Prevention of Future Deaths reports · 2024

John Bass

Regulation 28 report to prevent future deaths, reference 2024-0251, written 8 May 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report8 May 2024
Reference2024-0251
DeceasedJohn Bass
CoronerKrestina Hayes
Coroner areaSurrey
CategoryRoad (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: 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 Executive at Surrey County Council 

1  CORONER 

I am Krestina HAYES, HM Assistant Coroner for Surrey for the coroner area of Surrey 

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 13 December 2022 I commenced an investigation into the death of John William BASS 
aged 80.  The investigation concluded at the end of the inquest on 30 April 2024.  The 
conclusion of the inquest was that: 

Mr John William Bass died of head and chest injuries, at the age of 80 years of age, on 
A217 Brighton Road Tadworth, following a road traffic collision with a vehicle whilst he was 
riding his bicycle on 6th December 2022. 

4  CIRCUMSTANCES OF THE DEATH 

On 6th December 2022 Mr Bass, a fit and active cyclist fell from his bicycle on 6th 
December 2022 from the pavement on A217 Brighton Road, Tadworth, Southbound into 
approaching vehicle resulting in head and chest injuries from which he died. My conclusion 
was Road Traffic Collision. 

Surrey County Council is the highway authority responsible for the maintenance of this part 
of the public highway (the “Highway Authority”). 

A subsequent police investigation identified the footpath from which Mr Bass fell measured 
approximately 1.4 meters in width. However, due to the encroachment of mud/grass, twigs 
and acorns over the pavement space where Mr Bass was able to cycle it only measured 0.6 
meters wide. 

The Highways Authority confirmed in witness evidence, which was accepted under rule 23, 
that the A217 Brighton Road, Tadworth is subject to a yearly inspection. 

At the inquest the family advised that the footpath is used regularly by cyclists to avoid the 
vehicles on the busy road, where the speed limit is up to 40mph. This stretch of highway 
was said to have last been inspected on 14th November 2022 by car. A second scheduled 
inspection took place by foot on 22nd November 2022, just prior to the accident on 6th 
December 2022. The inspections did not identify any safety defects meeting the 
intervention level set out in Surrey County Council's policy. I am informed by the family 
shortly after the accident the pavement was cleared. 

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 

Regulation 28 – After Inquest 
Document Template Updated 30/07/2021 

 circumstances it is my statutory duty to report to you. 

The MATTERS OF CONCERN are as follows: 
(brief summary of matters of concern) 

When the footpath was inspected in November 2022, just weeks before the accident, the 
highway inspector did not consider the narrowing of pathway as a safety concern and or 
met an intervention level which required action. It is noted in the policy that there is 
reference to trees and vegetation, but no clear guidance in terms of vegetation which 
encroaches on pavements. I am concerned that there is a risk to future pavement users if 
clear guidance is not provided to inspectors to identify safety concerns regarding vegetation 
growth on footpaths. The Highways current inspection of the pavement is only yearly albeit 
in evidence given at inquest by the family, this road is used frequently by cyclists next to a 
busy road. I am therefore concerned that the frequency of the inspections need to be 
reviewed. 

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 July 03, 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 

 –  son 
Surrey County Council 

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: 08/05/2024 

Krestina HAYES 
HM Assistant Coroner for Surrey for 
Surrey 

Regulation 28 – After Inquest 
Document Template Updated 30/07/2021

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 Surrey County Council (PDF)
Krestina Hayes 
HM Coroner’s Court 
Station Approach 
Woking 
Surrey 
GU22 7AP 

Woodhatch Place 
11 Cockshot Hill 
Woodhatch 
Reigate  
RH2 8EF 

3rd July 2024 

Re: Bass 28 Report - Action to Prevent Future Deaths – John William BASS 

Dear Assistant Coroner Hayes, 

Further to the issuing of a Prevention of Future Deaths (PFD) Report on 8 May 2024, please 
find below Surrey County Council’s (SCC) response.  

At the outset, Surrey County Council wishes to pass on our condolences to the  Bass family 
following this tragic incident. 

