Prevention of Future Deaths reports · 2021

Zahid Ahmed

Regulation 28 report to prevent future deaths, reference 2021-0062, written 3 Mar 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report3 Mar 2021
Reference2021-0062
DeceasedZahid Ahmed
CoronerTom Stoate
Coroner areaBedfordshire and Luton
CategoryRoad (Highways Safety) related deaths · Other related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

48515-2019 

Senior Coroner - Emma Whitting 
Bedfordshire & Luton  
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO:  

HIGHWAYS ENGLAND 

1 

CORONER 

I am Tom Stoate, Assistant Coroner for the area of Bedfordshire and Luton.  

2 

CORONER’S LEGAL POWERS 

I make this Report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 
and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 

3 

INVESTIGATION and INQUEST 

On 6 December 2019 I commenced an Investigation into the death of Mr Zahid Ahmed, 
aged 19. The investigation concluded at the end of the inquest on 14 January 2021.  

The conclusion of the inquest was Road Traffic Collision. 

4 

CIRCUMSTANCES OF THE DEATH 

On the afternoon of 1 December 2019, Zahid Ahmed (where relevant, “the deceased”), 
aged 19 years, was a passenger in the rear nearside passenger seat of a blue Kia Sedona 
multi-person vehicle with five other occupants.  

Whilst it was on the smart motorway at the M1 South Junction 11a, the Kia suffered a 
mechanical defect which caused it to lose power and the engine check light to 
illuminate on the instrument panel.  

The Kia exited the main carriageway and entered an Emergency Refuge Area (ERA), 
where it remained stationary for approximately 12 seconds. The Kia re-entered the 
main carriageway and, shortly after, its hazard lights were illuminated. The Kia then 
stopped in lane one, approximately 145m south of the ERA, a section operating as a 
running lane with no hard shoulder. Three other vehicles were able to avoid colliding 
with the Kia.  

At approximately 15:15 hours, a Polish registered black Scania R450 articulated heavy 
goods vehicle travelling at 56 MPH hit the rear of the Kia causing significant damage, 

##DW<<corAddress>> 
Tel ##DW<<corTel>>    |    Fax ##DW<<corFax>> 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 and causing Mr Ahmed multiple traumatic injuries. At 16:37 hours a paramedic 
examined the body of the deceased at the scene and confirmed his death.  

The road surface was good, and the weather conditions were cold but clear and dry. As 
the Kia was stationery and the parking brake applied, Mr Ahmed had probably removed 
his seatbelt (although I concluded in any event that a seatbelt would not have made 
any difference to the injuries he sustained).  

The driver of the Scania had a clear and unobstructed view, allowing him between 
approximately 8 and 10 seconds to identify and react to the presence of the Kia, and to 
use the road space and time available either to stop safely in lane one or to move into 
lane two in order to avoid the collision.  

The collision occurred primarily due to the failure of the Scania driver to perceive and 
respond to the presence of the Kia in enough time to avoid a collision, and also due to 
the presence of the Kia in a running lane of the motorway as no alternative was 
available to the driver after leaving the ERA. 

The cause of Mr Ahmed’s death was determined to be: 

Ia Multiple Traumatic Injuries 
Ib  
Ic  
II   

5 

CORONER’S CONCERNS 

During the course of the Inquest the evidence revealed matters giving rise to concern. 
In my opinion there is a risk that future deaths will occur unless action is taken. In the 
circumstances it is my statutory duty to report to you. 

The MATTERS OF CONCERN are as follows: 

1)  The stretch of the M1 motorway where this fatal collision occurred is part of the 
‘Managed Motorway’, which runs from Junction 13 to Junction 10. It features 
variable speed limits and, in places, an ‘actively managed hard shoulder’, which 
is a hard shoulder that in certain circumstances may be driven on. Variable 
speed limit and ‘hard shoulder running’ information is conveyed to drivers via 
electronic matrix signals message boards, and verge signs positioned along the 
Managed Motorway. These signals are controlled by operators within the 
Highways Agency Eastern Regional Control Centre (ERCC). At around 400m 
south of the Toddington Services southbound entry, the hard shoulder 
commences and is managed for a distance of around 1.1 km, before the 
motorway becomes designated ‘All Lanes Running’ (ALR) again around 500m 
north of Junction 11a. Travelling south from Junction 12, however, the 
motorway is ALR, and there is no hard shoulder.  

