Mark Welsh
PFD Report
All Responded
Ref: 2017-0456
All 1 response received
· Deadline: 22 Feb 2018
Coroner's Concerns (AI summary)
Transport for London displayed an inordinate delay in implementing pedestrian crossings at a dangerous junction, using flawed decision-making based on incomplete accident statistics that omitted overall incidents and near misses.
View full coroner's concerns
I heard at inquest that:
Transport for London (TfL) made a decision in 2007 that that it would not undertake any consideration of pedestrian crossings at that crossroads until after the completion of HS1; £50,000 was paid to TfL in 2009 by UNISON as part of planning permission to allow building on the opposite corner, £20,000 of which was used on a feasibility study in 2013, but TfL decided that traffic flow would be impeded by four pedestrian crossings, so none was installed and use was not made of the remaining £30,000; UNISON has made several complaints to Camden Council/TfL about the dangers of this particular crossroads, but TfL’s best expectation of delivery of any improvement is for the year 2020.
I appreciate that every decision about traffic control at one junction must be taken in the context of the whole network, but 13 years after the issue was first raised seems an inordinately long time to wait for some improvement at such a busy crossroads (about which there had been several complaints prior to this fatality).
Consideration of the junction was described to me as being based on four new crossings or none, which I did not quite understand.
The statistics upon which TfL decisions about traffic control are based, were described to me by TfL’s lead sponsor as only taking account of the proportion of collisions/accidents that result in serious injury or death, not taking into account the overall incidence of collisions/accidents (or even taking into account reported near misses). This seems an omission.
Transport for London (TfL) made a decision in 2007 that that it would not undertake any consideration of pedestrian crossings at that crossroads until after the completion of HS1; £50,000 was paid to TfL in 2009 by UNISON as part of planning permission to allow building on the opposite corner, £20,000 of which was used on a feasibility study in 2013, but TfL decided that traffic flow would be impeded by four pedestrian crossings, so none was installed and use was not made of the remaining £30,000; UNISON has made several complaints to Camden Council/TfL about the dangers of this particular crossroads, but TfL’s best expectation of delivery of any improvement is for the year 2020.
I appreciate that every decision about traffic control at one junction must be taken in the context of the whole network, but 13 years after the issue was first raised seems an inordinately long time to wait for some improvement at such a busy crossroads (about which there had been several complaints prior to this fatality).
Consideration of the junction was described to me as being based on four new crossings or none, which I did not quite understand.
The statistics upon which TfL decisions about traffic control are based, were described to me by TfL’s lead sponsor as only taking account of the proportion of collisions/accidents that result in serious injury or death, not taking into account the overall incidence of collisions/accidents (or even taking into account reported near misses). This seems an omission.
Responses
Action Planned
Subject to Camden Council agreement, Transport for London intends to progress a banned turning movement in order to provide a signal controlled crossing on Dukes Road, to be implemented next year. (AI summary)
Subject to Camden Council agreement, Transport for London intends to progress a banned turning movement in order to provide a signal controlled crossing on Dukes Road, to be implemented next year. (AI summary)
View full response
Dear Coroner Hassell Euston Road Junction with Duke's Road Regulation 28 Prevention of Future Deaths Report wish to pass my sincere condolences to the family of Mark Welsh after hearing of the tragic collision that occurred on 6 2017 . We have carefully considered your Prevention of Future Deaths Report dated 28 December 2017, in which you raise concern over the length of time it has taken to provide improvements on the junction of Euston Road with Duke's Road and Churchway and how we have considered our options; and TfL's use of statistics upon which we take decisions about traffic control. respond as follows: TfL's use of statistics to drive improvement of traffic control at junctions understand and share your concerns to ensure the decisions we take in this area are as far as possible taken on the best and most appropriate collision data sets_ However, TfL's collision statistics are based on police reports of collisions at which a casualty has occurred_ These casualties are categorised by the police according to injury type, which is then allocated to an injury severity category (either fatal, serious or slight) . Police reports are taken when either police officer has been called to the scene of a collision at which a personal injury occurred, or the injury has been reported to the police over the counter or via the new MPS online tool, which can be found here: https IlWWmet police uklreport/report-a-road-traffic-incidentl disability confident MAYOR OF LONDON EMPLOYER VAT number 756 2769 90 July has
