Tracey Haybittle

Coroner's concerns

AI summary

Satnav verbal commands at a specific junction are confusing drivers, causing them to turn the wrong way onto a slip road, creating a frequent and serious risk of collisions.

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I have made observations regarding the slip road at this junction in my initial pre-Inquest Report To Prevent Future Deaths dated the 21st December 2023 in respect of the linked case of Amal Mohamed Ahmed. National Highways undertook a number of immediate remedial measures to try to prevent drivers turning and travelling the wrong way down this slip road, including narrowing the "mouth" of the slip road to one lane, placement of very large temporary "No Entry" signs and placement of signs indicating "Do Not Use Satnav" at the site. CCTV monitoring of driver behaviour was commenced. Police activity and monitoring by National Highways showed that despite these measures, drivers were still turning early and attempting to drive the wrong way down the slip road. Further enquiries by the police and information volunteered by members of the public who made the same incorrect manoeuvre led to the finding that while the visual map display on commonly used satnav applications at this junction displayed the correct information, the verbal commands gave information likely to confuse and direct drivers down the wrong slip road into the path of oncoming traffic. This was observed to happen frequently.

Responses

4 respondents

TomTom

16 Oct 2024 PDF

Action Taken

TomTom has implemented additional safeguards to limit driver confusion by timing verbal commands closer to the actual exit, after passing the off-slip road. The changes require users to update their maps for them to be effective. (AI summary)

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Dear Mr. Cummings, We are writing in response to your reports dated 22nd and 23rd August 2024, regarding the accident at the A5 near the Little Brickhill junction. First of all, we would like to extend our condolences to all those affected by this tragic event. At TomTom, the safety of our customers and all road users is our priority, and we take security matters very seriously. Following the report, we reviewed our navigation systems’ verbal instructions provided near the junction at hand. We have simulated different scenarios, including speed variations of 60mph and 30mph, to better understand how our navigation systems presented instructions based on driver speed. The scenarios assumed that the driver would either (i) maintain maximum speed until the junction; or (ii) slow down when approaching it. The outcome of the review revealed that instructions were given either (i) right when passing by the off-slip road; or (ii) after passing by the off-slip road, when on the overpass towards the exit. As part of our ongoing efforts to enhance road safety, we recently implemented additional safeguards, to limit drivers’ confusion where possible, regardless of their speed behavior on the road, by timing the verbal commands closer to the actual exit, and in any event after passing the off-slip road. However, please note that in order for these changes to be effective and visible by end users, they need to use the latest map and therefore in certain circumstances need to update their systems/devices. Although our navigation systems offer road assistance and simplify each journey, drivers remain responsible for driving. That said, we believe that the mentioned changes in verbal instructions, combined with the steps taken by National Highways to improve safety at this location will provide drivers with clearer and more timely guidance. Thank you for bringing this to our attention. Please do not hesitate to contact us if you have any further questions. This letter is submitted without prejudice and TomTom reserves all rights accordingly.

Google UK & Ireland Other

16 Oct 2024 PDF

Action Planned

Google is working on improvements to the timing of the audio guidance on Google Maps and anticipates providing enhanced audio guidance in situations such as those in this case. This will involve an amended audio prompt as a driver approaches a junction where they would cross an overpass: “after the overpass, turn right”. (AI summary)

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Dear Sean Cummings Regulation 28: Report to Prevent Future Deaths – Tracey Haybittle and Amal Ahmed We refer to your report dated 22 August 2024 regarding Mrs Haybittle and to your report dated 23 August 2024 regarding Ms Ahmed. This letter serves as a formal response to the queries and points raised within the reports. Circumstances of death We are deeply saddened to hear of the tragic circumstances relating to the deaths of Mrs Haybittle and Ms Ahmed. We understand from the reports that on 20 November 2023, Ms Ahmed’s vehicle collided with Mrs Haybittle’s vehicle on the A5 adjacent to the Little Brickhill junction. Ms Ahmed died at the scene; Mrs Haybittle died later at the John Radcliffe Hospital. A passenger of one of the vehicles required critical care and suffered life threatening and changing injuries. The reports indicate that Ms Ahmed appeared to have been using a GPS – or “satnav” – navigation system, but mistakenly entered the “off” slip road at the Little Brickhill junction and drove the wrong way at speed before colliding with Mrs Haybittle. We understand that the junction was painted with “No Entry” on the road surface – along with white, double broken lines (indicating “give way”) – and was flanked by two red “No Entry” road signs. National Highways subsequently undertook a number of measures to prevent other drivers from incorrectly entering the slip road, but observed that drivers frequently continued to do so. Enquiries by the police and information volunteered by members of the public suggested that the audio guidance given by their satnav systems may be confusing drivers into making the incorrect manoeuvre. Google Maps Google Maps is a mapping and navigation application provided to users in the UK by Google LLC. It can provide directions for users to travel from one point to another on foot, in a vehicle, by bicycle or by public transport. The application offers directions that can visibly be shown on the user’s device and/or offers audio guidance to prepare users for upcoming manoeuvres, and to guide them to the point at which they must turn or make the manoeuvre. Registered address: Belgrave House, 76 Buckingham Palace Road, London SW1W 9TQ Registered in England and Wales with registration number 03977902

