Dear Miss Persaud Regulation 28 Prevention of Future Deaths Notice: Ellie Jessalyn Isaacs (Inquest 01/09/2020) am personally very sorry to hear of the tragic death of Ms Ellie Isaacs and wish to express my sincere condolences and those of Transport for London (TfL) to the family and friends of Ms Isaacs_ We note that this Prevention of Future Deaths Notice is addressed t0 the London Borough of Havering: The London Borough of Havering forwarded it to us on 15 September 2020 to respond to as TfL is the responsible Highway Authority for the A12- Please accept this letter as TfL's response to the Prevention of Future Deaths (PFD) report dated 1 September 2020 pursuant to regulation 28 of the Coroners (Investigations) Regulations 2013. The Commissioner and the Managing Director of Surface Transport have asked me to write to you: TfL is a Highway Authority and is the responsible highway authority for the A12 Colchester Road for the section which is within London, that includes the location of the collision and this letter outlines actions already taken and those that we intend to take to improve safety along the A12 in the vicinity of the A12/A127 Gallows Comer junction_ Road safety, particularly the reduction of personal injuries, is core to our business at TfL. We actively seek to reduce collisions across the whole of London with initiatives detailed in the Mayor's Transport Strategy (March 2018) and the Vision Zero Action Plan (July 2018). These policy documents set our vision t0 eliminate all deaths and serious injuries by 2041, as well as reduce the danger on our road network These documents outline the important first stages in a wide-ranging programme of actions that we, as an organisation; are now and over the coming years taking

Site Visits It is our standard practice and part of our wider commitment to Vision Zero to organise a visit t0 the site of every fatal incident that occurs on TfL's network: This is to identify any issues and actions that can be taken immediately to prevent future loss of life . These site visits involve TfL employees with different expertise within the organisation who review the site collectively to identify any inherent problems at the location that to be addressed immediately. Also noted during the site visits are any other issues that may require a longer-term investigation of the highway conditions or any issues relating to the behaviour of road users, that may need to be addressed by TfL's road safety education team andlor require enforcement by the Metropolitan Police (MPS): In this case, the initial site visit by TfL took place on 1 July 2019 and included traffic officers from the MPS. No road user violation was noted during the site visit This section of the A12 is patrolled by the MPS. The MPS have not indicated any additional concerns about this area which would result in increased enforcement activity: No immediate or urgent concerns were identified by the site visit: As part of this visit the street furniture was reviewed and it was considered that it did not obstruct drivers' view of pedestrians in the area however issues with overgrown vegetation were noted_ A number of other minor action points were identified for follow up (details of work then subsequently undertaken is provided below): A further site inspection was undertaken by TfL Engineering's Traffic Control team on 29 August 2019 following an enquiry from Ms Isaac's family which was forwarded to us by the MPS regarding the location of the crossing facility. This inspection determined that the design and operation of the pelican crossing met TfL'$ current design standards and this finding was communicated to the MPS. It additionally determined that there was good visibility of the traffic signals which have five signal heads on both approaches (with two positioned at 6m high and three at 4m high as illustrated in the photos below): road need

Photo 1: A12 Colchester Road pelican crossing looking south-west towards Gallows Corner (6m high signal heads highlighted blue; 4m high signal heads highlighted red) Photo source: Google Streetview April 2018. Photo 2: A12 Colchester Road pelican crossing looking north-east away from Gallows Corner (6m high signal heads highlighted blue; 4m high signal heads highlighted red): Photo source: Google Streetview July 2019. Technical information about the crossing The controlled pedestrian crossing facility in question was moderised in 2005 and it was converted to a 'ped-x' type crossing in 2015. A 'ped-x' type crossing is a standalone signal-controlled pedestrian facility using pedestrian signals which are operated with push buttons. The traffic signal sequence is the same as at ajunction with a steady amber period for traffic (rather than flashing). Pedestrians receive a steady green pedestrian symbol (rather than flashing) indicating that it is safe to cross, followed by a black out period where no pedestrian signal is displayed, followed by a red pedestrian signal (details of the timings of the crossing are provided below): KFC

