Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0543, written 21 Dec 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Dec 2023 |
|---|---|
| Reference | 2023-0543 |
| Deceased | Amal Ahmed |
| Coroner | Sean Cummings |
| Coroner area | Milton Keynes |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 4 |
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 before an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 2 Chief Executive National Highways Chief Executive of Milton Keynes City Council 1 CORONER I am Dr Sean Cummings, Assistant Coroner for the coroner area of Milton Keynes 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 On 20 November 2023 I commenced an investigation into the death of Amal Mohamed AHMED aged 38. The investigation has not yet concluded and the inquest has not been heard. 4 CIRCUMSTANCES OF THE DEATH Ms Amal Mohamed Ahmed died on the A5 southbound Little Brickhill at or adjacent to the point where the A5 joins the "off" slip road. She appears to have been using a satnav directing her to Queensway, Bletchley. She entered the exit to the off slip road and drove the wrong way down the slip road, ultimately colliding with a vehicle travelling at speed on the A5 head on. Ms Ahmed died at the scene. The driver of the other vehicle died later at the John Radcliffe Hospital. A passenger of one of the vehicles required critical care treatment and suffered life threatening and changing injuries. 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) The exit point of the A5 "off" slip road at the Little Brickhill junction is wide. The signage indicating No Entry appears to be inadequate as there are two No Entry signs which are widely spaced at the junction. One is positioned to appear to forbid entry to the road over the bridge leading over the A5 and does not obviously relate to the slip road. The second is positioned such that it obliquely faces the road over the bridge and would not be visible to a driver turning right onto the slip road until they had completed the manoeuvre placing them at risk. There is a No Right Turn sign as the junction is approached. There is also No Entry in large white letters at the mouth of the slip road junction, however, this may be (1) obscured by vehicles leaving the slip road and (2) the junction is unlit and was said by a witness as being "pitch black". After the collision attending police officers saw three further vehicles perform exactly the same manoeuvre as Ms Ahmed and attempt to travel down the slip road in the wrong direction. Local residents have contacted police and complained that it is a very Regulation 28 – Before Inquest Document Template Updated 30/07/2020 common occurrence for drivers to mistakenly travel down the slip road in the wrong direction. The slip road is long and allows for the build up of considerable speed in turn facilitating what the police describe as a high energy impact. Following the collision, large temporary No Entry signs were positioned at the slip road junction. They were quickly removed apparently because the original signs were deemed to comply with necessary regulations. That seems wholly irrelevant to me because drivers are clearly commonly not seeing the signs because of the large numbers who mistakenly drive the wrong way onto the slip road. In my opinion, consideration should be given to alternative arrangements to prevent vehicles entering and travelling along the slip road in the wrong direction. 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 February 14, 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 Chief Coroner and to the following Interested Persons Chief Executive of Milton Keynes City Council Chief Executive National Highways I have also sent it to The families of the deceased who may find it useful or of interest. 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. 9 Dated: 21st of December 2023 Dr Sean Cummings Assistant Coroner for Milton Keynes Regulation 28 – Before Inquest Document Template Updated 30/07/2020
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 Coroner 2 Apple UK LIMITED 3 Google 4 TomTom 1 CORONER I am Sean CUMMINGS, Assistant Coroner for the coroner area of Milton Keynes 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 20 November 2023 I commenced an investigation into the death of Amal Mohamed AHMED aged 38. The investigation concluded at the end of the inquest on 16 July 2024. The conclusion of the inquest was that: Road traffic collision 4 CIRCUMSTANCES OF THE DEATH Ms Amal Mohamed Ahmed died on the A5 southbound Little Brickhill at or adjacent to the point where the A5 joins the "off" slip road. She appears to have been using a satnav directing her to Queensway, Bletchley. The exact satnav application is not known due to the physical damage occasioned to the phone during the collision. She entered the exit to the off slip road at the Little Brickhill junction and drove the wrong way down the slip road, ultimately colliding with a vehicle travelling at speed on the A5 head on. Ms Ahmed died at the scene. The driver of the other vehicle died later at the John Radcliffe Hospital. A passenger of one of the vehicles required critical care treatment and suffered life threatening and changing injuries. 