Prevention of Future Deaths reports · 2023

Minaal Salam

Regulation 28 report to prevent future deaths, reference 2023-0145, written 13 Feb 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report13 Feb 2023
Reference2023-0145
DeceasedMinaal Salam
CoronerEmma Serrano
Coroner areaStoke on Trent and North Staffordshire
CategoryChild Death (from 2015) · Road Traffic Collision
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 

THIS REPORT IS BEING SENT TO:  STOKE-ON-TRENT CITY COUNCIL 
CORONER 

1 

I am Emma Serrano Area Coroner for Stoke-on-Trent & North Staffordshire Coroner's Court 

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 19/04/2022 I commenced an investigation into the death of Minaal  Salam, aged 5. The investigation 
concluded at the end of the inquest on 17th January 2023. The conclusion of the inquest was Minaal 
Salam passed away on the 1 April 2022 outside her primary school Newstead Primary Academy, Blurton, 
Stoke-on-Trent, on Waterside Drive, after she was struck by a Volkswagen Touran.  This caused poly 
trauma that led to a traumatic cardiac arrest.  

The medical cause of death was: 
1a) Traumatic cardiac arrest. 
1b) Polytrauma. 
1c) Road Traffic Collision (Car on Pedestrian). 

II) - 
CIRCUMSTANCES OF THE DEATH 

4 

Minaal Salam was being collected, by her father, from her school.  This is Newstead Primary 
Academy Blurton Stoke-on-Trent.  The incident occurred outside the pedestrian school gate on 
Waterside Drive.  When leaving the school with her father, they were standing on the side of the road, 
waiting to cross.  She was hit by a motor vehicle, which caused survivable injuries.  She passed away at 
the sight of the incident.     

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.  –  

During the course of the inquest I heard evidence to suggest that investigations into the traffic is 
managed around this school should be done to prevent future occurrences.  In light of this, I have a 
concern that, if the traffic measures are not looked at, there is a risk of future deaths 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 6 

ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe you Stoke on Trent City 
Council 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 11 
April 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 

1.  The family of Minaal Salam; and 

2.  Staffordshire Police 

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

I may also send a copy of your response to any other 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. 

9 

13/02/2023 

Signature_
Emma Serrano Area Coroner Stoke-on-Trent & North Staffordshire Coroner's Court 

________________________

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 Stoke on Trent City Council (PDF)
City of Stoke-on-Trent (Traffic Regulation) (Waterside 
Drive, Newstead) (No.2) Order, 2023 and Highways Act 1980 
- Section 90 Proposed Traffic Calming –Waterside Drive, 
Newstead. 

NOTICE  IS  HEREBY  GIVEN  that  the  City  of  Stoke-on-Trent 
Council  in  exercise  of  its  powers  under  Section  90  of  the 
Highways Act 1980 and all other enabling powers, proposes to 
amend the existing row of 3 speed cushions on Waterside Drive 
into  a  full  carriageway  tapered  road  hump  (4250mm  x  full 
carriageway width x 75mm) at the following locations:-

1.  The Speed cushions located approximately 10m south west 

of its junction with Yaxley Place. 

2.  The Speed cushions located o/s No’s 253 / 257 Waterside 

Drive 

NOTICE  IS  HEREBY  GIVEN  that  the  Council  of  the  City  of 
Stoke on Trent propose to make an Order under Sections 1, 2, 4 
and 122 of the Road Traffic Regulation Act, 1984.  The effect of 
this Order is as follows: -

1.  To introduce school zig zag markings (No stopping At Any 
time) on the south side of Waterside Drive between points 
51m and 83m west of Yaxley Place. 

2.  Introduce  Double  Yellow  Lines  on  the  south  side  of 
Waterside Drive between points 83m west of Yaxley Place 
to its junction with Yeovil Place. 

Full  details  of  these  proposals,  including  plans  and  the  City 
Council’s  statement  of  the  reasons  for  proposing  to  make  this 
Order may be examined online at Stoketraffweb.uk 
If you wish to object to the proposals please send your reasons for 
objection 
to 
traffic.orders@stoke.gov.uk  by  the  17th  day  of  March  2023. 
(Please state DF/NM/TRO2/2023 on all correspondence. 

fao  Dave  Follows  by  e-mail 

in  writing 

DATED this 23rd day of February 2023. 

4 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                           
 
 City of Stoke-on-Trent (Traffic Regulation) 

(Waterside Drive) (No.2) Order, 2023. 

Statement of Reasons 

These proposals are intended to remove the inconsiderate parking that occurs around 
the  school  pedestrian  and  vehicular  entrances  onto  Waterside  Drive.  Following  the 
unfortunate  fatality  that  occurred  last  year  the  police  report  indicated  that  additional 
measures needed to be looked at to create better pedestrian visibility and reduce the 
vehicle/pedestrian conflict that could occur. 

By proposing these proposals, it will improve road safety outside Newstead Academy 
and long Waterside Drive within the vicinity of the school entrances. 

It  appears  to  the  City  Council  that  it  is  expedient  to  promote  this  Traffic  Regulation 
Order,  in order to prevent  danger to persons  or  other  traffic  using  the  road  to  which 
the order relates and prevent the likelihood of any such danger arising. 

6

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