Source · Prevention of Future Deaths

Heike Mojay-Sinclare

Ref: 2021-0313 Date: 17 Sep 2021 Coroner: Peter Nieto Area: Derby and Derbyshire Responses identified: 1 / 1 View PDF

Lack of mandatory standards and inspection for river ford depth gauges, combined with poor inter-agency information sharing on previous incidents, creates significant safety risks, especially with increasing severe rainfall.

Date 17 Sep 2021
56-day deadline 12 Nov 2021
Responses identified 1 of 1
Other related deaths Road (Highways Safety) related deaths

Coroner's concerns

AI summary
Lack of mandatory standards and inspection for river ford depth gauges, combined with poor inter-agency information sharing on previous incidents, creates significant safety risks, especially with increasing severe rainfall.
View full coroner's concerns
The MATTERS OF CONCERNS are as follows: 1. The inquest heard that with regard to water depth gauges, specifically for river fords, the Traffic Signs and General Directions 2016 removed prescription of the type of signs to be used and the requirement for their use at river ford crossings. Those requirements were in the previous 2002 Directions. There s relevant guidance (Ch.4 Traffic Signs Manual) but this is not mandatory and leaves enactment to the discretion of the relevant local authority. As water depth gauges are outside of the regulatory regime there may be fords without gauges, or where they are installed they may be sub-optimal and deficient. There is also lack of clarity for local authorities and the lack of a prescribed design and standard means that manufacturers do not have an approved design to work to and provide to local authorities.
2. The inquest heard that river fords and depth gauges do not currently lie within mandatory highways inspection requirements and therefore there is no guarantee of their maintenance and review, and therefore no guarantee that they continue to provide on-going usability and safety.
3. The inquest heard that there were a number of previous serious incidents which it appears were not notified to the relevant local authority, and that if they had been there would likely have been a review of measures relating to the river ford. A mandatory requirement for inter-agency information sharing in these circumstances is indicated. Please note that these concerns are raised within the context of what appear to be increasingly frequent severe rainfall and flooding events.

Responses

1 respondent
Dpeartment for Transport Central Government
18 Nov 2021 PDF
Noted

The Department for Transport clarified that local authorities are responsible for hazard signage and highway maintenance, and that existing guidance is available but not mandatory. (AI summary)

View full response
Dear Peter, Thank you for your letter of 20 September 2021 and the accompanying report into the fatal accident near Ashbourne in Derbyshire. was deeply saddened to learn of the death of Mrs Mojay-Sinclare. You raised a number of concerns in your letter which have addressed below. 1, With regard to signing; | should first clarify that it is the responsibility of local authorities t0 ensure hazards on their network are identified and appropriately signed to warn drivers Traffic signs warning of a ford ahead are prescribed in the Traffic Signs Regulations and General Directions 2016, and available for local authorities to use without reference to the Department: Advice on their use is given in Chapter 4 of the Traffic Signs Manual 2 The water depth gauge was prescribed in the Traffic Signs Regulations and General Directions 2002, but the decision to place them at any site would have still been at the discretion of the local authority. Their use was not mandated by this Department. There is relevant guidance on the use of the water depth gauge in Chapter 4 of the Traffic Signs Manual, including a diagram showing dimensions and appearance which can be used by manufacturers. should stress that is guidance issued by the Department as "good practice guidance" and provides local authorities advice on working practices which can choose to adopt or choose to ignore Local authorities do not have to conform to good practice guidance; good they

however the Department believes that conformance to the guidance is desirable. 3 With regards to highways inspection requirements , local highway authorities have a duty, under section 41 of the Highways Act 1980,to maintain the highway network in their area The Act does not set out specific standards of maintenance; as it is for each individual local highway authority to assess which parts of its network are in need of repair and what standards should be applied, based upon their local knowledge and circumstances. The Government has no powers to override local decisions in these matters or intervene in these kinds of local issues: That said the Government does support the Code of Practice on Well- Managed Highway Infrastructure and this publication provides advice to highway authorities on a number of issues, including inspections of the highway: This free document is available at the following link:

4_ appreciate that there were a number of previous incidents at this ford that the local highway authority was not made aware of, but am afraid cannot comment on the why this might have happened. While service agreements are often in place between forces and local authorities there are no existing requirements for this to take place. The sharing of information locally is a matter for local agencies. You may wish to consider bringing this matter to the attention of your Local Resilience Forum hope this response has explained my thinking on why do not believe there are any actions necessary from the Department. am afraid the concerns that you have raised are issues where the decision to act rests with the local authority, and there are tools available to them already to enable them to do SO_

Report sections

Investigation and inquest
On 10/12/2018 I commenced an investigation into the death of Heike MOJAY-SINCLARE aged 29. The investigation concluded at the end of the inquest on 16 September 2021. The conclusion of the inquest was: I a Drowning I b I c
Copies sent to
2. Derbyshire County Council 1. Derbyshire Fire and Rescue Service2. Derbyshire Police

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Report details

Reference
2021-0313
Date of report
17 September 2021
Coroner
Peter Nieto
Coroner area
Derby and Derbyshire

Responses identified

Responses identified 1 of 1
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 12 Nov 2021.

Sent to

Department for Transport

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