November 5, 2024

Polly Friedhoff: Prevention of Future Deaths Report

Other related deaths

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Date of report: 04/11/2024

Ref: 2024-0594

Deceased name: Polly Friedhoff

Coroners name: Darren Salter

Coroners Area: Oxfordshire

Category: Other related deaths

This report is being sent to: Oxfordshire County Council

	REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
	THIS REPORT IS BEING SENT TO: [REDACTED] Director of Highways and Operations Oxfordshire County Council
1	CORONER I am Mr Darren Salter, Senior coroner, for the coroner area of Oxfordshire
2	CORONER’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.
3	INVESTIGATION and INQUEST On 24 October 2024 at Oxfordshire Coroner’s Court I conducted the inquest into the sad death of Polly Friedhoff, aged 81, who died at the John Radcliffe Hospital on 2 December 2022 from injuries sustained in a collision with a pedal cyclist on 20 November 2022. It occurred on the path beside the River Thames at Iffley Lock, Oxford. I returned a conclusion of Accident and I attach a copy of the Record of Inquest for your information. I heard oral evidence from the cyclist, investigating police officers’, and, helpfully, from [REDACTED], Operations Manager, Countryside Access and Tree Service, Oxfordshire County Council (OCC). I was grateful to [REDACTED]/OCC for providing a witness statement at relatively short notice. I note the towpath is recorded as a public footpath and it forms part of the Thames Path National Trail. I understand OCC are responsible for managing the footpath although Iffley Lock itself, through which it passes, is owned by the Environment Agency.
4	CIRCUMSTANCES OF THE DEATH The brief circumstances are set out in the Record of Inquest but I also attach the investigating police officer’s report, that of [REDACTED], and also the aforementioned statement of [REDACTED] for your information. It will be seen that raises some safety issues about the path at the end of his report and [REDACTED] outlines at paragraphs 2.6 and 2.7 that OCC and local Councillors have given considerable thought to the issue of safety. Mrs Friedhoff’s two son’s have also raised significant concerns which I share (see below).
5	CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The concern relates to the safety of users, particularly pedestrians who appear to at greatest risk of injury as was the case with Mrs Friedhoff. Indeed, the speed of the cyclist was not excessive in this case but the injuries caused in the subsequent fall were serious. I understand this part of the path at the lock is popular with pedestrians and cyclists. It is a shared space, albeit strictly speaking it is a footpath and cyclists are not permitted to use it unless they have permission. In reality it is heavily used by cyclists for leisure and commuting and some cyclists travel at significant speed in close proximity to pedestrians. One of the main problems is that the path at the location of Mrs Friedhoff’s accident is only about 2 metres wide. A short distance before this the path is only 1.6 metres wide. I understand from [REDACTED] that national guidance for such a path is 3.5 metres. Mrs Friedhoff’s sons are very familiar with the location and describe it as normal pavement width but with cyclists permitted to cycle on it, thereby creating an obvious accident risk. It is also noteworthy that the surface of the path has been upgraded in recent years which, in all probability, has encouraged its use by cyclists and enabled them to cycle faster. I appreciate that OCC, and perhaps the Environment Agency, have given considerable thought to the safety issue and have not found a clear solution. It is not for me to make recommendations but I do request a further review to see if there are any mitigating measures, not least with clear signage reminding users, particularly cyclists, of the need to take care and slow down around pedestrians. At inquest, there was some evidence and discussion in relation to the following; -A communications package, perhaps with a public consultation element. -Stronger enforcement ( I understand the Environment Agency do not permit cyclists to cycle through locks and there are signs about this but they do so nevertheless). I appreciate it is difficult to enforce this and the focus may necessarily be on speed. -Gates or similar to slow cyclists. -Segregation lines but the narrow width of the path no doubt makes this problematic. -Reconfiguring so that the path is redirected through the small woods that are present at the location. This may afford the opportunity to have 2 separate paths at the location, one that is gated for pedestrians and one for cyclists. In short, given my concern that accidents may continue to occur that could result in death, OCC are asked to carry out a safety review in conjunction with the Environment Agency and other stakeholders where appropriate.
6	ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you Oxfordshire County Council have the power to take such action.
7	YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 31 December2024. I, the coroner, may extend the period. 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.
8	COPIES and PUBLICATION I have sent a copy of my report to: The Chief Coroner The Family of Mrs Polly Friedhoff [REDACTED] Solicitors I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. 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.
9	[SIGNED BY CORONER] 4^th November 2024