Louis Thorold

ANNEX A 

REGULATION 28:  REPORT TO PREVENT FUTURE DEATHS (1) 

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

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO: 

1.  THE SECRETARY OF STATE FOR THE DEPARTMENT OF TRANSPORT 

1 

CORONER 

I am Simon Milburn, area coroner, for the coroner area of Cambridgeshire & 
Peterborough 

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. 
[HYPERLINKS] 

3 

INVESTIGATION and INQUEST 

On 24.01.21 I commenced an investigation into the death of Louis Steven James 
THOROLD (age 5 months 18 days). The investigation concluded at the end of the 
inquest on 26.07.23. 

The conclusion of the inquest was that Louis died as the result of a ‘road traffic collision’. 

The medical cause of Louis’ death was ‘multiple traumatic injuries’. 

4 

CIRCUMSTANCES OF THE DEATH 
Louis died at 1701hrs on 22.01.21 at Addenbrookes Hospital in Cambridge. Postmortem 
examination revealed that he died as a result of multiple severe traumatic injuries. At 
around 1551hrs earlier that day the driver of a car travelling north on the A10 Ely Road 
at Landbeach turned right across the southbound carriageway where it was struck by an 
approaching van. The van left the carriageway to the nearside as a result of the impact 
and struck Louis and his mother as she pushed him in his pushchair along the 
pavement. The van came to rest in a ditch on the far side of the pavement trapping 
Louis underneath. He was extricated by a passer-by and treated at the scene. Sadly, 
Louis went into cardiac arrest and despite prolonged attempts at resuscitation and 
transfer to hospital he died of his injuries. 

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 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.  – 
During the inquest I heard evidence that drivers who reach 70 years of age and are 
therefore required to reapply for their driving licence at that point(and thereafter every 3 
years) do so via an online self-certification process and that there is no need for 
independent medical scrutiny or input unless there is an issue which is specifically 
drawn to the attention of a medical practitioner. In this case one of the drivers involved in 
the road traffic collision was driving with undiagnosed dementia which effected their 
cognitive ability to perceive hazards on the road. 

1 

 I am concerned that if drivers beyond the age of 70 continue to drive without 
independent medical scrutiny of their continued ability to drive then there is a risk of 
deaths occurring in similar circumstances. 

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 [DATE]. 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 
Louis’ Family 
I am also under a duty to send the Chief Coroner a copy of your response. 

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. 

18 AUGUST 2023 

9 

2

Date:  12th October 2023 

PRIVATE AND CONFIDENTIAL 
Mr S. Milburn 
Cambridgeshire and Peterborough Coroner Service 
Lawrence Court 
Princes Street 
Huntingdon 
PE29 3PA 

Chief Executive’s Office 
Box ALC2609 
New Shire Hall 
Emery Crescent 
Enterprise Campus 
Alconbury Weald 
Huntingdon 
PE28 4YE  

Dear Mr Milburn,  

Response to Regulation 28 Report regarding Louis Stephen James THOROLD 

Cambridgeshire County Council has considered the Regulation 28 report regarding the 
tragic circumstances surrounding the death of Louis Thorold and, in particular, the 
questions regarding the Council’s ‘Settlement Policy’. Your letter questioned whether the 
policy had been correctly applied (i.e., whether the location in question should be set at 
30mph). 

Since the collision, the County Council, in collaboration with Cambridgeshire 
Constabulary and developers Urban and Civic, have implemented a reduced speed limit 
in this area to 40mph, and has overseen the delivery of improvements associated with the 
Waterbeach New Town development, including a pedestrian crossing, and enhanced 
walking and cycling provision on the A10.  A separate note was provided to the inquest 
outlining these changes.   

Implementing Safe Speeds is a key pillar of the approach taken by the Cambridgeshire 
and Peterborough Vision Zero Partnership, of which the County Council is a member. 
The Partnership has developed a Speed Strategy, which alongside wider guidance and 
policies, assists in identifying the most appropriate speed for any given route1.  

This letter sets out the rationale for the current 40mph speed limit at Car Dyke Road. This 
rationale is informed by national and local policy and guidance.  

