George James Ainsworth · Prevention of Future Deaths report

On 20th December 2013 I commenced an Investigation into the death of George James Ainsworth, 84 years, born 19th April 1929. The Investigation concluded at the end of the Inquest on 24th 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.

2. 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 along Deansgate and was negotiating 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.

3. The evidence at the Inquest was that the collision occurred in Bolton 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 become 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 the 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 the collision scene the southbound lane comprises a bus lane only separated from 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 the 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.

4. 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 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 the “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 the presence of mirrors; all of which present physical obstruction to the driver’s view. The view is further compromised by the installation of blind spot 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 bus was travelling at less than 10 miles per hour on the immediate approach to the collision.

7. Evidence was also given at the 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.

During the Inquest evidence was heard that

1.

i. The junction of Deansgate into Knowsley Street is a 90 degree left hand bend with no restrictions on the vehicles entering the junction, other than the pedestrian crossing. Greater Manchester Police gave evidence that there is a “pinch point” when two large vehicles, such as buses, attempt to negotiate the bend at the same time resulting in one or the other having to give way. There was further evidence that the driver of a bus at the junction from Deansgate into Knowsley Street would have blind spots on the vehicle together with a limited pre-junction view around the bend due to the building line, which would affect the driver’s view of the road, particularly to the front nearside of the vehicle. The blind spots and limitations to the driver’s view of the road occur at a time when a driver is negotiating a narrow bend where there is a “pinch point” at the apex of the bend. Accordingly pedestrians who are free to cross the road outside the areas of the pedestrian crossing are at risk due to the driver’s restricted view.

The presence of guard rails, particularly along the stretch of pavement on the left hand side from Deansgate into Knowsley Street from where Mr Ainsworth crossed the road, with the exception of the area of the pedestrian crossing, would take account of the driver’s restricted view and would prevent pedestrians crossing the road outside the area of the pedestrian crossing, where a driver would have a restricted view.

ii. The time allowed for a pedestrian to cross the pedestrian crossing may not allow sufficient time for some pedestrians to cross the junction between Deansgate and Knowsley Street and an increase of the pedestrian crossing time would allow sufficient time for all pedestrians to cross the junction.

iii. The evidence raised concerns that there is a risk that future deaths will occur unless action is taken to review the above issues.

2. I request you to consider the above concerns and to carry out a review with regard to the following:

i. A general review of the pedestrian crossing at the junction of Deansgate and Knowsley Street with specific consideration of the erection of guard rails to limit pedestrians crossing the road to the confines of the pedestrian crossing.

ii. The time allowed by the automatic traffic signal at the pedestrian crossing to allow sufficient time for pedestrians to cross the road within the area of the pedestrian crossing.