Mervyn Holbrook
PFD Report
Partially Responded
Ref: 2022-0396
1 of 2 responded · Over 2 years old
Response Status
Responses
1 of 2
56-Day Deadline
3 Feb 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
1. I heard and considered evidence from West Midlands Police's Forensic Collision Unit which confirmed that where the footpath outside 214 Alcester Road South reaches the junction of Livingstone Road, it appears that there is a dropped kerb at the apex. On the opposite side of the junction, the kerbs are raised. West Midlands Police advise that this indicates that the dropped kerbs at this side of the junction are a result of vehicles mounting the kerb as they turn left from Livingstone Road to Alcester Road and therefore causing them to be eroded to be level with the road surface. There is also no tactile paving next to these kerbs, which indicate that this dropped kerb is not an "official" pedestrian crossing point - the same being situated approximately 9m from the end of Livingstone Road.
2. Mr Holbrook was able to leave the carriageway on his mobility scooter at apex/mouth of the junction due to the kerb being worn down to the road surface, and was struck in the carriageway.
3. On 12 September 2022, PC of West Midlands Police submitted a notification via Birmingham City Council's Highway Department's online portal of the defect, with the Highways responding via email on 20 September 2022 stating that it did not meet the intervention levels that require repair.
4. I am concerned that vulnerable road users - particularly users of mobility scooters or bicycles - may inadvertently consider the worn down and defective kerb to be an "official" crossing point and enter the carriageway when it is unsafe to do so.
5. Furthermore, if a mobility scooter or similar were to enter the carriageway at the mouth of the junction (as Mr Holbrook did), they would then be unable to mount the curb at the opposite side - they would have to travel West down the carriageway of Livingstone road to the official crossing point, or alternatively (and more dangerously) navigate South on the carriageway into oncoming traffic onto Alcester Road.
2. Mr Holbrook was able to leave the carriageway on his mobility scooter at apex/mouth of the junction due to the kerb being worn down to the road surface, and was struck in the carriageway.
3. On 12 September 2022, PC of West Midlands Police submitted a notification via Birmingham City Council's Highway Department's online portal of the defect, with the Highways responding via email on 20 September 2022 stating that it did not meet the intervention levels that require repair.
4. I am concerned that vulnerable road users - particularly users of mobility scooters or bicycles - may inadvertently consider the worn down and defective kerb to be an "official" crossing point and enter the carriageway when it is unsafe to do so.
5. Furthermore, if a mobility scooter or similar were to enter the carriageway at the mouth of the junction (as Mr Holbrook did), they would then be unable to mount the curb at the opposite side - they would have to travel West down the carriageway of Livingstone road to the official crossing point, or alternatively (and more dangerously) navigate South on the carriageway into oncoming traffic onto Alcester Road.
Responses
Birmingham City Council amended the kerb height at the junction of Alcester Road South and Livingstone Road in January 2023. They have also reviewed internal processes for defect reporting and are undertaking a study to identify other similar kerb defects and review intervention criteria.
AI summary
View full response
Dear Mr Hodson,
Further to the issue of Regulation 28 Report to Prevent Future Deaths, dated 08th December 2022, following the inquest into the death of Mr Mervyn Charles Gladstone Leonard Holbrook, I provide my response on the actions taken / proposed as follows;
1. I confirm the height of the kerb where the footpath outside 214 Alcester Road South reaches the junction of Livingstone Road was amended by the City Council in early January 2023 as per your recommendations.
Please refer to the photographs below showing the site before and after the remedial works.
Birmingham City Council
Highways & Infrastructure PO Box 37 Birmingham B4 7DQ
Kerb line outside 214 Alcester Road South reaches the junction of Livingstone Road BEFORE the remedial works
Kerb line outside 214 Alcester Road South reaches the junction of Livingstone Road AFTER the remedial works in January 2023
2. We have also commissioned to undertake a review of the available kerb defect information to identify locations similar to the incident site on the network so that the necessary processes are incorporated and similar sites are addressed as part of the Council’s maintenance activities. The scope of the study also includes a review of the intervention criteria and whether these need to be revised in the light of this incident. This study is well underway and is expected to be completed by March 2023. A copy of the report will be shared with you as soon as it is available along with details of further proposed actions.
