Response Ordnance Survey
Action Planned
• Ordnance Survey and GeoPlace have undertaken an extensive fact-finding investigation into the circumstances. • Corrective and improvement actions have been identified in consultation with GeoPlace. • A timetable for the completion of these actions has been established. (AI summary)
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Dear Senior Coroner Whitting Subject: Regulation 28 report to prevent future deaths dated 10 March 2026 Inquest into the death of Darryl Johnson (Deceased) Introduction I refer to the Regulation 28 report referenced above which Ordnance Survey Limited ('Ordnance Survey') received on 13 March 2026. This letter sets out Ordnance Survey’s response as required under section 7 of the Regulation 28 report. Firstly, on behalf of Ordnance Survey and GeoPlace LLP (‘GeoPlace’, who I describe below) I would like to take this opportunity to extend our sympathies to Darryl Johnson's family and friends. This is a tragic matter and we are grateful to you for bringing it to our attention and for the opportunity to review the matters of concern identified within your Regulation 28 report. Ordnance Survey and GeoPlace are taking the matters of concern very seriously. We have undertaken an extensive fact-finding investigation into the circumstances giving rise to your concerns and carefully considered the actions that we can take in response, which we believe will support Emergency Service response in relation to location queries and therefore help prevent future deaths. As part of our investigation, we have worked closely with GeoPlace, whose role we explain in detail in Schedule 1, and made enquiries with other relevant stakeholders involved in the compilation and use of the address data supplied by Ordnance Survey. In consultation with GeoPlace, we have also identified a number of
2 Registered in England and Wales under number 09121572 Registered Office: Explorer House, Adanac Drive, Southampton, SO16 0AS corrective and improvement actions which I detail below, as well as a timetable for completion of these actions (see Schedule 2). Matters of concern I note the matters of concern set out in your report as follows: 'The East of England Ambulance Services Trust confirmed that their CAD system utilises an address and map database supplied by Ordnance Survey but that postal addresses listed in this database along with mapping coordinates to locate the property are not always accurate. Whilst it is it is accepted that it is not feasible for the database to be 100% accurate and up to date because it will take time for the system to be updated (as for example in the following situations:
• New builds
• Change of property name/number
• Change of use for a property/dwelling) the Deceased had purchased his property over 11 years ago and had been paying Council Tax since that time. It is, therefore, of concern why the database still did not have full details of his address.'' Executive summary of our response to the matters of concern The key points to note from our detailed fact-finding investigation set out in Schedule 1 are as follows:
- Ordnance Survey's address products that were being used by East of England Ambulance Services Trust did not include any address information for 27B Market Square, Potton, SG19 2NP ('27B') at the relevant time.
- Ordnance Survey’s address products rely on the provision of accurate addresses through an established supply chain, whereby data is provided to Ordnance Survey (via its associated organisation, GeoPlace) by local authorities, Royal Mail and the Valuation Office Agency ('VOA').
- At the time of the incident, Ordnance Survey’s address products only included addresses that had been verified through an address matching process with the relevant local authority (see further details in Schedule 1). This is because local authorities have statutory responsibility for street naming and numbering and maintaining address information in the official register of addresses known as the Local Land and Property Gazetteer (‘LLPG’). The local authority is therefore considered to be the authoritative source of the address.
- Royal Mail had created address data for 27B in 2013 in the course of mail delivery, and this address was included in Royal Mail’s Postcode Address File (‘PAF’) database which is a key source of address data for GeoPlace and Ordnance Survey.
3 Registered in England and Wales under number 09121572 Registered Office: Explorer House, Adanac Drive, Southampton, SO16 0AS However, whilst GeoPlace had identified 27B’s inclusion in Royal Mail PAF data and had notified this to Central Bedfordshire Council for investigation, the address had not been reviewed by Central Bedfordshire Council and not 'matched' with their LLPG.
- Central Bedfordshire Council have now confirmed that they do not hold any records referring to 27B Market Square in their LLPG or other internal datasets. This explains why 27B is 'unmatched' and was not included in the Ordnance Survey address products at the relevant time. Central Bedfordshire Council have also confirmed that their Council Tax system holds two residential addresses at 27 namely “27A Market Square" and "The Cottage, 27 Market Square" whilst the LLPG only holds "27A Market Square".
