Prevention of Future Deaths reports · 2023

David Levett

Regulation 28 report to prevent future deaths, reference 2023-0121, written 18 Apr 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report18 Apr 2023
Reference2023-0121
DeceasedDavid Levett
CoronerAnne Pember
Coroner areaNorthamptonshire
CategoryRoad (Highways Safety) related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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

Regulation 28: REPORT TO PREVENT FUTURE DEATHS 

NOTE:  This form is to be used after an inquest. 

REGULATION 28 REPORT TO PREVENT DEATHS 

THIS REPORT IS BEING SENT TO: 

1  Chief Executive of National Highways 

1  CORONER 

I am Anne PEMBER, Senior Coroner for the coroner area of Northamptonshire 

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 18th  April 2018, I commenced an investigation into the death of David Levett aged 53 
years. The investigation concluded at the end of the Inquest on 13th  April 2023. The 
conclusion of the Inquest was: -

1a Bronchopneumonia 
1b Head and chest injuries sustained in a road traffic incident 28.1.18 

2 Megacolon due to faecal loading. 

4  CIRCUMSTANCES OF THE DEATH 

On the evening of 28th January 2018, a car broke down on a stretch of the M1 south-bound 
motorway near Daventry known as a “Smart Motorway”. A second vehicle came to the 
rescue of the first and parked behind the first vehicle in lane 1. A lorry collided with the rear 
of the second vehicle, pushing it into the rear of the first vehicle. Mr David Levett was a 
rear seat passenger in the second vehicle. He received severe head and chest injuries and 
was conveyed to Hospital. He succumbed to his injuries and was confirmed deceased on 
24th February 2018. 

My conclusion was Road Traffic Collision. 

5  CORONER’S CONCERNS 

During the course of the investigation my inquiries revealed matters giving 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 are as follows: 
(brief summary of matters of concern) 

DURING THE COURSE OF THE INQUEST, EVIDENCE WAS GIVEN THAT THE LOCATION OF 
THE COLLISION WAS ON AN ALL LANE RUNNING SMART MOTORWAY. THERE WAS 
NOWHERE FOR THE DRIVER OF THE FIRST VEHICLE TO PARK SAFELY e.g.. ON A HARD 
SHOULDER. 

Regulation 28 – After Inquest 
Document Template Updated 30/07/2021 

 6  ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe you (and/or 
your organisation) 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 June 12, 2023.  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 family of David Levett 

I am also under a duty to send a copy of your response to the Chief Coroner and all 
interested persons who in my opinion should receive it. 

I may also send a copy of your response to any person who I believe may find it useful or 
of interest. 

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  Dated: 18/04/2023 

Anne PEMBER 
Senior Coroner for 
Northamptonshire 

Regulation 28 – After Inquest 
Document Template Updated 30/07/2021

Responses

1 response 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)
REGULATION 29 RESPONSE TO A REPORT ON ACTION TO PREVENT FUTURE 
DEATHS 

THIS RESPONSE IS BEING SENT TO: 

The Senior Coroner for the Coroner Area of Northamptonshire, Anne Pember of The 
Guildhall, St Giles’ Square, Northampton NN1 1DE in response to a ‘Regulation 28 
Report to Prevent Future Deaths’ following an inquest hearing into the death of DAVID 
LEVETT that concluded on 13 April 2023. 

1. 

  NATIONAL HIGHWAYS  

, 
I am 
Chief Executive of National Highways Limited of Bridge House, 1 Walnut Tree Close, 
Guildford, SURREY, GU1 4LZ. 

 Director of Road Safety, responding on behalf of 

At the  outset,  on behalf of  National Highways, I would like to  express my deepest 
condolences to Mr Levett’s family, friends and all those affected by his tragic death.  

In complying with our duty, National Highways has responded within 56 days of the 
date of the Regulation 28 report to prevent future deaths, namely by 12 June 2023. 

2. 

  CORONER’S MATTERS OF CONCERN 

The MATTERS OF CONCERN were identified in the Regulation 28 as follows: 

“During the course of the inquest, evidence was given that the location of the collision 
was on an all lane running smart motorway. There was nowhere for the driver of the 
first vehicle to park safely e.g. on a hard shoulder.” 

