Source · Prevention of Future Deaths

Barbara Henderson

Ref: 2019-0180 Date: 30 May 2019 Coroner: Tom Osborne Area: Milton Keynes Responses identified: 1 / 1 View PDF

Road inspections conducted at speed failed to identify a critical drain problem, indicating an inadequate inspection process that needs urgent review.

Date 30 May 2019

56-day deadline 24 Jul 2019

Responses identified 1 of 1

Road (Highways Safety) related deaths

Coroner's concerns

AI summary

Road inspections conducted at speed failed to identify a critical drain problem, indicating an inadequate inspection process that needs urgent review.

View full coroner's concerns

The MATTERS OF CONCERNS are as follows: During the course of the evidence I heard how the roads are examined and monitored on a regular basis but that such inspections are conducted at speed and that the process failed to identify the problem with this particular drain on the A5. I believe that the process for inspection should be reviewed.

Responses

1 respondent

National Highways Other

23 Jul 2019 PDF

Action Planned

Highways England will issue a memorandum to all Areas highlighting the importance of inspection and defect rectification for recessed gullies. Area 8 will move to the new Asset Delivery approach on 1st October 2019. (AI summary)

View full response

Dear Mr Osborne, Regulation 28 Report into the death of Susan HENDERSON and Margaret SHAW On behalf of of Highways England Company Limited, please find attached the Highways England response to the Regulation 28 Report dated 30 May 2019 following the deaths of Susan Henderson and Margaret Shaw. We will also post a hard copy to the Milton Keynes Coroner’s Office in Saxon Gate East, Milton Keynes.

Report sections

Investigation and inquest

On 3rd September 2018 I commenced an investigation into the deaths of Susan Barbara HENDERSON aged 36 years and Margaret Louise SHAW aged 53 years. The investigation concluded at the end of the inquest on 5th April 2019. The conclusion of the inquest was that the drivers had died from multiple injuries and part of the narrative conclusion was that: The standing water had accumulated due to blocked gullies on the side of the road that had not previously been identified on routine inspection.

Circumstances of the death

Susan and Margaret died on the A5, Milton Keynes when one car aquaplaned across the road into the path of an oncoming vehicle. Both drivers died at the scene as a result of their injuries.

Similar PFD reports

Shared signals

Report details

Reference: 2019-0180
Date of report: 30 May 2019
Coroner: Tom Osborne
Coroner area: Milton Keynes

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: 24 Jul 2019.

Sent to

Highways England

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.