The revised design was implemented in accordance with the TfL design standard at the time (Reference TTS6): The implemented facility was fully compliant with this standard at the time of modernisation. In the intervening period TTS6 has been updated and a new set of TiL design standards has been developed, including the following: a) SQA-0643: Design for Signalised Junctions b) SQA-0644: Design for Signalised Crossings c) SQA-0845: Traffic Signal Timings We have not provided copies of these design standards due to their detailed and technical nature, however please let us know if the Coroner would like to see copies: The above design standards outline the parameters for the design and operation of traffic control facilities in London: The layout implemented on the A12 Colchester Road is shown in TfL standard SQA-0644: Design for Signalised Crossings Appendix E and is a 'H2" layout (diagram replicated below in Figure 1), albeit with the mast arm modified to two 6m poles on both sides of the crossing in accordance with current best practice. 1 Figure 1: SQA-0644: Controlled Crossing Layout "H2". In accordance with the TfL standard SQA-0643: Design for Signalised Junctions, a triangular warning sign is in place on the approach to the controlled crossing facility at this location. The aim of the advance warning sign is to provide advance notice to road users of the presence of the controlled crossing facility ahead. The controlled crossing facility is programmed to show 6 seconds of the 'green' pedestrian signal (the green man) , 6 seconds of signal black-out time and 5 seconds of the 'red' pedestrian signal, there is then a second 'all red' (pedestrian signals and traffic signals showing red) followed by a 2 second starting amber signal for traffic This gives adequate opportunity for pedestrians to cross unopposed by

general traffic and is compliant with the relevant standards (TfL standard SQA-0645: Traffic Signal Timings): Speed limits and siqnage at Gallows Corner roundabout Below is an aerial photo of the crossing: The speed limit for the Gallows Corner roundabout is 3Omph and remains so through the pedestrian crossing location for traffic exiting the roundabout to travel north-east along the A12. There is a speed limit change between 30/50mph which occurs on the other side of the pedestrian crossing (approximately 130m t0 the north east) for traffic approaching the roundabout. This road layout with the change f speed limit is in line with relevant highway regulations. Sce Irate| timag traffic and nearby placet 30/50mph speed limit change Crossinglocation ETEF 0o919 Work undertaken Following the site visits referred to above a number of additional minor works have been undertaken by TfL 's Asset Operations team in the vicinity of the pedestrian crossing: These include: a) Iiaison with the management team of the Gallows Corner Retail Park to request regular maintenance and of vegetation and trees within their property boundary; b) it was noted during the site visit that the 30mph signs were different sizes, the sign in the central reservation and farside of the road were smaller than the sign Sr" 130m Approx cutting

on the nearside. These signs were renewed and are now the same size; and resurfacing of the Gallows Comer roundabout including both lanes of the A12 Colchester Road up to the junction with Bryant Avenue. This includes renewal of the surfacing on the approaches to the pedestrian crossing, white lines and markings (including 3Omph warning markings), and the renewal of the bus stop cage and red surfacing: Conclusion TfL will undertake a further safety review by the end of November 2020 to ensure that the actions already taken address the matters of concem. As part of this review we will also again consider the positioning of street furniture and whether it is safe_ If any further actions are identified through this review, TfL will address these by 31 March 2021 . In addition to the measures outlined above, TfL is preparing to submit a bid to the Department for Transport (DfT) in late 2020 for Major Roads Network (MRN) funding to deliver further improvements to the A12IA127 Gallows Comer junction. Please do let me know if you require further information or can be of direct assistance to you in some way:

Dear Miss Persuad, Please find below our response to the Regulation 28 (Preventing Future Deaths) report sent to us on 4t September 2020, reference The incident location within the Regulation 28 (Preventing Future Deaths) report is on Colchester Road, classified as the A12, approximately 65 metres north east of the Gallows Corner roundabout. The extract below taken from Havering Councils Highways Register overlay on Earthlight shows that this location in black, along with the boundary of the adopted highway (red is footway, pink is carriageway). Boundary of the adopted highway taken from Haverings Hghways Register on Earthlight While Colchester Road is part of the adopted highway network, Havering Council are not the Highway Authority for this road, this responsibility falls to Transport for London (TfL): The plan shown below shows the boundary of TfLs responsibility around Gallows Corner roundabout and also the section of Colchester Road where the crossing point is situated

