Brema Virgo

Dear Mr Frazer Stuart (Assistant Coroner for Gwent) Regulation 28 response I write with the Council’s response to the Regulation 28 report to prevent deaths dated 27/2/26, arising out of the Investigation and Inquest into the death of Brema Elizabeth Virgo. I note that you considered that your duty to make a PFD report was engaged. The concern you identified was:- ‘The methods used for assessing and interpreting height of the defects in pavements allows for circumstances to occur whereby the actual height of the entire defect may not be reflected. Relevant defects may not be properly identified resulting in preventative remedial action not being taken, which presents a risk of future deaths’. I and other senior members of the Council’s highways department have given detailed consideration to the report and reviewed the Council’s Manual and methods with reference to the specific concern raised. We have concluded that we do not consider that any immediate or short term changes need to be made. In reaching this conclusion, we have considered the following relevant factors:- Highway policy/Manual - The Council identifies and categorises defects on the highway with reference to its Highway Maintenance Manual 2022. This is the latest approved version used by Newport City Council. The Council categorises highway defects using the County Surveyors’ Society Wales (CSSW) Highway Asset Risk Review Method, ensuring that its standards meet or exceed the CSSW minimum standards. The CSSW Risk Review Method was developed as a collaborative approach to create a consistent risk-based methodology across Welsh local authorities. This risk based approach is applied when assessing defects. This approach, as set out in the CSSW Highway Asset Risk Review Method, determines how each defect is assessed in terms of:
- Severity
- Location and context
- Likelihood of causing a safety risk
- Potential consequences if the defect is not addressed

[Page 2] This ensures that all defects are managed proportionately, with higher risk issues prioritised for repair and lower risk defects managed appropriately Methods of identifying defects - Trained Highway inspectors carry out inspections on a schedule or a third party enquiry of all adopted highways based assets on the hierarchy as set out in the Council Highway Maintenance Manual. These inspections identify defects such as potholes, surface deterioration, damaged street furniture, drainage issues, and hazards that could cause harm to users of the highway. Planned routine inspections are a combination of: o Driven Inspections: inspections of the carriageway undertaken with a driver and a Highway Inspector. o Walked Inspections: inspections undertaken by a Highway Inspector on foot, where the footway and carriageway are assessed Training of highways inspectors - Highway Inspectors are required to have a specific qualification in highway inspection. Street Works qualification, CoP reaccreditation and Lantra NHSS 12D (M7). Training and monitoring of inspectors includes the procedures set out in the Council’s Highway Maintenance Manual and the CSSW guidance, so that defect identification, measurements and risk assessment are undertaken to the expected professional standard. Measuring two potential defects located close together - In line with the Highway Maintenance Manual 2022 and national guidance, including the CSSW Risk Based Approach Method and the Highway Inspection Defect Recording Manual, Newport City Council applies a risk based approach to all highway inspections. These documents set out how defects must be assessed by severity, location, and risk, rather than by simply merging defects together. When inspectors encounter a situation where two potential defects are located close together, they are required to record and assess each potential defect separately. This ensures that every defect is evaluated on its own characteristics—such as size, severity, and location—while still allowing inspectors to take account of any wider combined risks as part of the overall assessment. Whilst we consider that no immediate or short term changes need to be made, in view of the serious nature of the incident in question, Highways intend to undertake a review of the Highway Maintenance Manual to consider whether any alterations to this may be necessary in view of your comments. Should any changes be identified, these would need to be reviewed by senior managers and proceed through a cabinet member approval process, before being ratified and implemented. I trust that this provides you with sufficient information.