Google UK Limited Belgrave House, 76 Buckingham Palace Road, London SW1W 9TQ, United Kingdom Safety is core to how Google develops and operates the Google Maps service, and we understand our responsibility to keep our users and other road users safe. We implement a multi-layered approach to ensure navigation instructions are provided safely, including through real-time data updates and algorithm optimisation, user feedback and reporting, and integration with other safety features such as Car Crash Detection on certain Pixel devices. We endeavour to ensure that any audio guidance given by Google Maps serves as a useful tool for drivers, though users must always obey road signs and traffic signals. Steps taken in response to the reports We recognise that the cases identified in the reports are tragic. While it is not clear whether Google Maps was involved, we have carefully considered whether there are improvements we can make to Google Maps to help ensure that similar incidents do not occur in future. We have therefore taken the following measures: ● We have liaised with National Highways and reviewed their helpful dashcam footage of the relevant junction. This has assisted our product and engineering teams in carefully investigating the audio guidance provided by Google Maps. Our teams are working on improvements to the timing of the audio guidance. ● As part of these improvements, we anticipate providing enhanced audio guidance in situations such as those in this case. This will involve an amended audio prompt as a driver approaches a junction where they would cross an overpass: “after the overpass, turn right”. We hope that this will provide clearer guidance for drivers and help reduce the risk that they make an incorrect turn. Although changes such as these require significant internal validation before they can be launched publicly, we hope to launch them in the near future. More generally, Google remains committed to continually improving its services to provide helpful navigation services, and we welcome feedback from users which can be submitted through the Google Maps mobile application or website.

Apple Other

17 Oct 2024 PDF

Action Planned

Apple is adding special voice guidance for drivers heading past the A5 offramp toward the A5 onramp, instructing them to "Continue straight at the overpass" and then "Turn right onto A5 toward Milton Keynes, Bletchley." (AI summary)

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Dear ,

Thank you for your email providing Regulation 28 Preventing Future Death Reports which was passed to Apple’s privacy and law enforcement requests team for review. We immediately investigated the concerns raised and found no data or routing error on Maps which would have contributed to these tragic events.

However, to ensure we were following the very best approach we are taking an additional measure to add the following special voice guidance for drivers heading past the A5 offramp toward the A5 onramp, which we intend will be live by the start of next week.
- Drivers heading past the A5 offramp toward the A5 onramp would be instructed to "Continue straight at the overpass” (that will happen as they are traveling west toward the offramp).
- While on the overpass, drivers would be instructed to “Turn right onto A5 toward Milton Keynes, Bletchley."

We trust that the steps we are taking will be helpful to try to avoid any future such tragic events.

National Highways Other

PDF

Action Taken

National Highways installed temporary 'No Entry' signs, addressed sign interference, and is conducting CCTV monitoring to measure the effectiveness of the temporary layout. Feasibility work has been undertaken by external design consultants, to determine and recommend appropriate permanent changes at the junction. (AI summary)

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NATIONAL HIGHWAYS UPDATE TO CORONER (JUNE 2024)

THIS FURTHER RESPONSE IS BEING SENT TO:

The Assistant Coroner for the coroner area of Milton Keynes, Dr Sean Cummings, of Civic Offices, 1 Saxon Gate East, Milton Keynes MK9 3EJ to provide an update of the actions National Highways has taken and intends to take as committed to in our Regulation 29 response dated 14 February 2024 following the ‘Regulation 28 Report to Prevent Future Deaths’ issued before an inquest into the death of Amal Mohamed Ahmed.

