Anthony Paine: Prevention of Future Deaths Report

Road (Highways Safety) related deaths

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Date of report: 09/01/2025 

Ref: 2025-0013 

Deceased name: Anthony Paine 

Coroners name: Nicholas Graham 

Coroners Area: Oxfordshire 

Category: Road (Highways Safety) related deaths 

This report is being sent to: Oxfordshire County Council  

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

Oxfordshire County Council Highways Department
1CORONER

I am Mr N Graham, Area Coroner for the Coroner area of Oxfordshire.
2CORONER’S LEGAL POWERS

I 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. 
3INVESTIGATION AND INQUEST

On 12th April 2023 I commenced an investigation into the death of Anthony John PAINE, a 75 year old male. The investigation concluded at the end of the inquest on 7 January 2025 and my conclusion as to the death was one of Road Traffic Collision. 
4CIRCUMSTANCES OF THE DEATH 

At approximately 22:45 hours on Friday 24th March 2023, a fatal road traffic collision occurred on the A361 North Bar Street, Banbury, Oxfordshire. A red Nissan Pixo collided with a pedestrian, Anthony Paine on the A361 North Bar Street, Banbury. Mr. Paine was crossing the carriageway on a pedestrian crossing from right to left as viewed by the driver of the Nissan. The pedestrian crossing was controlled by traffic signals.  Mr Paine did not wait to use the pedestrian controlled lights having considered the that the road was clear. He was struck by the vehicle and sadly died at the scene.   
5CORONER’S CONCERNS

During the course of the Inquest the evidence revealed matters giving rise to concerns. In my opinion there is a risk that future deaths will occur unless action is taken. 
In the circumstances it is my statutory duty to make this report to you.

The MATTERS OF CONCERN are in relation to the following:

The speed limit on the A361 North Bar Street at the location of the collision is 30 mph. There was a concern expressed at the Inquest that this speed limit may be too high, given the characteristics of the road and the volume of pedestrian traffic in the area. 

The A361 at this location is a long, straight, single carriageway with one lane in each direction. Traveling southbound, the pedestrian crossing is approached  from  a  gradual  rise  in  the  road  from  Banbury  Cross Roundabout, some 150 meters away. The rise in the road obscures the view of the pedestrian crossing to approaching vehicles.  

There are a number of pubs and restaurants on both sides of the road and a number of pedestrians in the area late into the evening. 

The Forensic Collision Investigator concluded that in the short window of time in which Mr. Paine was likely visible to the driver, they failed to see him. The Investigator’s evidence was that even if the driver had seen Mr. Paine, there would have been insufficient time to react and avoid the collision. However, the Investigator’s evidence also stated that if the vehicle had been traveling at a slower speed, this may have provided the driver with sufficient time to react and either avoid the collision or reduce the severity of the impact. 

In the opinion of the Forensic Collision Investigator, the speed of the driver’s vehicle was 32.6 mph ± 3.6 mph and was a contributing factor to the severity of the collision and that, as a general point, the slower the vehicle is travelling the less severe the effects of any impact. 

It was further noted that other nearby town/city centres (eg Oxford) have introduced 20 mph speed limits on roads in the city centre. 
6ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.  
7YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report, namely by 6th March 2025. I may extend the period on request. 
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.
8COPIES and PUBLICATION

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons  

The family of Anthony Paine 
Thames Valley Police 

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 response, about the release or the publication of your response by the Chief Coroner. 
9Signed
Mr N. Graham 
HM Area Coroner for Oxfordshire
Date
9th January 2025