Source · Prevention of Future Deaths

Paul Collingridge

Ref: 2025-0100 Date: 20 Feb 2025 Coroner: Sonia Hayes Area: Essex Responses identified: 4 / 4 View PDF

Roadworks safety procedures have flaws regarding distance calculations, inconsistent road markings, and a lack of requirement to report fatalities on permit applications, hindering safety assessments.

Date 20 Feb 2025
56-day deadline 17 Apr 2025 est.
Responses identified 4 of 4
Road (Highways Safety) related deaths

Coroner's concerns

AI summary
Roadworks safety procedures have flaws regarding distance calculations, inconsistent road markings, and a lack of requirement to report fatalities on permit applications, hindering safety assessments.
View full coroner's concerns
(1) Where Road Works Permits are required by utility companies these are often urgent to carry out vital repairs. This can mean that roadworks are set up in hours of darkness and may cause difficulties calculating distances as set out in the Safety at Street Works Code of Practice.

(2) The Safety of Street Works Code of Practice sets out how to take measurements to set out street works that include utlising street furniture that are at set distances and standard road markings that have standard lengths on carriageways with specific road speeds.
a. Some carriageways do not have street furniture
b. Some of the road markings on the carriage where the fatal collision did not comply to standard lengths and therefore the markings can have variations.
c. The Code of Practice does not set out how to calculate the distance where there is road curvature where the road markings have differing lengths on opposing sides where the markings are delineated on bends in a carriageway.

(3) A road works warning sign was placed at the junction that joined the carriageway of a road that obscured visibility of traffic joining the main carriageway. Whilst this did not cause or contribute to this incident this was not in accordance with the Code of Practice.

(4) The fatal incident that occurred on 6 December 2022 was not notified on the retrospective permit application for roadworks on the following day. There is no requirement for a fatality within roadworks be notified on application for an application for a permit .

Responses

4 respondents
Affinity Water Private Sector
4 Apr 2025 PDF
Action Taken

Affinity Water expresses condolences and describes existing safety measures and a commitment to zero harm. Following the death, they reviewed and strengthened traffic management practices and implemented stricter oversight of contractors, resulting in a reduction in street works requiring emergency permits; they also enhanced permit application processes, including additional resourcing, improved communication, and reinforced training. (AI summary)

View full response
Dear Ms Hayes Affinity Water Limited Tamblin Way Hatfield Hertfordshire AL10 9EZ 4 April 2025 Inquest into the death of Paul Collingridge: Report under Regulation 28 of the Coroners (Investigations) Regulations 2013 (Your Ref: 2025-0100) We are writing in relation to the above inquest and in particular the above-mentioned report of 20 February 2025 (the “PFD Report”) that Affinity Water Limited (“Affinity”) have received from yourself. We have duly considered the issues raised in the PFD Report and this letter serves as Affinity’s formal response to the same. In the first instance, Affinity extends its deepest sympathies to the family, fiancée and friends of Paul, and to anyone else who may be affected by his loss. Secondly, we thank you for forwarding us a copy of the PFD Report that was made following the inquest into Paul’s death. Affinity always strives for high standards of safety and welcomes opportunities to improve the services it provides to the public. Affinity has a shared vision that “we all have a responsibility to make sure that everyone goes home to friends and family safely everyday” and we are committed to achieving zero harm by promoting a culture of collaboration, awareness and prevention. In helping achieve this vision, Affinity has in place robust health and safety measures and a good and collaborative relationship with its various stakeholders including local councils and its contractors. Matters of Concern You have asked for a response to several matters of concern in your report and our responses to these concerns are set out below, including details of action taken or proposed to be taken and setting out a timetable for action, or alternatively explaining why no action

is proposed. We have not provided a response to the second matter of concern as the Safety at Street Works Code of Practice (the “Code”) is published and controlled by the Department of Transport (DfT) and therefore we do not believe that Affinity is required to respond to that point.