There is no consistent way of recording damage-only collisions, as the police dont routinely attend site or require those involved to report the incident_ A damage-only collision be relatively trivial (i.e. scraping a wing mirror) , and may not even be taken into account by insurance companies (who would be the other potential source of data): There is also no reasonable way of recording near misses, and it would be impossible to ensure consistency throughout the reporting: Our decisions on traffic control and which locations to prioritise for improvement are therefore informed by analysis of where and how collisions have occurred, as these have the greatest impact on the well-being of Londoners. Annual priority lists for intervention are created based upon collisions of all severity involving vulnerable road users. We also analyse the data collected to detect any patterns of accidents , and will prioritise further a junction for improvements if a pattern of types, modes or precise location of collisions can be detected. No such pattern has been detected in the collision data for the Duke's Road/Euston Road/Churchway junction: Where sites have been identified for investigation or investment; TfL might undertake further investigation to understand what damage-only or near-miss collisions regularly occur. Although no patterns have been identified, our intention is to provide a controlled pedestrian crossing on this junction in order to improve the provision for pedestrians and vulnerable road users to take account of the expected growth of pedestrians in the area; Consideration of improvements at the Euston RoadiDuke's Roadl Churchway Junction; including consideration of options. We have been working closely with Camden Council to deliver a design for this junction that improves the safety for pedestrians and other vulnerable road users, and history of our work on this was submitted to you as of our evidence to the inquest. However, our decisions about traffic control and the use of signals must be coordinated with the surrounding road network to prevent excessive congestion, which is likely to have impacts both on safety and air pollution: The roads in this area are currently operating at the maximum level of capacity, and it has proven very difficult to find a solution for this junction which is acceptable both t0 us and Camden Council given potential local and wider traffic impacts, and does not have significant negative impacts elsewhere_ When considering whether it is possible to introduce a new controlled crossing facility at a junction, it is necessary to consider how the junction currently operates. Currently, at the junction, all vehicle movements are permitted except for the right turn into Dukes Road: To introduce a signal controlled pedestrian crossing; we need to either Ban a further turning movement into Dukes Road to remove the pedestrian and vehicle conflict; or Hold all the traffic on a red signal s0 that there is a period of time when traffic is not moving into or out of any Of the approaches. This could provide crossings on all four arms and therefore deliver the greatest benefits to pedestrians in terms of safety and convenience. may part
As set out in a previous report supplied in evidence to you at the inquest; the latter option would also enable TfL to put pedestrian crossings on the other arms of the junction providing the greatest benefits to pedestrians in terms of safety and convenience_ However; our modelling analysis demonstrated that the introduction of pedestrian crossings and holding traffic would create severe congestion both in this area and more widely across the network; which would have negative impacts for pedestrians, other vulnerable road users and local air quality: Subject to Camden Council agreement; we intend to progress a banned turning movement in order to provide a signal controlled crossing on Dukes Road to be implemented next year. We will continue working with Camden Council to develop a design for this junction and others in the near vicinity which will enable more and safer pedestrian and cycle facilities to be provided thereby encouraging people to walk, or use public transport:
There is no consistent way of recording damage-only collisions, as the police dont routinely attend site or require those involved to report the incident_ A damage-only collision be relatively trivial (i.e. scraping a wing mirror) , and may not even be taken into account by insurance companies (who would be the other potential source of data): There is also no reasonable way of recording near misses, and it would be impossible to ensure consistency throughout the reporting: Our decisions on traffic control and which locations to prioritise for improvement are therefore informed by analysis of where and how collisions have occurred, as these have the greatest impact on the well-being of Londoners. Annual priority lists for intervention are created based upon collisions of all severity involving vulnerable road users. We also analyse the data collected to detect any patterns of accidents , and will prioritise further a junction for improvements if a pattern of types, modes or precise location of collisions can be detected. No such pattern has been detected in the collision data for the Duke's Road/Euston Road/Churchway junction: Where sites have been identified for investigation or investment; TfL might undertake further investigation to understand what damage-only or near-miss collisions regularly occur. Although no patterns have been identified, our intention is to provide a controlled pedestrian crossing on this junction in order to improve the provision for pedestrians and vulnerable road users to take account of the expected growth of pedestrians in the area; Consideration of improvements at the Euston RoadiDuke's Roadl Churchway Junction; including consideration of options. We have been working closely with Camden Council