Investigation and inquest
On 4 July 2022 I commenced an investigation into the death of Mervyn Charles Gladstone Leonard HOLBROOK. The investigation concluded at the end of the inquest on 8 December 2022. The conclusion of the inquest was: Road traffic collision
Circumstances of the death
At 14:30 on 16/06/2022, Mr Holbrook was knocked off his mobility scooter and was run over at the junction of Livingstone Road and the A435 Alcester Road. He had been travelling Southbound along the footpath and left the pedestrian walkway at the mouth of the junction (where the kerb had been worn down) and entered the carriageway at the same time as Nissan Qashqai ████████ tried to navigate and turn left onto the Alcester Road from Livingstone Road. He suffered catastrophic thoracic injuries, and despite life-saving treatment by emergency services, he could not be saved and was pronounced deceased at the scene at 14:57.
Following a post mortem the medical cause of death was determined to be:
1a RIB FRACTURES WITH FLAIL SEGMENT
1b ROAD TRAFFIC COLLISION
1c
II ISCHAEMIC HEART DISEASE WITH CARDIOMEGALY
Coroner’s concerns
1. I heard and considered evidence from West Midlands Police's Forensic Collision Unit which confirmed that where the footpath outside 214 Alcester Road South reaches the junction of Livingstone Road, it appears that there is a dropped kerb at the apex. On the opposite side of the junction, the kerbs are raised. West Midlands Police advise that this indicates that the dropped kerbs at this side of the junction are a result of vehicles mounting the kerb as they turn left from Livingstone Road to Alcester Road and therefore causing them to be eroded to be level with the road surface. There is also no tactile paving next to these kerbs, which indicate that this dropped kerb is not an "official" pedestrian crossing point - the same being situated approximately 9m from the end of Livingstone Road.
2. Mr Holbrook was able to leave the carriageway on his mobility scooter at apex/mouth of the junction due to the kerb being worn down to the road surface, and was struck in the carriageway.
3. On 12 September 2022, PC ████████ of West Midlands Police submitted a notification via Birmingham City Council's Highway Department's online portal of the defect, with the Highways responding via email on 20 September 2022 stating that it did not meet the intervention levels that require repair.
4. I am concerned that vulnerable road users - particularly users of mobility scooters or bicycles - may inadvertently consider the worn down and defective kerb to be an "official" crossing point and enter the carriageway when it is unsafe to do so.
5. Furthermore, if a mobility scooter or similar were to enter the carriageway at the mouth of the junction (as Mr Holbrook did), they would then be unable to mount the curb at the opposite side - they would have to travel West down the carriageway of Livingstone road to the official crossing point, or alternatively (and more dangerously) navigate South on the carriageway into oncoming traffic onto Alcester Road.