3. An investigation into the PC Glyn Hanks’ submitted notification on 12th September 2022 via Birmingham City Council's Highway Department's online portal reporting the defect and the Highways response, provided on 20 September 2022, has also been undertaken and our findings are as follows;
a. Fatal and serious collisions are normally notified to BCC by the Staffordshire and West Midlands Police Serious Collision Investigation Unit. On this occasion however, the established protocol between BCC and West Midlands Police had not been followed and as such BCC were unaware of the incident until 12th September 2022.
b. Having reviewed the report submitted by whilst somewhat ambiguous, our Highway Inspector should have contacted to
Birmingham City Council
Highways & Infrastructure PO Box 37 Birmingham B4 7DQ
obtain further information given the circumstances and the nature of the incident. The issue should have been further escalated within BCC. Our processes and procedures have been reviewed so that a similar occurrence does not happen in the future.
c. BCC will also be contacting West Midlands Police, reiterating the need to adhere to the already established protocol when reporting fatal or serious road traffic collisions on the City’s highway network.
I trust the above addresses the concerns raised in your Regulation 28 Report to Prevent Future Deaths. If you require any further information / clarification however, please do not hesitate to contact me.
Further to the issue of Regulation 28 Report to Prevent Future Deaths, dated 08th December 2022, following the inquest into the death of Mr Mervyn Charles Gladstone Leonard Holbrook, I provide my response on the actions taken / proposed as follows;
1. I confirm the height of the kerb where the footpath outside 214 Alcester Road South reaches the junction of Livingstone Road was amended by the City Council in early January 2023 as per your recommendations.
Please refer to the photographs below showing the site before and after the remedial works.
Birmingham City Council
Highways & Infrastructure PO Box 37 Birmingham B4 7DQ
Kerb line outside 214 Alcester Road South reaches the junction of Livingstone Road BEFORE the remedial works
Kerb line outside 214 Alcester Road South reaches the junction of Livingstone Road AFTER the remedial works in January 2023
2. We have also commissioned to undertake a review of the available kerb defect information to identify locations similar to the incident site on the network so that the necessary processes are incorporated and similar sites are addressed as part of the Council’s maintenance activities. The scope of the study also includes a review of the intervention criteria and whether these need to be revised in the light of this incident. This study is well underway and is expected to be completed by March 2023. A copy of the report will be shared with you as soon as it is available along with details of further proposed actions.
3. An investigation into the PC Glyn Hanks’ submitted notification on 12th September 2022 via Birmingham City Council's Highway Department's online portal reporting the defect and the Highways response, provided on 20 September 2022, has also been undertaken and our findings are as follows;
a. Fatal and serious collisions are normally notified to BCC by the Staffordshire and West Midlands Police Serious Collision Investigation Unit. On this occasion however, the established protocol between BCC and West Midlands Police had not been followed and as such BCC were unaware of the incident until 12th September 2022.
b. Having reviewed the report submitted by whilst somewhat ambiguous, our Highway Inspector should have contacted to
Birmingham City Council
Highways & Infrastructure PO Box 37 Birmingham B4 7DQ
obtain further information given the circumstances and the nature of the incident. The issue should have been further escalated within BCC. Our processes and procedures have been reviewed so that a similar occurrence does not happen in the future.
c. BCC will also be contacting West Midlands Police, reiterating the need to adhere to the already established protocol when reporting fatal or serious road traffic collisions on the City’s highway network.
I trust the above addresses the concerns raised in your Regulation 28 Report to Prevent Future Deaths. If you require any further information / clarification however, please do not hesitate to contact me.