2)  Detective Constable 

, of the Bedfordshire Police Serious Collision 

Investigation Unit, gave evidence at Mr Ahmed’s inquest as follows: “The 

Bedfordshire and Luton Coroner Service 
Tel 0300 300 8383 | FAX  

 
 
 
 
 
 
 
 
 
 
 absence of a hard shoulder contributed to the collision. Had the [deceased’s] 
vehicle been able to stop in a location other that a live lane, the offending HGV 
would not have driven into the back of it”. 

3)  The vehicle in which the deceased was a passenger suffered a mechanical 

defect which caused it to lose power. It is not clear where the vehicle could 
have pulled to a halt in a safe place in these circumstances, given that there was 
no hard shoulder and all lanes were live. I consider that could create a risk of 
future deaths.  

6 

ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe you have 
the power to take such action.  

7 

YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, 
namely by 29 April 2021. I, the coroner, may extend the period. 

Your response must contain details of action taken or proposed to be taken, setting out 
the timetable for action. Otherwise you must explain why no action is proposed. 

8 

COPIES and PUBLICATION 

I have sent a copy of my report to the Chief Coroner and to the family of Mr Zahid 
Ahmed. I have also sent it to DC 
 of the Bedfordshire Police Serious 
Collision Investigation Unit who may find it useful or of interest. 

I am also under a duty to send the Chief Coroner a copy of your Response.  

The Chief Coroner may publish either or both in a complete or redacted or summary 
form. He may send a copy of this report to any person who he believes may find it 
useful or of interest. You may make representations to me, the coroner, at the time of 
your response, about the release or the publication of your response by the Chief 
Coroner. 

9 

Tom Stoate 
Assistant Coroner for the area of Bedfordshire and Luton  

Dated: 3 March 2021 

Bedfordshire and Luton Coroner Service 
Tel 0300 300 8383 | FAX

Responses

1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response from Highways England (PDF)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS RESPONSE IS BEING SENT TO: 

The Assistant Coroner for the Coroner Area of Bedfordshire and Luton, Mr 
Tom  Stoate  of  The  Court  House,  Woburn  Street,  Ampthill,  Bedfordshire, 
MK45  2HX  in  response  to  a  ‘Regulation  28  Report  to  Prevent  Future  Deaths’ 
following an inquest hearing into the death of Zahid Ahmed that concluded on 14 
January 2021. 

1  HIGHWAYS ENGLAND 

, Safety, Engineering and Standards Executive Director, and 
I am 
Chief Highways Engineer, responding on behalf of 
, Acting Chief 
Executive  of  Highways  England  Company  Limited  of  Bridge  House,  1  Walnut 
Tree Close, Guildford, Surrey, GU1 4LZ. 

Highways  England  did  not  fall  within  the  statutory  definition  of  an  Interested 
Person as contained at Section 47(2) of the Coroners and Justice Act 2009 and 
did not otherwise receive notification of the inquest hearing date or a request to 
attend the inquest. 

As such, we were not present at the hearing and had no prior awareness of the 
discussions  which  occurred  or  the  conclusions  that  were  reached.  We  were 
therefore  not  afforded  the  opportunity  to  provide  input  to  the  inquest  as  the 
highway authority. 

In complying with our duty, Highways England have responded within 56 days of 
the date of the Regulation 28 report to prevent future deaths, namely by 29 April 
2021.       

