLOR-NOONAN died as a result of Road Traffic Collision, the medical cause of death being: 1a. Head Injury Sustained in a Road Traffic Collision 1b. 1c.
2.
Circumstances of the Death
On the afternoon of Tuesday 4th December 2018, whilst as a pedestrian crossing the A607 road adjacent to The Sir William Robertson School, Welbourn, Lincolnshire, the deceased stepped into the road and was immediately struck by a car being driven in a lawful and appropriate manner that the deceased had failed to appreciate being in close proximity to her. As a consequence of the collision, the deceased suffered a significant head injury and cardiac arrest. She received active resuscitation at the scene and was transferred to the Queen's Medical Centre, Nottingham. The nature and extent of the brain injury was such that her condition was considered to be un-survivable. She was declared to be brain stem dead at 14:42 on the 5th December 2018. Following organ donation procedures, active support was withdrawn and she was formally to be pronounced as dead.

Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.