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) I have made observations regarding the slip road at this junction in my initial pre-Inquest Report To Prevent Future Deaths dated the 21st December 2023. National Highways undertook a number of immediate remedial measures to try to prevent drivers turning and travelling the wrong way down this slip road, including narrowing the "mouth" of the slip road to one lane, placement of very large temporary "No Entry" signs and placement of signs indicating "Do Not Use Satnav" at the site. CCTV monitoring of driver behaviour was commenced. Police activity and monitoring by National Highways Regulation 28 – After Inquest Document Template Updated 30/07/2021 showed that despite these measures, drivers were still turning early and attempting to drive the wrong way down the slip road. Further enquiries by the police and information volunteered by members of the public who made the same incorrect manoeuvre led to the finding that while the visual map display on commonly used satnav applications at this junction displayed the correct information, the verbal commands gave information likely to confuse and direct drivers down the wrong slip road into the path of oncoming traffic. This was observed to happen frequently. 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 October 17, 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. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons National Highways Milton Keynes Council DirectLine Group I have also sent it to who may find it useful or of interest. 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: 23/08/2024 Sean CUMMINGS Assistant Coroner for Milton Keynes Regulation 28 – After Inquest Document Template Updated 30/07/2021 Regulation 28 – After Inquest Document Template Updated 30/07/2021
4 responses 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.
Subject: Re: Preventing Future Death Reports: AHMED HAYBITTLE 11/2023 Sent: From: To: 17/10/2024, 21:13:27 Importance: High Follow Up Flag: Follow up Flag Status: Flagged Dear , CAUTION: This email originated outside of Milton Keynes City Council. Please be extra vigilant when opening attachments or clicking on links. Report spam or suspected malicious email via the REPORT MESSAGE icon above. Thank you for your email providing Regulation 28 Preventing Future Death Reports which was passed to Apple’s privacy and law enforcement requests team for review. We immediately investigated the concerns raised and found no data or routing error on Maps which would have contributed to these tragic events. However, to ensure we were following the very best approach we are taking an additional measure to add the following special voice guidance for drivers heading past the A5 offramp toward the A5 onramp, which we intend will be live by the start of next week. - Drivers heading past the A5 offramp toward the A5 onramp would be instructed to "Continue straight at the overpass” (that will happen as they are traveling west toward the offramp). - While on the overpass, drivers would be instructed to “Turn right onto A5 toward Milton Keynes, Bletchley." We trust that the steps we are taking will be helpful to try to avoid any future such tragic events. Yours sincerely On Sep 24, 2024, at 11:25 AM, wrote: Good morning Please see attached the Regulation 28 Preventing Future Death Reports produced by the Coroner following the Inquests touching the deaths of Ms. Amal AHMED and Mrs. Tracey HAYBITTLE who died following a Road Traffic Collision on the 16th of November 2023. If you require anything further, please do get in touch. Best wishes, Coroner’s Officer Milton Keynes
Belgrave House, 76 Buckingham Palace Road, London SW1W 9TQ, United Kingdom Google UK Limited Mr Sean Cummings The Coroner’s Office Civic Offices 1 Saxon Gate East Milton Keynes MK9 3EJ By post and email: Dear Sean Cummings 16 October 2024 Regulation 28: Report to Prevent Future Deaths – Tracey Haybittle and Amal Ahmed We refer to your report dated 22 August 2024 regarding Mrs Haybittle and to your report dated 23 August 2024 regarding Ms Ahmed. This letter serves as a formal response to the queries and points raised within the reports. Circumstances of death We are deeply saddened to hear of the tragic circumstances relating to the deaths of Mrs Haybittle and Ms Ahmed. We understand from the reports that on 20 November 2023, Ms Ahmed’s vehicle collided with Mrs Haybittle’s vehicle on the A5 adjacent to the Little Brickhill junction. Ms Ahmed died at the scene; Mrs Haybittle died later at the John Radcliffe Hospital. A passenger of one of