2  CORONER’S MATTERS OF CONCERN 

The MATTERS OF CONCERN were identified as follows: –  

1) The stretch of the M1 motorway where this fatal collision occurred is part of 
the ‘Managed Motorway’, which runs from Junction 13 to Junction 10. It features 
variable speed limits and, in places, an ‘actively managed hard shoulder’, which 
is a hard shoulder that in certain circumstances may be driven on. Variable speed 
limit and ‘hard shoulder running’ information is conveyed to drivers via electronic 
matrix signals message boards, and verge signs positioned along the Managed 
Motorway.  These  signals  are  controlled  by  operators  within  the  Highways 
Agency Eastern Regional Control Centre (ERCC). At around 400m south of the 
Toddington  Services  southbound  entry,  the  hard  shoulder  commences  and  is 
managed  for  a  distance  of  around  1.1  km,  before  the  motorway  becomes 
designated ‘All Lanes Running’ (ALR) again around 500m north of Junction 11a. 
Travelling south from Junction 12, however, the motorway is ALR, and there is 
no hard shoulder.  

2)  Detective  Constable 
,  of  the  Bedfordshire  Police  Serious 
Collision  Investigation  Unit,  gave  evidence  at  Mr  Ahmed’s  inquest  as  follows: 
“The  absence  of  a  hard  shoulder  contributed  to  the  collision.  Had  the 
[deceased’s]  vehicle  been  able to  stop  in a  location  other that  a live lane, the 
offending HGV would not have driven into the back of it”.  

1 

 
 
 
 
 
 
 
 
 
 
 
 
 3) The vehicle in which the deceased was a passenger suffered a mechanical 
defect which caused it to lose power. It is not clear where the vehicle could have 
pulled to a halt in a safe place in these circumstances, given that there was no 
hard shoulder and all lanes were live. 

3  DETAILS OF ACTION TAKEN 

Highways England is the Government-owned company charged with operating, 
improving England's  motorways  and  major  A-roads.  
maintaining  and 
Responsibility  for  the  road  network  in  other  parts  of  the  UK  rests  with  the 
devolved administrations.  This response accordingly addresses the position in 
England. 

The introduction and continuing roll-out and development of smart motorways in 
England  has  been  Government  policy  since  2008.    Smart  motorways  provide 
substantially  more  road  capacity  than  conventional  motorways.  In  the  face  of 
increased traffic volumes, they reduce congestion, congestion related incidents 
and allow faster and more reliable journeys, without the greater disruption, cost 
and environmental impacts of conventional road widening.  At the same time, the 
Government’s  Stocktake  demonstrates  that  smart  motorways  have  improved 
overall safety compared to the conventional motorways they have replaced. But 
not in every way, hence we are taking forward an Action Plan to further improve 
safety. 

Safety is Highways England’s top priority.  According to the 2019 performance 
report published by CEDR (Conférence Européenne des Directeurs des Routes 
/  Conference  of  European  Directors  of  Roads),  motorways  in  the  UK  have  by 
some margin the lowest rate of fatal accidents of any roads in Europe1, in terms 
of fatality rates, smart motorways are the safest roads in the country. 

The  design  standard 
following  a 
comprehensive safety assessment and hazard analysis which demonstrated that 
they would be at least as safe as, or safer, than the conventional motorways they 
replaced. 

for  smart  motorways  was  adopted 

Each smart motorway scheme must also meet this same strict test: to be at least 
as safe as, or safer than, the conventional motorway it replaced. We carefully 
monitor all schemes after delivery to ensure that this standard is met in all cases. 

Smart  motorways  incorporate  a  number  of  important  features  designed  to 
improve the safety of people using them.  These include technology to monitor 
traffic flow, set variable speed limits to ease congestion, and give information to 
drivers, such as closing lanes via Red ‘X’. And smart motorways are safe, with 
the number of fatalities low given the volume of traffic using them. 

However, risk cannot be eliminated entirely from roads.  Hard shoulders do not 
eliminate  the  risk  of  collision  and,  indeed,  8%  (or  1  in  12)  of  all  deaths  on 
motorways  are  on  hard  shoulders.  The  specific  risk  posed  by  the  absence  of 
hard shoulders on all lane running smart motorways, and in particular the greater 
risk  of  collision  between  stationary  and  moving  vehicles  has  been  recognised 
throughout.   But that specific  increased  risk  is  outweighed by  the  reduction  in 

1 https://www.cedr.eu/download/Publications/2020/CEDR-Technical-Report-2020-01-
TEN-T-2019-Performance-Report.pdf 

2 

 
 
 
 
 
 
 
 
 
                                                 
 other risks brought about by all lane running  smart motorways.  The evidence 
has demonstrated that all lane running smart motorways lead to fewer, not more, 
deaths. 

