AN INQUEST INTO THE DEATH OFCONSTANCE CAROLLE HARRISON

CORONERS COURT OF THE AUSTRALIAN CAPITAL TERRITORY Case Title: AN INQUEST INTO THE DEATH OF

CONSTANCE CAROLLE HARRISON Citation: [2018] ACTCD 11 Date of Findings: 28 June 2018 Before: Coroner B. C. Boss Decision: 1. Constance Carolle Harrison died on 10 September 2014 at the intersection of Canberra Avenue and Manuka Circle, Griffith, in the Australian Capital Territory;

2. The manner and cause of death of Ms Harrison are sufficiently disclosed and a hearing is unnecessary;

3. The manner and cause of Ms Harrison’s death is severe crush injury of chest due to involvement in a motor vehicle accident; and

4. Pursuant to s 52(4)(a)(i) of the Coroners Act 1997, a matter of public safety is found to arise in connection with this inquest.

File Number: CD 200 of 2014

1. Constance Harrison was known as Carolle to her friends and family and the many Canberrans whose lives she touched as a long standing primary school teacher. She was 65 years old when she was run over by a school bus at the intersection of Canberra Avenue and Manuka Circle, Griffith at approximately 3:41pm on 10 September 2014. She was walking across the pedestrian crossing on Canberra Avenue in a southerly direction when the bus turned left from Manuka Circle onto Canberra Avenue crossing her path. Ms Harrison was knocked to the ground with the rear wheels of the bus running over her body. Members of the public immediately provided assistance, and Police and Ambulance Services were quickly in attendance, but despite their best efforts Ms Harrison was unable to be revived and she died at the incident scene.

2. A post mortem examination of Ms Harrison undertaken at my direction identified the direct cause of her death as severe crush injury of chest due to involvement in a motor vehicle accident. I make formal findings accordingly.

Related Criminal Proceedings

3. Shortly after Ms Harrison’s death the driver of the bus was charged by Police with an offence of negligent driving occasioning death in respect of the incident that resulted in her death. I determined that it would be inappropriate for me to proceed further with the inquest while criminal proceedings of direct relevance were on foot.

4. The criminal proceedings were heard by the ACT Chief Magistrate on 8 September 2015, and after a hearing the charge was dismissed.

5. It is clear from written submissions made to me that Ms Harrison’s family struggle with the outcome of the criminal proceedings. However, it is inappropriate for me to look behind the decision of the ACT Chief Magistrate or to make any findings which would potentially conflict with the outcome of the criminal proceedings. This includes enquiring into the circumstances of what the bus driver may or may not have seen, any reasons why he may not have seen Ms Harrison, or what he should have done on the day of the incident.

Matter of Public Safety

6. It became apparent during the course of the investigation that Ms Harrison was lawfully crossing Canberra Avenue at a marked pedestrian crossing in accordance with the lights ie. the “green man”, but that the pedestrian light turned green at the same time as the ordinary traffic signal. I consider that this simultaneous signalling constitutes a matter of public safety insofar as turning vehicles are permitted to cross pedestrian crossings at exactly the same time pedestrians are told they can cross the road.

7. Ms Harrison’s family made the suggestion, supported by the Police Crash Investigation Team, that the traffic signals at the intersection in question be modified to allow pedestrians to walk unimpeded for several seconds prior to any other traffic receiving green signals and entering across that intersection. The suggestion was informed by advice that NSW Roads and Maritime Services had adjusted approximately 5000 sets of signals across the Sydney CBD to achieve this outcome as a result of a similar fatality involving a pedestrian.

8. RoadsACT voluntarily agreed to modify the signals programming at the intersection of Canberra Avenue and Manuka Circle accordingly, and this was completed on 5 November 2015. Specifically, the new programming of the lights allows for four seconds between the commencement of the “walk” signal for pedestrians to cross the eastbound carriageway of Canberra Avenue on the eastern side of the intersection, and the start of the green signal for southbound traffic on Manuka Circle. I am grateful to RoadsACT for their responsiveness in this regard.

9. I then caused enquiries to made with RoadsACT as to whether similar programming modifications should be rolled out to all appropriate intersections in the ACT. The advice received back was that many ACT intersections already provide protection for pedestrian crossings by way of red arrow protection, last start green lights or

intersection geometry (which was described as including left turn slip lanes where turning drivers do not conflict with crossing pedestrians). However, there remained a number of intersections which either provided no protection for pedestrian crossings, or only some of the pedestrian crossings were protected. While many of these intersections could be modified in terms of their programming to provide some protection to pedestrians, some complex intersections could not be reprogrammed due to specific phasing arrangements and pedestrian protection would need to be provided in another way. RoadsACT indicated that it was developing a policy in relation to dealing with conflicts at traffic signals between turning traffic and vulnerable road users such as pedestrians or cyclists which emphasised the need to individually assess the intersection to determine what protection measures might be appropriate.

10. It is my personal observation that in the period since Ms Harrison’s death, many more ACT intersections have now been modified to allow a period of time between the pedestrian walk signal and the allied green road traffic light so that pedestrians get a “head start” on the crossing and are therefore more visible to turning traffic. While nothing will bring Ms Harrison back nor diminish the grief of her family and friends, these changes may been seen as something positive to have resulted from her death.

In these circumstances I consider no further recommendation by me is necessary.

11. Ms Harrison’s family also raised in their submissions to me concerns in relation to the standards required for a licence to drive a bus in the ACT, and suggested an effective reverse onus of proof upon drivers who have been involved in an incident resulting in the death of a person to prove that they remain suitable to hold a heavy vehicle license.

With respect, the fact that Ms Harrison was unfortunately killed in a road traffic accident does not in and of itself call into question general ACT licencing standards. I am also advised that public vehicle licence holders are already required to provide an annual medical report to remain licenced in the ACT. Accordingly, I do not find this issue amounts to a matter of public safety, and I make no recommendation in relation to this issue. I do however note the family’s concerns in my reasons in case this is a matter the ACT Government may care to voluntarily advance.

Hearing

12. In all the circumstances as detailed above in my view there is no necessity to hold a public hearing in relation to Ms Harrison’s death. I believe I have all the evidence which exists or is likely to exist which could possibly bear on the decisions I must make. There is no issue about which I would be empowered to hold a public hearing and which in and of itself warrants that course being taken.

13. I will however publish my findings and reasons on the ACT Coroners Court website, together with any response I might receive from Ministers or Government. I will forward a copy of this document to the Attorney-General and the Roads Minister for their consideration.

14. I extend my condolences to David, Ms Harrison’s husband, as well as Ms Harrison’s family and friends.

I certify that the preceding fourteen [14] numbered paragraphs are a true copy of the Findings of Coroner B. C. Boss Associate: Date: 28 June 2018