the vehicles required critical care and suffered life threatening and changing injuries. The reports indicate that Ms Ahmed appeared to have been using a GPS – or “satnav” – navigation system, but mistakenly entered the “off” slip road at the Little Brickhill junction and drove the wrong way at speed before colliding with Mrs Haybittle. We understand that the junction was painted with “No Entry” on the road surface – along with white, double broken lines (indicating “give way”) – and was flanked by two red “No Entry” road signs. National Highways subsequently undertook a number of measures to prevent other drivers from incorrectly entering the slip road, but observed that drivers frequently continued to do so. Enquiries by the police and information volunteered by members of the public suggested that the audio guidance given by their satnav systems may be confusing drivers into making the incorrect manoeuvre. Google Maps Google Maps is a mapping and navigation application provided to users in the UK by Google LLC. It can provide directions for users to travel from one point to another on foot, in a vehicle, by bicycle or by public transport. The application offers directions that can visibly be shown on the user’s device and/or offers audio guidance to prepare users for upcoming manoeuvres, and to guide them to the point at which they must turn or make the manoeuvre. Registered address: Belgrave House, 76 Buckingham Palace Road, London SW1W 9TQ Registered in England and Wales with registration number 03977902 Belgrave House, 76 Buckingham Palace Road, London SW1W 9TQ, United Kingdom Google UK Limited Safety is core to how Google develops and operates the Google Maps service, and we understand our responsibility to keep our users and other road users safe. We implement a multi-layered approach to ensure navigation instructions are provided safely, including through real-time data updates and algorithm optimisation, user feedback and reporting, and integration with other safety features such as Car Crash Detection on certain Pixel devices. We endeavour to ensure that any audio guidance given by Google Maps serves as a useful tool for drivers, though users must always obey road signs and traffic signals. Steps taken in response to the reports We recognise that the cases identified in the reports are tragic. While it is not clear whether Google Maps was involved, we have carefully considered whether there are improvements we can make to Google Maps to help ensure that similar incidents do not occur in future. We have therefore taken the following measures: ● We have liaised with National Highways and reviewed their helpful dashcam footage of the relevant junction. This has assisted our product and engineering teams in carefully investigating the audio guidance provided by Google Maps. Our teams are working on improvements to the timing of the audio guidance. ● As part of these improvements, we anticipate providing enhanced audio guidance in situations such as those in this case. This will involve an amended audio prompt as a driver approaches a junction where they would cross an overpass: “after the overpass, turn right”. We hope that this will provide clearer guidance for drivers and help reduce the risk that they make an incorrect turn. Although changes such as these require significant internal validation before they can be launched publicly, we hope to launch them in the near future. More generally, Google remains committed to continually improving its services to provide helpful navigation services, and we welcome feedback from users which can be submitted through the Google Maps mobile application or website. Yours faithfully Legal Department Google UK Limited Registered address: Belgrave House, 76 Buckingham Palace Road, London SW1W 9TQ Registered in England and Wales with registration number 03977902
Updated letter Dr Sean Cummings HM Assistant Coroner for Milton Keynes By email 24 January 2024 Dear Dr Cummings Regulation 28 Report - Fatal Road Crash, A5 Little Brickhill, 16 November 2023 Thank you for contacting me regarding the tragic events of 16 November 2023. We have been asked to respond to the Regulation 28 Report (Report to prevent future deaths) on 21 December 2023 with a deadline set of 14 February 2024. This letter sets out our position in respect of: • Confirmation of any concerns raised with MKCC regarding this junction. • Copies of the concerns raised. • MKCC’s responses to these concerns. MKCC has received no formal complaints in relation this junction nor related signage that we have been able to establish from examination of our customer service records. We have had some reports using our on-line forms and a note of those is set out in the annex to this letter. The slip road, its junction with the local road, and the signage and road markings at the end of the slip road are part of the National Highways asset and they are therefore