Jennifer Wong

Department for Transport 
Great Minster House 
33 Horseferry Road 
London 
SW1P 4DR 

Web Site: www.gov.uk/dft 

:  

28 October 2022 

Mr Darren Michael Salter 
HM Senior Coroner for Oxfordshire 
Oxfordshire Coroner’s Office 
Oxfordshire District Register Office 
2nd Floor 
1 Tidmarsh Lane 
Oxford 
OX1 1NS 

Dear Mr Salter, 

Thank you for your Regulation 28 report dated 2 September and 
accompanying documentation, sent to the Department for Transport following 
the conclusion of the inquest into the death of Jennifer Wong. I am replying 
as Head of Vehicle Safety Systems & Consumer Incentives in the 
International Vehicle Standards division, which leads for the Department on 
vehicle construction standards. 

I understand that Ms Wong sustained fatal injuries whilst riding her bicycle 
when a mobile crane collided with her whilst it was turning left at a traffic light 
junction. You found that the evidence considered during the inquest revealed 
matters of concern relating to the construction of the vehicle, including driver 
vision and the fitting of side mounted direction indicators. 

The Road Traffic Act 1988 generally requires vehicles used on the roads of 
Great Britain to comply with a range of regulations with respect to 
construction and use, including the Road Vehicles (Construction and Use) 
Regulations 1986 (as amended) (C&U) covering, view to the front and 
mirrors, together with the Road Vehicles Lighting Regulations 1989 (as 
amended) (RVLR) covering direction indicators. 

Mobile cranes based on a standard Heavy Goods Vehicle (HGV) chassis will 
need to meet the standard provisions set for HGVs, including any mandatory 
requirements for close proximity and front mounted mirrors. However, some 
mobile crane types, typically those with a greater lifting capacity which are 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 specially designed and constructed to fulfil their purpose are not classifies as 
HGVs and are permitted to operate under the Road Vehicles (Authorisation of 
Special Types) (General) Order 2003 (STGO). The Order provides 
exemptions from some elements of the standard requirements but also 
imposes additional provisions to mitigate potential risks, such as setting 
requirements for the use of amber warning beacons and speed restrictions. I 
understand that the vehicle involved in this collision was operating under 
STGO rules but, it is noteworthy that the Order with respect to mobile cranes 
offers no exemptions for view to the front, mirrors, or direction indicators.  

Regulation 30 of C&U covers view to the front and requires every motor 
vehicle to be so designed and constructed that the driver has a full view of the 
road and traffic ahead. As you have noted, for the purposes of Regulation 33 
of C&U, the subject vehicle is classified as a locomotive and requires as a 
minimum one exterior mirror fitted to the offside. From the evidence provided, 
the vehicle appears compliant with regards to the C&U requirements. 
However, these regulations set the minimum standards considered necessary 
and there is flexibility for manufacturers/operators to install additional devices 
for indirect vision, including additional mirrors, cameras, and sensors should 
they wish to do so, and I note from the evidence that this vehicle is fitted with 
an additional mirror to the nearside. 

Regulation 18 of RVLR sets requirements for the obligatory lamps and 
requires most vehicles first used after 1986 to be fitted with approved front, 
rear, and side direction indicators. By reference to publicly available records, 
the vehicle appears to have been first registered and used in 1997 and 
should therefore be fitted with side mounted direction indicators. However, 
the records also indicate that the vehicle was not registered in the UK until 
2007, suggesting that it may have been imported, and may explain why the 
side direction indicators were not present and the vehicle non-compliant with 
our domestic regulations.  

Enforcement of road traffic law is generally a matter for the Police, but most 
vehicles are also subject to annual  roadworthiness testing (popularly known 
as the MOT). However, vehicles operating under STGO are exempt from the 
statutory annual testing regime as many are too large or too heavy to fit into a 
standard Heavy Goods Vehicle Authorised Test Facility. These vehicles must 
still comply with the law and be maintained in a roadworthy condition so 
operators should have in place a robust programme of daily driver checks, 
regular inspections undertaken by a vehicle examiner and an annual safety 
inspection undertaken by an independent vehicle examiner. To help 
operators comply with the law and ensure safety, the Construction Plant-hire 
Association (CPA)1 in collaboration with the Driver and Vehicle Standards 
Agency of the Department for Transport prepared a detailed guidance 

1 The  CPA  is the leading  membership  and  representative  body  for  construction  plant -hire  in the UK. 
Established  for  80 years,  it now  has more  than  1800  members  and  supplies 85%  of  hired  plant  to the 
construction  industry. 

