Terence Gillard: Prevention of Future Deaths Report
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Date of report: 05/11/2024
Ref: 2025-0264
Deceased name: Terence Gillard
Coroners name: Jeane Mellani
Coroners Area: West London
Category: Road (Highways Safety) related deaths
This report is being sent to: London Borough of Hounslow | Transport for London | Department for Transport
| REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: 1. London Borough of Hounslow, Hounslow House 7 Bath Road, Hounslow, Middlesex, TW3 3EB (LBH) 2. Transport for London, Palestra, 197 Blackfriars Road, London, SE1 8NJ (TFL) 3. Department for Transport, Great Minster House, 33 Horseferry Road, London, SW1P 4DR (DFT) | |
| 1 | CORONER I am Dr. Jeane Rosa Mellani, HM Assistant Coroner for the coroner area of West London, 25 Bagley’s Lane, Fulham, London SW6 2QA |
| 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 27 September 2022 I commenced an investigation into the death of Terence William Gillard aged 84. The investigation concluded at the end of the inquest on 30 September 2024. The conclusion of the inquest was a short form conclusion of “Road Traffic Collision” and the medical cause of death was as follows: 1a Pulmonary Embolism 1b Brain and multiple traumatic injuries |
| 4 | CIRCUMSTANCES OF THE DEATH Mr Gillard on 11 September 2022 was crossing a three-lane carriageway on the A4 Great West Road near the junction with Jersey Road, in Hounslow, using the appropriate pedestrian crossing which is a crossing with no pedestrian traffic lights. Mr Gillard crossed the road at a time he considered safe to do so and whilst doing so, the traffic lights turned green in favour of the cars whilst Mr Gillard was still in the road trying to complete the crossing. Mr Gillard collided with a moving vehicle and suffered brain and multiple traumatic injuries which led to a pulmonary embolism from which he died on 18 September 2022 in hospital. The A4 Great West Road, is located in West London and it is orientated along an east-west axis. The collision occurred on the west bound carriageway of the A4, at the pedestrian crossing located immediately to the west of the junction with Jersey Road (south). |
| 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 MATTERS OF CONCERN are as follows: The A4 Great West Road is a major route for vehicles of all types travelling in and out of west London. The crossing area, where Mr Gillard collided with the moving vehicle on 11 September 2022, is a designated uncontrolled crossing area across Jersey Road. There are no pedestrian traffic lights, no demand button, no sound signals. This pedestrian crossing area spans across a dual carriageway subject to a speed limit of 40mph. It has three lanes in both directions, separated by a raised central kerb. This crossing point also leads pedestrians into the cycling lane. I understand that at no point during the normal use of the traffic light controlled junction does traffic cease to flow at the marked crossing area, making it difficult for pedestrian to judge when and from where the next vehicle would approach. This means that pedestrians will need to use their own judgment as to when it is safe to cross this road without the aid of pedestrian traffic lights. I received evidence that there have been other accidents involving pedestrians and moving vehicles at this pedestrian crossing in the past. I received evidence from the TFL of existing plans to re-design this pedestrian crossing to improve pedestrian safety. However, their implementation may not take place before the end of 2026 and it remains subject to the consent of the DFT and LBH, the outcome of any public consultation as well as funding considerations. I am concerned that there appears to be no certainty that the redesign plans for the pedestrian crossing in question will be implemented. I understand that the TFL, LBH and DFT are the organisations with the power to take the necessary actions to improve pedestrian safety at this junction. |
| 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisations 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. 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: Mr Gillard’s Next of Kin HHJ Alexia Durran, Chief Coroner of England & Wales I am also under a duty to send the Chief Coroner a copy of your response. 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. |
| 9 | 5 November 2024 Dr. Jeane Rosa Mellani HM Assistant Coroner for West London |