Charles Stringer

Dr Karen Henderson 
HM Coroner’s Court 
Station Approach 
Woking 
Surrey 
GU22 7AP 

Woodhatch Place 
11 Cockshot Hill 
Woodhatch 
Reigate 
RH2 8EF 

5th  December 2022 

Re: Regulation 28 Report - Action to Prevent Future Deaths - Charles Michael 
STRINGER 

Dear Coroner Henderson, 

Further  to the issuing of a Prevention of  Future Deaths Report  on 10 October  2022, please 
find below Surrey County Council’s (SCC) response. 

At  the outset,  Surrey County Council once again wishes to  pass  on our  condolences  to  the 
Stringer family following this tragic incident. 

The  Inquest  concluded  on  30  November  2021 and  a  conclusion  of  ‘Accident’  was  reached. 
Following  the  hearing,  written  submissions  were  provided  on  the  issue  of  whether  a  PFD 
Report or a Letter of Concern should be issued. SCC made submissions that neither would 
be appropriate in the circumstances but understands that the Coroner reached the decision 
that  a  Letter  of  Concern  would  be  written.  However,  notwithstanding  this  decision  a  PFD 
Report was issued on 10 October 2022. It is to this Report that SCC now responds. 

SCC  understands  that  the  two  issues  which  the  Coroner  would  like  addressed  are  set  out 
within Section 5 of the PFD Report: 

1.  A lack of reflection by SCC following Mr Stringer’s death. 
2.  A  lack of  action and/or change to the management  of  potholes  by SCC following  Mr 

Stringer’s death. 

Lack of reflection 

SCC  indicated  to  the  Coroner  that  a  witness  in  senior  management  was  available  to  give 
evidence on reflection and learning following Mr Stringer’s death, once the Coroner had raised 
this as a concern. Prior to this, the Coroner had not requested such evidence and it was not 
incumbent on SCC to proffer such evidence in the absence of a direction to do so or indication 
that  it  was  a  concern  that  needed  to  be  addressed.  Once  the  Coroner  had  indicated  her 

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 concern  in  this  regard,  evidence  was  provided  (in  written  form)  by  Ms  Amanda  Richards, 
addressing each of the points of concern raised by the Family. 

SCC maintain that a significant degree of reflection did take place following Mr Stringer’s death 
and is unclear about the respects in which this was deemed to be inadequate. SCC would like 
to  reiterate that  reflection  did  take place  following  Mr Stringer’s  death  as set  out  below and 
changes aimed at improving the service have occurred since the sad death of Mr Stringer. 

Lack of action and/or change to the management of potholes 

The  Coroner  has  indicated  that  the  written  submissions  provided  (it  is  assumed  by 

 refer to ‘a number of discussions…but there has been no documented changes in 
systems of practice’. SCC notes that the conclusion of the Inquest was Accident and that the 
Coroner determined that at every relevant inspection where the index defect was identified, it 
was classified correctly, and an appropriate repair completion date was imposed. Tragically, 
Mr Stringer’s accident  occurred whilst the pothole was scheduled  for repair (and was within 
the appropriate repair time window). 

The  Inquest  did  not  therefore  determine  that  the current  system  was  inadequate.  However, 
given the tragic circumstances of Mr Stringer’s death, SCC has undertaken reviews of each 
of the issues raised by the Family (set out at paragraphs 1-5 in Section 5 of the PFD Report) 
and several changes have been made since the Inquest (albeit not all directly as a result of 
this Inquest). Most pertinently the main changes since Mr Stringer’s passing are: 

1.  We  have  recently  reprocured  our  Highways  Term  Maintenance  contract  and  have 
taken  the  opportunity  to  consider  improvements  to  the  services  we  deliver.  For 
example,  SCC have now increased the  potential  to be able to  carry out larger  scale 
pothole  repairs,  where  conditions  warrant  it,  which  will  help  prevent  future  potholes 
and improve road condition for all users. 

2.  The  highways-inspector  role  (for  routine  and  reactionary)  inspections  has  been 
brought in-house to SCC having previously been a function that was outsourced to our 
Term  Maintenance  Contractor.  This  has  facilitated  greater  local  knowledge  and 
consistency  across  inspections  (for  example,  all  inspectors  are  more  likely  to  know 
which routes are popular cycle-routes due to their local knowledge) and allows SCC to 
have control over all highways-inspector training. 

3.  The Local Transport Plan 4 (LTP4) is currently being implemented. This has prompted 
broad consideration of ways to improve the services we deliver.  In particular, the LTP4 
places greater emphasis on cyclist-use of roads within the network and steps are being 
taken to collect data on cycle-routes in order to inform future decisions about how best 
to  incorporate  this  knowledge  into  the  policy  and  systems  and,  if  appropriate,  to 
facilitate access to this data for highways-inspectors. 

