Harry Colledge

HMC Kate Bisset 

Preston Coroner's Court 

2 Faraday Drive 

Fulwood 

Preston 

PR2 9NB 

Dear Ms Bisset 

Response to Regulation 28 Report 

Inquest into the death of Harry Colledge 

Date: 

18/01/2024 

I am writing in response to your Regulation 28 notice dated 16.11.2023 to outline the actions taken by 

Lancashire County Council (“the Council”) to address your concerns. 

The Council has taken this incident, and your findings, very seriously. The Council took a proactive 

approach in addressing your concerns immediately following the conclusion of the inquest hearing, 

prior to receipt of your Regulation 28 notice. Geotechnical investigations were undertaken prior to the 

inquest to identify whether any short-term actions were required at the accident locus to ensure the 

safety of highway users. I provide further detail below. In addition, the Council took immediate action 

following the conclusion of the inquest on 13.10.2023. 

The following actions have been taken to address your concerns: 

1. 

Inquest Debrief 

Following the conclusion of the inquest, a meeting was arranged between Senior Managers to review 

this case and discuss your findings, which were delivered in Court on 13.10.2023, and ensure steps 

were put in place to address your concerns. 

As a result of the meeting between Senior Managers, a debrief presentation was developed containing 

the key facts of the case, lessons learnt, and operational instructions. This presentation was delivered 

to all Countywide Operational Managers and the Highway Inspection Manager on 18.10.2023. The 

presentation was then shared with all maintenance operational staff and Highway Safety Inspectors in 

a series of team meetings, which were completed by 27.10.2023. The incident debrief has also been 

delivered to wider Highway services to ensure a greater operational awareness. 

In summary, the debrief highlighted: 

Lancashire County Council 
PO Box 100, County Hall, Preston, PR1 0LD 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
  
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
   
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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That it was inappropriate to use Highway Operative staff to identify defects in a "find and fix" 

way, as carried out on 14.09.2022 following the series of defect reports provided by the Parish 

Council, and that this practice would not be used in future. 

That the recording of all defect reporting by the public must be managed through the service 

Highway Asset Management System and that any works done must also be recorded. 

That operational staff and Highway Safety Inspectors must be on notice of surface cracking – 

particularly but not exclusively, on the Moss Road Network. 

That operational staff and Highway Safety Inspectors must be on notice of defects which are a 

hazard to all road users including cyclists and non-motorised users. 

2.  Training 

In addition to the specific learning from this incident delivered through debrief sessions, the Council 

has developed its training programme as follows: 

a)  Highway Safety Inspectors 

The role of a Highway Safety Inspector is to carry out cyclic inspections in line with the inspection 

regime set out in the Council’s Highway Safety Inspection Policy. The policy sets out that this role will 

be responsible for the identification and consequent action relating to maintainable vehicular highway 

defects within the bounds of Section 41 of the Highways Act 1980. 

It is recommended in national guidance set out in Well Managed Highways that Highway Inspectors are 

trained, qualified and competent in the identification of defects. The UK Roads Board sets out 

minimum competency standards and these are delivered through the IHE (Institute of Highways 

Engineers) Training and Certification scheme. Highways Authorities are required to demonstrate that 

Highway Safety Inspectors have been assessed against these standards. 

The core modules of the training undertaken by Highway Inspectors employed by the Council include: 

an understanding of highway law, inspection policies and procedures (including maintenance 

priorities, road hierarchies, inspection frequency, methods, levels, and response criteria), material 

recognition and measuring techniques, hazard and defect recognition (including types of defects, 

techniques of defect repair), health and safety, and safety inspection and assessment. 

The Council currently employs 13 cyclic Highway Safety Inspectors. Existing highway safety inspectors 

are required to refresh their formal training every 5 years and there were a number of new inspectors 

who required foundation training. This training is in line with national standards as set out by IHE. It is 

accredited by CABWI and is identified as a mandatory training requirement including refresher training 

for all Lancashire County Council Highway Inspectors. Refresher training was completed on 

31.10.2023. Foundation training was delivered over 3 sessions on 13.11.2023, 11.12.2023 and 

08.01.2024. The final course was completed on 12.01.2024. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
     
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
   
 
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On-going development and ensuring that Highway Safety Inspectors are up to date with any national 

changes, is delivered through targeted additional accredited training and through regular team 

meetings which are held monthly. 

b)  Highway Technicians for Countrywide Maintenance 

The role of Highway Technicians as part of the Countywide Maintenance Team includes the 

responsibility to reactively respond to publicly reported defects on the maintainable vehicular highway. 

This role will assess and validate the reported defect in line with the Council's Highway Safety 

Inspection Policy and manage the delivery of a permanent repair within the response times set out in 

the policy. 

As part of a review of the role and the responsibilities required for the validation and assessment of 

highway defects, it was identified that to ensure Highway Technicians were suitably trained and 

competent in this part of their role, they should also be trained to the same standard as the Highway 

Safety Inspectors through on-the-job and formal accredited training. It was also identified that their 

operational line manager, the Assistant Operations Engineer, should also undertake formal training. A 

further 26 countywide staff have completed this training over 4 sessions which concluded in January 

2024. The same training sessions delivered to Highway Safety Inspectors, as highlighted above, have 

also been delivered to Highway Technicians. 

c)  Highway Operative 

The role of Highway Operatives is to drive and operate vehicles and plant to prepare and lay materials 

to maintain and improve the highway network as directed by the Countywide Maintenance Team 

compliant with site plans, and Health and Safety Legislation and completing records on hand-held IT 

equipment. 