All  lane  running  schemes  are  designed  to,  and  do,  operate  safely  without  the 
need for radar stopped vehicle detection (SVD) technology.  But SVD systems 
can make all lane running smart motorways safer still, by automatically detecting 
stopped  vehicles  on  the  carriageway  and  thereby  enabling  a  more  rapid 
response.  In 2013 the Highways Agency identified an automated SVD system 
to further reduce the risks of vehicles stopped in live lanes, and this was trialled 
between 2014 and 2016.  Following successful trials, in September 2016 it was 
decided  that  SVD  would  be  included  as  standard  in  all  new  all  lane  running 
schemes entering the design stage. The standard requires a coverage of at least 
95%  of  the  carriageway,  with  a  minimum  detection  accuracy  of  80%  and  a 
maximum time to alert an operator of 30 seconds. 

Action  will  now  be  taken  to  retrofit  SVD  to  all  existing  all  lane  running  smart 
motorways.  This  is  an  ambitious,  highly  engaged  and  complex  programme, 
which the Government and Highways England have committed to completing by 
the end of September 2022.  

In October 2019, the Secretary of State for Transport asked his department to 
review the safety evidence in relation to smart motorways.  In March 2020, the 
Department  for  Transport  (DfT)  published  an  Evidence  Stocktake  and  Action 
Plan for Smart Motorway Safety. The Action Plan set out 18 measures to make 
smart motorways even safer than they  already are, and to tackle the negative 
public perception of, and build public confidence in their safety.  

We have recently published our Smart motorways stocktake first year progress 
report 2021. This sets out our progress in delivering the March 2020 Action Plan, 
the latest evidence on the safety of smart motorways, and commitments we are 
making to accelerate measures to further help drivers feel safe and be safer on 
smart motorways. 

Highways England, working in partnership with the DfT and other stakeholders, 
has made and continues to make good progress in delivering on the Action Plan.   
In the 12 months since the Stocktake and Action Plan were published: 

•  We  have  progressed  our  commitment  to  end  the  use  of  dynamic  hard 
shoulders by March 2025.  At the time of this response, 7 schemes are 
at the preliminary design and survey stage. 

•  We are progressing our commitment to install SVD technology on every 
all lane running smart motorway. We have so far trialled SVD on the M25 
junctions 5-6 and junctions 23-27 (which covers all 25 miles of all lane 
running on the M25). The technology is currently being commissioned on 
the  M3  Junctions  2  to  4a  and  M20  Junctions  3  to  5.  Work  on  the  M1 
Junctions 32 to 35a started in February 2021. We have also completed 
the  design  stages  on  three  further  schemes.  In  addition,  we  have 
completed a large-scale trial of a system that analyses CCTV images to 
identify stopped vehicles on the M4 junctions 19-20. 

•  We  are  on  target  to deliver  the  roll-out  of  changes  to  our  traffic  officer 
patrols to increase traffic officer presence on smart motorway sections, 
where the average distance between places to stop in an emergency is 
more than one mile. This supports the aim, by July 2021, to reduce the 

3 

 
 
 
 
 
 
 
 average  time  it  takes  traffic  officers  to  attend  incidents  from  17  to  10 
minutes.   

•  We have published a new design standard for the provision of places to 
stop in an emergency.  The new design standard (GD 301), which applies 
to all schemes entering the design stage, means that a place of relative 
safety will be spaced at ¾ miles apart, with a maximum of one mile where 
¾ mile spacing is not feasible2 

•  We  have  installed  10  additional  emergency  areas  on  the  M25  and  we 
have begun a programme to monitor their impact on live lane breakdown 
rates to understand if they have reduced the level of live lane stops 
•  We are developing delivery programmes for additional safety measures 
for the M6 Bromford viaduct and four sections of the M1 (including the 
location  of  this  incident).  To  inform  this  programme  we  commissioned 
independent reports and have undertaken feasibility studies of potential 
additional measures. The measure details are included in the “Details of 
further action proposed” section of this response  

•  We have upgraded all existing emergency areas on smart motorways to 

have bright orange surfacing and marked stopping areas.  

