Source · Prevention of Future Deaths

Lynne Lawrence

Ref: 2021-0158 Date: 17 May 2021 Coroner: Caroline Saunders Area: Gwent Responses identified: 1 / 1 View PDF

An uneven pedestrian pavement creates a future fall risk, particularly for elderly individuals with reduced mobility.

Date 17 May 2021
56-day deadline 12 Jul 2021 est.
Responses identified 1 of 1
Road (Highways Safety) related deaths Wales prevention of future deaths reports (2019 onwards)

Coroner's concerns

AI summary
An uneven pedestrian pavement creates a future fall risk, particularly for elderly individuals with reduced mobility.
View full coroner's concerns
1. Condition of Pavement on At the time of her fall, Mrs Lawrence was walking along a narrow pedestrian pavement near Alma Street, Brynmawr, Newport, NP23. The video footage available to me at the inquest demonstrated that the pavement was uneven. Whilst I could not conclude that it was the unevenness of the pavement that caused Mrs Lawrence to fall, nonetheless I consider that this is a factor which could people's lives at risk in the future, especially the elderly with reduced mobility.

Responses

1 respondent
Blaenau Gwent County Borough Council Local Authority / Fire Service
6 Jul 2021 PDF
Noted

The council investigated the footway condition outside Alma Street and concluded that it does not meet the standard for intervention based on their inspection regime, which exceeds national minimum standards for safety and maintenance defects intervention. (AI summary)

View full response
Dear Ms Saunders Re: Response to Senior Coroners Report – Lynne Pamela Lawrence 17th May 2021 I write in response to a Regulation 28 report provided by Caroline Saunders – Senior Coroner for the area of Gwent following an investigation that was opened on the 13th October 2020 into the death of Lynne Pamela Lawrence. During the course of the inquest, evidence revealed matters giving rise to concern in relation to the footway condition outside Alma Street, Brynmawr and although the Coroner could not conclude the unevenness of the pavement caused the fall it is considered to be a factor which could put people’s lives at risk. Blaenau Gwent County Borough Council - Highway Authority have investigated this matter and considered the Coroners opinion and I would advise as follows: - “As a Highway Authority the council has a duty to meet the requirements of the following legislation: The Highway Act 1980: this places a duty upon Highway Authorities to maintain highways, maintainable at public expense, and to keep them safe for public use”. To assist authorities in meeting their duties National Guidance is provided and the methods adopted are based upon the contents of the following “Well-Managed Highway Infrastructure: A Code of Practice (CoP), UK Roads Liaison Group, 2016”. The Code is designed to promote the adoption of an integrated asset management approach to highway infrastructure based on the establishment of local levels through risk-based assessment. The Authority has developed their own levels of service based on the above Code, along with adopting the County Surveyors

Cont.;

Society Wales (CSSW) principles (adopted 2018) as identified within the Blaenau Gwent Highways Maintenance Plan (HMP), therefore provides guidance to when developing the council’s approach in accordance with local needs, priorities and affordability.

The Highway Authority deploys Highway Inspector’s to undertake a regime of inspections to monitor the condition and repair needs of the public highway, they have received and passed accredited training programmes for specific competency in highway inspections to allow them to assess the condition of the public highway.

Details of asset hierarchy, inspection and repair regimes are adopted by the Council and implemented. For the purpose of managing maintenance Councils allocate a hierarchy level to each road and footway to establish inspection frequencies and repair regimes. The most significant factor affecting the risk presented to users is the level of use. As no footfall data is available in many situations across the council, officer judgement is used to estimate footfall for different footways in order to apply the CSSW principles.