1.  What steps have been taken to ensure inspectors of defects are fully informed 
of  recent  complaints  including  those  from  members  of  the  public  regarding 
damage to bicycles by the state of the road. 

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 Inspections are based on what the Inspector sees at the point in time that the inspection takes 
place. SCC often gets multiple reports of what might be the same defect and there can be a 
variety of reasons why certain defects may be the subject of multiple reports (it is not always 
the case that a higher number of reports means that a defect poses a greater risk than a defect 
which  has  received  only  one  report).  For  this  reason,  while  we  assess  all  reports  from  the 
public  regarding  potential  safety  defects,  we  need  to  ensure  that  limited  resources  are  not 
diverted or biased based on what can be inconsistent reporting by the public.  It is important 
that inspections that are prompted by a customer complaint are carried out to review what is 
reported  at  that  point  in  time  as  an  independent  one-off  inspection  carried  out  by  a  trained 
Inspector. 

There are risks and benefits to providing historical data and not providing it. These have been 
carefully  considered,  and  SCC  is  still  giving  specific  consideration  to  whether  providing 
historical complaint data to Inspectors would be beneficial. 

SCC is in the process of building a new data system and is exploring the option of having a 
data history available to inspectors as part of this. 

2.  What  steps  have  been  taken  in  the  provision  of  a  detailed  and  robust  risk 
assessment  by  inspectors  with  all  the  available  information  available  such  as 
past  complaints,  the  nature  of  the  road  and  who  uses  the  road  to  ensure  a 
‘holistic’  approach  to  decision  making  with  regard  to  the  necessity  and  the 
speed of road repairs. 

As above, Mr Stringer’s death prompted further internal discussions about whether historical 
complaint data should be provided to Inspectors. There are risks and benefits of providing this 
information and these are being carefully considered. 

Inspectors identify risks by visual inspection and evaluate them in terms of their significance, 
which means assessing the likely impact should the risk occur and the probability of it actually 
happening. 

The impact is quantified by assessing the extent of damage likely to be caused should the risk 
become  an  incident.  As  the  impact  is  likely  to  increase  with  increasing  speed,  the  level  of 
traffic,  the  type  of  traffic,  and  the  type  of  road,  all  of  these  aspects  are  considered  in  the 
assessment. 

The probability is quantified by assessing the likelihood of users, passing by or over the defect, 
encountering the risk. As the probability is likely to increase with increasing flows and the type 
of traffic, the network hierarchy and defect location are considered in the assessment. 

Based upon the potential impact and probability and in accordance with the guidance set out 
in  the  Highways  Risk  Matrix,  the  Inspector  will  determine  the  appropriate  category  for  the 
defect. 

We have recently reviewed one of our key strategies, our Local Transport Plan (LTP4), which 
sets the policy direction for transport across Surrey. As part of that we are reviewing how to 

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 more positively accommodate more sustainable modes of transport on our network, including 
cyclists, into our network management regimes.  Implementation of the LTP4 has specifically 
focused efforts on factoring in use by cyclists of particular routes and data is currently being 
gathered on this issue. 

The  main  sources  of  information  we  have  identified  for  mapping  cycle  movements  is 
Propensity to Cycle data, the SCC Better Points app, Strava, and cycle counting technology 
such as image recognition from CCTV cameras.  Following analysis of the data, decisions will 
be made on whether changes to maintenance polices are needed.  In particular, consideration 
is currently being given to creating a cycle hierarchy similar to the existing carriageway and 
footway hierarchies.  A bespoke hierarchy focussed on cycle routes will enable interventions 
on routes that are used by cyclists to be more clearly based on the usage and risks for cyclists. 
In terms of Inspections, this will give the Inspectors valuable information about the cycle usage 
of the routes they are inspecting, rather than relying on their local knowledge. 

This  work  is  ongoing  with  data  gathering  and  consultation  taking  place  with  relevant 
stakeholders  including  Council  officers,  Members,  other  authorities  and  cycling  groups. 
Outputs  are  due  to  be  reported  within  the  next  6  months  with  any  recommendations  for 
changes then going through council governance processes. 

Also  relevant  is  the  change  in  our  Highways  Maintenance  Contractor  which  although  not 
related to the inquest, it has allowed us to make changes to how the service is delivered.  SCC 
has moved all highways-inspector roles (routine and reactionary) in-house (from 2022) which 
enables  enhanced  and  better  use  of  ‘local  knowledge’  and  continuity  to  inspections.  All 
Inspectors will now have access to SCC asset data including street history information (details 
of works or defects that have previously occurred on the section of road), and all officers will 
have  a  clear  understanding  of  the  inspection  process  and  points  of  contact  though  regular 
meetings and training. 