•  We have completed initial surveys in readiness for installing more signs 
in between places to stop in an emergency.  We expect to install around 
1,000 new signs. 

•  We  have  continued  to  run  public  information  campaigns  focusing  on 
specific  elements  of  motorway  driving.    In  2020 these  included  activity 
urging drivers not to drive in lanes closed by Red ‘X’ signs, to adhere to 
variable  speed  limits  and  to  keep  left  (February/March);  a  summer 
campaign encouraging drivers going on holiday or day trips to check their 
vehicles  before  setting  out, 
the  risk  of  breakdowns 
(July/August); and a campaign discouraging tailgating, a factor in around 
1 
in  8  casualties  on  England’s  motorways  and  major  A-roads 
(September/October).   

to  reduce 

•  We have also committed an additional £5 million this year on a campaign 
to improve driver awareness further.  On 10 March 2021 we launched a 
national  targeted  campaign  to  increase  road  user  confidence  and 
awareness of what to do in the event of a breakdown.  This included TV 
advertisement, additional short films, and print and digital advertising to 
ensure  maximum  reach  amongst  the  target  audience.  The  campaign 
launch was subject to changes in Government travel guidance and was 
accordingly postponed from January 2021.  Key messages conveyed by 
the campaign includes: 

The advice to drivers who experience a problem with their vehicle is to leave the 
motorway if possible. But if that is not possible Highways England recommends 
the 
found  on  our  website  here: 
https://highwaysengland.co.uk/road-safety/breakdowns/ 

following,  which  can  also  be 

2 with some exceptions where not feasible to construct additional emergency areas, such as 
where junctions intersect or on bridges   

4 

 
 
 
 
 
 
 
 
                                                 
 If your vehicle has a problem, or you get into trouble on a motorway, stay calm 
and try to exit at the next junction or motorway service area. If that’s not possible: 

Go left  

o  put your left indicator on and move into an emergency area, onto 
a  hard  shoulder, motorway  service  area, left-hand  verge  or  A-
road lay-by.   

o  switch your hazard warning lights on, even during the day. If it’s 

dark, use side lights and in poor visibility use fog lights as well    

o  on a motorway without a hard shoulder, it should be possible for 
most  vehicles experiencing  a  problem  to  reach an  emergency 
area. These  are  spaced regularly, and are  marked  by  a  clearly 
visible  orange  road  surface  and blue  signs  featuring  an  orange 
SOS telephone symbol.   

Get safe   
o 

if it is safe to do so, and you can get out with any passengers, 
exit your vehicle on the side furthest from traffic. If it is not safe 
to do so, stay in your vehicle and wait for help. 

o  keep  well  away  from  moving  traffic and  your  own  vehicle.  Get 
behind a safety barrier where there is one, and where it is safe to 
do so. If you’re on a verge, be aware of any unseen hazards such 
as uneven ground or debris.   

Get help  

o  contact  Highways  England  on  0300  123  5000  and  then  a 

o 

breakdown recovery provider.   
if you are unable to exit your vehicle and get to a safe place, have 
stopped in a live traffic lane or feel your life is in danger, stay in 
your vehicle with your seatbelts and hazard lights on and call 999 
immediately.  

