Prevention of Future Deaths reports · 2021

Thomas Pickering

Regulation 28 report to prevent future deaths, reference 2021-0289, written 20 Aug 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report20 Aug 2021
Reference2021-0289
DeceasedThomas Pickering
CoronerTim Deeming
Coroner areaSuffolk
CategoryRoad (Highways Safety) related deaths
Sourcejudiciary.uk record · original PDF
Responses published2

The report

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

REGULATION 28:  REPORT TO PREVENT FUTURE DEATHS (1) 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO: 

1.  Suffolk Highways 
2.  National Highways 

1 

CORONER 

I am Tim Deeming, Assistant Coroner, for the coroner area of Suffolk. 

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. 

3 

INVESTIGATION and INQUEST 

On 4th December 2020 we commenced an investigation into the tragic death of 
Thomas Pickering 

The investigation concluded at the end of the inquest on 19th August 2021. The 
conclusion of the inquest was that:- 

On the 26 August 2020 Mr Pickering left home at approximately 22.20 with his 
girlfriend as a passenger.  He was driving his Kia car towards Maningtree train station 
on the A137 near Tattingstone, Ipswich in order for her to depart on the 22.54 train.  

At around 22.45 a road traffic collision occurred in the northbound lane near to Nine 
Oaks and Wallers Farm at the brow of the hill.  The likely cause of this collision was 
due to the Kia overtaking a VW Golf despite the white lines, resulting in the collision 
with the oncoming Saab in an offset head-on impact. The speedometer of the Kia was 
recorded as 71mph and the speed limit at this section was 60mph. 

Emergency services were called and fire crew service support was provided given 
that the Kia was inverted due to the collision and Mr Pickering remained upside down 
in the driving seat.  Following his release from the car, paramedic support was then 
able to be assessed but Mr Pickering was recognised as passing away at 23.45 at the 
scene of the collision due to massive multiple injuries sustained. 

The medical cause of death was confirmed as: 

1a Massive Multiple Injuries 
1b RTC 

4 

CIRCUMSTANCES OF THE DEATH 

Following on from the above and the Forensic Collision Investigator report I 
understand that the site of the incident already has solid white lines and a 60mph 
limit, however I heard that the area is a blind summit without signage or other 
warnings on approach, and the family understand that there have been other RTC’s 
at the location. 

5 

CORONER’S CONCERNS 

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

the MATTERS OF CONCERN as follows.  –  

I am concerned as to whether further preventative steps can be taken to mitigate the 
risk of future RTC’s at the site given the apparent lack of signage – eg hidden dips, or 
signage relating to notification of recent incidents at the area to increase awareness 
eg the number of fatalities/collisions. 

6 

ACTION SHOULD BE TAKEN 

In my opinion action should be taken in order to prevent future deaths, and I believe 
you or your organisation have the power to take any such action you identify.  

7 

YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, 
namely by 15th October 2021 I, the Assistant Coroner, may extend the period if I 
consider it reasonable to do so. 

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 following Interested 
Persons;-  

1. Mr Pickering’s next of kin. 
2. Suffolk Police 

I am 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 Assistant Coroner, at 
the time of your response, about the release or the publication of your response by 
the Chief Coroner. 

9 

20 August 2021                                        Tim Deeming

Responses

2 responses 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 National Highways (PDF)
National Highways Response - Thomas Pickering Redacted Reg 28 final - 

Dear Julie 

Thank you for your email to National Highways dated 31 August regarding the death 
of Thomas Pickering on the A137. 

I'm very sorry to hear you've had to email us regarding safety concerns following the 
sad passing of Thomas Pickering.  

Details of the roads that we're responsible for can be found here 
-  https://www.gov.uk/government/publications/roads-managed-by-highways-england 

National Highways is responsible for the motorways and trunk roads in England and 
the A137 isn't a road we're responsible for so we can't comment on this matter. I see 
you sent this to Suffolk County Council as well so they'll have to respond to this.  

Thank you once again for contacting us and I hope that we’re able to assist you with 
your enquiry. 

If you’ve any further questions regarding this or any other National Highways issue, 
please feel free to contact us via our 24 hour Customer Contact Centre on 0300 123 
5000. 

Alternatively, please e-mail us at info@highwaysengland.co.uk or access our 
website http://www.highwaysengland.co.uk where information on all National 
Highways policies and procedures can be found. 

Kind regards 

Customer Contact Centre | Advisor 

National Highways | National Traffic Operations Centre | 3 Ridgeway, Quinton Bus. 
Park | Birmingham | B32 1AF 

Email: Info@highwaysengland.co.uk 

Tel: 0300 123 5000 

National Highways Company Limited | Registered Office: Bridge House, 1 Walnut 
Tree Close, Guildford GU1 4LZ | Registered in England and Wales No. 9346363
Response from Suffolk County Council (PDF)
From: Highways Safety and Speed Management 

Sent: 16 September 2021 16:31 
To: 

Cc: 
Subject: Fatal collision A137 Tattingstone 

Dear all, 

following a fatal road collision on 26 August 2020 the Assistant Coroner, Tim Deeming, 
issued a Regulation 28 Report to Suffolk County Council Highways in which he 
recommended action be taken in order to mitigate the risks of future collisions. Particular 
reference was made to the vertical alignment of the road and the presence of a hidden dip. 
Please see maps and photo’s below. 

For your information SCC Highways has assessed the Report and agreed to install a pair of 
hidden dip signs north of the Wallers Farm access, facing southbound traffic. 

Work will now proceed to design suitable locations, leading to the erection of new posts and 
signs in due course. 

  
 
 
 
  
 regards 

Safety and Speed Management Engineer 

 
 
 
 
 
 
 
 Growth, Highways and Infrastructure 
Phoenix House, Ipswich, IP1 5NP 
Suffolk County Council 

Web: www.suffolkroadsafe.com 
and suffolk.gov.uk/roads-and-transport 
Twitter: www.twitter.com/suffolkroadsafe

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