3.  What, if any, changes have been made to the pictorial guide and the matrix given 
to inspectors to ensure training there is not an ‘overly mechanistic’ assessment 
of a road defect. 

All highway authorities have their own guidance and processes to provide guidance to staff in 
carrying out their role. The pictures are helpful to give an indication of the types of defect that 
may  fall  into  each  category  and  as  an  aide-mémoire.  The  document  clearly  states  that  it  is 
there to “assist” with identification and classification and that it should be used in conjunction 
with other information. Comparing the visual characteristics of a defect against the pictures in 
the  guide provides a good  starting  point  for Inspectors when assessing the  risk posed by a 
defect. 

The pictorial guide is periodically reviewed and following this inquest SCC has reviewed it in 
detail  and  a  new  draft  has  been  produced  with  a  number  of  pictures  updated  along  with 
updates  to  reflect  the  changes  introduced  as  part  of  the  new  contact  arrangements.  SCC 
maintains  that  the  pictures  provide  suitable  supplementary  assistance  for  classification  of 
defects  in  accordance  with  the  policy.  The  most  recent  review  aligns  the  guide  with  the 
changes  made  as  part  of  the  new  contract  arrangements  in  terms  of  repairing  the  area 

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 surrounding  the defect  if  the surrounding  surface is not  sound  rather than repairing just  the 
defect itself. 

SCC has also re-emphasised to Inspectors that the pictorial guide and matrix are to be used 
as only part of their dynamic risk assessment for each defect, with the visual characteristics 
of  each  defect  (and  comparison  to  the  pictures  in  the  guide)  being  only  one  aspect  of  that 
assessment. 

In addition to the pictorial guide and matrix, the training that Inspectors receive continues to 
emphasise  that  the  situational  and  wider  characteristics  of  a  defect  are  important  –  as 
described  in  point  2  above.  Refresher  training  happens  regularly  for  SCC  Inspectors  which 
covers the risk assessment process and how a dynamic risk assessment is to be conducted 
without placing over-reliance on the dimensions of a defect in an overly mechanistic way. 

Recent  changes  to  the  organisational  structure  have  meant  that  all  the  highway  inspectors 
now work directly for SCC (as above).  This will improve the control and consistency in training 
and also SCC’s ability to ensure that regular training is undertaken for all highways-inspectors. 

SCC also has a team dedicated to carrying out internal audits of the quality of repairs and of 
the assessment of defects to ensure that an ‘overly mechanistic’ approach is not adopted. All 
stages of the safety defect process from identification and categorisation through to the repair 
Issues  are  reviewed  and,  where  necessary, 
are  monitored  and  scrutinised  continuously. 
discussed  with  relevant  officers.  Trends  and  performance  are  reported  through  a  monthly 
performance  board  and  as  a  result  processes  are  continuously  evolving  across  the  teams 
involved. 

4.  What  steps  have  been  taken  to  ensure  there  is  appropriate  and  timely 
communication between the SCC contact centre and the highways department 
such  as  a  standard  operating  procedure  in  place  when  complaints  must  be 
forwarded on and responded to? 

The  primary  method  for  contacting  the  Highways  service  is  by  using  the  on-line  web-portal 
which is where the  vast  majority  of  highway  concerns are reported  and which go directly to 
the  Highways  Service.  Customers  are  also  able  to  phone  the  SCC  contact  centre  to  raise 
issues and the contact centre will log issues with the Highways Service on their behalf.  The 
corporate standard response time is 5 days. 

Performance  with  regards  to  response  times  for  enquiries  is  monitored  regularly  and  any 
issues with processes or systems are addressed.  Regular discussions take place between 
the  Highways  Service  and  the  Customer  Contact  Centre.  Discussions  took  place  following 
this case and Customer Care Centre operatives were subsequently instructed to make direct 
and immediate contact with Highways if there is anything they are unsure about. 

5.  What steps have been taken to ensure repairs are completed in a timely fashion 
after serious injuries and deaths have occurred, as a result of a road defect? 

We have reviewed the timeline of notification to repair a defect following incidents on the road 
network.  We have reinforced the process to both Surrey Police and the Surrey Contact Centre 

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 of  the  requirement  to  notify  the  Highways  Service  immediately  in  these  circumstances  to 
enable a timely response. 

SCC  hopes  that  the  above  demonstrates  that  significant  reflection  and  action  has  occurred 
since Mr Stringer’s sad passing and that work is ongoing to improve the service. 

Yours sincerely, 

Chief Executive of Surrey County Council 

Director of Highways and Transport 

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