- Whilst 27B was included within Royal Mail’s PAF database, the property appears to have been identified in a number of other sources with different and inconsistent descriptors. For instance, HM Land Registry do not hold any record of “27B” and Mr Johnson was the proprietor of a freehold title registered with the description of “Land to the South of 27 Market Square”, and not 27B.
- Similarly, 27B is not included in the Valuation Office Agency’s Council Tax rating lists (another key source dataset used by GeoPlace and Ordnance Survey). Although VOA does contain records for “27A Market Square” and “Flat at 27”. We note that whilst Central Bedfordshire Council hold a Council Tax record for “27A Market Square”, they do not hold a record of “Flat at 27” for Council Tax purposes, but do hold “The Cottage, 27 Market Square”: we do not have confirmation that these two addresses are the same rateable properties. I wish to make it clear that I do not include this context (nor the detailed explanations in Schedule 1) by way of excuse or justification for 27B not being included in Ordnance Survey address products, rather to explain the scale and complexity of the task, the multiple stakeholders and sources involved, and to explain why addresses were only included within Ordnance Survey address products once matched to the local authority LLPG address. Further details of our fact-finding investigation can be found in Schedule 1. Corrective and improvement actions Before I set out a summary of the actions Ordnance Survey is taking in response to the matters of concern, it is notable that the latest version of our most recent Address product - NGD Address Version 3 (‘NGD Address V3’) which was released in October 2025 - already includes unmatched Royal Mail address data, including 27B, in the 'Royal Mail Address' feature type. Since 27B remains unmatched with any Central Bedfordshire Council LLPG record, the product only includes the address of 27B and an estimated position at the beginning of Market Square, rather than assigning geographic co-ordinates to the specific building to which 27B relates.
4 Registered in England and Wales under number 09121572 Registered Office: Explorer House, Adanac Drive, Southampton, SO16 0AS Regarding the actions we are taking, these fall into two categories, the first of which relate to Data Quality and Improvement and the second of which relate to Customer adoption, awareness and guidance.
In relation to the first category of Data Quality and Improvement, the actions are summarised as follows:
1. Ordnance Survey and GeoPlace will undertake a comprehensive analysis of unmatched address records across England and Wales, and will use the results of the analysis to prioritise unmatched records for resolution by individual local authorities.
2. As part of this, Ordnance Survey and GeoPlace will work with Central Bedfordshire Council to address unresolved and unmatched VOA and PAF records, including 27B. Ordnance Survey and GeoPlace will also seek to work with Royal Mail on how we could improve collaboration on national address sharing and management. We will also seek to agree new resolution targets with local authorities in relation to this review and for future management of unmatched addresses, although this will of course be subject to agreement with local authorities. However, I must stress that whilst Ordnance Survey and GeoPlace will do everything they reasonably can to help facilitate the resolution process, the success of this review will depend on the co-operation and engagement of local authorities including Central Bedfordshire Council. As such, we will be seeking support from the Local Government Association (LGA) which is the national membership body for local authorities in England and Wales. In relation to the second category of Customer adoption, awareness and guidance, the actions are summarised as follows:
1. We will promote the adoption and use by the Emergency Services (and by our Licensed Partners who include Ordnance Survey data within their products and services and work with the Emergency Services) of NGD Address V3, which as noted above, includes Royal Mail addresses such as 27B which have not been matched.
2. We will review and update our best practice guidance to Ordnance Survey’s Emergency Services working group in relation to determining location and position. This will include guidance for situations where an emergency call handler is working with unmatched addresses and locations. This guidance will be extended to local authority address custodians and local authority emergency planners for information and awareness. Details of the action plan, including timescales, can be found in Schedule 2.