From a nationally consistent approach the following table gives an indication of the principles adopted by CSSW, as follows;

Code of Practice Footway Network Hierarchy Category CSSW Footway Hierarchy Footfall Level (indicative) City Centre Pedestrian Area FHVHU > 10,000 (15,000 used for calculations) Town Centre Pedestrian Area FH1 5,000 - 10,000 Footway Outside Public Facilities FH2 1,000 - 5,000 Link Footway (between estates / areas) FH3 500 - 1,000 Housing Estate Footway FH4 < 500 Little Used Rural Footway FH5 < 100

Cont.; The footway outside Alma Street, Brynmawr (Lower Alma Street) is considered to have a low footfall and inspected on a 6 monthly basis, the purpose of inspections are to identify defects that have the potential to cause harm to users and to identify defects that require repair in order to prevent escalation of deterioration and increased (avoidable) maintenance needs.

Defect types identified and the intervention levels that are prescribed for each defect category in the footway is a guidance and minimum standards created by considering risk to users, see below; Safety Defects Table Asset Type Defect Type Hierarchy Dimensional Criteria CSSW National Minimum Standard Depth/Height Extent Depth/Hieght Extent Carriageways Pothole CHSR, CH1 and CH2 > 50mm Any Size > 50mm Maximum horizontal dimension greater than 150mm Pothole CH3, CH4 and CH5** >50mm Any Size >75mm Maximum horizontal dimension greater than 150mm Footways Pothole All > 25mm Any Size > 40mm Maximum horizontal dimension greater than 75mm Crack or Gap All > 25mm Any Size > 40mm Maximum horizontal dimension greater than 75mm Trip All > 25mm Any Size > 40mm Maximum horizontal dimension greater than 75mm Rocking Slabs All > 30mm N/A > 40mm N/A Kerbing Dislodged, Loose, Missing, Damaged - Causing a trip hazard All > 25mm N/A > 40mm N/A

Cont.; Blaenau Gwent County Borough Council has chosen to exceed the CSSW national minimum standards for safety and maintenance defects intervention as shown in the Safety Defects table above. A method has been developed under CSSW’s Highways Asset Management Plan (HAMP) project designed to allow all authorities to adopt the risk-based approach recommended by the new code of practice (CoP). Highway Inspections prior to the accident in July 2020 and post accident in January 2021 have not identified defects approaching this standard >25mm. A further assessment on receipt of the Regulation 28 report has been undertaken and although the footway reconstruction has raised paving <16mm (photo’s attached) they are not at a standard that the Highway Authority would intervene or consider a risk to the highway user and as such there are no proposals for BGCBC Highway Authority to take remedial works actions at this location.

Blaenau Gwent CBC is fully commited to the national inspection regime and the importance of it when it comes to preventing accidents across the highways infrastructure.

Head of Service Environment & Community Services Blaenau Gwent County Borough Council

CC
– Chief Executive BGCBC

Photo’s taken immediately outside number Alma Stree Brynmawr 4th June 2021

Report sections

Investigation and inquest
On 13/10/20 an investigation was opened into the death of Lynne Pamela LAWRENCE The investigation concluded at the end of the inquest on: 23/4/21 The conclusion of the inquest was recorded as: Death By Accident The medical cause of death was: 1a) Subdural haemorrhage 2 Atrial fibrillation
Circumstances of the death
On 21St September 2020, Mrs Lynne Lawrence tripped on the pavement on her way home from Brynmawr. She was taken to hospital where the head injury she sustained was not initially diagnosed on scan but became evident after Lynne collapsed 2 days later. She had suffered an intracerebral haemorrhage made worse by the effects of warfarin which she took for atrial fibrillation. The bleed was catastrophic and Lynne Lawrence died at 15:54 on 23/9/20 in the Intensive Care Unit of the Royal Gwent Hospital in Newport.
Action should be taken
I should be grateful if the following information be provided to me:
1. Confirm whether any steps have or will betaken to address the quality of the pavement.

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Report details

Reference
2021-0158
Date of report
17 May 2021
Coroner
Caroline Saunders
Coroner area
Gwent

Responses identified

Responses identified 1 of 1
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 12 Jul 2021 (estimated).

Sent to

Blaenau Gwent County Borough Council

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