Report Sections
Investigation and Inquest
On 4 July 2022 I commenced an investigation into the death of Mervyn Charles Gladstone Leonard HOLBROOK. The investigation concluded at the end of the inquest on 8 December 2022. The conclusion of the inquest was: Road traffic collision
Circumstances of the Death
At 14:30 on 16/06/2022, Mr Holbrook was knocked off his mobility scooter and was run over at the junction of Livingstone Road and the A435 Alcester Road. He had been travelling Southbound along the footpath and left the pedestrian walkway at the mouth of the junction (where the kerb had been worn down) and entered the carriageway at the same time as Nissan Qashqai tried to navigate and turn left onto the Alcester Road from Livingstone Road. He suffered catastrophic thoracic injuries, and despite life-saving treatment by emergency services, he could not be saved and was pronounced deceased at the scene at 14:57. Following a post mortem the medical cause of death was determined to be: 1a RIB FRACTURES WITH FLAIL SEGMENT 1b ROAD TRAFFIC COLLISION 1c II ISCHAEMIC HEART DISEASE WITH CARDIOMEGALY CORONER'S CONCERNS During the 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 taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows.
1. I heard and considered evidence from West Midlands Police's Forensic Collision Unit which confirmed that where the footpath outside 214 Alcester Road South reaches the junction of Livingstone Road, it appears that there is a dropped kerb at the apex. On the opposite side of the junction, the kerbs are raised. West Midlands Police advise that this indicates that the dropped kerbs at this side of the junction are a result of vehicles mounting the kerb as they turn left from Livingstone Road to Alcester Road and therefore causing them to be eroded to be level with the road surface. There is also no tactile paving next to these kerbs, which indicate that this dropped kerb is not an "official" pedestrian crossing point - the same being situated approximately 9m from the end of Livingstone Road.
2. Mr Holbrook was able to leave the carriageway on his mobility scooter at apex/mouth of the junction due to the kerb being worn down to the road surface, and was struck in the carriageway.
3. On 12 September 2022, PC of West Midlands Police submitted a notification via Birmingham City Council's Highway Department's online portal of the defect, with the Highways responding via email on 20 September 2022 stating that it did not meet the intervention levels that require repair.
4. I am concerned that vulnerable road users - particularly users of mobility scooters or bicycles - may inadvertently consider the worn down and defective kerb to be an "official" crossing point and enter the carriageway when it is unsafe to do so.
5. Furthermore, if a mobility scooter or similar were to enter the carriageway at the mouth of the junction (as Mr Holbrook did), they would then be unable to mount the curb at the opposite side - they would have to travel West down the carriageway of Livingstone road to the official crossing point, or alternatively (and more dangerously) navigate South on the carriageway into oncoming traffic onto Alcester Road.
1. I heard and considered evidence from West Midlands Police's Forensic Collision Unit which confirmed that where the footpath outside 214 Alcester Road South reaches the junction of Livingstone Road, it appears that there is a dropped kerb at the apex. On the opposite side of the junction, the kerbs are raised. West Midlands Police advise that this indicates that the dropped kerbs at this side of the junction are a result of vehicles mounting the kerb as they turn left from Livingstone Road to Alcester Road and therefore causing them to be eroded to be level with the road surface. There is also no tactile paving next to these kerbs, which indicate that this dropped kerb is not an "official" pedestrian crossing point - the same being situated approximately 9m from the end of Livingstone Road.
2. Mr Holbrook was able to leave the carriageway on his mobility scooter at apex/mouth of the junction due to the kerb being worn down to the road surface, and was struck in the carriageway.
3. On 12 September 2022, PC of West Midlands Police submitted a notification via Birmingham City Council's Highway Department's online portal of the defect, with the Highways responding via email on 20 September 2022 stating that it did not meet the intervention levels that require repair.
4. I am concerned that vulnerable road users - particularly users of mobility scooters or bicycles - may inadvertently consider the worn down and defective kerb to be an "official" crossing point and enter the carriageway when it is unsafe to do so.
5. Furthermore, if a mobility scooter or similar were to enter the carriageway at the mouth of the junction (as Mr Holbrook did), they would then be unable to mount the curb at the opposite side - they would have to travel West down the carriageway of Livingstone road to the official crossing point, or alternatively (and more dangerously) navigate South on the carriageway into oncoming traffic onto Alcester Road.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.