(1) Matter of concern: Where Road Works Permits are required by utility companies these are often urgent to carry out vital repairs. This can mean that roadworks are set up in hours of darkness and may cause difficulties calculating distances as set out in the Safety at Street Works Code of Practice. (2) Matter of concern: A road works warning sign was placed at the junction that joined the carriageway of a road that obscured visibility of traffic joining the main carriageway. Whilst this did not cause or contribute to this incident this was not in accordance with the Code of Practice. As recognised in the PFD Report, it is sometimes necessary for utility companies to carry out urgent works, meaning that roadworks are set up in the hours of darkness, which can cause difficulties in the calculation of distances set out in the Code.

Public safety, as well as the safety of its personnel, is of paramount importance to Affinity. To ensure this, Affinity has in place robust processes for ensuring compliance with roadworks requirements, including ensuring all personnel are trained and qualified to carry out works under the New Roads and Street Works Act 1991 (“NRSWA”); that all operatives carrying out street works understand the requirements of the NRSWA and the Code; that all operatives are trained on and understand our common standards relating to safety when carrying out works in the public highway; and the production of site specific risk assessments and safe systems of work for all street works.

Affinity use traffic management contractors to set up its roadworks. All of our contractors are appointed following a rigorous procurement process that assesses the contractor’s health and safety compliance, and all of our contracts contain requirements for adherence to health and safety standards and KPIs regarding the conduct of street works. Affinity’s zero harm policies are also fed down to its contractors, including regular partnership forums to discuss health and safety matters. There are also monthly and weekly reporting of street work performance to ensure compliance with health and safety and street work legal requirements. Following Paul’s death, Affinity reviewed its traffic management practices including the strengthening of our planning and execution of emergency works and have already implemented stricter protocols with regard to oversight of our contractors. Regular audits and assessments are carried out to monitor adherence and identify areas for continuous improvement. This has resulted in a significant reduction in the number of street works requiring emergency permits.

(3) Matter of concern: The fatal incident that occurred on 6 December 2022 was not notified on the retrospective permit application for roadworks on the following day. There is no requirement for a fatality within roadworks be notified on application for an application for a permit.

Affinity has a good and proactive relationship with the local councils in its supply areas, and we regularly attend stakeholder groups to discuss any issues with health and safety when conducting street works.

Affinity carried out a review of its permit application processes following Paul’s death and again following the inquest, and we have made a number of changes to our processes, including additional resourcing to ensure for prompt permit applications, better communications with councils regarding permitting and improving our training and operational protocols to reinforce compliance with all permitting requirements, particularly for emergency or out-of-hours works.

Affinity will also work collaboratively with DfT and councils in relation to any proposed revisions to the Code and/or any new rules with regard to permit applications and the safe conduct of roadworks.
Department for Transport Central Government
21 May 2025 PDF
Action Planned

The Department for Transport expresses condolences and notes that road safety is a high priority. It describes the role of the Safety at Street Works and Road Works Code of Practice and that the code is currently being updated with a consultation planned for early summer and publication by the end of 2025, taking the coroner's report into account. (AI summary)

View full response
Dear Ms Hayes,

Thank you for your letter of 21 February regarding your Regulation 28 Report about the tragic death of Paul Stephen Collingridge on 12 December 2022. May I begin by expressing my deep sadness about Paul Collingridge’s death and offering my condolences to his family and loved ones. I am also very sorry that there has been a delay in responding to your report.

I would like to make clear that road safety is one of my Department’s highest priorities. Too many people are killed and seriously injured in road traffic collisions, and this government will work hard to prevent these tragedies. As part of this, it is vital that we ensure safety at street and road works for road users and workers.

My Department is responsible for the Safety at Street Works and Road Works Code of Practice (“the Safety Code”) which is statutory guidance that must be adhered to at all street and road works sites in England, Scotland, Wales and Northern Ireland. The code of practice seeks to ensure street and road works sites in the highway are set up safely in the interest of those carrying out the works and road users, including pedestrians and those with disabilities. The Safety Code is issued under section 65 of the New Roads and Street Works Act 1991 and section 174 of the Highways Act 1980. Failure to comply with the code is evidence that an offence of failing to comply with safety measures under section 65 of the 1991 Act has been committed.