Highway Operatives are trained to use the vehicles, plant and tools required to carry out highway 

defect repairs safely. They are specifically trained in the method of repair required for the wide range 

of highway defects that they are directed to repair. Highway Operatives work in crews of 2 or 3 and 

crews are made up of a Chargehand and Operative, the Chargehand having supervisory responsibility 

over the Operative. Chargehand are usually more experienced highway workers and have a wide and 

comprehensive experience of highway repairs. 

Highway Operatives are not required to identify or assess any defect as set out in the Highway Safety 

Inspection Policy, however they are given the scope to repair additional defects they may see within 

the area of highway contained in any traffic management already in place. 

The delivery of the inspection regime set out in the Highway Safety Inspection Policy is the primary 

responsibility of the Highway Safety Inspectors and Highway Technicians and not that of the Highway 

Operatives. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
  
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
   
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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As outlined above, there is an instruction in place that Highway Operatives are not to be used for 

defect identification through the "find and fix" method of working, their capacity being limited to 

repairing additional defects to those directed where they can be seen within existing traffic 

management arrangements. 

However, in light your findings, the Council recognises that Highways Operatives would benefit from 

awareness training in the form of a toolbox talk to include general defect types and impacts on all 

types of highways users is to be delivered to all operatives. The presentation has been drafted and 

approved in readiness for countrywide delivery and will be delivered over a 2 week period starting on 

22.01.2024. This will also set out a clear process for reporting defects to Highways Inspectors and 

Highways Technicians for assessment should they be seen whilst carrying out their general duties. 

d)  Awareness Training – front line highway teams 

The Council has carefully considered how, in addition to formal training, continued development and 

awareness can be delivered to front line highway teams. 

The Council intends to deliver an annual workshop for highway staff who are responsible for the 

inspection and assessment of highway defects to ensure compliance with the Highway Safety 

Inspection Policy, to deliver a consistent countywide approach and to update staff on any national 

guidance changes and learning from operational activities. This will be arranged in April 2024 and 

annually thereafter. 

3.  Development and promotion of “LoveCleanStreets” 

In April 2022, the Council launched “LoveCleanStreets”, a new public reporting system to replace its 

web-based reporting tool. LoveCleanStreets has significant advantages over the original reporting 

tool, in that it can be used both as an App and in a web-based form. It also allows customers to pin 

the location of a defect onto a map and attach photographs. This allows the receiving maintenance 

team to be directed correctly to the exact location so defects can be assessed within the 2-day 

response time set out in the Highways Safety Inspection policy. LoveCleanStreets passes all provided 

information directly into the County's Highway Asset Management system where it is managed by the 

Countywide Teams. 

In April 2023 the Council’s web-based reporting system was replaced by LoveCleanStreets and all 

digital requests are now received via this system. 

Whilst the Council remains open to other forms of defect reporting for example through telephone 

calls, the use of LoveCleanStreets is being actively promoted as the most efficient and accurate way in 

which customers can advise of highway defects. Where reports are received by telephone or other 

means, the Customer Access Team will now create a LoveCleanStreets report to ensure that any 

defects are mapped accurately and can be responded to effectively. 

4.  Highway Safety Inspection Policy Review 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
     
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
   
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
  
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The Council has identified that in addition to the current requirement set out in the Policy to review it 

as and when necessary, but especially when changes to either legislation or national guidance are 

introduced, an annual review of the whole policy should also be carried out. The Policy has been 

updated and republished to include this change. 

The Council has also identified that a peer review of the Highway Safety Inspection Policy could assist 

in identifying any changes or improvements to the current policy. The original policy was written in 

2018 and was compared with other local authorities at that time. A peer authority has been 

commissioned and the review will start on 22.01.2024. It is anticipated that this review will take up to 

8 months to complete. 

Although this review will consider all aspects of the Council’s Highway Safety Inspection Policy, the 

Council will highlight the outcome of this case and ask the reviewer to consider this as a matter of 

priority to ensure any additional learning or recommendations can be progressed. 

5.  Moss Road Strategy 

In light of Mr Colledge’s accident, the Council commissioned a full Geotechnical Survey of Island Lane, 

which was disclosed prior to the inquest. 

Research into increasing the longevity of moss roads is ongoing within the Council.  New and 

innovative techniques and products (including the use of geosynthetic materials) have been trialled in 

several locations with varying degrees of success. 

Where cracking in the carriageway surface is reported, the area will be inspected by a qualified 

Highways Inspector to determine the depth of the cracking. If the cracking is shallow and only 

penetrates the surface course, the affected area can be cut out and resurfaced. Where the cracking 

penetrates down the superficial deposits, the affected road surface area could be cut out and the 

underlying road construction excavated and replaced. Alternatively, it may be possible to inject/pour 

material into the crack to fill the void to avoid excavating large sections of the road. 

Awareness of common defects on peat moss roads has been raised through the post-incident debrief, 

which is set out above. 

The Council’s current Moss Road Strategy will be reviewed by the Council’s Asset Management Team. 

It is anticipated that this review will be completed by April 2024. The strategy will also be re-published 

with any updates and will be reviewed annually from 2024. 

Yours sincerely, 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
  
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Director of Highways and Transport