Prevention of Future Deaths reports · 2023

Mason Williams

Regulation 28 report to prevent future deaths, reference 2023-0442, written 10 Nov 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report10 Nov 2023
Reference2023-0442
DeceasedMason Williams
CoronerMichaela Blackmore
Coroner areaWarwickshire
CategoryChild Death (from 2015) · Road (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:  Prevention of Future Deaths Report    

Master Mason Williams 

THIS REPORT IS BEING SENT TO:    

1.  The Chief Executive 

 of Warwickshire County Council.  

1.  CORONER    

I am:  Michaela Blackmore, Assistant Coroner for Warwickshire, Warwickshire Justice Centre, 
Newbold Terrace, Royal Leamington Spa. 

2.  CORONER’S LEGAL POWERS    

I make this report under the Coroners and Justice Act 2009, paragraph 7, Schedule 5, and  

The Coroners (Investigations) Regulations 2013, regulations 28 and 29.    

3. 

INVESTIGATION and INQUEST    

On 16 December 2022, I commenced an investigation into the death of Master Mason Williams 
(aged 13 years). The investigation concluded at the end of the inquest on 10 November 2023 at 
Warwick Coroners Court and my conclusion was a Road Traffic Collision. 

4.  CIRCUMSTANCES OF THE DEATH  

On the 30 November 2022, at about 5.00pm Mason Williams was walking with three friends along 
the footpath next to Trinity Road, Piccadilly near Kingsbury. A car was travelling along Trinity Road, 
in the same direction as the boys. At this time, it was dark and the street lighting were not working. 
Mason and two of his friends decide to hide from a friend who has walked on ahead. As a group they 
crossed the road onto the opposite verge. Mason attempted to cross the carriageway back to his 
friend and was struck by a car. He died in hospital 3 days later. 

The conclusion of the Inquest was a Road Traffic Collison. 

5.  CORONER’S CONCERNS   

During the inquest, the evidence and information 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:  

i. 

ii. 

The street lighting along Trinity Road, Piccadilly, nr Kingsbury was not illuminated at the 
time of the Road Traffic Collision due to a fault. I am told the fault was with the 
underground cabling which was affecting lamp posts 16 to 21 along Trinity Road.  
I am aware that the cabling may have been damaged from a previous Road Traffic Collision 
that occurred on 20 October 2022.  

6.  ACTION SHOULD BE TAKEN    

In my opinion, action should be taken to prevent future deaths and I believe that you 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 6th January  2024.    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 following:   

1.  HHJ Teague QC the Chief Coroner of England & Wales Chief Coroner's 
Office, 11th Floor  Thomas  More,  Royal  Courts  of  Justice,  Strand,  
London,  WC2A  2LL. chiefcoronersoffice@judiciary.gsi.gov.uk   

2.  The family of Master Mason Williams 

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 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. 

Date: 10th November  2023

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 Warwickshire County Council (PDF)
Ms Michaela Blackmore 
Assistant Coroner 
Warwickshire Justice Centre 
Newbold Terrace 
Leamington Spa 
CV32 4EL 

28th December 2023 

Dear Ms Blackmore,  

Resources Directorate 
Shire Hall, Warwick, CV34 4RL 
DX 723362 Warwick 5 

Director of Strategy, Planning & Governance  

www.warwickshire.gov.uk 

RE:   REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

FOLLOWING INQUEST INTO THE DEATH OF MASTER MASON WILLIAMS 

I refer to your report to the Chief Executive dated 10 November 2023 in which you raise 
concerns about faults with the street lighting on Trinity Rd, Piccadilly near Kingsbury.  

You  indicate  that  the  street  lighting  was  not  illuminated  at  the  time  of  the  road  traffic 
collision on 30th November 2022 that resulted in the death of Mason Williams and that 
this was due to a fault with the underground cabling which affected lamp posts numbered 
16 to 21 along Trinity Road.  Your report states that you are aware that this fault may 
have been caused by damage to the cabling as a result of a previous road traffic collision 
on 20 October 2022. 

You  have  written  to  the  Council  because  you  believe  that  action  should  be  taken  to 
prevent future deaths. 