The  Highways  England  website  also  includes  information  on  how  to  drive  on 
motorways: 
https://highwaysengland.co.uk/road-safety/how-to-drive-on-
motorways/ 

•  We have begun rolling out automated “report of obstruction” messages 
on signals when SVD technology identifies a potential incident. “Report 
of  obstruction”  messages  were  enabled  on  the  M3  junctions  2-4a  in 
December 2020. 
In  March  2021,  we  made  location  information  for  all  smart  motorway 
emergency areas available to satnav providers 

• 

•  We  have  engaged  with  car  manufacturers  to  help  build  greater 
awareness of eCall (SOS, which has been fitted to new cars as standard 
from April 2018) and bCall (roadside assistance) functions in newer cars.  
•  We  have  begun  to  upgrade  HADECS  enforcement  cameras  and 
associated  technology  to  provide  automated  detection  to  facilitate  the 
enforcement  of  Red  ‘X’  violations  across  the  whole  smart  motorway 
network.  As at the date of this response we have upgraded 39% of all 
cameras.  The Road Traffic Offenders (Prescribed Devices) Order 2019 
came into force on 10 June 2019 to enable recordings to be used in the 
enforcement of Red 'X' violations (3 points, £100 fine). 

•  We have drafted new provisions for The Highway Code to provide more 
guidance  for  motorists  driving  on  high-speed  roads,  including  smart 

5 

 
  
 
 
 
 
 motorways.  A  4-week  consultation  on  these  proposed  amendments 
commenced in early March 2021 and finished end of March 2021.  
•  We  have  signed  a  strategic  partnership  agreement  to  strengthen  our 
relationship  with  the  independent  recovery  industry,  setting  out  a 
common and agreed set of safe operating procedures for use across the 
industry  when  helping  road  users  who  get  into  difficulty  on  smart 
motorways. 

•  We  have  commissioned  an  independent  review  of  the  widths  of 
operational  emergency  areas.    This  found  that  13  were  less  than  4.4 
metres wide, but that all 13 are wider than the 3.3 metre width of a hard 
shoulder. We are now working on completing safety risk assessments to 
help guide our next steps for widening any narrow emergency areas.  
•  The  Department  for  Transport  has  completed  its  review  of  existing 
evidence relating to the use of red flashing lamps. Ministers have agreed 
to implement off-road trials to understand the likely impact of allowing the 
use of red flashing lamps for road recovery operators, and to work with 
the  recovery  industry  to  promote  best  working  practices  and  develop 
specific industry guidance on vehicle lighting. 

On 26 February 2021, the Transport Select Committee publicly announced that 
it would conduct an inquiry into the roll-out and safety of smart motorways, with 
a particular focus on: 

•  The benefits of smart motorways, for instance to reduce congestion on 

busy sections of motorway, and how necessary they are 

•  The  safety  of  smart  motorways,  the  adequacy  of  safety  measures  in 

place and how safety could be improved 

•  Whether all lane running motorways are the most suitable type of smart 

motorway 

•  Public confidence in smart motorways and how this could be improved 
•  The impact of smart motorways on the usage and safety of other roads 

in the strategic road network 

•  The  effectiveness  of  Highways  England’s  delivery  of  the  smart 
motorways programme, the impact of construction works, and the costs 
of implementation 

Highways  England  welcomes  this  inquiry,  and  is  committed  to  assisting  the 
Committee in whatever way it can. 

Highways England has also previously attended two previous smart motorway 
Transport Select Committees in 2016 and 2019.  

4  DETAILS OF FURTHER ACTION PROPOSED 

Highways  England  is  committed  to  ensuring  that  all  roads  for  which  it  is 
responsible remain safe and, indeed, to continuing to make them safer still.  As 
part of this, it will continue to deliver on the Smart motorway evidence stocktake 
and action plan.  One year on from its publication we have made good progress 
and we will continue with this important programme of work. 

We have published our Smart motorways stocktake First year progress report 
2021 which sets out our progress in delivering the March 2020 Action Plan, the 
latest  evidence  on  the  safety  of  smart  motorways,  and  commitments  we  are 

6 

 
 
 
 
 
 
 
 
 making to accelerate measures to further help drivers feel safe and be safer on 
smart motorways. 

•  As noted above, we are developing delivery programmes for additional 
safety measures for the M6 Bromford viaduct and four sections of the M1 
including the location of this incident. We intend to publish the findings of 
our safety reviews in June 2021. 