to deliver a design for this junction that improves the safety for pedestrians and other vulnerable road users, and history of our work on this was submitted to you as of our evidence to the inquest. However, our decisions about traffic control and the use of signals must be coordinated with the surrounding road network to prevent excessive congestion, which is likely to have impacts both on safety and air pollution: The roads in this area are currently operating at the maximum level of capacity, and it has proven very difficult to find a solution for this junction which is acceptable both t0 us and Camden Council given potential local and wider traffic impacts, and does not have significant negative impacts elsewhere_ When considering whether it is possible to introduce a new controlled crossing facility at a junction, it is necessary to consider how the junction currently operates. Currently, at the junction, all vehicle movements are permitted except for the right turn into Dukes Road: To introduce a signal controlled pedestrian crossing; we need to either Ban a further turning movement into Dukes Road to remove the pedestrian and vehicle conflict; or Hold all the traffic on a red signal s0 that there is a period of time when traffic is not moving into or out of any Of the approaches. This could provide crossings on all four arms and therefore deliver the greatest benefits to pedestrians in terms of safety and convenience. may part
As set out in a previous report supplied in evidence to you at the inquest; the latter option would also enable TfL to put pedestrian crossings on the other arms of the junction providing the greatest benefits to pedestrians in terms of safety and convenience_ However; our modelling analysis demonstrated that the introduction of pedestrian crossings and holding traffic would create severe congestion both in this area and more widely across the network; which would have negative impacts for pedestrians, other vulnerable road users and local air quality: Subject to Camden Council agreement; we intend to progress a banned turning movement in order to provide a signal controlled crossing on Dukes Road to be implemented next year. We will continue working with Camden Council to develop a design for this junction and others in the near vicinity which will enable more and safer pedestrian and cycle facilities to be provided thereby encouraging people to walk, or use public transport:
Sent To
- Transport for London
Response Status
Linked responses
1 of 1
56-Day Deadline
22 Feb 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
Report Sections
Investigation and Inquest
On 17 July 2017, I commenced an investigation into the death of Mark Nicholas Welsh, aged 55 years.
The investigation concluded at the end of the inquest on 18 December 2017. I made a determination of death by road traffic collision, when Mr Welsh was knocked over by a lorry whilst crossing Duke’s Road at the junction with Euston Road in London at approximately 9.30am on Thursday, 6 July 2017.
The medical cause of death was: 1a multiple injuries.
The investigation concluded at the end of the inquest on 18 December 2017. I made a determination of death by road traffic collision, when Mr Welsh was knocked over by a lorry whilst crossing Duke’s Road at the junction with Euston Road in London at approximately 9.30am on Thursday, 6 July 2017.
The medical cause of death was: 1a multiple injuries.
Circumstances of the Death
Despite travelling at just 7 miles per hour, the lorry driver turning left into Duke’s Road from Euston Road would only have had a second to see Mr Welsh as a hazard, through the front passenger cab window, before the pedestrian disappeared from his view.
The lorry would have been visible to Mr Welsh and it did have its indicator on, but because it had to swing out to make the turn, it might have appeared to him that the lorry was going to carry straight on along Euston Road, falsely reassuring him that it was safe to cross.
The lorry would have been visible to Mr Welsh and it did have its indicator on, but because it had to swing out to make the turn, it might have appeared to him that the lorry was going to carry straight on along Euston Road, falsely reassuring him that it was safe to cross.
Copies Sent To
Camden Council
Department of Transport
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Ministerial Familiarity with Legislation
RHI Inquiry
Incomplete Public Project Cost-Benefit Analysis
Revise signal sighting standard to explicitly consider signal readability
Ladbroke Grove Inquiry
Hazardous road design
Define additional time required for reading gantry-mounted and complex signals
Ladbroke Grove Inquiry
Hazardous road design
Clarify "very short duration" definition within the signal sighting standard
Ladbroke Grove Inquiry
Hazardous road design
Identify and retrospectively review locations affected by "very short duration" ambiguity
Ladbroke Grove Inquiry
Hazardous road design
Clarify "overhead line equipment" in signal sighting standard to mean wires and droppers
Ladbroke Grove Inquiry
Hazardous road design
Define acceptable limits for temporary signal obscuration in sighting standards
Ladbroke Grove Inquiry
Hazardous road design
Explicitly define cab sight lines for signal positioning based on driver's eye
Ladbroke Grove Inquiry
Hazardous road design
Railtrack to conduct safety examination of Paddington station layout and operations.
Ladbroke Grove Inquiry
Hazardous road design
Study appraisal procedures for safety elements in railway investment proposals
Hidden Inquiry
Incomplete Public Project Cost-Benefit Analysis
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.