We note that the Inquest took place in the Spring of 2024 and confirm that SCC provided a 
witness statement to the Assistant Corner detailing the Inspection history of the site, however 
SCC were not classed as an “interested party” at the inquest and so were not invited to attend 
the inquest to give evidence. 

SCC understands that the two matters of concern which the Assistant Coroner would like SCC 
to consider are set out within Section 5 of the PFD Report: 

1.  There is a risk to future pavement users if clear guidance is not provided to inspectors 
to identify safety concerns in terms of vegetation which encroaches on pavements 
2.  The current inspection regime whereby the pavement is inspected yearly needs to be 
reviewed based on the evidence provided at the inquest by the family of Mr Bass that 
the pavement is used frequently by cyclists 

Risk to future pavement users 

Background – Highway Authority responsibilities for pavements 

SCC understands that at the time of the accident Mr Bass was cycling on the pavement of the 
A217 Brighton Road Tadworth in a southbound direction north of Vicarage Close.   

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Section 72 of the Highways Act 1835 and Rule 64 of the Highway Code state that pavements 
are for the use of pedestrians not cyclists and accordingly, SCC’s Highway Safety Inspection 
policy only considers the safety of pavements with regards to pedestrians and not cyclists.   

Further to the receipt of the PFD report, SCC requested and received from the Coroners 
Service a copy of the Forensic Collision Report prepared for the Inquest and photos taken 
for the report.  The photos show the mud/grass, twigs and acorns described in Section 4 of 
the PFD report.  Highway case law from Rollinnson -v- Dudley Metropolitan Borough Council 
(judiciary.uk) found that that the duty upon Highway Authorities under s.41(1) of the 
Highways Act 1981 to maintain did not extend to a duty to remove surface-lying material, 
obstructions or spillages, whether or not they resulted in danger. The Court of Appeal upheld 
the Judge’s decision.  The Judge in the Rollinson vs Dudley Metropolitan Borough Council 
case described the conclusion as inescapable as the law had been established and further 
stated in his judgement that “The duty imposed by s.41 is a duty to maintain the fabric of the 
road, including its substructure such as its drains. The removal of surface-lying material 
which creates a danger is not within the section.” 

National Guidance on types of surveys 

Well  Managed  Highway  Infrastructure  –  A  code  of  practice,  provides  guidance  to  local 
authorities  on  developing  a  risk-based  approach  to  maintenance  of  highway  infrastructure.  
The  Code  identifies  a  number  of  different  types  of  inspections  and  surveys  that  Highway 
Authorities may carry out which are summarised below; 

1.  Safety inspections are designed to identify all defects likely to create danger or serious 
inconvenience to users of the network or the wider community. The risk of danger is 
assessed on site and the defect identified with an appropriate priority response 

2.  Service inspections mainly comprise detailed inspections tailored to the requirements 
of particular highway assets and elements to ensure that they meet requirements for 
serviceability.  The  scale  and  scope  of  these  inspections  will  be  determined  by  the 
authority’s approach to asset management 

3.  Condition surveys are primarily intended to identify deficiencies which, if untreated, are 

likely to adversely affect long term performance, serviceability and safety. 

4.  Reports  from  members  of  the  public  provide  a  further  source  of  information  on  the 

condition of all aspects of the highway network. 

Safety Inspections carried out by Highway Safety Inspectors are regular focused inspections 
where any immediate risks are identified and rectified within a limited time period of either 2 
hours, 5 working days or 20 working days depending on the Inspectors’ assessment of severity 
and risk which takes account of considerations such as the location and volume of use.  It 
should be noted that the time periods quoted are for SCC, other authorities may use different 
time  periods  for  rectification  of  defects.    This  service  ensures  that  our  Highway  Safety 
Inspection  resources  are  deployed  to  the  highest  risk  locations  and  situations,  however  as 
shown  above,  other  methods  are  employed  to  deal  with  less  immediate  risks  with  longer 
timescales for resolutions.   

Issues with regards to debris on the carriageway would generally be dealt with under the fourth 
item above, in response to reports from members of the public.  The resolution to this type of 

2 

 
 
 
 
 
 
 enquiry could either be that SCC will arrange clearance of the debris or they may liaise with 
the local borough council who provide street cleansing activities.  