3. 

  DETAILS OF ACTION TAKEN 

is 

the  government-owned  company,  sponsored  by 

the 
National  Highways 
Department 
for  Transport  (DfT),  charged  with  operating,  maintaining  and 
improving England's  motorways  and  major  A-roads.    Responsibility  for  local  roads 
rests  with  local  highway  authorities  and  the  road  network  in  other  parts  of  the  UK 
rests with the devolved administrations.   

At National Highways safety is at the forefront of every decision we make, and we 
are committed to the safety of everyone who uses our roads. 

According  to  the  2019  performance  report  published  by  CEDR  (Conférence 
Européenne  des  Directeurs  des  Routes  /  Conference  of  European  Directors  of 
Roads), motorways in the UK have by some margin the lowest rate of fatal accidents 
of any roads in Europe1. And overall, according to the latest published data (2016-
2020) in terms of fatal or serious casualties, smart motorways are our safest roads2. 

The technology currently used on smart motorways3, all focused on drivers, is 
made up of a system of different features so that there is no over-reliance on a 
single feature. It includes: 

• 

variable speed limits to help keep traffic moving, reducing stop-start traffic. 

1 https://www.cedr.eu/download/Publications/2020/CEDR-Technical-Report-2020-01-TEN-T-2019-Performance-
Report.pdf 
2 https://nationalhighways.co.uk/media/uivj2zem/smart-motorways-stocktake-second-year-2022.pdf 
3 Smart motorways are in three forms. 1) All lane running (ALR) motorways apply variable speed limits and 
permanently convert the hard shoulder into a running lane. 2) Dynamic hard shoulder (DHS) motorways apply 
variable speed limits and use the hard shoulder as a running lane at the busiest times. 3) Controlled motorways apply 
variable speed limits to a conventional motorway and retain a permanent hard shoulder. 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 •  MIDAS which is a detection system to monitor traffic for changes in flows and 

speeds and automatically sets signs and signals (speed limits) 

•  CCTV cameras that our operators can remotely move and zoom to monitor 

• 

and manage congestion and incidents, when notified.  
signs  and  signals  to  provide  better  information,  which  can  alert  drivers  to 
hazards ahead and display Red X signals to close a lane or lanes to traffic, 
including when a stopped vehicle is identified. 

•  enforcement  cameras  to  deter  the  minority  who  exceed  mandatory  speed 
limits  and  fail  to  comply  with  Red  X  signals.  These  signals  are  set  for  the 
safety  of  drivers  and  their  passengers  in  difficulty,  or  road  workers  and 
emergency services who need a safe space to work. 
clearly signed and orange-coloured emergency areas set back from the road, 
with telephones linking directly to our regional control rooms.  

• 

To further reduce the risks associated with live lane stops and to enable a quicker 
response we have introduced a radar based stopped vehicle detection (SVD) system.  
This is specific to all lane running motorways (ALR)3 and further enhances the system 
of features on these roads.  

All of these features are overseen by our dedicated National Highways teams, both 
in control rooms and on-road 24 hours a day, 365 days a year. 

Although risk cannot be completely eliminated, according to the latest published data 
(2016-2020) overall, in terms of fatal or serious casualties, smart motorways are our 
safest roads. Most incidents (95%) across the SRN are single vehicle collisions or 
incidents involving two or more moving vehicles. The rest of the collisions, which form 
a small proportion of all incidents (5%), involve moving vehicles colliding with stopped 
vehicles. These types of collision happen on all roads.  

The risk of a collision and the risk of a serious injury or death due to a stopped vehicle 
collision is lowest on conventional and controlled motorways. As reported in our smart 
motorways stocktake second year progress report4, the risk of a collision between a 
moving and a stopped vehicle is greater on ALR and DHS motorways than on other 
motorway types, but the risk of a collision involving only moving vehicles is lower.  

The concern raised focuses on the lack of a hard shoulder on an ALR motorway, and 
the subsequent question of where a driver can safely  stop in an emergency. Hard 
shoulders do not eliminate the risk of collision, and 1 in 14 of all deaths on motorways 
happen  on  hard  shoulders  (based  on  2016-2020  data).  The  hard  shoulder  is 
perceived to be a place of safety, but in reality it does not provide a completely safe 
place to stop. 