the responsible highway authority. MKCC has no powers to action any improvements to the junction mouth, the signage located there, or any road markings to prevent unauthorised entry. MKCC is highway authority for the local road that the A5 on and off slips connect to. Comments about the absence of highway lighting in the vicinity are noted, and this would be MKCC’s responsibility on the connecting local road and National Highway’s on the slip road, although it is a rural location and there is no nearby power supply at present. City highways officials visited the site on 20 November after the fatal incident with Thames Valley Police (TVP). TVP then convened a video call with MKCC and National Highways on 21 November and National Highways took subsequent actions on their junction. We would Civic, 1 Saxon Gate East, Central Milton Keynes, MK9 3EJ agree with National Highways that the signage appeared adequate to regulations, although we would suggest that the National Highways no-entry signage at the slip road junction may benefit from illumination (although the Traffic Signs Regulations and General Directions guidance does not require this). We will, of course, co-operate with any actions arising from the inquest that are in our power. Yours sincerely Chief Executive Annex ‘Report-Its’ Received We have looked back over 2023 using the search terms ‘A5 Slip Road’ and we have had some ‘Report-Its’ made. There are other ‘Report-Its’ relating to potholes and flooding in the vicinity. We received a ‘Report-It’ made on 28 May 2023. The records show that in this case a highways inspector visited the location on 2 June 2023 and made the following note ‘Inspection on 02/06/23 enough signage and road marking on road saying no entry. No safety defects found all below investigatory levels’. This reflects his remit to consider the condition of those assets in respect of safety. A standardised response was sent to the customer. We have another ‘Report-It’ made on 21 November 2023 which was made following the incident. The same inspector visited the site again and again found no immediate safety hazard based on condition (of the asset) and highlighted to the resident on 13 January 2024 that we have investigated and intend to review the situation at a later date as part of our planned work programme. A standardised response was sent to the customer. If at any time we identify an urgent safety hazard on a road where National Highways has responsibility for doing any works we would engage with them. Civic, 1 Saxon Gate East, Central Milton Keynes, MK9 3EJ
HM Coroners Office Civic 1 Saxon Gate East Milton Keynes MK9 3EJ United Kingdom Email: By email Amsterdam, 16 October 2024 Subject: Regulation 28 – Report to Prevent Future Deaths Dear Mr. Cummings, We are writing in response to your reports dated 22nd and 23rd August 2024, regarding the accident at the A5 near the Little Brickhill junction. First of all, we would like to extend our condolences to all those affected by this tragic event. At TomTom, the safety of our customers and all road users is our priority, and we take security matters very seriously. Following the report, we reviewed our navigation systems’ verbal instructions provided near the junction at hand. We have simulated different scenarios, including speed variations of 60mph and 30mph, to better understand how our navigation systems presented instructions based on driver speed. The scenarios assumed that the driver would either (i) maintain maximum speed until the junction; or (ii) slow down when approaching it. The outcome of the review revealed that instructions were given either (i) right when passing by the off-slip road; or (ii) after passing by the off-slip road, when on the overpass towards the exit. As part of our ongoing efforts to enhance road safety, we recently implemented additional safeguards, to limit drivers’ confusion where possible, regardless of their speed behavior on the road, by timing the verbal commands closer to the actual exit, and in any event after passing the off-slip road. However, please note that in order for these changes to be effective and visible by end users, they need to use the latest map and therefore in certain circumstances need to update their systems/devices. Although our navigation systems offer road assistance and simplify each journey, drivers remain responsible for driving. That said, we believe that the mentioned changes in verbal instructions, combined with the steps taken by National Highways to improve safety at this location will provide drivers with clearer and more timely guidance. Thank you for bringing this to our attention. Please do not hesitate to contact us if you have any further questions. This letter is submitted without prejudice and TomTom reserves all rights accordingly. Yours sincerely, TomTom International B.V. VP / Head of Commercial Legal
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