Guidance to Inspectors 

As stated in our witness statement, the pavement on the A217 where the incident occurred, 
had been inspected by foot on 22nd November 2022, just prior to the accident and no safety 
defects meeting our intervention level were identified.  

Within SCC’s Highway Safety Inspection standards and procedures policy, there is a “Trees 
and Vegetation” defect category which relates to “Fallen debris causing obstruction to 
passage or vision”.  The inspection carried out on 22/11/22 did not identify any defect under 
this category because the Highway Safety Inspection Team interpret the policy reference to 
‘fallen debris’ as being an instance of an individual substantial tree, branch or hedge that has 

recently fallen and causing a definitive obstruction.  

Instances such as the situation on the pavements of the A217 in November/December 2022 
where there has been a narrowing of the footway due to seasonal vegetation growth/detritus, 
are considered as street cleansing or general maintenance issues rather than as “safety 
defects” which require an immediate response.  These situations are generally identified 
through reports from the public. 

Where members of the public report issues to us, a Highways Customer Officer will attend 
and may report issues such as this as “maintenance issues” which are passed on to our 
maintenance team to carry out routine maintenance.   This location was reported by a 
member of the public in January 2023 and following a review by the Highways Customer 
Officer, work was requested to remove debris and cut any encroaching vegetation 
overhanging the footway.  This is the work which was carried out in January 2023, as 
mentioned during the Inquest.   

SCC believes that our current inspection processes are in line with the legal requirements 
and with the risk-based approach encouraged by national guidance.  Following the receipt of 
the Prevention of Future Deaths report however, we have reminded our inspectors to 
consider the risk that narrowing/obstruction situations may pose, particularly to vulnerable 
users of pavements, such as wheelchair users or those with push chairs etc and to request 
maintenance works where needed, or to raise as an immediate risk for a quicker response 
where they consider such a risk to be very serious or life threatening. 

The current inspection regime 

The footway Hierarchy, which determines the inspection frequency, is established through a 
data led exercise and footways (pavements) are assessed according to the Council’s 
Hierarchy Definition Policy which can be found here.   

As outlined in the policy document the datasets used to determine hierarchy include shops, 
businesses, transport hubs, schools, industrial areas and other community facilities.  Once 
the data exercise has been undertaken, each area is reviewed by local engineers to sense 

3 

 
 
 
 
 
 
 
 
 
 
 check the outcomes of the data exercise and to recommend any amendments based on 
their local knowledge.  

Footways have four levels of hierarchy. The highest is a primary walking route (Category 1) 
which is inspected monthly, then a secondary walking route (Category 2) which is inspected 
every three months, link footways (Category 3) which are inspected every 6 months and 
finally local access footways (Category 4) which are inspected annually.  

The footway running along Brighton Road has been assigned as a Category 4 (link footway) 
in our policy because it does not meet any of the criteria for a higher category.  For this 
footway to have its hierarchy increased it would have to provide access to 5+ shops in the 
local vicinity, which it does not, and there are no other drivers to warrant it being 
recategorised as a Category 3 footway; namely – Linking local access footways, small retail 
shopping outlets typically +5 shops, large schools and Industrial outlets, +500 pupils or 
equivalent pedestrian movements. 

SCC considers the footway hierarchy for this section of the A217 Brighton Road to have 
been correctly assessed as Category 4 which is subject to an annual walked inspection, 
however we will respond to any reports of issues from the public at any point during the year.  

SCC hopes that the above demonstrates that SCC is managing our pavements in line with 
our legal responsibilities and national guidance.  As described, we have mechanisms in place 
to  respond  to  issues  with  debris  on  pavements  outside  of  our  Highway  Safety  Inspection 
process, and we have given due consideration to the recommendations made by providing 
further  reminders  to  our  Inspection  Team  around  consideration  of  risk  to  vulnerable  users 
posed by debris on pavements. 

Yours sincerely, 

Interim Head of Paid Service  

Director of Highways and Transport 

4

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