However, the County Council and the Cambridgeshire and Peterborough Combined 
Authority (CPCA) are presently developing an Outline Business Case to implement 
strategic enhancements of the A10 corridor. Route safety is a key consideration in the 
development of the business case.  In July 2023 the officer Project Board confirmed that 
the following four packages should be developed within the Outline Business Case: 

1  Vision Zero Speed Strategy 

Chief Executive 

 www.cambridgeshire.gov.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
 
 
 
 
 
 
 
 
 •  Package 2b: Online dualling between the A14 and Waterbeach  

•  Package 3b: Dualling between A14 and Ely (without the Waterbeach Bypass) 

•  Package 4: Offline dualling between the A14 and Waterbeach with a single 

carriageway route to Ely 

•  Package 7: focuses on public transport, and includes the Stretham Park and Ride 

Currently, the packages are only at concept stage, so the specific improvements are yet 
to be designed.  However, by managing both the strategic and local movements through 
the A10 corridor using proposed infrastructure including dualling, junction improvements 
and active travel measures the packages are being designed to improve road safety.  For 
example, by addressing the current congestion issues shunt type collisions and those 
associated with turning movements will be addressed.  The current timeline is that the 
Outline Business Case, which will include the results of stakeholder engagement and two 
periods of statutory consultation, will be completed in summer 2024 with a specific 
package of improvements identified for further development subject to further funding. 

Speed / Settlement Policy 
The Regulation 28 report refers to the County Council speed policy, with respect to 
settlements.  This policy states: 

The County Council will work towards the introduction of a 30mph speed limit in the 
developed parts of all settlements in the County where appropriate in relation to the 
nature of the street frontage, activity, environment, and density. Where suitable and 
affordable, complementary features may be required to encourage drivers to travel at an 
appropriate speed. Each location will be considered on its own merit. 

For speed limit purposes the following definitions will apply:  

I. 

II. 

A settlement will be ‘20 properties fronting onto a length of public highway over 
a distance of 600m’.  

The extent of a settlement will be ‘The point at which full frontage development 
begins’, or ‘at the first property fronting a road entering a settlement, on which 
there is at least 3 properties/100 metre length of road, prior to the point at 
which full frontage development begins’. 

First, it is important to note that speeds are not informed by a single, blanket policy. The 
latest policy with regards to settlements, as set out above, does highlight that there are 
other considerations, primarily relating to the nature of the route in terms of physical 
characteristics and demand.  

The route at Car Dyke Road does not present as a logical 30mph, as it takes the form of 
a primary road, and the surrounding land use context is not significantly developed. 

Whilst we recognise the number of frontages over the extended length of the route, it 
cannot be considered as ‘full frontage’ development in this location. The properties are 
set back from the road, in some cases not visible from the road and they are well spaced 
out.  This section does not, therefore, meet the criteria to be classed as a settlement. 

Chief Executive 

 www.cambridgeshire.gov.uk 

 
 
 
 
 
 
 
 
 
 National Speed Guidance  
The County Council’s speed limit policy is based upon the DfT Circular 1/13, Setting 
Local Speed Limits and gives characteristics of a road together with the appropriate 
speed limit. The table below sets out the DfT Speed limits for single carriageway roads 
with a predominant motor traffic flow function, such as the A10. 

There are safety implications with installing an artificially low speed limit. Speed limits 
should be easy to determine and should encourage self-compliance, i.e., the visual clues 
should tell a driver what the appropriate speed is, and it will feel natural as they are 
driving.  

Changing the speed limit and introducing nothing but a change in signage is very unlikely 
to ensure driver compliance on its own. If all speed limit signage were taken away, the 
driver should instinctively know what the speed limit is from the environment: a driver will 
choose different speeds for a rural road through open countryside and a built-up road 
through a town centre. 

The A10 is a primary route and was designed and built as a national speed limit road. 
There are some junctions, accesses, and bends.  Where a speed limit is set below the 
natural limit, compliance is likely to be low unless drivers can see the reason for the 
reduced limit. Compliance with the previous 50mph speed limit was good.  Since the 
reduction in speed limit to 40mph the compliance is low, with a vehicle average speed 
being recorded as 47mph.  

Department for Transport Circular 1/13 states that speed limits should not be used to 
attempt to solve the problem of isolated hazards such as a single road junction or 
reduced forward visibility (e.g., at a bend). 