•  We will end the use of dynamic hard shoulder motorways by March 2025 
by  converting  the  current  63  miles  of  dynamic  hard  shoulder  into  a 
permanent  traffic  lane  providing  greater  consistency  for  motorists  and 
reducing the potential for confusion.  

•  We will continue to retrofit SVD to all existing all lane running motorways 
and will complete this programme by the end of September 2022. This is 
six months earlier than the 2020 Action Plan commitment. We have also 
made a new commitment that all new schemes will have SVD technology 
installed  before  they  open,  including  the  six  schemes  currently  in 
construction.  

•  We will continue with our programme to increase traffic officer presence 
on smart motorways, where the average distance between places to stop 
in an emergency is more than one mile, and reduce the attendance times. 
•  We  will  continue  to  ensure  that  all  newly  designed  smart  motorways 
starting  design  from  November  2020  conform  to  the  new  design 
standard,  including  in  relation  to  the  spacing  of  places  to  stop  in  an 
emergency. 

•  We will continue to monitor and assess the evidence relating to live lane 
breakdowns,  and  to  safety  on  smart  motorways  in  general,  and  make 
necessary design changes (including increasing the frequency of places 
to stop) if the evidence supports it. In the 2020 Action Plan we committed 
to complete the M25 monitoring period by 31 December 2021. We have 
accelerated this commitment to complete the monitoring and present a 
report to the Department for Transport by the end of August 2021. 

•  We  will  complete  our  programme  of  installing  more  signs  in  between 
places to stop in an emergency by September 2022, six months earlier 
than the 2020 Action Plan commitment. 

•  We will continue to invest to improve driver awareness.   
•  We will we will work with the DfT to review whether the emergency area 
data we made available to satnav providers is being shared with drivers. 
•  We will continue to work with stakeholders to agree the key messages 
for a public information campaign focusing on the use of eCall (SOS) and 
bCall (breakdown assistance) buttons in vehicles which will run later in 
2021. 

•  We will, in partnership with the DfT, publish the updated Highway Code 

by Autumn 2021.  

•  We will continue rolling out changes to automate “report of obstruction” 
messages on variable message signs when SVD technology identifies a 
stopped vehicle. 

•  We  will  complete,  by  September  2022,  our  programme  to  upgrade 
HADECS  enforcement  cameras  and  associated  technology  to  provide 
automated  detection  to  facilitate  the  enforcement  of  Red  ‘X’  violations 
across the whole smart motorway network. 

•  We will complete our programme to widen emergency areas which are 

narrower than the current standard.  

7 

 
 
 
 
 5  TIMETABLE FOR ACTION 

Future Action 
Publish the findings of our safety reviews for the M6 J5-6 
and M1 J10-13, J30-35, and J39-42. 
Implement action plans to reduce Traffic Officer 
attendance time from an average of 17 minutes to 10 
minutes. 

Date 

June 2021 

July 2021 

Update of The Highway Code 

Complete the monitoring of live lane breakdowns on the 
M25 after the installation of 10 new emergency areas. 
Deliver a public information campaign communicating 
the benefits of eCall and bCall functions to road users 
More communication with drivers – second run of 
campaign launched in March 2021. 
Consider a national programme of retrofitting additional 
emergency areas on existing smart motorways where 
places to stop in an emergency are more than one mile 
apart 

Autumn 2021 

August 2021 

Autumn 2021 

November 2021 

April 2022 

Complete national rollout of SVD on existing ALR 
sections 

September 2022 

Install additional traffic signs giving the distance to the 
next place to stop in an emergency 

September 2022 

Complete the upgrade of HADECS3 cameras to enforce 
Red ‘X’ compliance 

September 2022  

Automate the display of ‘report of obstruction’ messages   March 2023 

End the use of dynamic hard shoulders. 

