Dear Mr Salter

RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

This is Oxfordshire County Council’s (“the council”) response to HMSC Salter’s Report to Prevent Future Deaths made under Regulation 28 of the Coroners (Investigations) Regulations 2013 dated 2nd September 2022 (Report).

The report arose from an inquest concluded on 2nd September 2022 into the death of Jennifer Wong.

I would like to take this opportunity to add my condolences to Ms Wong’s family and acknowledge the tragic nature of this case. I would also like to thank the Coroner for his report. The Report to Prevent Future Deaths covered 2 material matters of concern. This response is structured accordingly.

Those matters were:

1) The first and main concern is in relation to the nearside cycle lane and what appeared to be an element of confusion or perhaps a dilemma for cyclists at this location intending to cycle straight across the junction. The cycle lane puts cyclists on the nearside of a lane that is specifically for vehicles turning right into Headley Way. There is the box/advanced stop line in front of the line of traffic in the lane, but this requires the cyclist to decide to use it and, importantly, to have time to make it pass the nearside of the vehicles and into the box before the vehicles in the lane commence their right turn.

If there was no cycle lane, it appears more likely that a cyclist heading straight across would position themselves in lane 2 for vehicles also heading straight on. I believe that further consideration should be given to this issue and if improved signage has a part to play to mitigate the risks.

I appreciate of course that it is not possible to remove risk completely and cyclists will make different choices about where to position themselves at a junction such as this one. I anticipate that the junction is not dissimilar to many others in Oxford. The issue of

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cyclists in nearside blind spots, particularly involving large commercial vehicles with limited visibility, therefore presents a significant and ongoing risk.

2) The second concern relates to the width of the cycle lane. It is believed to be 0.95 metres wide at this location, but the recommended width is 1.2m or perhaps 1.5m. I understand this is an issue which has already been raised following a site meeting. There may be valid reasons why the lane is the width it is, but I would be grateful if this could be considered.

This response therefore firstly covers action that the council is taking to respond to your Matters of Concern.

It then reports on what the council are further actioning in conjunction with our Highways maintenance provider Milestone to respond to your concerns. Finally, it refers to several other relevant actions that the council is either taking or has already taken to help mitigate the risk of these circumstances happening again in the future. I anticipate that we will need to send you a further report in 6 months to update you on the progress of these developments.

I would now like to outline activity that the council has taken and is now taking regarding traffic signals, cyclist safety and cycle lanes.

Improvements to traffic signals, timings, signage for cyclists and cycle lane safety

The council has taken on board your concerns and several measures have already been put in place to improve the public highway for vulnerable road users at both the Headley way junction and at two other key sites within the city. The works that have been completed at Headley Way include: A 5 second advance green lights for cyclists heading east bound and a dropped kerb facility to bring cyclists off the London Road to turn left into Headley Way. We have also commissioned our highway maintenance contractors to undertake a series of road marking amendments to make it clearer for cyclists to utilise the junction. The redesign of the lane/cycle markings has been commissioned to specifically consider the concerns that you raised in your Matter of Concern point 1. The design and delivery of the works at the Headley junction are due to be completed by the end of November 2022.

Width of cycle lane

The original width of 0.95m was a legacy of a scheme that was installed some 10 plus years ago. The cycle widths are being amended to meet the current standards set out by the Department for Transport (1.2m minimum) and work is being undertaken by the council to establish where other sections of the city cycle network may be falling short of current standards. As mentioned previously, the amended designs and works will be completed by the end of November 2022.

Other Action

Finally, reference below are additional steps that the council is taking in response to concerns raised throughout the inquest and in your Report, that we are committed to addressing at this time.

These include:

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- Dropped kerb – The council has now completed the dropped kerb facility at Headley way. We will also be removing the stone planter to increase the space for pedestrians and cyclist at this junction. This now means that cyclists are directed off the London Road before the Headley Way junction to afford them safe passage to the shared use cycle/footway on Headley way.

- Elsewhere within the city (and beyond) a cycle safety group has been set up to undertake detailed reviews of known hotspots for cycle incidents. Currently these are The Plain Roundabout, Iffley Road, The Driftway and The Parkway entrance to ensure that there is a safe system for all road users. This work is linked to the council’s commitment to Vision Zero (zero fatalities or seriously injured on our highway network by 2050). The working group is made up of councillors, senior council officers and local cycling groups.

- Stage 4 Road Safety Audit (RSA) – The RSA4 was completed in October
2022. The report is attached. The council is now ensuring that the recommendations are implemented in a timely manner that is proportionate to the risk posed by the measures being recommended for delivery.

- Vulnerable Road Users (VRU) Audit – following a request from the family, this was commissioned though our Highway maintenance provider on Friday 7 October 2022. There was slight delay in requesting this as we had to wait for the Stage 4 RSA to be completed to ensure a different team were used to undertake the additional assessment. This is to ensure the impartiality of both reports. The findings normally take a minimum of 31 days to be compiled into a report. This is the standard length of time that we would expect for such a report to be developed. The council will write to the coroner with the recommendations of this report upon receipt. The council can confirm that any further actions that are recommended within either the Stage 4RSA or the VRU report will be actioned with immediate effect where it is a priority measure recommended. These measures will be agreed with the cycle safety group to ensure that local users of the network are consulted and that they are content with the council’s proposals.

- Users of the council’s highways and cycle paths can recommend suggestions for amendments to the cycle infrastructure through our defect reporting system Fix My Street. The council monitors the inbox for these suggestions/requests and measures are then implemented if they are deemed to be of benefit to the users of the highway and the cycle network. These suggestions can range from the removal of a single bollard to a whole junction review.

- The council has recently undertaken a detailed review of the Plain Roundabout and The Parkway junction with amendments planned to be implemented to both locations in November 2022.

