Prevention of Future Deaths reports · 2022

Paul Morris and Alison Morris

Regulation 28 report to prevent future deaths, reference 2022-0295, written 8 Jun 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report8 Jun 2022
Reference2022-0295
DeceasedPaul Morris and Alison Morris
CoronerHugh Bricknell
Coroner areaHerefordshire
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.

H G Mark Bricknell 
Senior Coroner 
for County of Herefordshire 

REGULATION  28 REPORT TO  PREVENT FUTURE  DEATHS 

THIS  REPORT  IS  BEING  SENT TO: 

, Chief Executive,  Herefordshire Council  and 

,  Contract Director,  Balfour Beatty Living Places 

1 

CORONER 

I am  Hugh Gregory Mark Bricknell, Senior Coroner for County of Herefordshire. 

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 the 13th day of September 20211  commenced an  investigation into the deaths of Paul  Haydn  MORRIS 
and Alison  Margaret MORRIS.  The investigation concluded  at the end of the inquest on the 25th day of 
May 2022. The conclusion  of the inquests were Road Traffic Collision. 

4 

CIRCUMSTANCES OF THE  DEATH 

Mr and Mrs Morris died together with their family dog following a Road  Traffic Collision on the A44 at 
Crooked Well,  Kington,  Herefordshire.  They were on holiday and followed a recognised footpath which 
crossed  the A44.  The inquest heard from (inter alia) a Collision  Investigator of the West Mercia Police 
who confirmed: 

a)  The curve of the road and foliage restricted the view to a maximum of 78  metres in the relevant 

direction. 

b)  There were no advance warning signs for motorists approaching from the Leominster direction 

of the footpath which crosses the A44 at this location. 

c)  Calculations show the oncoming vehicle was travelling at or below the speed  limit for the area . 

d)  The pedestrians likely left the safety of the pavement at around the same time the oncoming 

vehicle would have come into view. 

e) 

In  only a few seconds both motorist and pedestrians would be required to react and consider 
what action to take. 

 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  point where the footpath crosses the A44 provides limited visibility to both pedestrians and 

motorists 

(2) You  may care to give consideration to 

(i)  the prevailing foliage 

(ii) the position of the safety barriers for both the  pedestrian and the motorist 

(iii) the position or nature of the crossing 

(iv) the speed  of traffic at this point on the A44 

(v)  the level  of signage 

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 
3rd August 2022,  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 following Interested Persons,  the 
Chief Constable of West Mercia Police. 

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 

8th June 2022 

Signaturfl  fV\./VV 
HG  Mar~ry{I, HM Senior cl/oner: Herefordshire 

.

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 Balfour Beatty Living Places (PDF)
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Balfour Beatty  O  Council 

•  Herefordshire

Working for Herefordshire 

Thorn Depot 
Unit 3,  Thom Business Par!< 
Rotherwas, Hereford 
Herefordshire 
HR2 6JT 

H G Mark Bricknell 
H.M. Senior Coroner Herefordshire 
Town  Hall 
St Owen Street 
Hereford 
HR1  2PJ 

26  July 2022 

Dear Mr HG  Mark Bricknell , 

Inquest into the deaths of Alison  Margaret Morris and  Paul  Haydn  Morris 
Your ref:  MB/NP/ab/4523/21  & MB/NP/ab/4524/21 

Thank you for proving  us with  your Regulation 28  report raising  your concerns following  the tragic deaths of 
Mr and  Mrs Morris whilst crossing the A44  at  Kington. 

As  you  know,  Balfour Beatty Living  Places  Limited  (BBLP) are contracted  by  Herefordshire Council to 
provide public realm  services in  accordance with the terms of the Highways Maintenance Plan  (HMP) . 

The HMP sets out a risk-based  approach and  refers to  the  location of the  accident in  terms of the  USRN 
which  is  unique  reference  number.  The  location of the accident is  not an  accident cluster site and did 
therefore not fall  into any special  remit for inspections and  maintenance and was inspected  in  line with the 
HMP. 

The Site History Report (SHR)  shows the  area  is subject to a statutory monthly driven inspection which was 
carried  out prior to the accident on  1 September 2021  and  no  actionable defects were raised.  By way of 
clarification , in  a driven  inspection there are two individuals in  the vehicle,  one acts as  driver and one 
inspecting  in  order to pick up actionable defects and  looking for damaged sign age or damaged trees in 
accordance with the  list set out in  page 24/25 of the  HMP. 

