Wilfred Breakell

Transport and Engineering  
Town Hall Annexe 
St Stephen’s Road 
Bournemouth BH2 6EA 

Mr Brendan J Allen 

Date 13 July 2021 

HM Acting Area Coroner 

The Coroner’s Office 

Bournemouth Town Hall 

Bournemouth BH2 6DY 

: 

Dear Mr Allen,  

Regulation 28 Report – Wilfred Roy Breakell 

Thank  you  for  your  letter  of  21  May  2021  and  the  accompanying  Regulation  28  Report,  in 
connection with the Inquest on 12 May 2021 relating to the death of Mr Wilfred Roy Breakell 
that occurred at the Blackwater Traffic Signal Junction on 17 May 2020.  

BCP Council has undertaken its own investigation into the circumstances of this unfortunate 
incident.  We  have  reviewed  the  audio  recording  of  the  Inquest  which  your  offices  kindly 
supplied  to  us. We  have  also  discussed the  findings  of the  inquest  and  your  Regulation  28 
Report with senior officers of BCP Council, and would respond as follows. 

The incident concerned is not recorded as a fatal road traffic accident on the Dorset Police 
collision  database.  It  is  appreciated  that  Police  reports  focus  on  the  cause  of  the  accident 
rather than the immediate cause of death but these reports hold information which is relevant 
to the Council’s reporting requirements and I have outlined this below.  

The Dorset Police Data Team’s view that the cause of Mr Breakell’s fall into the storm drain 
could not be established. In arriving at this decision the Data Team considered the report of 
the  Police  Officer  in  Charge  of  investigating  the  incident  who  reported  that  “The  working 
hypothesis was he (Mr Breakell) was taken ill on his bike, has mounted the verge, travelled a 
short distance before falling into the ditch. All available evidence pointed towards this being a 
medical episode”. This was based on the ambulance crew’s initial opinion expressed whilst the 
Police Officer was on the scene that the incident was as a result of a medical episode. 

The Dorset Police Data Team therefore concluded that while the cause of death was injuries 
sustained in the fall, the cause of the collision was most likely a medical episode. Therefore 
this would not fall under the Stats 19 requirements to report the incident to the Department for 
Transport as a Road Traffic Accident. This means BCP Council are responding to a Regulation 
28 Report for an incident which we do not have recorded as a fatal road traffic accident. 

In addition to this it is not clear in which direction Mr Breakell was travelling before he fell into 
the ditch. In their statement read out at the Inquest the family of Mr Breakell indicated that he 

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was most likely negotiating the traffic signal Toucan facility across the mouth of the junction 
(i.e. cycling from east to west). They further indicated that Mr Breakell then failed to negotiate 
a 90 degree right turn when reaching the east side of the Toucan crossing, surmising that this 
was either because the pavement was too narrow here, causing him to end up in the ditch or 
there was no physical barrier to prevent him from doing so. 

  statement  given  to  the  Inquest  he  reported  that  there  was  physical 
In  PC 
evidence indicating that Mr Breakell may have been riding up the ‘off’ slip road of the A338 
Spur Road before leaving the road just short of the paved area of the shared footway/cycleway 
and then ending up in the storm drain which runs parallel with the off slip road. PC 
 also 
confirmed that there was evidence of damage to Mr Breakell’s cycle helmet resulting from the 
crash and no evidence of another person or vehicle being involved in the incident. 

I am aware that following what happened on the morning of Sunday 17 May 2020 you remain 
concerned that there is a risk that future deaths will occur, unless action is taken to extend the 
existing timber post and rail fencing along the slip road to prevent cyclists falling into the storm 
drain. 

The A338 Blackwater Junction Improvements were completed in April 2020 and it was a project 
delivered  jointly  by  Dorset  and  BCP  Councils.  The  storm  drain  in  question  is  designed  to 
receive surface water runoff from the slip road through a series of road gullies situated against 
the  kerb  line.  The  scheme  involved  clearing  the  storm  drain  of  vegetation  and,  to  prevent 
surface water runoff from eroding its banks, concrete slabs were placed at intervals along the 
back of the storm drain, coinciding with each gully location. 

The engineers involved in delivering the original scheme have indicated that the original design 
did not include for any fencing at this crossing point adjacent to the ditch. They have stated 
that following a reported safety concern here, a temporary barrier was initially erected and then 
a  permanent  timber  post  and  rail  fence  was  installed.  The  permanent  timber  post  and  rail 
fencing was completed by the 15 June 2020. 

BCP Council acknowledges that someone has died here as a result of a tragic accident and 
would address the Coroner’s concerns and Regulation 28 Report as follows: 

(i) 
(ii) 

(iii) 

(iv) 

(v) 

(vi) 

There remains a low risk that a similar event will re-occur at this location. 
The small level difference from the slip road surfacing down into the ditch is in highway 
design terms deemed insufficient to require protection in the event of a vehicle leaving 
the carriageway. 
If the post and rail fencing is extended, it is as likely to cause injury to occupants of any 
vehicle that fails to negotiate the bends as to protect them from it. A known cause of 
injury  and  death  to  road  users  is  from  vehicles,  including  motorcycles  and  cyclists 
leaving  the  highway  and  striking  posts,  barriers  or  other  obstructions  that  are  not 
passively  safe.  There  is  a  risk  therefore  that  a  timber  barrier  here  could  create  an 
additional safety hazard. 
The concrete slabs in the storm drain are widely spaced and there is therefore a low 
risk that anyone would come into contact with them should they leave the road. 
The  ditch  runs  parallel  with  the  carriageway  and  is  on  the  inside  of  the  bend.  The 
geometry of the road is such that any vehicle losing control here is more likely to end 
up on the outside of the bend away from the ditch than end up in the ditch itself. 
The Council has reached these decisions in the context of a public highway which is a 
regulated  environment  and  also  in  the  context  of  professional  judgement  of 
experienced and qualified officers. This project was delivered in accordance with the 
national  Standards  for  Highways  including  the  essential  document  for  the  design, 
construction and maintenance of highways, the Design Manual for Roads and Bridges.  

We  would  note  that  there  is  now  a  much  improved  crossing  provision  for  both  cyclists  and 
pedestrians  at  this  junction.  This  additional  timber  post  and  rail  fencing  would  only  be 
recommended if the accident record itself warranted it and there is no evidence of such a trend 
at the present time. There have been no recorded cyclist injuries here since October 2017. As 

 
 
 
 
 
 
 
 
 
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highlighted  above  we  would be  in  danger  of  potentially  creating  greater numbers  of  injuries 
than the measure might prevent were this work to be undertaken.  

In  light  of  the  above,  the  Council  does  not  believe  it  is  appropriate  to  introduce  additional 
fencing  to  the  inside  of  the  bend  on  the  slip  road.    The  Council  will,  however,  continue  to 
monitor this site and others like it in conjunction with the police.  

I trust this  is  satisfactory  but  please feel free to contact me  should  you wish for  any further 
information. 

Yours sincerely 

Team Leader Road Safety 
BCP Council