5 Registered in England and Wales under number 09121572 Registered Office: Explorer House, Adanac Drive, Southampton, SO16 0AS Conclusion Having conducted a thorough investigation into the matters of concern, it has become apparent that there were a number of complexities associated with this particular address, both in terms of its address data history and competing source information, HM Land Registry title registration, physical location, and signage, as detailed in Schedule 1. We trust this letter (and the attached schedules) provide sufficient explanation regarding the detail and circumstances relating to the particular address 27B, but also provide a clear explanation of the overall process of address data creation, maintenance and supply. Although collating and maintaining address data is complex and relies on a number of sources, this does not reduce our regret that Ordnance Survey's products did not include address information for Mr Johnson’s residence at the relevant time. Moreover, this investigation has highlighted some areas for improvement from which we have been able to identify actions that we and other key stakeholders can focus on to drive improvements to the accuracy and reliability of address data for the benefit of Emergency Services, citizens and the nation as a whole. The matters of concern in your Regulation 28 report are being taken very seriously by Ordnance Survey and GeoPlace and we are working with relevant stakeholders to ensure, to the extent of our control and influence, that the issues and action plans identified are being addressed. Should you consider it helpful, we can provide you with an update on progress against the above actions at the end of September
2026. Furthermore, should you require further clarification on any part of our response, I would be pleased to assist.
2 Registered in England and Wales under number 09121572 Registered Office: Explorer House, Adanac Drive, Southampton, SO16 0AS corrective and improvement actions which I detail below, as well as a timetable for completion of these actions (see Schedule 2). Matters of concern I note the matters of concern set out in your report as follows: 'The East of England Ambulance Services Trust confirmed that their CAD system utilises an address and map database supplied by Ordnance Survey but that postal addresses listed in this database along with mapping coordinates to locate the property are not always accurate. Whilst it is it is accepted that it is not feasible for the database to be 100% accurate and up to date because it will take time for the system to be updated (as for example in the following situations:
• New builds
• Change of property name/number
• Change of use for a property/dwelling) the Deceased had purchased his property over 11 years ago and had been paying Council Tax since that time. It is, therefore, of concern why the database still did not have full details of his address.'' Executive summary of our response to the matters of concern The key points to note from our detailed fact-finding investigation set out in Schedule 1 are as follows:
- Ordnance Survey's address products that were being used by East of England Ambulance Services Trust did not include any address information for 27B Market Square, Potton, SG19 2NP ('27B') at the relevant time.
- Ordnance Survey’s address products rely on the provision of accurate addresses through an established supply chain, whereby data is provided to Ordnance Survey (via its associated organisation, GeoPlace) by local authorities, Royal Mail and the Valuation Office Agency ('VOA').
- At the time of the incident, Ordnance Survey’s address products only included addresses that had been verified through an address matching process with the relevant local authority (see further details in Schedule 1). This is because local authorities have statutory responsibility for street naming and numbering and maintaining address information in the official register of addresses known as the Local Land and Property Gazetteer (‘LLPG’). The local authority is therefore considered to be the authoritative source of the address.
- Royal Mail had created address data for 27B in 2013 in the course of mail delivery, and this address was included in Royal Mail’s Postcode Address File (‘PAF’) database which is a key source of address data for GeoPlace and Ordnance Survey.
3 Registered in England and Wales under number 09121572 Registered Office: Explorer House, Adanac Drive, Southampton, SO16 0AS However, whilst GeoPlace had identified 27B’s inclusion in Royal Mail PAF data and had notified this to Central Bedfordshire Council for investigation, the address had not been reviewed by Central Bedfordshire Council and not 'matched' with their LLPG.
- Central Bedfordshire Council have now confirmed that they do not hold any records referring to 27B Market Square in their LLPG or other internal datasets. This explains why 27B is 'unmatched' and was not included in the Ordnance Survey address products at the relevant time. Central Bedfordshire Council have also confirmed that their Council Tax system holds two residential addresses at 27 namely “27A Market Square" and "The Cottage, 27 Market Square" whilst the LLPG only holds "27A Market Square".
- Whilst 27B was included within Royal Mail’s PAF database, the property appears to have been identified in a number of other sources with different and inconsistent descriptors. For instance, HM Land Registry do not hold any record of “27B” and Mr Johnson was the proprietor of a freehold title registered with the description of “Land to the South of 27 Market Square”, and not 27B.