The term ‘live lane stop’ is used to describe instances where vehicles are required to 
stop and do this in a running lane with live traffic in it rather than a designated place 
of relative safety. This is not specific to ALR motorways and can occur on any road. 
On ALR motorways, there are designated ‘emergency areas’ which are places to stop 
in an emergency.  

Emergency  areas provide  a place  to stop  which are  safer than  the hard shoulder. 
Between 2016 to 2020 there have not been any fatalities in emergency areas.  

Since  the  time  of  the  incident  in  2018  there  has  been  ongoing  work  on  smart 
motorways  and  specifically  in  this  location  on  the  M1  Junction  18-17  southbound. 
This has included SVD being put in place in August 2022, more signs being installed 
in the vicinity of this incident informing drivers of the distance to the next place to stop 

4 https://nationalhighways.co.uk/media/uivj2zem/smart-motorways-stocktake-second-year-2022.pdf 

2 

 
 
 
 
 
 
 
 
 in an emergency, and the enforcement cameras have been upgraded to enable the 
detection of Red X violations to allow the police to take enforcement action. 

Smart  Motorway 
Recommendations 

Stocktake 

and 

Transport 

Select  Committee 

In March 2020 the government published a comprehensive smart motorway safety 
evidence stocktake and  action plan which sought to further raise the bar on smart 
motorway safety. National Highways has published two progress reports, one in 2021 
and a second in 2022, with a third planned to be published, setting out the progress 
we  have  made  towards  achieving  the  commitments  set  out  in  the  2020  stocktake 
report. 

The progress reports set out the actions that have been taken, including those which 
relate to the concerns raised in this Regulation 28 report. This includes, for example, 
an increase in the number of places to stop in an emergency, increased visibility of 
emergency areas and public awareness of what to do in an emergency if required to 
stop on a high-speed road, including smart motorways.  

In November 2021, the Transport Select Committee (TSC) published its report on the 
rollout  and  safety  of  smart  motorways,  and  made  a  number  of  recommendations 
which the government agreed to take forward in its response. Work to deliver these 
recommendations  is  ongoing  and  will  further  improve  safety  on  smart  motorways 
while supporting the actions started through the 2020 stocktake report. 

In April 2023 the government announced that plans for new smart motorways would 
be cancelled in recognition of the current lack of public confidence felt by drivers, and 
public  spending  cost  pressures.  This  followed  a  pause  in  the  rollout  of  new  smart 
motorways previously announced by the government, in January 2022 in response 
to the November 2021 TSC report.  

Our work to enhance  existing smart motorways continues.  The following initiatives 
are specifically ones that were designed to help further reduce the risks associated 
with live lane stops and to improve public awareness of actions to take if they are 
required  to  stop  in  an  emergency  on  any  high-speed  road,  including  smart 
motorways.  

Stopped vehicle detection  
SVD has been put in place on all operational ALR motorways. This is a radar-based 
system which detects stopped vehicles and will alert our regional control room if a 
stopped vehicle is identified. The operators in the control room can then respond by 
taking  actions  to  help  to  reduce  the  risks  associated  with  live  lane  stops,  such  as 
setting Red X signals to close lanes, displaying reduced mandatory speed limits and 
deploying National Highways traffic officers. SVD was put in place on the M1 between 
junctions 18 and 17 in August 2022. 

Report of obstruction messages 
We  committed  to  automatically  displaying  a  ‘report  of  obstruction’  message  on 
electronic overhead signs on the motorway, to warn approaching drivers of a stopped 
vehicle  ahead.  Since  September  2022,  where  SVD  is  in  place,  the  system 
automatically sets ‘report of obstruction’ messages each time the system detects a 
stopped vehicle, and this includes on the M1 between junctions 18 and 17. 

Places to stop in an emergency signage 
We have installed clearer, easier to understand and more frequent approach signs 
showing the distance to the next place to stop in an emergency. We have installed 
over 700 extra signs (some of which are on the M1 in the vicinity of this collision) so 
drivers should almost always be able to see a sign informing them of the distance to 
the next place to stop in an emergency. 