Cambridgeshire County Council has sought the view from the police regarding safe 
speeds in this location.  Cambridgeshire Constabulary does not support a reduction in 
the speed limit to 30mph, commenting that: 

“whilst the circumstances surrounding the fatality were tragic, it was not speed related 
and a change in speed limit would be unlikely to have changed the outcome. The 
collision history at the location prior to and after the revised speed limit of 40mph was 

Chief Executive 

 www.cambridgeshire.gov.uk 

 
 
 
 
 
 
 
 put in place was benign. There is no evidence to suggest this location would be a cause 
for focus for road safety measures’.2  

Data 
The current speed limit is 40mph at the location. A one-week speed survey was 
conducted between Tuesday 19th and Monday 25th September 2023 using automatic 
traffic counting equipment. This is the preferred method of gathering speed data as 
drivers are less inclined to react to the presence of automatic counters unlike speed 
detection guns which can cause alarm and result in drivers braking.  

During the survey period 92,889 vehicle movements were recorded. The data showed 
that there is already a lack of compliance under the existing 40mph limit (52.5mph 
average velocity for the first 85% of vehicles). The average speed recorded across the 
one-week period was 44.1mph. It should be noted that this is an all-day average which 
includes peak times when average speeds are likely to be reduced due to the high 
volume of traffic. The lowest average speed recorded during the sample period was 
31mph which occurred during peak flow on Monday and Tuesday between 16.00 and 
17.00 hours. Whilst the highest average speed was 57mph on Thursday between 03.00 
and 04.00 hours. It is also noted that the average daily speed peaks at 47 and 48 mph for 
Saturday and Sunday respectively, indicating that speeds are likely to be higher at 
weekends.  

Taking all of this data into consideration, a further speed limit reduction would be unlikely 
to be adhered to under the current road and development environment.  

Summary 
Cambridgeshire County Council is committed to reducing Deaths and Injuries on all of our 
roads for all road user types.  

We recognise Safe Speeds as a fundamental pillar of the Safe Systems approach 
endorsed by the County Council and its Vision Zero partners. 

At the present time, based on (i) the nature of the route, (ii) observed vehicle speeds, (iii) 
national and local policies and (iv) comments from Cambridgeshire Police support, we do 
not propose to reduce the speed further.  

However, speeds on the A10 will remain under review, and road safety forms a key 
component of the A10 Outline Business Case (due to report in Summer 2024), which has 
potential to change the physical nature of the route.  

As part of the agreed planning mitigated for the Waterbeach New Town, a range of 
measures have been secured to provide enhanced services and facilities for non-
motorised road users, including a railway station, off-road walking and cycling and 
equestrian routes, and bus services. Furthermore, with the Greater Cambridge 
Partnership, we are developing segregated mass transit and adjacent non-motorised 
routes which will contribute to the safety and sustainability of the network in the area. 

2 

 – Cambridgeshire Constabulary Traffic Management Officer 

Chief Executive 

 www.cambridgeshire.gov.uk 

 
 
 
 
 
 
 
 
 
 Yours sincerely, 

Chief Executive 

Chief Executive 

 www.cambridgeshire.gov.uk

From the Secretary of State 
The Rt Hon Mark Harper MP 

Great Minster House 
33 Horseferry Road 
London 
SW1P 4DR 

05 January 2024 

Mr Simon Milburn,   
Area Coroner, Coroners Office  
Cambridgeshire & Peterborough Coroner Service  
Lawrence Court  
Princes Street  
Huntingdon   
PE29 3PA  

Dear Mr Milburn, 

Thank you for your report of 18 August 2023 made under the Coroners and 
Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) 
Regulations 2013, following the inquest you conducted into the death of Louis 
Steven James Thorold.  

I was very sorry to learn of the circumstances of Louis Thorold’s death and 
would like to express my sincere condolences to his family.   

I have considered your report and its recommendations very carefully and 
although our roads are some of the safest in the world, I would like to assure 
you that we are not complacent about road safety. I must stress that one road 
death is one too many and the Driver and Vehicle Licensing Agency (DVLA) 
is focused on ensuring that only those who meet the required medical 
standards are granted a licence.  