The  SHR also  indicates that the  public right of way footpath  located at the accident locus was  inspected 
prior to the  accident on  the  17  March 2021  and  no  action  or defects were found . 

As you  note there is  a safety barrier located at the crossing  point to  prevent pedestrians from  walking 
straight out into the A44. 

Under the contract, verges were subject to two  planned cuts per year,  the last prior to  the accident being  on 
27/28 August 2021 . 

Further in  accordance with the  contract, the trees  in  the  stretch  leading  up to the area were  not subject to 
any  proactive survey and  therefore were only cut back when there was  a request to  do so or if they were 

Balfour Beatty  Living Places  Limited , registered in England and Wales no. 02067112 , 
registered office. The Curve , 2nd  Floor, Axis Business Park, Langley , Berks SL3 8AG 
an agent of Balfour Beatty Group Limited, registered no. 101073, registered office. 130 
Wilton Road. London SW1V 1 LQ 

 
 Page 2 

noted to  be  affecting visibility during the driven inspection . There had  been  no  reports  of any visibility  issues 
in  the  12 months in  the  area  prior to the accident. 

The verges and tree foliage were cut back following  the  accident at the request of West Mercia Police 
following their accident investigation. 

The signage erected in  the  area predates the  BBLP contract and  had  remained  unchanged since BBLP 
commenced the  public realm  contract. 

We have been consulting with  Herefordshire Council  subsequent to the accident and  can  report the 
following  in  relation  to the  concerns  raised: 

In  relation  to the prevailing foliage , Herefordshire Council  have visited the site and  now requested 
improvements to the  sight lines.  The Council have now instructed  BBLP to remove vegetation from the 
wall,  cut back trees and the verges on  both side of the  road,  so  as to  increase sight lines to  160 metres. 
The  order is  at quotation stage .  Cyclical  grass cutting will take place  in  May and August each  year. 

Herefordshire Council have  confirmed to  BBLP that it does not have  any  concerns  in  relation to  the 
pedestrian of vehicle restraint system  (VRS)  barriers, but has commissioned  BBLP to carry out bi-annual 
clearance  around the VRS  barrier.  The Council  have further confirmed that the  position  and  nature of the 
pedestrian crossing will  not require  altering . 

BBLP have been  informed that Herefordshire Council  have commissioned  a Traffic Regulation Order 
review of the speed limit at the site,  with  a view to the  speed  limit being  reduced to 50mph .  The review will 
also  consider appropriate signage at the  site.  The  Council  have reported that it is  hoped that this review 
will  be  completed within 9 months and although  BBLP will  play no part in  the  review,  it will  of course carry 
out any further works as  instructed by the Council with  a view to  preventing further accidents. 

Yours sincerely 

Contract Director 
Balfour Beatty Living  Places
Response from Kington Bypass Herefordshire Council (PDF)
Mr M Bricknell  
Coroner’s Office 
Town Hall  
St Owen Street  
Hereford  
HR1 2PJ  

Dear Mark, 

Your Ref: 

Our Ref: 

Please ask for: 

Direct line / Extension: 

Fax: 

E-mail: 

Chief Executive 

1 August 2022 

Inquest into the deaths of Alison Margaret Morris and Paul Haydn Morris 

Thank you for providing us with your Regulation 28 report raising your concerns following the tragic deaths 
of Mr and Mrs Morris whilst crossing the A44 at Kington.  

I am writing to you in the capacity of the Chief Executive Officer for Herefordshire Council, the Highway 
Authority for the A44 Kington Bypass.  I am responding to your concerns as outlined in Section 5 of your 
Regulation 28 report, namely: 

“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 section 5 (1) the Coroner notes the matter of concern as: 

“The point where the footpath crosses the A44 provides limited visibility to both pedestrians and 
motorists.” 

The Coroner further states that the Council may wish to give consideration to the following: 

I.  The prevailing foliage;  

II.  The position of the safety barriers for both the pedestrian and the motorist; 

III. 

 The position or nature of the crossing; 

IV.  The speed of the traffic at this point on the A44; 

V.  The level of signage. 

I will address each point in turn. 