- Similarly, 27B is not included in the Valuation Office Agency’s Council Tax rating lists (another key source dataset used by GeoPlace and Ordnance Survey). Although VOA does contain records for “27A Market Square” and “Flat at 27”. We note that whilst Central Bedfordshire Council hold a Council Tax record for “27A Market Square”, they do not hold a record of “Flat at 27” for Council Tax purposes, but do hold “The Cottage, 27 Market Square”: we do not have confirmation that these two addresses are the same rateable properties. I wish to make it clear that I do not include this context (nor the detailed explanations in Schedule 1) by way of excuse or justification for 27B not being included in Ordnance Survey address products, rather to explain the scale and complexity of the task, the multiple stakeholders and sources involved, and to explain why addresses were only included within Ordnance Survey address products once matched to the local authority LLPG address. Further details of our fact-finding investigation can be found in Schedule 1. Corrective and improvement actions Before I set out a summary of the actions Ordnance Survey is taking in response to the matters of concern, it is notable that the latest version of our most recent Address product - NGD Address Version 3 (‘NGD Address V3’) which was released in October 2025 - already includes unmatched Royal Mail address data, including 27B, in the 'Royal Mail Address' feature type. Since 27B remains unmatched with any Central Bedfordshire Council LLPG record, the product only includes the address of 27B and an estimated position at the beginning of Market Square, rather than assigning geographic co-ordinates to the specific building to which 27B relates.
4 Registered in England and Wales under number 09121572 Registered Office: Explorer House, Adanac Drive, Southampton, SO16 0AS Regarding the actions we are taking, these fall into two categories, the first of which relate to Data Quality and Improvement and the second of which relate to Customer adoption, awareness and guidance.
In relation to the first category of Data Quality and Improvement, the actions are summarised as follows:
1. Ordnance Survey and GeoPlace will undertake a comprehensive analysis of unmatched address records across England and Wales, and will use the results of the analysis to prioritise unmatched records for resolution by individual local authorities.
2. As part of this, Ordnance Survey and GeoPlace will work with Central Bedfordshire Council to address unresolved and unmatched VOA and PAF records, including 27B. Ordnance Survey and GeoPlace will also seek to work with Royal Mail on how we could improve collaboration on national address sharing and management. We will also seek to agree new resolution targets with local authorities in relation to this review and for future management of unmatched addresses, although this will of course be subject to agreement with local authorities. However, I must stress that whilst Ordnance Survey and GeoPlace will do everything they reasonably can to help facilitate the resolution process, the success of this review will depend on the co-operation and engagement of local authorities including Central Bedfordshire Council. As such, we will be seeking support from the Local Government Association (LGA) which is the national membership body for local authorities in England and Wales. In relation to the second category of Customer adoption, awareness and guidance, the actions are summarised as follows:
1. We will promote the adoption and use by the Emergency Services (and by our Licensed Partners who include Ordnance Survey data within their products and services and work with the Emergency Services) of NGD Address V3, which as noted above, includes Royal Mail addresses such as 27B which have not been matched.
2. We will review and update our best practice guidance to Ordnance Survey’s Emergency Services working group in relation to determining location and position. This will include guidance for situations where an emergency call handler is working with unmatched addresses and locations. This guidance will be extended to local authority address custodians and local authority emergency planners for information and awareness. Details of the action plan, including timescales, can be found in Schedule 2.
5 Registered in England and Wales under number 09121572 Registered Office: Explorer House, Adanac Drive, Southampton, SO16 0AS Conclusion Having conducted a thorough investigation into the matters of concern, it has become apparent that there were a number of complexities associated with this particular address, both in terms of its address data history and competing source information, HM Land Registry title registration, physical location, and signage, as detailed in Schedule 1. We trust this letter (and the attached schedules) provide sufficient explanation regarding the detail and circumstances relating to the particular address 27B, but also provide a clear explanation of the overall process of address data creation, maintenance and supply. Although collating and maintaining address data is complex and relies on a number of sources, this does not reduce our regret that Ordnance Survey's products did not include address information for Mr Johnson’s residence at the relevant time. Moreover, this investigation has highlighted some areas for improvement from which we have been able to identify actions that we and other key stakeholders can focus on to drive improvements to the accuracy and reliability of address data for the benefit of Emergency Services, citizens and the nation as a whole. The matters of concern in your Regulation 28 report are being taken very seriously by Ordnance Survey and GeoPlace and we are working with relevant stakeholders to ensure, to the extent of our control and influence, that the issues and action plans identified are being addressed. Should you consider it helpful, we can provide you with an update on progress against the above actions at the end of September
2026. Furthermore, should you require further clarification on any part of our response, I would be pleased to assist.