 
 
 
 
 
 
 
                                                 
 document entitled “Guide to maintaining Roadworthiness of Mobile Cranes,” 
which is available at the following link: - 

https://www.cpa.uk.net/safety-and-technical-publications/mobile-and-
crawler-crane-guidance 

Irrespective of these measures, the vehicle appears to have been used in a 
condition which was not compliant with regulations. Whilst it is impossible to 
determine with any certainty whether full compliance with the regulations 
would have prevented this collision, I shall be writing to the CPA in the next 
month to raise the issue of compliance and encouraging its members to 
consider additional devices or technology to help improve mobile crane driver 
vision. 

Finally, I note your comment regarding the launch of the Government’s Road 
Safety Investigation Branch (RSIB). This is at an early stage and action is 
underway to secure the necessary primary and secondary legal powers to 
enable the branch to operate and will also need to recruit a specialised team 
of inspectors. Colleagues leading this work intend to engage with the Chief 
Coroner’s office to determine how the RSIB might best respond to Regulation 
28 reports in future, but the branch will not become operational until 2025.  

I hope you find this information helpful and are assured that the Department 
and its agencies are taking appropriate action to respond to your concerns. 

Head of Vehicle Safety Systems & Consumer Incentives 
International Vehicle Standards

Date: 27 October 2022 

Mr D M Salter 
HM Senior Coroner for Oxfordshire 
Coroner’s Office  
Oxfordshire  

County Hall 
New Road 
Oxford 
OX1 1ND 

Dear Mr Salter 

RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

This is Oxfordshire County Council’s (“the council”) response to HMSC Salter’s Report to 
Prevent Future Deaths made under Regulation 28 of the Coroners (Investigations) 
Regulations 2013 dated 2nd September 2022 (Report).  

The report arose from an inquest concluded on 2nd September 2022 into the death of 
Jennifer Wong.  

I would like to take this opportunity to add my condolences to Ms Wong’s family and 
acknowledge the tragic nature of this case. I would also like to thank the Coroner for his 
report. The Report to Prevent Future Deaths covered 2 material matters of concern. This 
response is structured accordingly.  

Those matters were:  

1) 

The first and main concern is in relation to the nearside cycle lane and what appeared to 
be an element of confusion or perhaps a dilemma for cyclists at this location intending to 
cycle straight across the junction. The cycle lane puts cyclists on the nearside of a lane 
that is specifically for vehicles turning right into Headley Way. There is the box/advanced 
stop line in front of the line of traffic in the lane, but this requires the cyclist to decide to 
use it and, importantly, to have time to make it pass the nearside of the vehicles and into 
the box before the vehicles in the lane commence their right turn.  

If  there  was  no  cycle  lane,  it  appears  more  likely that  a  cyclist  heading  straight  across 
would position themselves in lane 2 for vehicles also heading straight on. I believe that 
further consideration should be given to this issue and if improved signage has a part to 
play to mitigate the risks. 

I  appreciate  of  course  that  it  is  not  possible  to  remove  risk  completely  and  cyclists  will 
make different choices about where to position themselves at a junction such as this one. 
I  anticipate  that  the  junction  is  not  dissimilar  to  many  others  in  Oxford.  The  issue  of 

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 cyclists  in  nearside  blind  spots,  particularly  involving  large  commercial  vehicles  with 
limited visibility, therefore presents a significant and ongoing risk. 

2) 

The second concern relates to the width of the cycle lane. It is believed to be 0.95 metres 
wide at this location, but the recommended width is 1.2m or perhaps 1.5m. I understand 
this is an issue which has already been raised following a site meeting. There may be 
valid reasons why the lane is the width it is, but I would be grateful if this could be 
considered. 

This response therefore firstly covers action that the council is taking to respond to your 
Matters of Concern. 

It then reports on what the council are further actioning in conjunction with our Highways 
maintenance provider Milestone to respond to your concerns. Finally, it refers to several 
other relevant actions that the council is either taking or has already taken to help mitigate 
the risk of these circumstances happening again in the future.  I anticipate that we will 
need to send you a further report in 6 months to update you on the progress of these 
developments.  

I would now like to outline activity that the council has taken and is now taking regarding 
traffic signals, cyclist safety and cycle lanes. 

Improvements to traffic signals, timings, signage for cyclists and cycle lane safety 

The council has taken on board your concerns and several measures have already been 
put in place to improve the public highway for vulnerable road users at both the Headley 
way junction and at two other key sites within the city.  The works that have been 
completed at Headley Way include: A 5 second advance green lights for cyclists heading 
east bound and a dropped kerb facility to bring cyclists off the London Road to turn left 
into Headley Way. We have also commissioned our highway maintenance contractors to 
undertake a series of road marking amendments to make it clearer for cyclists to utilise 
the junction.  The redesign of the lane/cycle markings has been commissioned to 
specifically consider the concerns that you raised in your Matter of Concern point 1.  The 
design and delivery of the works at the Headley junction are due to be completed by the 
end of November 2022. 