I would like to address the matters of concern you raised in your report.

You raised several concerns about how set distances can be measured accurately when a work site is set out with signing and guarding as required by the Safety Code.

You made references to the use of street furniture and road markings to determine distances and measuring distances accurately in the hours of darkness. The Safety Code details the sequence for setting out a street work site with reference to a table of distances. These distances are determined with reference to the street work site and do not depend on the presence of street furniture or road markings. The Safety Code makes it clear that it is the responsibility of those carrying out the works to ensure that the distances are measured accurately. This also includes during the hours of darkness. Failure to comply with the distances set out in the Safety Code is evidence that an offence for failing to comply with the Safety Code has been committed. If it appears to the highway authority that an undertaker has failed to comply with the Safety Code, they may take necessary steps and recover their reasonable costs from the undertaker.

The Safety Code also states that bends in the road must be considered before setting up work sites. If a site is on or near a bend in the highway, then extra care must be taken to ensure safety. This includes providing additional advance signs, using reflective barriers and ensuring adequate visibility for both drivers and workers at all times of the day.

You raised a further concern regarding a sign that was placed incorrectly at a junction which obscured visibility but was not a contributing factor to Mr Collingridge’s death. It appears that the placement of the sign was not in accordance with the Safety Code. However, it is for the local highway authority that granted the permit to decide on any enforcement action. It would have been for them to do this at the time of the incident.

You raised a final concern that the fatality was not mentioned on the permit application for the works. For immediate works, permits can be submitted within two hours of arriving on site. If a fatality happens at the site, there is no requirement for it to be referred to on the permit application, as the permit is concerned with agreeing timings and durations of works. It is the Safety Code and the risk assessments that are carried out that take account of incidents to ensure sites are set up correctly.

The Safety Code was last published in 2013 and is currently in the process of being updated, with a consultation due to take place in early summer. We are inviting comments on whether there are any parts of the Safety Code that can be improved to maximise safety, and we plan to publish an updated version by the end of 2025. I will ensure that we take into account your report when completing this work.

I am sorry again for the lengthy delay in responding to your letter. This was due to handling errors within the Department. My officials will review this case and ensure necessary training is undertaken to avoid delays occurring in the future.

I am sending a copy of this letter to the recipients of your report.
Hatton Traffic Management
PDF
Action Taken

Hatton Traffic Management undertook a full review of emergency works procedures, resulting in new design layouts for all traffic light schemes which were rolled out across the business. A specific toolbox talk addressing this issue and the above changes, was devised and rolled out across the business. (AI summary)

View full response
Dear Ms Hayes,

HTML is not in a position to respond or comment in relation to recommendations 5 (1), (2) and (4) of the Regulation 28 Report.

Insofar as recommendation 5 (3) is concerned, HTML can confirm that it undertook a full review of emergency works procedures which resulted in new design layouts for all traffic light schemes on all road speeds. These provide additional more detailed guidance and direction on the placement of signs and were rolled out across the business on 23rd January 2025.

A specific toolbox talk addressing this issue and the above changes, was devised and rolled out across the business on 30th January 2025.

In addition, an additional question has been added to the installation process flow which requires the relevant operative to answer and record whether sight lines to signage have been checked and assessed as appropriate.
Essex County Council Local Authority / Fire Service
PDF
Noted

Essex County Council explains its role in regulating street works, noting limitations in refusing permits and the use of the Street Manager system. They will raise the lack of incident reporting in retrospective permit applications with the Department for Transport. (AI summary)

