Adam Simms

Date:

7 December2022 

Private and Confidential via Email 
Mr Paul Duncan Smith 
Acting Senior Coroner 
North Lincolnshire & Grimsby 

www.northlincs.gov.uk 

Church Square House 

30-40 High Street

Scunthorpe

North Lincolnshire 

DN15 6NL 

Dear Mr Smith, 

Ref: Regulation 28 Response for A18 Mortal Ash Hill Incident of 25 May 2021 

Thank you for your regulation 28 report to prevent future deaths dated 17th October 
2022. I have investigated your concerns, raised in section 5 of your report, and can 
provide you with the following information. 

(1) I received evidence regarding the system of inspection utilised to identify and
remedy any blocked drainage gullies. Two blocked gullies were found at the site of
the accumulation of water upon the carriageway notwithstanding that an inspection
undertaken only four days previously on 17 May 2021 had not identified those
defects. They had not been included in cleansing works undertaken on 8 April 2022.

North  Lincolnshire  Council  carry  out  monthly  driven  safety  inspections  on  principal 
roads,  like  the  A18,  utilising  a  fully  livered  highway  vehicle  with  flashing  beacons, 
travelling  at  an  appropriate  speed  to  the  road,  without  putting  other  road  users  in 
danger  by  driving  too  slowly.  They  are  undertaken  by  two  people,  a  driver  and  a 
qualified highway inspector. The driver has no part in the inspection other than driving 
the vehicle. All observations are made by the inspector. This is set out in our highway 
inspection code of practice.  

Previous safety inspections at this location prior to the 17 May 2021 did not identify 
any  standing  water  issues  as  they  were  not  undertaken  in  wet  weather.  Previous 
safety inspections have been driven and no issues identified.  There are no records of 
any wet weather complaints for this location prior to the 17 May 2021.  

No works were undertaken on the 8 April 2021 at this location as the area concerned 
was in the taper of the traffic management for works further along the road. There was 
no  indication  on  record  that  suggested  an  extension  of  the  traffic  management  to 
consider this area where the gullies were located. Our records show gullies on this 
stretch  of  road  are  cleansed  on  a  biannual  basis.  This  cleansing  includes  gulley 
emptying, road sweeping of channels, grass cutting and cutting back of any vegetation 
that may be affecting the highway drainage systems. The last scheduled cleansing of 
this area took place on the 8 December 2020. The next scheduled cleansing would 
have been in July 2021.  

The evidence the Coroner received did not establish on balance of probabilities that 
those blocked gullies identified were the cause of patches of water. 

 
 
 
 
 
 
 
 
 (2) The evidence suggested that at around the point at which Mr Simms lost control of 
his  motor  car  there  were  two  separate  patches  of  standing  water  upon  the 
carriageway. They were said to be 62m in length and 36m in length respectively. They 
occupied the majority of the width of the Eastbound carriageway. Water was noted to 
a depth of between 10 and 15mm. There was plainly a significant quantity of standing 
water which posed a serious hazard to road users. 

From the reports included in the Police investigation and witness statements contained 
therein, it is clear that on the day of the incident the weather was inclement and excess 
water was found around across the county. There was no severe weather warning for 
this location on the day of the incident. From our records there was no indication of 
any wet weather issues at this location previously and since receipt of the coroners 
report we have undertaken 3 wet weather inspections of the area on 15, 17 and 22 
November  2022.  No  evidence  of  standing  water  was  identified  during  these  wet 
weather events.  

From these additional inspections we can only conclude on the balance of probabilities 
that it was the sheer volume of water, that was not forecast, at that point in time of the 
incident that contributed to the accumulation of water on the highway at this location.  

(3)  Whilst  the  evidence  I  received  did  not  establish  on  balance  of  probabilities  that 
those  blocked  gullies  were  the  cause  of  the  patches  of  water  described  above,  no 
alternative explanation for such a significant accumulation of water was provided by 
the evidence. It had plainly rained heavily, although there was no evidence to suggest 
an exceptional downpour had occurred. 

Whilst noting the coroner’s assessment, the Council does not agree that there was no 
evidence to suggest an exceptional downpour had occurred on the day in question.  
There  are  several  witness  accounts  set  out  in  summary  below  on  the  issue  of  the 
weather and driving conditions throughout the highway network:  

•  HGV driver statement - “ On this particular day I was travelling to North Lincs Waste 
transfer station and my journey takes me from the M180 onto the A18 Mortal Ash Hill 
to get there. The weather for the previous 24 hours had been pretty consistent rain 
with some really heavy downpours. It was still raining at this time, and there was a lot 
of surface water and puddles throughout the journey.”  

•  Sutton Transport driver statement travelling westbound on A18 -  “it was raining on 
and  off…onto  the A18.  By  this time  it  was  raining  very heavily…There  was  a  lot  of 
surface water on the road…I didn’t go faster because of the weather conditions.” 

•  PC 897 statement – “whilst making my way to the scene, the weather conditions 
were  extremely  poor.  There  was  heavy  rain  throughout  the  journey  and  areas  of 
standing  water  were  apparent  both  on  the  A15  southbound…on  the  M180  towards 
junction  4…if  the  weather conditions are  appropriate,  I  would  use my  police  driving 
exemptions…but  on  this  occasion,  I  felt  it  was  inappropriate  to  do  so…I  recall  that 
even along sections of road that were less affected by the poor weather and standing 
water, it was difficult to attain the speed limit of 70mph for the roads concerned and 
most  of  the  journey,  my  speed  was  substantially  lower  than  that...i  can  say  at  the 
scene,  the  road  conditions  were  comparable  to  those  that  I  had  experienced  whilst 
making my way to the scene and in particular, there was an area of standing water 

 
 
 
 
 
 
 
 
 
 
 apparent to me at the point where the dual carriageway central reservation sends at 
the top of  Mortal Ash Hill. ”  

•  Police reconstruction report –  
o  para.3.30 – …“cloudy with heavy rainfall and the road surface was wet.” 

(4)  The  absence  of  any  explanation  for  this  accumulation,  and  the  consequential 
absence  of  any  remedial  action  undertaken  to  prevent  a  repetition  of  these  events 
gives rise to a concern that the highway at that location remains at risk of water ingress 
(from whatever source) unless and until the cause can be established and appropriate 
remedial action taken. 

As noted above we have undertaken 3 wet weather safety inspections of the area on 
15, 17 and 22 November 2022.  There was no evidence of standing water identified 
during these inspections. We can only conclude it was the sheer volume of water, that 
was not forecast, during that morning that contributed to the accumulation of excess 
surface water on the highway. There were no issues reported regarding standing water 
at this location on the day in question or prior to this incident. 

In conclusion, and after further investigations  of this area, we conclude that this was 
an unforeseeable event caused by extreme rainfall with  there being no evidence of 
subsequent accumulation of water at this location. We have had no further complaints 
of standing water at this location which we consider corroborates our findings. 

In the circumstances,  we do not intend to take  any further action at this location, other 
than ensuring monitoring of the highway in accordance with the Council’s system of 
inspection as set out above.  

It is recognised that the loss of a life is a tragedy in any circumstances and the council 
are  focused  on  ensuring  that  there  are  lessons  learnt  from  any  incidents  and  their 
highway  network is safe  as  reasonably practicable  for road  users  by  managing  the 
presence of safety defects on the highway. 

I  can  confirm  that  we  have  no  issues  with  the  publication  of  this  response  to  any 
interested parties by the Chief Coroner. If you require any further information, please 
do not hesitate to contact me. 

Yours Sincerely 

Assistant Director Economy and Environment