Width of cycle lane 

The  original  width  of  0.95m  was  a  legacy  of  a  scheme  that  was  installed  some  10  plus 
years ago.  The cycle widths are being amended to meet the current standards set out by 
the  Department  for  Transport  (1.2m  minimum)  and  work  is  being  undertaken  by  the 
council to establish where other sections of the city cycle network may be falling short of 
current  standards.  As  mentioned  previously,  the  amended  designs  and  works  will  be 
completed by the end of November 2022. 

Other Action 

Finally, reference below are additional steps that the council is taking in response to 
concerns raised throughout the inquest and in your Report, that we are committed to 
addressing at this time. 

These include:  

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Dropped  kerb  –  The  council  has  now  completed  the  dropped  kerb  facility  at 
Headley  way.  We  will  also  be  removing  the  stone  planter  to  increase  the 
space for pedestrians and cyclist at this junction. This now means that cyclists 
are  directed  off  the London  Road  before the  Headley Way  junction  to afford 
them safe passage to the shared use cycle/footway on Headley way.  

Elsewhere within the city (and beyond) a cycle safety group has been set up 
to undertake detailed reviews of known hotspots for cycle incidents. Currently 
these are The Plain Roundabout, Iffley Road, The Driftway and The Parkway 
entrance to ensure that there is a safe system for all road users.  This work is 
linked to the council’s commitment to Vision Zero (zero fatalities or seriously 
injured on our highway network by 2050).  The working group is made up of 
councillors, senior council officers and local cycling groups. 

Stage  4  Road  Safety  Audit  (RSA)  –  The  RSA4  was  completed  in  October 
2022.    The  report  is  attached.    The  council  is  now  ensuring  that  the 
recommendations are implemented in a timely manner that is proportionate to 
the risk posed by the measures being recommended for delivery. 

Vulnerable Road Users (VRU) Audit – following a request from the family, this 
was  commissioned  though  our  Highway  maintenance  provider  on  Friday  7 
October 2022.  There was slight delay in requesting this as we had to wait for 
the  Stage  4  RSA  to  be  completed  to  ensure  a  different  team  were  used  to 
undertake the additional assessment. This is to ensure the impartiality of both 
reports. The findings normally take a minimum of 31 days to be compiled into 
a report. This is the standard length of time that we would expect for such a 
report  to  be  developed.    The  council  will  write  to  the  coroner  with  the 
recommendations  of  this  report  upon  receipt.    The  council  can  confirm  that 
any further actions that are recommended within either the Stage 4RSA or the 
VRU  report  will  be  actioned  with  immediate  effect  where  it  is  a  priority 
measure  recommended.    These  measures  will  be  agreed  with  the  cycle 
safety group to ensure that local users of the network are consulted and that 
they are content with the council’s proposals.  

Users of the council’s highways and cycle paths can recommend suggestions 
for  amendments  to  the  cycle  infrastructure  through  our  defect  reporting 
system  Fix  My  Street. 
these 
suggestions/requests  and  measures  are  then  implemented  if  they  are 
deemed  to  be  of  benefit  to  the  users of  the  highway  and  the  cycle  network. 
These suggestions can range from the removal of a single bollard to a whole 
junction review.   

  The  council  monitors 

inbox 

the 

for 

The  council  has  recently  undertaken  a  detailed  review  of  the  Plain 
Roundabout  and  The  Parkway  junction  with  amendments  planned  to  be 
implemented to both locations in November 2022. 

The council has reviewed its key junctions that were deemed to be a potential 
risk to vulnerable road users with input from the cycle safety groups.  These 
reviews have involved site meetings and virtual meetings to fully understand 
what  is  required  to  make  the  junctions  as  safe  as  is  reasonably  practicable 
with the resources that are available.  In some locations these have been split 
into short, medium and long-term measures to enable some quick mitigations 
whilst  having  a  more  strategic  overview  of  future  developments  in  the  area 
that will dramatically change the layout of some of the areas. 

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 The  council  is  committed  to  the  delivery  of  Vision  Zero  and  several  work  streams  have 
been  set  up  to  ensure  that  a  holistic  approach  is  taken  when  considering  maintenance, 
renewal,  and  development  of  schemes  within  Oxfordshire.  The  council  has  a  dedicated 
team  who  are  project  managing  the  implementation  of  this  work.  Oxfordshire  County 
Council  is  determined  to  learn  from  this  deeply  tragic  case  and  takes  the  coroner’s 
concerns very seriously.  

Yours sincerely 

Interim Chief Executive 
Oxfordshire County Council 

 www.oxfordshire.gov.uk  

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