View full response
Subject: Response to Coroner’s Regulation 28 Report We are writing in response to the concerns raised in the Regulation 28 Report issued following the tragic incident that occurred on 6 December 2022. Firstly, we would like to express our deep condolences to the family of Mr. Paul Collingridge. The loss of life is deeply saddening, and our thoughts are with them. The role of Essex County Council in the regulation of street works is that it has to operate a statutory scheme made by the Department for Transport. Certain organisations called ‘statutory undertakers’ have the right to work in the highway; although they need a permit applied for in advance – other than in an emergency where they are required to apply for a retrospective permit if the works are urgent – we can only issue permits to regulate hours of work and to co-ordinate timings, we do not have any ability to refuse permission for works done in accordance with the Safety at Street Works Code of Practice (the Code). We can encourage good practice in some ways, but as statutory undertakers work with many different local authorities, local authorities are required to operate standard systems. Also, all local authorities and statutory undertakers are required to work with an online road works system for permits known as Street Manager, which is supplied by others. Our response has to be viewed in this context. With regard to the points raised in the report, we wish to address the following:
1. Road Works Permits and Setup in Hours of Darkness. All work is more difficult during the hours of darkness. Undertakers and those working on their behalf are responsible for ensuring emergency works are set up safely and are required to have a trained and qualified person on site to ensure compliance with the Code. ECC does not have the ability to inspect all emergency roadworks as that does not form part of the safety system.
2. Variations in Street Furniture and Road Markings: In general, road markings are maintained to standard lengths but everyone working in the highway – including statutory undertakers - will appreciate that there will always be variations to take account of local features in the road such as junction locations and curvature in the road. Road markings will also fade over time as a result of weather conditions, high traffic volumes, and other factors. At Essex County Council, we employ a robust inspection system according to our Maintenance Strategy, adopting a risk-based approach to identify and prioritise any required works. We also note that the Safety at Street Works Code of Practice provides guidance as to how to proceed in setting up appropriate traffic management. Regarding curved carriageways, the absence of specific guidance on distance calculation in the statutory Code of Practice is acknowledged. While this remains a broader area for review for the Department for Transport, Essex County Council is prepared to support any request from the Department of Transport to improve the Code to address such circumstances. There is an overarching duty for statutory undertakers to have a safe system of work and the training they have will cover this.

3. When applying for retrospective permission for street works there is no requirement for a statutory undertaker to notify the authority of any serious incidents that have occurred during the emergency period. There is a national database run by the Department for Transport named Street Manager. This is the way that all local authorities communicate with all statutory undertakers. That database does not have a data field to allow permit applicants to report incidents or unusual events. We will raise this with the Department for Transport. However, the involvement of the police in any fatal road accident already provides a communications channel, meaning that in practice ECC is notified quickly of any fatalities and can quickly take any necessary action that it has the power to take. In closing, Essex County Council is fully committed to working with all parties involved in this matter to improve safety standards and prevent similar incidents in the future. Please do not hesitate to contact us if we can provide further assistance.

Report sections

Investigation and inquest
On 12 December 2022, I commenced an investigation into the death of Paul Stephen COLLINGRIDGE, AGE 28. The investigation concluded at the end of the inquest on 3 October 2024 . The conclusion of the inquest was 1a Multiple Traumatic Injuries. Road Traffic Collision
Circumstances of the death
Paul Stephen Collingridge died on 6 December 2022 of Multiple Traumatic Injuries sustained when his motorcycle high sided on an unlit road in the hours of darkness following sudden braking on the approach to roadworks ejecting him into the path of oncoming traffic. Mr Collingridge was travelling on the Colchester bound single carriageway navigating a bend when there was queuing traffic and was struck by an oncoming vehicle that had no opportunity to take avoiding action on the B1027 Colchester Road at junction with Frowick Lane, St Osyth. The roadworks for utility repairs had been put in place overnight and the required permit was not in place.

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Report details

Reference
2025-0100
Date of report
20 February 2025
Coroner
Sonia Hayes
Coroner area
Essex

Responses identified

Responses identified 4 of 4
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 17 Apr 2025 (estimated).

Sent to

Affinity Water
Department for Transport
Essex County Council
Hatton Traffic Management

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