March 2025 

Work with the DfT to review whether the emergency area 
data we made available to satnav providers is being 
shared with drivers 

Ongoing 

6  SAFETY OF ROAD USERS 

Every road death is a tragic loss of life. We are determined to reduce the number 
of fatal incidents, and injuries, on our roads and we want everyone who travels 
or works on any of our roads to feel confident and safe. 

risk-free 
Although  roads,  especially  high-speed 
environments, our absolute priority is the reduction of road deaths and injuries 
on our network.  

roads,  can  never  be 

This is why we invest in road safety initiatives and public awareness campaigns, 
to  help  prevent  death  and  injury  and  to  help  give  drivers  the  information  they 
need, to have safe journeys. This is in addition to information provided in other 
areas, for example The Highway Code. 

The Smart Motorway Safety Evidence Stocktake and Action Plan published by 
the Government in March 2020 set out 18 measures to improve safety and build 

8 

 
 
 
 
 
 
 
 greater public confidence in smart motorways. We welcomed the stocktake and 
action plan as an opportunity to further improve the safety of smart motorways.  

We are constantly listening to motorists, continually assessing how we can make 
motorways safer for those who use them.  

We urge road users to act safely and sensibly, including by informing themselves 
about what to do in an emergency3, who to contact, and how to avoid dangerous 
situations where possible, thereby minimising the risks to themselves and other 
road users.  We have recently launched our biggest ever, high profile multi-media 
road safety campaign to help drivers know what to do if they break down on any 
motorway, including one without a hard shoulder. 

Respectfully,  we  would  ask  that  coroners  use  the  means  at  their  disposal  to 
reinforce  this  message  as  appropriate.    I  have  previously  written  to  the  Chief 
Coroner to make this request of coroners. 

Regarding  this  tragic  incident,  we  note  from  the  Police  Forensic  Collision 
Investigation report that the vehicle which was struck, a Kia,  suffered a defect 
which  caused  it  to  lose  power  and  the  engine  check  light  to  illuminate  on  the 
instrument panel.  

The  driver  was  able  to  exit  the  main  carriageway  and  entered  an  emergency 
area.  At this point the driver should have contacted Highways England for advice 
via  the  emergency  telephone  provided  before  re-joining  the  carriageway.  He 
could have also contacted a breakdown recovery service for assistance. 

The Kia remained stationary in the emergency area for 12 seconds and then re-
entered the main carriageway. Shortly after, the Kia stopped in lane one, 145m 
south of the emergency area. It was struck by a Scania HGV approximately one 
minute later.   

, the driver of the Scania HGV, received a 46-month 
We note that 
custodial  sentence  for  causing  death  by  dangerous  driving  and  for  causing 
serious injury by dangerous driving. In addition, he was disqualified from driving 
for a lengthy period.   

We  want  to  prevent  further  tragedies. We  have  listed  earlier  in this  report  the 
measures we have taken since the publication of the stocktake. We believe our 
actions are having an effect and will continue to make a difference.  

Independent analysis provided by Transport Focus from the National Road 
User Satisfaction Survey over the period 2014/15 to 2019/20 demonstrated 
year-on-year improvements in the awareness of: 

•  Emergency areas (58% in 2019/20 compared to 36% in 2014/15); 
•  Use of the hard shoulder as an extra lane during busy times (74% in 

2019/20 compared to 64% in 2014/15); 

3  The  Highways  England  website  provides  guidance  on  what  to  do  in  case  of  a 
breakdown on any motorway: https://highwaysengland.co.uk/road-safety/breakdowns/ 

9 

 
 
 
 
 
 
 
 
 
 
 
                                                 
 
 •  Understanding when there is no hard shoulder when it permanently 
converts to a traffic lane (64% in 2019/20 compared to 39% in 
2014/15).  

But  we  are  not  complacent.  The  death  of  Mr  Ahmed  was  tragic.  Our  deepest 
sympathies remain with his loved ones. We also extend our sympathies to the 
driver and other passengers in the vehicle for the injuries they sustained.  

We remain committed to improving communication with road users and to taking 
steps to further improve the safety of smart motorways. 

8 

29 April 2021                Signed:  

, Safety, Engineering and Standards 

Executive Director and Chief Highways Engineer, 
on behalf of Nick Harris, Acting Chief Executive of 
Highways England 

10

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