Prevention of Future Deaths reports · 2024

Sonny Farrier

Regulation 28 report to prevent future deaths, reference 2024-0358, written 3 Jul 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report3 Jul 2024
Reference2024-0358
DeceasedSonny Farrier
CoronerJeremy Chipperfield
Coroner areaDurham and Darlington
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 
(After Inquest) 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO: 

The Chief Executive, Durham County Council 

1 

CORONER 

I am Jeremy Chipperfield , senior coroner, for the coroner area of Durham and 
Darlington 

2 

CORONER’S LEGAL POWERS 

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice 
Act 2009  (linked here) and Regulations 28 and 29 of the Coroners 
(Investigations) Regulations 2013 (linked here). 

3 

INVESTIGATION and INQUEST 

On 08-Dec-23, I commenced an investigation into the death of  

Sonny James FARRIER , 18 years old. 

The investigation concluded at the end of the inquest on 03-Jul-24. I concluded 
that death resulted from head injuries sustained in a road traffic collision, as 
described below. 

4 

CIRCUMSTANCES OF THE DEATH 

At around 1300 hrs on 2nd December 2023, the deceased was a passenger in a 

van travelling north-east along  Butsfield Lane in Consett, when driving control 

was lost as the van slid downhill on ice and collided with a tree at the bottom of 

the hill, where the road changes direction.  

Having disembarked from the van, the deceased was struck by a car travelling in 

the same direction, a few minutes after the van; at the point of collision, the car 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 was also out of control due to slippery conditions on the same stretch of 

Butsfield Lane. 

On the same day, at least two further independent incidents of loss of vehicular 

control were caused by slippery conditions on the same stretch of Butsfield 

Lane. 

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.  –  

The Road called Butsfield Lane in Consett (locally known as “Bogle Hole Lane”), 

approximately 1 km north-east of its junction with Delves Lane, includes a hill of 

between 19 and 21% gradient, with a bend immediately beyond its lower 

portion.  

In slippery conditions, and in the absence of effective mitigation, passage of 

vehicular traffic along this stretch of Butsfield Lane presents a hazard and risk of 

death to road users. 

6 

ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe 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 29 August 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. 

2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 8 

COPIES and PUBLICATION 

I have sent a copy of my report to the Chief Coroner and to the family of the 
deceased.  

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 

03-Jul-24                                 

Jeremy Chipperfield 

3

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 Durham County Council (PDF)
Mr Jeremy Chipperfield 
Senior Coroner for County Durham and Darlington 
HM Coroner’s Office 
Fourth Floor  
Civic Centre 
North Terrace 
Crook   DL15 9ES 

By email 

3rd September 2024 

Dear Mr Chipperfield 

Fatal Road Traffic Accident  
Saturday 2nd December 2023 – Unclassified 11.3 – Butsfield Lane 

I write regarding the attached correspondence dated 3rd July 2024 relating to the 
unfortunate fatal accident which took place on the Unclassified Butsfield Lane in Consett, 
known locally as “Bogle Hole Lane”, on 2nd December 2023. 

The fatal accident investigation team identified six observations/recommendations. I can 
confirm following receipt of the fatal accident report council officers took the following 
actions regarding the observations/recommendations: 

•  Replace damaged black and white marker post – The post has been replaced; 
•  Check accuracy of gradient and if required change the existing sign with the “new” 
gradient – The gradient was checked between 2 known points 120m apart. It is 
accepted there are some isolated locations between the 2 points where the gradient 
exceeds 13% but the average gradient is 13%. No further action required/taken; 

•  Repair existing weight restriction sign – Work completed;  
•  Consider the provision of an additional salt bin – New additional salt bin provided; 

Neighbourhoods and Climate Change 

www.durham.gov.uk 

 
 
 
 
 
 
 
 
 
   
 
 
 
 
  
 
 
 
 
 
 
 
 
 Page 2 of 3 

•  Consider repairing void “off the carriageway” near to the accident location – Work 

completed; and  

•  Determine if the existing timber post and rail fencing surrounding the bridge parapet 
is sufficient - The bridge parapet (designed with a return) was assessed under IAN 
97/07 Parapet Assessments as part of a Principal Bridge Inspection in 2017 and its 
condition at that time was deemed adequate for containment. As there has been no 
significant deterioration in the bridge condition these findings remain current. The 
existing timber post and rail fence is not part of the bridge structure and is in private 
ownership. No further action required/taken. 

In terms of the council’s winter maintenance policy I can confirm. 

Gritting Routes 
The Council precautionary salts 45% of our highway network as part of our Priority 1 
network, with a further 10% being treated in prolonged severe weather as part of our 
Priority 2 network.  This is much higher than many other similar Highway Authorities and 
shows the Council’s commitment to provide the best winter maintenance service we can in 
line with available resources. 

However, we need to ensure that these limited resources are used where they are most 
effective.  Therefore, we concentrate our resources on strategic roads. Butsfield Lane is 
not a strategic road, and therefore, like many other rural / residential roads countywide it is 
not included in our priority treatment network. 

Our Winter Service Plan explains the rationale for our priority treatment routes and this is 
available on our website as follows: 

http://www.durham.gov.uk/winterserviceplan 

Emergency Assistance 
Our Winter Service Plan details how we can assist in the event of emergencies and 
prolonged severe weather. 

In summary, routes not on the priority treatment routes will be cleared at the request of the 
Emergency Services as appropriate.  

Prolonged Severe Weather 
The public may request for routes not on the priority treatment routes to be cleared by 
contacting our Customer Services team by one of the following routes: 

•  Website: https://doitonline.durham.gov.uk/ 
•  Telephone: 03000 260000  

However, these requests can only be considered once the Priority 1 and Priority 2 routes 
are cleared and are prioritised subject to available resources. 

Salt Bins 
In addition to the gritting routes the council provides salt bins placed strategically across 
the highway network.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Page 3 of 3 

The assessment uses a salt bin scoring system for footways and carriageways which 
considers local factors such as gradients, highway usage, severity and frequency of 
bends, accident history, etc., in determining whether a request is justified. 

As a Council we currently provide over 2,400 salt bins countywide, and we must target our 
resources where they are most needed and where they can have the greatest impact 
considering the local factors mentioned above.  

Signage 
Following receipt of the council’s fatal accident report and the concerns highlighted in your 
report we have also investigated other potential safety features we could facilitate to 
improve safety on Butsfield Lane for example the introduction of additional signage. 
However, having reviewed and considered the advice provided in The Traffic Signs 
Regulations and General Directions 2016 there is not a sign, or combination of signs which 
would be suitable for this location. 

The council takes its responsibility to ensure the highway network is maintained in a safe 
and serviceable condition all year round and especially during the winter period. This can 
be evidenced by the importance it places on its winter service. However, on this particular 
road, having reviewed all options we don’t consider improvements to the network can be 
achieved practically and therefore whilst we accept the death of an individual as a result of 
weather conditions is a very emotive subject we have come to the very difficult conclusion 
that no further action is required on Butsfield Lane. 

Yours sincerely 

Head of Highways  

Copy 

, Strategic Highways Manager

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