On 20* December 2013 I commenced an Investigation into the death of George James Ainsworth, 84 years, born 19t April 1929. The Investigation concluded at the end of the Inquest on 24t August 2015. The medical cause of death was 1a) Multi organ failure; 1b) Multiple injuries, II) Calcified aortic valve stenosis; The conclusion of the Inquest was George James Ainsworth died as a consequence of injuries sustained in a Road Traffic Collision on a background of naturally occurring disease:

1, George James Ainsworth died at the Salford Royal Hospital, Eccles Old Road, Salford on the 13th December 2013. On the 29th November 2013 Mr Ainsworth was struck by a bus on Knowsley Street; Bolton, near to its junction with Deansgate, Bolton: The bus was being driven east Deansgate and was negotlating a left hand bend where the road name changes to Knowsley Street; Bolton: The nearside of the vehicle was in collision with Mr Ainsworth, who had entered the carriageway from the drivers nearside: Mr Ainsworth, who suffered from naturally occurring calcified aortic valve stenosis, suffered multiple injuries and he was taken to Salford Royal Hospital, Salford where he subsequently deteriorated and died: The evidence at the_Inquest was that the collision occurred in Bolton the along

Town Centre which is a busy shopping area with high volumes of pedestrians and vehicular traffic throughout the day. Prior to the formation of pedestrian areas at the location of the collision a crossroad junction was in place with Deansgate having priority over Knowsley Street and Oxford Street; Following alteration in the road layout Deansgate on the eastern side of the junction and Oxford Street to the south were closed to vehicular traffic, where Deansgate (to the west) and Knowsley Street became a through road with Deansgate running generally west to east and Knowsley Street south to north The transition point at which the road name changes now forms a bend at 90 degrees: The Greater Manchester Police investigation noted that the bend where Deansgate becomes Knowsley Street creates a "pinch point" when two large vehicles, such as buses, attempt to negotiate bend at the same time resulting in one or the other having to give way: Traffic on both roads on the approach to the bend is controlled by an automatic traffic signal to stop vehicles whilst the pedestrian crossing at the junction is in operation: The traffic signal incorporates a pedestrian crossing facility located at the apex of the bend operated by various demand boxes. The bounds of the pedestrian crossing are highlighted by metal studs embedded in the road, creating a cross crossing that Is some 9.5 metres wide Travelling south along Knowsley Street towards collision scene the southbound lane comprises a bus lane only separated the northbound lane on the immediate approach to the bend by hazard warning lines: The lane markings terminate at the stop line controlling the southbound traffic some 20 metres from the centre of the crossing on the apex of the bend: Travelling east along Deansgate towards the collision scene east and westbound lane are separated by a hazard warning lines and there are no restrictions regarding access by specific vehicles: The lane markings terminate at a stop line controlling eastbound traffic some 17 metres from the centre of the crossing from the apex of the bend Beyond the restrictive stop lines there are no lane dividers through the bend and the area of the crossing: There are no guard rails on the footpath on either side of the road both before and after the pedestrian crossing: Accordingly pedestrians are free to cross the road outside the pedestrian crossing without restriction by guard rails. The evidence considered the steering of a bus around the left hand bend at the junction of Deansgate into Knowsley Street; The steering wheels on the bus are set back from the front of the vehicle by some 2.3 metres and are behind the driver's seat position; Therefore, when negotiating a tight turn such as the left hand turn through the junction onto Knowsley Street the front of_the vehicle_will be beyond the arched path taken bY_ the the from the the front wheels: The evidence at the Inquest accepted that there were blind spots which affect the driver's view of the road, specifically to the front nearside of the vehicle in this collision. Blind spots are created by the structure of the vehicle such as "A" pillars at either corner of the front windscreen, as well as the various panels such as those which make up the framework of the passenger doors and presence of mirrors; all of which present physical obstruction to the driver's view: The view is further compromised by the installation of bandit or security screens around the driver's cab which were fitted in the vehicle in the collision. The Greater Manchester Police evidence was that the blind spots on the bus were sufficient to fully obscure the presence of a pedestrian in certain areas to the front nearside of the vehicle:
5. The evidence at the Inquest revealed the fact that the building line at the junction of Deansgate and Knowsley Street, on the side from which Mr Ainsworth was crossing the road, would also restrict the view of the driver in relation to a pedestrian crossing from that side road when the driver was making the left turn_
6. It was accepted that Mr Ainsworth was crossing the road outside the pedestrian crossing but there is nothing to prevent a pedestrian crossing the road from that location; Mr Ainsworth entered the carriageway outside the bounds of the crossing and against the pedestrian signals, which were showing red for pedestrians, when the collision occurred: At the time the bus driver had negotiated the apex of the bend and continued through the turning manoeuvre passing, over the pedestrian crossing, as Mr Ainsworth continued to walk out towards the centre of the road; Calculations indicated that the was travelling at less than 10 miles per hour on the immediate approach to the collision: Evidence was also given at Inquest; as an incidental comment,; that some pedestrians find the time allowed to cross the crossing within the pedestrian crossing phase to be insufficient and further evidence was given that the time allowed for pedestrians to cross at the pedestrian crossing could be extended by an adjustment to the automatic traffic signal;