The Council’s response 

The  Council’s  records  indicate  that  the  previous  road  traffic  collision  on  Trinity  Road 
occurred on 28 October 2022 and not 20 October 2022 when a street lighting column (no. 
18) was damaged by a vehicle.  The Council received police incident report 108 of the 
28/10/2022 notifying of a collision at the location.  The Council instructed its contractors 
to  attend  as  an  emergency  and  they  attended  on  28  October  2022.  On  attending,  the 
contractors  found  that  lighting  column  no.  18  had  been  hit  and  was  unsafe  so  took 
emergency action to cut down the column and prevent it from falling before a new column 
could be ordered and installed.    Damage to the underground cabling was not detected 
at this time. The Council was not aware that streetlights 16, 17, 19, 20 and 21 were out 
until 5 December 2022 when its contractors attended following the police report of the 
fatality and discovered the damaged cabling.  

  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 When  faults  with  street  lighting  are  identified,  officers  instruct  the  Council’s  contractor 
(
) to attend and carry out a repair.  The Council aims to attend and/or take 
action in respect of identified faults within the following timescales:  

Urgent or dangerous faults  

General faults  

Appropriate action within one hour depending on the 
severity of the situation  
Attend within five working days  

•  Light being out  
•  Dim  
•  Flickering/flashing  
•  On during the day  

Underground  electrical  cable 
faults  

Once  fault  has  been  identified  -  within  25  working 
days. Lighting with complex issues can take longer to 
resolve.  

The Council has the facility for members of the public to report street lighting faults via a 
‘Report it’ link on its home page of the website or by telephone via the Council’s Customer 
Service Centre.   

The  Council  uses  a  central  management  system  to  monitor  street  lighting  (known  as 
Telensa  PLANet).   Where  the  system  identifies  a  problem  with  a  streetlight  (such  as 
flickering) it raises an automatic fault alert.  The system does not have the functionality to 
raise a fault alert where there has been a complete loss of power to a streetlight column.   

Streetlights 16 to 21 on Trinity Road were out in November 2022 due a complete loss of 
power so there was no automatic alert. No faults with the street lighting on Trinity Road 
had been reported to the Council via the website or the Customer Service Centre.   

In  order  to  detect  a  complete  loss  of  power  to  a  streetlight,  officers  have  to  manually 
interrogate  the  central  management  system  to  check  for  lights  that  have  not 
communicated with the system and judge whether the problem is transient or due to an 
on-going issue with the power supply.  This work requires a level of specialist knowledge 
of  the  central  management  system.   In  October  and  November  2022  the  resource 
capacity within the street lighting team meant that it was not possible to carry out regular 
manual interrogation of the system. 

Details of Action Taken: 

1.  The  damaged  power  cabling  on  Trinity  Road  was  temporarily  repaired  by  the 
Council’s  contractors  on  5  December  2022  to  restore  the  street  lighting.    The 
lighting  column  damaged  on  28  October  2022  (no.  18)  was  replaced  and  a 
permanent repair to the cable carried out on 17 January 2023.  The street lighting 
on Trinity Road has been fully operational since that date. 

 
  
  
  
 
 
 
 
 
 
 
 2.  The  Council’s  street  lighting  team  has  recruited  two  additional  employees  who 
started  work  on  6  November  2023.    The  central  management  system  is  now 
interrogated by an appropriately qualified officer on a daily basis. This means that 
street lighting faults that are not alerted automatically (ie due to power outage) or 
are not reported by the public will be detected very quickly.  

3.  The Council continues to respond to all reports or detection of faults in line with the 

timescales referenced above.  

4.  The Council met with Telensa, its contracted supplier of the central management 
system, in March 2023 and highlighted the lack of an automatic systems alert in 
the  event  of  a  complete  power  loss  to  a  street  lighting  column.    Telensa  have 
advised that they will consider updates and improvements that could be made to 
the system.  The Council will continue to work with Telensa to pursue a solution to 
this issue.  

On behalf of the Council I would like to offer our deepest condolences to Mason’s family 
and friends.  I hope that this letter will give some assurance about the steps taken to 
make Warwickshire’s roads safer for all who use them.   

Please do not hesitate to contact me if you have any queries about the content of the 
Council’s response.  

Yours sincerely 

Director of Strategy, Planning & Governance

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