Holn0i7 CiJO Locutlon Flan S4a XLD Guows (4e @) Galr Cumal heTm TFL supplied boundary plan. The TfL an shows a dotted line as the kerb Iine along the edge of the footway, whie the solid blue line that runs almost pararell to this line at the rear of the footway shows the limits of TfLs responsibility as the Highway Authority: We have been advised by pf the metropolitan police that pf Transport for London will be liaising direcuy Ine coroners' officer. A site inspection was undertaken on Thursday 17t September to look at the incident site so that Havering could give responses to the points raised in the coroners report While these comments are made by a Senior Engineer at Havering it must be stressed that TfL would need to carry out their own investigation as they would be ultimately responsible for any action (or inaction) carried out to the highway network at this location. POINT 1. The Inquest heard that there are a number of items of street furniture that obstruct the view that drivers should have of pedestrians waiting at the Pelican crossing (signage, bus stand, safety camera and overhanging foliageltree branches) While the report does not state which side of the crossing point the incident occurred, the bus stand and safety camera are on the south east footway so it is this location that has been investigated. The footway at this location is split into a cycle way at the rear of the footway with the pedestrian side adjacent to the carriageway: The safety camera is located at the rear the footway approximately 25 metres before the crossing; within the cycle way section; and would not cause any sight line issues for car drivers approaching the controlled crossing point:

Safety camera located at the rear of the footway: Upon insection on the 17* September 2020 all the trees that are contained within the grounds of the Gallows Corner Retail Park were found to be well cut back, with no branches lower than six foot overhanging the footway: There were no bracnches overhanging the carriageway at all. At the crossing point itself there is a street light that illuminates the crossing point at night; and this area was found to be completely clear of any over hanging branches so there would be no shadows over pedestrians waiting to cross at this point on the footway: Unobstructed lamp column at the controlled crossing point: All the bushes and the trees at this location are within the Gallows Corner Retail Park and appear well maintained, causing no obstruction to the highway. There are no highway trees or Council maintained verges at this location_

The bus stand is located at approximatley 55m before the controlled crossing point When a bus is stopped within the bus stand it blocks the near side running lane of the dual carriageway which would tend to then slow traffic down as vehciles manouvre around the stationary vehcile. At this distance the bus stand its self does not cause any obstruction to for sight lines t0 the crossing point; and once any stationary vehicle that was occupying the bus stand had been passed there would still be at least 55m between the drivers positon and any pedestrian waitng at the crossing: With regard to signage, there is no signage blocking site lines at the crossing point; and there is very little signage on the approach to the controlled crossing either (see photos below) The large roundabout sign is some 140m prior to the crossing point; and the only other road sign is & "no u turn" sign approximately 7Om before the crossing, neither of which would obstruct drivers sight lines: Signage in the vicinity of the controlled crossing point Although not mentioned in the report; but worthy of note, is the fact that there is pedestrian guard railing along the length of the footway for approximately 30m prior to the controlled crossing: As can be seen from the photo below there is a clear viewing panel through the guard railing to aid drivers to see whatever is on the footway or waiting at the crossing point

2 The Pelican crossing is sited shortly following a bend in the road and the immediate speed limit approaching the crossing is 30 miles per hour: shortly before the Pelican crossing; the speed limit is SOmph: Travelling along the carriageway in a south westerly direction the boundary of the SOpmh/3Omph change is approximately 140m prior to the crossing point Between the start of the 3Omph zone and the controlled crossing point is the speed camera which would encourage most vehicle users to have reduced their speed prior to the crossing: It should be noted that it is TfLs responsibility for setting the speed limits on the TLRNISRN and the speeds currently set should have taken into regard the current layout of the highway features at this location. While on site there was no visible bend apparent in the carriageway along this length of the road that would cause any sight line issues for drivers what sO ever:
3. A recent site visit noted a very high level of non-compliance with the automated traffic signals. Vehicles were noted not to be stopping at the amber traffic light phase: During the site visit on 17th September the non-compliance witnessed above was not seen. This may well be down to the fact that someone standing near the crossing point dressed in black wearing a high-viz jacket may have given the impression of a police presence in which case any comment here is possibly flawed. In London it is the Metropolitan Polices role to enforce traffic light control contraventionslspeed offences etc. so it would fall to them to carry out any further necessary investigation at this particular site. While Havering Council are not the Highway Authority for this location are responsible for the cleanliness of the area as the Litter Authority. On inspection there area was clean, there was no build-up of litter or detritus on the highway that would have had any input into this incident: In conclusion we do not feel that there any actions Havering Council can take in relation to this Regulation 28 (Preventing Future Deaths) report: If you have any queries relating to any of these responses please do not hesitate t0 contact me at