Moira Farnell

Regulation 28 Response to Coroner – 
Mentieth Close, Bletchley. 

Prepared by 

, Director Environment and Property  

Date 

 8 October 2024 

(To be submitted by 10 October 2024) 

Executive Summary  

This note responds to the Regulation 28: Report to Prevent Future Deaths dated 28 August 2024 
issued by the Senior Coroner for Milton Keynes in respect of the death of Moira Farnell.  

The Council extends its deepest sympathies to her family. 

The Council as the highway authority for the City of Milton Keynes is required by the Highways Act 
1980 to maintain the public highway network in a condition that is safe for users. The public highway 
network includes footpaths, such as the footway at Mentieth Close. 

To keep the highway in a safe condition we regularly inspect our network in accordance with the 
Council’s Code of Practice for Highway Safety Inspections. This is a public document dated May 2022, 
which is in line with well managed highway infrastructure 2016. This is national guidance and 
compliant with relevant statutory obligations. These documents are regularly reviewed and kept up 
to date by both the Council and the UK Roads Leadership Group to ensure they are always relevant 
and reflect national best practice. 

The process for inspection and determination whether to act is a risk-based approach, with several 
factors being considered such as size, location, likelihood of danger, and other considerations that all 
play a part in the final determination. Applying these assessments against the national guidance and 
based on national training and qualifications, to arrive at a ‘standard’ national approach that all 
highway authorities adhere to. 

Our codes of practice ensure that we fully comply with the nationally set out approach, and our 
records demonstrate we meet the minimum inspection frequency requirements and as the Highway 
Authority we are robust and responsive in our approach. This was demonstrated by our same day 
attendance after the first reported incident at Mentieth Close and our subsequent visits to check if all 
assessment considerations had been applied correctly and any lessons recorded.  

Our records demonstrate that we carry out regular inspections to our assets including over 1,550 km 
of highway, 350 km of redway, over 600 bridges, 75,000 gullies, 58,000 streetlights and illuminated 
items plus over 130 roundabouts. The number of assets we look after is growing all the time with 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 new development areas and adoptions of roads and footways. Each year our highway network 
increases by 10 to 12km as we adopt new highway from developed areas. 

Like all local authorities, we do not have limitless resources, so we prioritise what work we can do to 
fix immediate safety issues whilst also looking at how we can prolong the life of our assets and so we 
don't have to keep making regular, minor repairs.  

Once a highways issue has been reported to us, we'll look at the details and if necessary, carry out an 
inspection and assess if it meets the minimum requirements for action based on the relevant codes 
of practice, detailed above. This process is based on the guidance, which dictates a risk analysis-
based approach dependant on the specific sites and local factors. Where something exceeds the risk-
based action level it will be recorded as a defect. If a defect is a high-risk safety issue, we will carry 
out emergency repairs or will close off an area for safety and plan the necessary works as soon as 
possible. Depending on the nature of the defect, sometimes they are added to our wider yearly 
capital programmes to be covered by project work at that location. 

Summary of contact/actions at Mentieth Close 

On the 18 April 2024, a member of the public reported to the highways service of the Council that an 
incident had occurred resulting in a personal injury, at Bala Close, with an alternative location of 
Mentieth Close added to notes.  

In response, an inspection was carried out on the same day by a Council’s highways inspector at both 
Bala Close and Mentieth Close. The Inspector who undertook the inspection found no defects, i.e. 
nothing met or exceeded thresholds as set out in the codes of practice or national guidance at either 
location, therefore no action was recorded by the inspector. 

On the 19 April 2024 an internal email from the housing service was sent to the Director stating that 
a woman had fallen and injured herself at  Mentieth Close and was subsequently taken to hospital. 
This information was passed to highways on 19 April 2024 with the exact location. 

On 22 April 2024 another member of the public reported to highways on the Mentieth Close incident 
and gave the exact location of the incident – 

 Mentieth Close.  

As a result of these reports, and notwithstanding the inspector's finding of 18 April 2024, the Council 
carried out another site inspection on 24 April 2024 at 
 Mentieth Close this time by two different 
inspectors (working as a pair) for a review of the previous decision making / application of the code. 
Their conclusion of ‘no actionable defects’ was applied consistently in line with the codes of practice. 
Again, no area of the surface of the footway met the intervention criteria for action based on the 
national guidance and local code of practice, and therefore no defect was identified for repair 
following the inspection. Please see the photographs below from this inspection in annex A.   