You set out your concerns that if drivers beyond the age of 70 continue to 
drive without independent medical scrutiny of their continued ability to drive 
then there is a risk of deaths occurring in similar circumstances and 
you asked that the department take action to prevent future deaths.    

The current driving licence arrangements are underpinned by a legal 
requirement that all drivers, of any age, must inform the DVLA if at any time 
they develop a medical condition that may affect safe driving. All drivers must 
meet the appropriate health standards for fitness to drive and a licence will 
only be issued to those who meet those standards.   

When applying for or renewing a driving licence, applicants must self-declare 
whether they have any medical conditions. The DVLA will investigate drivers 
who notify a relevant medical condition by obtaining information from them 
and where appropriate from their medical professionals.  

 
 
   
 
 
 
 
 
 
 
 
 
   
   
   
   
   
   
   
 
 
 
 
 
 
 
 
 
 The DVLA will also investigate notifications from third parties, including 
concerned family, neighbours, or health care professionals. This is in 
recognition of the fact there may be times when individual drivers do not 
notify the DVLA appropriately or where a health condition affects their insight 
into their driving safely.   

The DVLA takes road safety very seriously and wants to make sure that 
licence holders are fit and safe to drive. Drivers are encouraged to discuss 
any concerns about their driving fitness with their own medical professionals.  

Although there is no legal obligation on medical professionals to notify the 
DVLA about a patient who is medically unfit to drive, they do have a duty of 
care to their patient and to the public to report when they have concerns and 
their patient is unwilling or unable to notify the DVLA.  The guidelines issued 
by the General Medical Council (GMC) were updated in April 2017 and 
highlight a doctor’s duty to disclose information to the DVLA where the patient 
has failed to do so.   

In regard to older drivers, it is recognised that health can deteriorate in later 
life and driving licences expire at age 70 and are then renewed at least every 
three years. Applicants renewing a licence from age 70 must declare that 
they meet the legal eyesight standards for safe driving and confirm whether 
they have any relevant medical conditions which may affect safe driving. 
These regular renewals provide a timely reminder for drivers to consider their 
health in the context of driving.   

We have considered whether any changes to this policy are justified and 
proportionate. Driver licensing arrangements are designed to be balanced 
and proportionate for all drivers, and we are of the view that the current 
process for drivers renewing their licence at 70 strikes the appropriate 
balance between fairness, road safety and the individual. There is little 
evidence to suggest that introducing a stricter regime which includes 
mandatory testing or medical examination would improve road safety. For this 
reason, we do not propose to change the current approach.  

The DVLA recently published a Call for Evidence (CfE) on driver licensing for 
people with medical conditions. The CfE ran for 12 weeks and was an early 
stage request for input into a review of the legislative framework. Evidence 
has been gathered from members of the public and a range of experts across 
organisations. The CfE closed on 22 October and the responses are currently 
being analysed.    

The full information regarding the CfE is available 
via https://www.gov.uk/government/consultations/driver-licensing-for-people-
with-medical-conditions-call-for-evidence  

 
 
 
 
   
   
   
   
   
   
   
   
 The CfE is looking to identify areas where policy or legislative changes may 
be able to improve outcomes for all drivers and other road users. Once the 
outcomes to the CfE have been analysed the DVLA will be in a position to 
provide an update to Ministers.    

The Department for Transport does recognise that older people must be able 
to maintain the skills and confidence required to remain safe and effective 
drivers. With funding from my department, the Royal Society for the 
Prevention of Accidents (RoSPA) has developed an older drivers 
website www.olderdrivers.org.uk/. The website contains information to help 
older people to continue to drive for as long as they are safe to do so. It 
includes details on driving assessments and refresher training. It also 
provides advice on making the decision to retire from driving, if an individual 
is no longer able to drive safely. Driver education schemes are also provided 
by local authorities, and these are an effective way of providing support for 
older drivers and ensuring they remain fit and competent to drive.  

I can assure you that our policies are kept under constant review and 
reducing the numbers of those killed and injured on our roads is a key priority 
for the Department.   

Yours sincerely,  

The Rt Hon Mark Harper MP  

SECRETARY OF STATE FOR TRANSPORT