Sonia Stante

Date of report: 28 November 2017 Ref: 2017-0428 Deceased name: Sonia Stante Coroners name: Jacqueline Devonish Coroners Area: London Inner (North) Category: Road (Highways Safety) related deaths This report is being sent to: Transport for London

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)

NOTE: This form is to be used after an inquest.

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO:

Transport for London Transport for London

1 | CORONER

!'am Jacqueline Devonish, assistant coroner, for the coroner area of Inner North London

2 | CORONER'S LEGAL POWERS

| make this report under Paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

3 | INVESTIGATION and INQUEST

On 31 July 2017] | commenced an investigation into the death of Sonia Elvira Stante, aged 69. The investigation concluded at the end of the inquest on 28 November 2017. The conclusion of the inquest was Road Traffic Collision and a cause of death of multi organ failure due to ischaemic bowel (Operated) as a direct result of multiple injuries.

4 | CIRCUMSTANCES OF THE DEATH

On 10 July 2017 Sonia Stante arrived in London for a three day trip as a part of multi country European trip which she had commenced on 30 May 2017. Ms Stante was evidenced on CCTV footage stepping off the pavement just east of the junction along Pentonville Road from Kings Cross Road into the path of a double decker bus without looking in the direction of the bus, but appearing to look across the road, not left, but diagonally.

The bus had a green light Signal and was travelling in the bus lane at a speed of between 18 and 22mph, in a 30moh zone. Upon seeing Ms Stante step into the road the bus driver applied the brakes reducing his speed to 16-9mph. She made contact with the front nearside of the bus and was thrown back onto the pavement along the kerb.

She was transferred to hospital in a conscious state and had been able to tell the London Ambulance Service paramedic that she had checked the road in the wrong direction.

She deteriorated and died from her injuries on 21 July 2017 at the Royal London hospital.

5 | CORONER’S CONCERNS

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur uniess action is taken. In the circumstances it is my Statutory duty to report to you.

The MATTERS OF CONCERN are as follows. —

Following the incident -/ Traffic Management Officer undertook a review of the road traffic layout at the scene. He met with TfL on site on 16 August 2017 anda number of findings were made:

(1) No road markings indicating the direction pedestrians should look when crossing

(2) Two separate junctions at that location make that crossing confusing for pedestrians (3) The phasing of the green man operates for each carriageway independently so causing confusion for pedestrians who may !ook at the wrong phasing

(4) Missing louvre on the green man on the north side of the crossing making the green man more visible to pedestrians crossing from the south

(5) With the location being close to the Eurostar Terminal there are several hotels nearby and foreign visitors may not have a full understanding if the junction.

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe your organisation have the power to take such action.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report, namely by 4 January 2018. |, the coroner, may extend the period.

Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.

COPIES and PUBLICATION

| have sent a copy of my report to the Chief Coroner and to as Interested Person. | have also sent it to | OS may find it useful or of interest.

{am also under a duty to send the Chief Coroner a copy of your response.

The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your tesponse, about the release or the publication of your response by the Chief Coroner.

28 November 2017 (pegretce hooves L