3 

 
 
 
 
 
 
 
 
 
 
 
 
 Upgrading enforcement cameras  
To help improve the safety of drivers, their passengers, road workers and emergency 
services, all enforcement cameras have been upgraded to enable the detection of 
vehicles that pass under a Red X or enter the lane beyond a Red X to enable the 
police to take enforcement action. This  includes the  cameras  in the vicinity  of this 
incident. 

Faster National Highways Traffic Officer attendance times  
We committed to achieve a national average 10 minute traffic officer attendance time 
on ALR sections where emergency areas are more than a mile apart (which includes 
the location in the vicinity of this incident). We achieved this by the end of September 
2022 and have continued to maintain it. 

Emergency areas on sat navs 
We  shared  information  with  sat  nav  companies  that  shows  places  to  stop  in  an 
emergency. We launched our Open Data Site in March 2021; this site enables sat 
nav  companies  to  access  National  Highways  geographical  datasets,  including  the 
location  of  all  emergency  areas.  We  have  informed  sat  nav  companies  of  the 
available  data  and  completed  discussions  with  them  and  the  DfT  to  understand 
uptake. 

Update to The Highway Code 
We worked with  the DfT and the Driver and Vehicle  Standards Agency (DVSA) to 
enable an updated Highway Code to be published on 14 September 2021. This is to 
help improve driver understanding and confidence when driving on a motorway. The 
update included clearer advice on where to stop in an emergency, the importance of 
not driving in a lane closed by a Red X, and how variable speed limits are used to 
keep traffic flowing. There was also updated guidance on key factors that contribute 
to safety-related incidents, including driving while tired, unroadworthy vehicles, safe 
towing, tailgating and driving in roadworks. 

Road safety / driver campaigns 
National Highways has an ongoing programme of road safety campaign activity to 
provide  important  guidance  to  drivers  to  make  journeys  safer,  easier  and  more 
reliable.  

In March 2021 we launched our biggest ever road safety campaign, ‘Go left’, to give 
drivers  clear  information  about  what  to  do  in  a  breakdown  on  a  high-speed  road, 
including smart motorways. This remains an ongoing campaign.  

We worked with campaigners, recovery operators, the freight industry and others to 
ensure  the  messages  addressed  their  concerns,  and  made  use  of  high-profile 
television,  radio,  print  and  digital  advertising.  We  also  worked  with  social  media 
influencers and partners to help highlight our safety messages and target different 
audiences.  

We have set out here our advice for what to do in the event of a breakdown. This can 
also be found on our website at nationalhighways.co.uk. 

If your vehicle has a problem, or you get into trouble on a motorway, stay calm and 
try to exit at the next junction or motorway service area. If that’s not possible:  

•  put your left indicators on  
•  move into the left lane  
•  enter the next emergency area, or hard shoulder  
•  put your hazard lights on  
•  get behind a safety barrier where there is one - keep well away from 

• 

moving traffic  
call National Highways on 0300 123 5000, then a breakdown provider for 
help. 

4 

 
 
 
 
 
 
 
 
 
 
 If you are unable to exit your vehicle and get to a safe place, have stopped in a live 
traffic lane or feel your life is in danger: 

• 
• 

stay in your vehicle with your seatbelts and hazard lights on 
call 999 immediately or press the SOS button in your car.  

We have also co-ordinated a wider programme of road safety campaigns addressing 
issues  which  can  lead  to  incidents.  These  included  advice  to  drivers  about  the 
importance of carrying out vehicle checks before setting off, and about the dangers 
of  tailgating.  The  campaigns  were  delivered  through  traditional,  digital  and  social 
media.  

We worked with external stakeholders to launch England’s first major campaign in 
2021  to  raise  awareness  of  the  eCall  or  'SOS'  button  function,  which  increasing 
numbers of newer cars come with and which can be used to call for help, by the driver 
or  by  the  driver  for  someone  else  needing  help,  if  a  situation  requires  emergency 
services. This was on digital channels, including a dedicated campaign page on our 
website. The Highway Code (updated in September 2021), also now advises the use 
of eCall to contact the police and communicate a location directly to a 999 operator 
(rules 277, 279 and 283).  

