Investigation and inquest
On 11 February 2022, ME Hassell, HM Senior Coroner for Inner North London, commenced an investigation into the death of Miriam Boulia, aged 33 years. The investigation concluded at the end of the inquest on 21 November 2022.
I made a determination of death by road traffic collision.
The medical cause of death was:
1(a) traumatic brain injury
Circumstances of the death
The collision occurred just before 9am on a Friday. It was a wet day. Ms Boulia was using a pedestrian crossing to cross Great Eastern Street at its junction with Curtain Road. After crossing safely to a pedestrian island, she initially waited there to cross Great Eastern Street, together with a small group of other pedestrians. Several other pedestrians crossed on a red man.
Ms Boulia then walked onto the crossing across Great Eastern Street, on a red man. She appeared to be holding her hood up whilst looking to her left. She was struck by a bus, which was travelling in a South Easterly direction, from her right, on green traffic signals. She fell underneath the bus and was dragged under it until it came to a standstill. As a result, she sustained catastrophic, unsurvivable injuries. She was declared deceased at the scene.
Although the driver of the bus took appropriate evasive action, the collision was unavoidable.
Coroner’s concerns
I received evidence, both in the form of a report and orally in court, from PC ████████, a Traffic Management Officer in the Road Safety Engineering Unit of the Metropolitan Police. He is a qualified Highway Inspector recognised by the Institute of Highway Engineers and holds a RoSPA certificate in Road Safety, Collision Investigation and Prevention. As part of preparing his report, he conducted two site visits, when he observed the operation of the signals at the crossings at this junction and the behaviour of pedestrians.
The current timings of the signals, both at the pedestrian crossing where Ms Boulia died (at the North West side of Curtain Road, which I refer to as crossing 1) and the crossing over Great Eastern Street at the South East side of Curtain Road (by the Old Blue Last pub, which I refer to as crossing 2) do not allow enough time for pedestrians to cross the road safely.
The inter-green period (the period when the road traffic’s signals are not at green) at crossing 1 is only 10 seconds, made up of 6 seconds when the pedestrian signal is at green man and 4 seconds of “blackout” or “clearance” period. 10 seconds is insufficient time to allow pedestrians to cross the road safely before the road traffic’s signals change to green.
The green man for pedestrians is an invitation to cross, hence the blackout period should allow enough time for any pedestrians who step onto the crossing a moment before the green man goes out to cross the road safely. The current blackout period does not allow for this.
Although at crossing 1, the 10 second inter-green period extends to 16 seconds when there is no road traffic filtering from Curtain Road to Great Eastern Street, in practice this is rarely the case. There is no filtering traffic at crossing 2, but the inter-green period is still insufficient to allow pedestrians to cross safely.
PC ████████ observed that pedestrians routinely cross on the red man at the crossings at the junction of Great Eastern Street and Curtain Road, probably due to the inadequate inter-green periods.
There have been 21 collisions involving injury at this junction over a recent three-year period, 9 of those involving injury to pedestrians. Of particular concern is that the number of collisions at this junction of a similar nature to that in which Ms Boulia died, is unusually high.
I also received a report from TfL, from which I note that this junction will now formally be included within TfL’s recently re-instituted Safer Junctions Programme (it previously was not part of the programme). However, the report indicates that the timescale for completion of any improvements to this junction is 2-4 years, subject to funding.
The TfL report indicated that any urgent safety improvements which need to be made at this junction in advance of progressing the wider scheme will be progressed, and that a site visit was being arranged for early December 2022 to consider any urgent safety improvements.
PC ████████ gave evidence that improvements to signal timings (including increasing the inter-green periods) can be made much quicker than installation of new signals (such as signals including countdown timers). I understand that such changes could be made much quicker than the 2-4 years envisaged for completion of the wider scheme.
I consider that changes to the signal timings would amount to urgent safety improvements.