1 DETAILS OF FURTHER ACTIONS TAKEN (since National Highways Regulation 29 response, dated 14 February 2024)

Additional temporary signing has been put in place at the exit point of the A5 off slip at the Little Brickhill junction in the form of two large 1200mm ‘No Entry’ signs on A-frames on each side of the carriageway (Traffic Signs Regulations and General Directions (TSRGD), Diagram 616 No entry for vehicular traffic). These signs are intended to provide mitigation against further wrong way driving incidents while a full safety review of the junction has been undertaken. Image 1 – Additional No-Entry signs installed on 07/12/2023. Existing fixed signs remained unchanged.

Interference with signs:

Following a site inspection on 24 April 2024, it was observed that the offside fixed (permanent) No-Entry sign had been rotated to face westwards (facing the Little Brickhill approach). This alteration had not been instructed or carried out by National Highways.

The result of this change meant neither of the fixed No-Entry signs were visible to drivers approaching the junction from the east (Woburn approach). To remedy this, the nearside sign was rotated to face westwards, see images below.

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Image 1 - Offside sign rotated (by unknown party/person(s)) – 24/04/2024 Image 2 - nearside sign rotated to the correct position on 26/04/2024

Image 3 - Offside sign before rotated – 07/12/2023 Image 4 - Offside sign after being rotated – 24/04/2024

Defacing/graffiti of the temporary signs

Following the installation of the additional temporary signs on 07 December 2023, regular inspections carried out identified that the signs have been defaced with graffiti on a number of occasions. The following extract of the inspection record details the date and details:

Date Time (approx.) Signs Present comments 22/04/2024 10:00 Sign damaged or graffitied Ringway attempting to source new sign faces 23/04/2024 09:40 Sign damaged or graffitied

24/04/2024 10:00 Both present and OK Ringway have removed the graffiti from the existing signage

3 25/04/2024 10:00 Both present and OK Ringway have installed a L2 closure and bought the no entry signs closer together (work carried out 24/04/2024) 29/04/2024 10:10 Both present and OK

01/05/2024 10:00 Both present and OK

03/05/2024 09:30 Sign damaged or graffitied Small scrawny white writing on the right-hand sign across the white section 03/05/2024 11:00 Sign damaged or graffitied 1 x wonky cone moved back out on longitudinal just after last 610 07/05/2024 09:30 Both present and OK 2 x cones out of placed - corrected under fix now 08/05/2024 10:00 Both present and OK

10/05/2024 11:00 Both present and OK

13/05/2024 11:00 Both present and OK

14/05/2024 10:00 Both present and OK Large number of lamps facing either left or right and batteries need checking - Ringway attended 15/05/2024 10:00 Both present and OK

17/05/2024 11:40 Both present and OK Large cone strike at beginning of taper and a few other cones out of place - Spoke to Ringway, they will send someone ASAP 20/05/2024 12:30 Both present and OK

22/05/2024 09:30 Both present and OK

24/05/2024 11:30 Both present and OK

29/05/2024 10:00 Both present and OK

28/05/2024 10:30 Sign damaged or graffitied Graffiti on one of the No Entry Signs. (Ringway) informed and arranging clean up today 31/05/2024 08:30 Both present and OK

03/06/2024 12:24 Both present and OK Photo supplied to Abi via WhatsApp 05/06/2024 10:00 Both present and OK Cone strike and use sat nav sign hanging - Ringway attended 07/06/2024 11:45 Both present and OK

10/06/2024 10:00 Sign damaged or graffitied Graffiti on both signs, reported to Ringway 12/06/2024 10:00 Both present and OK

14/06/2024 10:00 Both present and OK

17/06/2024 10:00 Both present and OK

4 19/06/2024 10:00 Both present and OK Some cones misaligned - emailed Ringway to attend 21/06/2024 09:15 Sign damaged or graffitied Graffiti on both signs, reported to Ringway 24/06/2024 11:20 Sign damaged or graffitied Graffiti on both signs, reported to Ringway

Further non-permanent enhancements

Further enhancements were made to the temporary signing layout following some additional reports of drivers attempting to turn into the slip road. These reports came from:

18 April 2024 – email received from local Councillor Tracey Bailey notifying us that reports had been made by residents directly to Cllr Bailey.

23 April 2024 – A Ringway operative (maintenance contractor for National Highways) carrying out maintenance to the No-Entry signs following an act of graffiti on the temporary signs.

These further changes involved closing the offside lane of the slip road to remove the potential ‘appearance’ of a two-way road. This also enabled the two large diameter No-Entry signs to be positioned closer together, see images below:

Image 5 - Additional measures at the slip road to mitigate right-turn manoeuvres.