In November 2022 we updated our eCall campaign, highlighting that the function can 
be used to help both the driver and passengers of a vehicle which has eCall, and to 
help other road users in difficulty. We also raised awareness of our campaign via the 
‘Driving  for  Better  Business’  programme.  In  April  2023  we  delivered  further  eCall 
campaign activity. A video about eCall is available on YouTube. 

Overall, the campaign has seen an increase in the correct use of the eCall system of 
connected emergency services calls from 22% in 2020 to 59% in 2022. This statistic 
was verified by the British Association of Public Safety Communications Officials. 

Driving on motorways hub 
We launched a ‘Driving on motorways' hub on our website in January 2022, which 
provides a central point for all our information and advice on motorway driving. The 
hub  was  launched  alongside  a  multimedia  campaign  and  radio  day,  with  content 
featured on over 450 stations reaching over 6 million listeners.  

These  activities  were  designed  to  reach  drivers  up  and  down  the  country  to  help 
provide a better understanding, and help increase their confidence, when travelling 
on all types of roads. 

4. 

  DETAILS OF FURTHER ACTION PROPOSED 

National Highways remains committed to helping drivers and their passengers to feel 
safer and be even safer on all our roads. We will continue with our programme of 
road  safety  campaign  activity,  which  is  intended  to  provide  important  guidance  to 
drivers to make journeys even safer, easier and more reliable.  

We will continue to work with stakeholders to raise road users’ knowledge of using 
eCall, so they can confidently use the safety feature if they are unable to leave their 
vehicle safely or if they see someone else needing help.  

In  taking  forward  the  2021  TSC  recommendations,  the  government  announced  in 
January 2022 it was committing £390 million to install over 150 additional emergency 
areas during the second Road Investment Period (2020-2025) on ALR motorways in 
operation and construction. This means drivers will have more places to stop if they 
get  into  difficulty.  In  comparison  to  January  2022  this  will  be  around  50%  more 
emergency areas, giving drivers added reassurance. 

5 

 
 
 
 
 
 
 
 
 
 
 
 
 
 National  Highways  will  also  continue  to  progress  the  remaining  actions  and 
recommendations from the government’s smart motorway stocktake (noting they do 
not directly affect this location), and also the TSC recommendations to continuously 
improve the safety of existing smart motorways.  

In  line  with  our  smart  motorway  stocktake  annual  progress  reports,  we  will  also 
continue to analyse the safety performance of smart motorways (including ALR) as 
part  of  our  ongoing  assessment  of  risks.  Based  on  the  findings  we  will  consider 
whether  we  need  to  take  additional  action  to  further  improve  the  safety  of  smart 
motorways. 

5. 

  TIMETABLE FOR ACTION 

DATE                            ACTION 

2023 and 2024 

Publication  of  the  Third  Year  Progress  Report  (2023)  and  a 
further  report  in  2024  to  continue  to  look  at  smart  motorway 
safety data. 

2025 

Emergency  area  retrofit  –  over  150  additional  emergency 
areas planned to be installed on ALR motorways currently in 
operation and construction, subject to governance. 

Retrofitting  more  emergency  areas  across  the  remainder  of 
ALR motorways will be considered when formulating the 2025-
30 Road Investment Strategy. This will be based on evidence 
of the potential benefits and considering whether the additional 
emergency areas help drivers to feel safer. 

6. 

  SAFETY OF ROAD USERS 

The safety of everyone on all roads matters; it is an imperative for our business in 
what we set out to achieve and a core value of our organisation.  

Every  death  on  our  roads  is  a  tragic  loss  of  life  and  we  again  offer  our  deepest 
sympathies to all those affected by Mr Levett’s death. 

Although roads, especially high-speed roads, can never be risk-free environments, 
our priority is the reduction of road deaths and injuries on our network, and we want 
everyone who travels or works on any of our roads to feel confident and safe. 

This is why we invest in road safety initiatives and public awareness campaigns, to 
help prevent death and injury and to help give drivers the information they need to 
have  safer  journeys.  This  is  in  addition  to  information  provided  by  other  external 
stakeholders, for example The Highway Code. 

National Highways remains committed to continuing to improve safety and providing 
even more information that is accessible to drivers. 

7 

SIGNED: 

, Director of Road Safety on behalf of 

, Chief 

Executive 

DATE:  12 June 2023 

6

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