PFD report

Amanda Coppen · Prevention of Future Deaths report

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Issued 19 Aug 2016•Inner South London

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
3

Raised in this report

Recipients
3

Named on the report

Responses found
3

Of 3 recipients

Stated actions
7

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

  1. Road layout misleading pedestrians and motorists about traffic direction
    Part of recurring concern: Inadequate control of pedestrian crossing risksPart of recurring concern: Unsafe busway and adjacent-road designPart of recurring concern: Unsafe road design and layout
  2. Potential risk to schoolchildren from increased pedestrian use of junction
  3. Presence of ordinary traffic in the dedicated busway
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.6

  1. Action

    Implement the proposed dual-carriageway and bus-lane changes to the road layout at the earliest opportunity, subject to considering consultation responses.

    Stated by Greater London Authority and Royal Borough of Greenwich and Transport for LondonStated plannedThe respondent said that this action was planned when they made their response on 19 August 2016.
  2. Action

    Install a raised zebra crossing south of the junction to provide safer pedestrian routes between Millennium Village, the existing school, Pilot Busway and West Parkside.

    Stated by Greater London Authority and Royal Borough of Greenwich and Transport for LondonStated completedThe respondent said that this action was complete when they made their response on 19 August 2016.
  3. Action

    Complete feasibility work identifying conversion of the existing layout to a dual carriageway with bus lanes to address road-safety concerns.

    Stated by Greater London Authority and Royal Borough of Greenwich and Transport for LondonStated completedThe respondent said that this action was complete when they made their response on 19 August 2016.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Road layout misleading pedestrians and motorists about traffic direction

Wider context from the report

“The evidence at the inquest was that Ms Coppen was crossing the busway on a signal controlled pedestrian crossing while the signal was red to pedestrians and green to traffic. However, the evidence also suggested that the layout of Pilot Busway and the neighbouring road (West Parkside) is unusual: they run side by side; West Parkside consists of a single carriageway in each direction; Pilot Busway consists of a single dedicated bus lane in each direction. The evidence was that this layout could mislead road users (pedestrians and motorists) into believing that this is a standard dual carriageway. Ordinary traffic has been seen in the dedicated busway, and pedestrians could be misled into looking the wrong way when crossing the road. ”

Is this part of a recurring concern?

Yes — Inadequate control of pedestrian crossing risks; Unsafe busway and adjacent-road design; Unsafe road design and layout.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Potential risk to schoolchildren from increased pedestrian use of junction

Wider context from the report

“I understand that a new school is shortly to be built close to this junction. This may increase the numbers of pedestrians using the junction and there is a potential risk to schoolchildren. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Presence of ordinary traffic in the dedicated busway

Wider context from the report

“The evidence at the inquest was that Ms Coppen was crossing the busway on a signal controlled pedestrian crossing while the signal was red to pedestrians and green to traffic. However, the evidence also suggested that the layout of Pilot Busway and the neighbouring road (West Parkside) is unusual: they run side by side; West Parkside consists of a single carriageway in each direction; Pilot Busway consists of a single dedicated bus lane in each direction. The evidence was that this layout could mislead road users (pedestrians and motorists) into believing that this is a standard dual carriageway. Ordinary traffic has been seen in the dedicated busway, and pedestrians could be misled into looking the wrong way when crossing the road. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implement the proposed dual-carriageway and bus-lane changes to the road layout at the earliest opportunity, subject to considering consultation responses.

Verbatim wording from the response

“It is the practice of both TfL and Greenwich to undertake local public consultation on significant changes to their road networks. Consistent with those practices, a joint public consultation exercise is underway to seek public and stakeholder opinion on the conversion of the existing arrangement to a dual carriageway with bus lane provision.”

Source location

2016-0299-Response-by-Transport-for-London
Page 2 · response
Published 19 August 2016

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Install a raised zebra crossing south of the junction to provide safer pedestrian routes between Millennium Village, the existing school, Pilot Busway and West Parkside.

Verbatim wording from the response

“As stated in your report, following the fatality a site visit was held on 14 January 2016 and was attended by representatives of all three organisations and the Metropolitan Police. Since then, a number of actions have been undertaken to improve road safety at the junction and in the vicinity.”

Source location

2016-0299-Response-by-Transport-for-London
Page 1 · response
Published 19 August 2016

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Complete feasibility work identifying conversion of the existing layout to a dual carriageway with bus lanes to address road-safety concerns.

Verbatim wording from the response

“TfL and Greenwich have been working on developing a solution to address road safety concerns, arising from the unique nature of the road layout. We recognise that significant development is taking place in the area, including the construction of a new school, and that additional movements associated with those developments will increase concerns about road safety.”

Source location

2016-0299-Response-by-Transport-for-London
Page 2 · response
Published 19 August 2016

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Introduce a 20-mile-per-hour speed limit with road markings and signage along Pilot Busway and West Parkside.

Verbatim wording from the response

“As stated in your report, following the fatality a site visit was held on 14 January 2016 and was attended by representatives of all three organisations and the Metropolitan Police. Since then, a number of actions have been undertaken to improve road safety at the junction and in the vicinity.”

Source location

2016-0299-Response-by-Transport-for-London
Page 1 · response
Published 19 August 2016

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Improve junction signage and road markings to increase pedestrian awareness of oncoming traffic.

Verbatim wording from the response

“As stated in your report, following the fatality a site visit was held on 14 January 2016 and was attended by representatives of all three organisations and the Metropolitan Police. Since then, a number of actions have been undertaken to improve road safety at the junction and in the vicinity.”

Source location

2016-0299-Response-by-Transport-for-London
Page 1 · response
Published 19 August 2016

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Review pedestrian safety provisions, including footways and crossings, for the school expansion.

Verbatim wording from the response

“TfL and Greenwich are also reviewing pedestrian safety provisions, including footway and crossings, which are to be provided as expansion of the school takes place.”

Source location

2016-0299-Response-by-Transport-for-London
Page 1 · response
Published 19 August 2016

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Conduct joint public consultation on converting the existing arrangement to a dual carriageway with bus lanes.

    Stated by Greater London Authority and Royal Borough of Greenwich and Transport for LondonStated in progressThe respondent said that this action was in progress when they made their response on 19 August 2016.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Conduct joint public consultation on converting the existing arrangement to a dual carriageway with bus lanes.

Verbatim wording from the response

“It is the practice of both TfL and Greenwich to undertake local public consultation on significant changes to their road networks. Consistent with those practices, a joint public consultation exercise is underway to seek public and stakeholder opinion on the conversion of the existing arrangement to a dual carriageway with bus lane provision.”

Source location

2016-0299-Response-by-Transport-for-London
Page 2 · response
Published 19 August 2016

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026