Herefordshire Council, Plough Lane, HR4 0LE 
www.herefordshire.gov.uk | facebook: hfdscouncil | twitter: @hfdscouncil 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 The A44 Kington bypass was designed as an all-purpose single carriageway road and was opened in 
1982. At the time that the road was constructed the design allowed for a forward visibility of 160m, this 
being the acceptable minimum within the design standards at that time. 

In accordance with the Road Safety Policy contained within the current Local Transport Plan, and in 
line with Section 39 of the Road Traffic Act 1988 together with historic national best practice guidance, 
Herefordshire Council undertakes an annual review of all recorded personal injury collisions on roads 
within the County. In line with the agreed criteria, these sites are subject to investigation and, where 
appropriate, additional measures may be introduced to improve road safety in line with available 
resources. Locations where such works have been carried out are subject to an ongoing enhanced 
inspection and maintenance regime, in addition to the monthly driven safety inspection policy, as 
detailed within the current Highways Maintenance Plan and the Public Realm Annual Plan.  

The location in question has not previously been identified as having a defined history of collisions 
from the above approach and has therefore not been subject to any form of enhanced maintenance 
regime.  

Following the collision, works were immediately undertaken to remove foliage and to improve the 
forward visibility at the location, this work taking place after the joint inspection by the Police and the 
Council’s lead road safety officer. An instruction has subsequently been issued to Balfour Beatty 
Living Places for the reinstatement of visibility splays along the length of the bypass; it is anticipated 
that this additional work will be complete before the end of September 2022. This piece of work will 
improve the visibility for pedestrians and motorists alike. 

Moving to the individual points within the Regulation 28 report: 

i)  The issue of prevailing foliage is addressed above. In addition, the Council will add the Kington 
Bypass to its list of sites that require an enhanced maintenance regime. On top of regular 
monthly maintenance inspections for the A44, the whole site will have specific quarterly safety 
inspections that will include the side road and the footpath. The locality steward responsible for 
the inspections will be made aware of the requirements needed to ensure safety at this 
location. The regime will also ensure that the forward visibility along the bypass is maintained 
as per the original design requirements, taking into account the prevailing speed limit in force. 

ii)  The safety barrier, in the form of pedestrian guardrail, was installed to prevent pedestrians 

moving from the river bridge directly onto the bypass. It has the effect of halting pedestrians 
and encouraging them to check for traffic prior to crossing the road. There are no plans to 
move or alter the position or layout of the pedestrian guardrail as it is considered adequate to 
prevent inadvertent entry onto the bypass. The police are aware of this and have not raised 
any objections. 

iii)  The crossing point is a historic one and pre-dates the construction of the bypass. The line of 
the path is a public right of way, reference Kington Urban Footpath 29. The line of the path is 
complicated by the presence of a footbridge over the adjacent Gilwern Brook. The path is 
popular locally and provides ready access to the Offa’s Dyke. There are no plans at this time to 
either move the line of the footpath or to provide a footbridge over the A44. The presence of 
the pedestrian guardrail is considered to offer adequate protection and is standard practice for 
numerous situations where public rights of way cross a highway in the county. 

 
 
 
 
 
 
 
 
 
 iv)  The A44 is currently subject to the National Speed Limit, i.e. 60mph for a single carriageway 
road.  The Council is soon to consult on the lowering of the speed limit to 50mph, the lowest 
speed limit that is considered appropriate for this class of road and its nature, i.e. a road with 
minimal access points and good overall visibility.  The Council will not be seeking to lower the 
speed limit further in the vicinity of the collision as speed limits are not set for point locations 
but rather for the overall look and feel of the network over a section of road. It is anticipated 
that this will take up to nine months to complete in order to allow for consultation and the 
statutory processes for making the necessary traffic regulation orders. 

v) 

It is noted that warning signs for pedestrians crossing exist only on the eastbound approach. A 
review of the location, using Google Maps StreetView, shows that this has been the case since 
at least 2009. That said, the Council will be reviewing signing and lining along the length of the 
bypass and will implement any improvements prior to March 2023. While this review will 
ultimately determine the details of the proposals, it is likely to at least include pedestrian 
warning signs on each approach to the three existing locations where public rights of way cross 
the bypass. The extended period for implementation is required to ensure that any proposed 
design complies with the requirements of the Traffic Signs Regulations and General Directions 
2016, and that there is sufficient time to make any relevant orders. 

Should you have any further queries or questions then please do not hesitate to contact me. 

Yours sincerely 

CHIEF EXECUTIVE

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