- The council has reviewed its key junctions that were deemed to be a potential risk to vulnerable road users with input from the cycle safety groups. These reviews have involved site meetings and virtual meetings to fully understand what is required to make the junctions as safe as is reasonably practicable with the resources that are available. In some locations these have been split into short, medium and long-term measures to enable some quick mitigations whilst having a more strategic overview of future developments in the area that will dramatically change the layout of some of the areas.

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The council is committed to the delivery of Vision Zero and several work streams have been set up to ensure that a holistic approach is taken when considering maintenance, renewal, and development of schemes within Oxfordshire. The council has a dedicated team who are project managing the implementation of this work. Oxfordshire County Council is determined to learn from this deeply tragic case and takes the coroner’s concerns very seriously.

Dear Mr Salter,

Thank you for your Regulation 28 report dated 2 September and accompanying documentation, sent to the Department for Transport following the conclusion of the inquest into the death of Jennifer Wong. I am replying as Head of Vehicle Safety Systems & Consumer Incentives in the International Vehicle Standards division, which leads for the Department on vehicle construction standards.

I understand that Ms Wong sustained fatal injuries whilst riding her bicycle when a mobile crane collided with her whilst it was turning left at a traffic light junction. You found that the evidence considered during the inquest revealed matters of concern relating to the construction of the vehicle, including driver vision and the fitting of side mounted direction indicators.

The Road Traffic Act 1988 generally requires vehicles used on the roads of Great Britain to comply with a range of regulations with respect to construction and use, including the Road Vehicles (Construction and Use) Regulations 1986 (as amended) (C&U) covering, view to the front and mirrors, together with the Road Vehicles Lighting Regulations 1989 (as amended) (RVLR) covering direction indicators.

Mobile cranes based on a standard Heavy Goods Vehicle (HGV) chassis will need to meet the standard provisions set for HGVs, including any mandatory requirements for close proximity and front mounted mirrors. However, some mobile crane types, typically those with a greater lifting capacity which are Department for Transport Great Minster House 33 Horseferry Road London SW1P 4DR

Web Site: www.gov.uk/dft

: 28 October 2022

specially designed and constructed to fulfil their purpose are not classifies as HGVs and are permitted to operate under the Road Vehicles (Authorisation of Special Types) (General) Order 2003 (STGO). The Order provides exemptions from some elements of the standard requirements but also imposes additional provisions to mitigate potential risks, such as setting requirements for the use of amber warning beacons and speed restrictions. I understand that the vehicle involved in this collision was operating under STGO rules but, it is noteworthy that the Order with respect to mobile cranes offers no exemptions for view to the front, mirrors, or direction indicators.

Regulation 30 of C&U covers view to the front and requires every motor vehicle to be so designed and constructed that the driver has a full view of the road and traffic ahead. As you have noted, for the purposes of Regulation 33 of C&U, the subject vehicle is classified as a locomotive and requires as a minimum one exterior mirror fitted to the offside. From the evidence provided, the vehicle appears compliant with regards to the C&U requirements. However, these regulations set the minimum standards considered necessary and there is flexibility for manufacturers/operators to install additional devices for indirect vision, including additional mirrors, cameras, and sensors should they wish to do so, and I note from the evidence that this vehicle is fitted with an additional mirror to the nearside.

Regulation 18 of RVLR sets requirements for the obligatory lamps and requires most vehicles first used after 1986 to be fitted with approved front, rear, and side direction indicators. By reference to publicly available records, the vehicle appears to have been first registered and used in 1997 and should therefore be fitted with side mounted direction indicators. However, the records also indicate that the vehicle was not registered in the UK until 2007, suggesting that it may have been imported, and may explain why the side direction indicators were not present and the vehicle non-compliant with our domestic regulations.

Enforcement of road traffic law is generally a matter for the Police, but most vehicles are also subject to annual roadworthiness testing (popularly known as the MOT). However, vehicles operating under STGO are exempt from the statutory annual testing regime as many are too large or too heavy to fit into a standard Heavy Goods Vehicle Authorised Test Facility. These vehicles must still comply with the law and be maintained in a roadworthy condition so operators should have in place a robust programme of daily driver checks, regular inspections undertaken by a vehicle examiner and an annual safety inspection undertaken by an independent vehicle examiner. To help operators comply with the law and ensure safety, the Construction Plant-hire Association (CPA)1 in collaboration with the Driver and Vehicle Standards Agency of the Department for Transport prepared a detailed guidance

1 The CPA is the leading membership and representative body for construction plant-hire in the UK. Established for 80 years, it now has more than 1800 members and supplies 85% of hired plant to the construction industry.

document entitled “Guide to maintaining Roadworthiness of Mobile Cranes,” which is available at the following link: -

crawler-crane-guidance

Irrespective of these measures, the vehicle appears to have been used in a condition which was not compliant with regulations. Whilst it is impossible to determine with any certainty whether full compliance with the regulations would have prevented this collision, I shall be writing to the CPA in the next month to raise the issue of compliance and encouraging its members to consider additional devices or technology to help improve mobile crane driver vision.

Finally, I note your comment regarding the launch of the Government’s Road Safety Investigation Branch (RSIB). This is at an early stage and action is underway to secure the necessary primary and secondary legal powers to enable the branch to operate and will also need to recruit a specialised team of inspectors. Colleagues leading this work intend to engage with the Chief Coroner’s office to determine how the RSIB might best respond to Regulation 28 reports in future, but the branch will not become operational until 2025.

I hope you find this information helpful and are assured that the Department and its agencies are taking appropriate action to respond to your concerns.

Head of Vehicle Safety Systems & Consumer Incentives International Vehicle Standards