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Image 6 - view of junction from the west (Woburn approach) Image 7 - view of junction from the east (Little Brickhill approach)

These works were undertaken on the night of the 24 April 2024. A daily inspection regime was put in place to monitor the signs and cones, and this is ongoing.

Abnormal Loads

The existing slip road includes a nearside overrun area. This is to cater for routing of Abnormal Loads. Whilst these temporary measures are in place, Network Occupancy teams are monitoring applications for abnormal loads to ensure changes can be made to the temporary works and replaced as required.

‘Do not follow Sat Nav’ signs

During the deployment of the non-permanent enhancements as detailed above, two vehicles were observed turning right into the slip road. On speaking to the driver of the second vehicle, the driver stated they were following Sat Nav instructions. At this time, the A5 carriageway was closed for routine drainage works so opposing traffic was not present.

Again, on the 29 April 2024, the location was visited by National Highways and Thames Valley Police (Traffic Management Officer). During the site visit, a vehicle was observed to attempt to turn right into the slip road against the No- Entry signing. The driver was flagged down and aborted the turn. On speaking to the driver, they said that the Sat Nav app said to turn right. This raised concerns that Sat Nav instructions may have been leading to driver confusion.

As a result, temporary signs displaying ‘Do not follow Sat Nav’ were deployed on site together with a customer information sign. These signs were installed on 07 May 2024, see images below.

6 Image 8 - sign installed on westbound approach to the slip road Image 9 - sign installed at the top of the slip road (left hand side)

Image 10 - sign installed at the top of the slip road (right hand side)

Sat Nav Routing

Investigations have been undertaken to understand the potential influence Sat Nav instructions are having on driver behaviour. Route drives were undertaken using various Sat Nav apps (Google Maps, Apple Maps and WAZE) to review route guidance given to drivers.

The key findings were:

1. There were no issues found where routing contravened no entry signs at the slip road.
2. Whilst all routing clearly indicates the correct route to be driven, an audible instruction is given to drivers coinciding with the top of the slip road.

As a result of these findings, contact was made with Google Maps (17 May

7
2024).

This is currently being investigated by Google Maps and we are awaiting further updates.

Further enquiries are being made with Apple Maps and WAZE.

As part of continued monitoring of the junction, we are planning to undertake CCTV monitoring, initially for 24hours a day for a period of 7 days, to measure the effectiveness of the temporary layout.

2 DEVELOPMENT OF PERMANENT WORKS

Following receipt of the Regulation 28 Report to Prevent future Deaths, we commissioned our external design consultant (WSP) to carry out feasibility work to determine and recommend appropriate permanent changes at the junction, including the following key activities:

1. Undertake Safety Risk Assessment of each engineering option as identified in the National Highways Safety Assessment Report.
2. Undertake appraisal effectiveness, cost and engineering difficulty of each engineering option as identified in the National Highways Safety Assessment Report.
3. Carry out TA 501 Road Lighting Appraisal (Design Manual for Roads and Bridges (DMRB)) of the study area to identify whether lighting is required.

Details of the external design consultants’ initial assessment and options were submitted to National Highways on 14 June 2024, and we are currently reviewing the outcomes and planning the next steps, which include:

1. Carry out workshop with the design consultants to review outcomes of Safety Risk Assessment and TA501 Road Lighting Appraisal to discuss and agree preferred option.
2. Produce outline preliminary design for preferred option, complete with Cost Estimate.
3. Prepare Stage 1 Road Safety Audit Brief.
4. Prepare Stage 1 Road Safety Audit Response Report.

Following completion of above actions, detailed design will be carried out and implementation programmed for the 2025/26 financial year.

During this period, temporary measures will remain in place, together with regular checks and inspections.

8 3 TIMETABLE FOR NEXT STEPS

DATE ACTION

Q2 2025 Programme implementation of enhanced mitigation measures

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25th June 2024 Signed:

, Head of Planning & Development on behalf of

Report sections

Investigation and inquest

On 21 November 2023 I commenced an investigation into the death of Tracey Julie HAYBITTLE aged 58. The investigation concluded at the end of the inquest on 16 July 2024. The conclusion of the inquest was that: Road traffic collision

Circumstances of the death

Tracey Julie Haybittle died at the John Radcliffe Hospital on the 17th November 2023. She had been driving along the A5 adjacent to the Little Brickhill junction. Another driver had mistakenly entered the "off" slip road believing it to be the correct turn. It appears she was following audio directions from her satnav application. She proceeded to drive down the slip road at speed and collided head on with Mrs Haybittle's vehicle. The other driver died at the scene and her female passenger was critically injured but survived.

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