Enquiries recorded relating to Mentieth Close – The Lakes Estate, 
Bletchley 

The Council has no history of relatable enquiries or similar reports at Mentieth Close for highways 
and landscape going back 25 years. The last 5 years for housing have also been checked to determine 
if the location has been previously reported.  

 
 
 
 
 
 
 
 
 
 
 Highways and Landscape 

Landscape – 28.10.1999 – Opposite 27 – Collapsed wall 
Landscape – 12.04.2000 – Side of No. 1 – report of a tree removed leaving chippings against wall 
Landscape – 20.07.2000 – General complaint about grass cutting 
Landscape – 29.09.2000 – No.3 – Tree Overgrown 
Highways – 22.02.2002 – Wall of property damaged by JCB machine 
Highways – 22.08.2002 – Missing cover 
Landscape – 08.08.2022 – Tree outside 18, roots causing damage to house slabs, wall and pathway. 
Inspected 12.09.2022, advised tree recently crown lifted, no action. Also advised resident to claim 
through Council Insurance.   
Landscape – 18.10.23 – tree outside 18, tree large, leaves coming into bedroom, bathroom and rear 
garden. Pulling up house slabs and street paving is dangerous. Inspected, advised no action – no work 
justified.  
Highways – 18.04.24 – Bala Close/Mentieth Close – Damaged footway – report of a fall causing injury 
(as listed above) 
Highways – 22.04.2024 – 

 Mentieth Close - Report of a fall causing injury (as listed above). 

We found records that 18 Mentieth Close made reports relating to the tree outside the property and 
relating to the pathway. Both the Landscape and Highway team inspected the location and 
concluded no risk-based action required. Please also refer to the Highway Authority inspection 
records below.  

Housing 

Apart from the email of 19 April 2024 from a Housing Officer no other contacts have been recorded 
at this location by the Housing Team or our Housing Contractor.  

Routine Highways Safety Inspections – Footway Mentieth Close 

As per the national guidance, all footways are routinely inspected in line with our ‘Code of Practice 
for Highway Inspections’. 

Our records show that in routine yearly cyclic inspections occurred for Mentieth Close in both 2022 
and 2023 and no actionable defects were found in either year. There has been no previous report to 
highways of a defective footway in Mentieth Close. 

Detailed below is a full list of routine inspections: 
Routine Inspection – 20.08.2019 16 Mentieth relay 4 slabs – works complete (different location).  
Routine Inspection – 2020 No routine estate inspections due to the pandemic. 
Routine Inspection – 20.08.2021 Rear 38 – Steps requiring relaying – works complete. 
Routine Inspection – 19.08.2022 No actionable defects found. 
Routine Inspection – 18.08.2023 No actionable defects found. 

 
 
 
 
 
 
 
 
 
 
 
 Statutory Obligations and Codes of Practice 

Under Section 41 of the Highways Act 1980, we (the Highway Authority/Milton Keynes City Council) 
have a duty to maintain the publicly adopted highway. Alongside this, section 58 of the Act outlines 
the duty for the authority to have a process of inspection and maintenance in place.  

In undertaking this statutory duty, we carry out a pre-planned programme safety inspections of the 
Public Highway in accordance with its Code of Practice for Highway Inspections. Reactive inspections 
are undertaken when possible defects are reported to the service. The plan details the minimum 
levels of service for inspections and timescales for reactive repairs that arise from the Highway 
Authority’s duty to maintain the highway and it is how local roads and footways are kept safe and 
serviceable for those who use them.  

This Code of Practice was originally prepared in accordance with the national guidance in ‘Well 
Maintained Highways Code’ – 2013 – United Kingdom Roads Leadership Group (UKRLG). 
It included a defined intervention-based risk approach for managing defect repairs, which considers 
factors such as hierarchy of road/footway, depth of defect, importance of infrastructure to 
determine the priority of the repair required.   

This national guidance was reviewed by UKRLG and updated in October 2016 and new 
documentation was issued as ‘Well Managed Highways Infrastructure 2016’. The revised guidance 
states that it is for local authorities to decide and determine the dimension of a defect as a basis for 
their decision-making, and the new procedures are clearer and involve a stronger ‘risk-based 
approach’ with highway inspectors making a judgment on which repairs are done and how soon they 
are repaired.   

Additionally, the new code uses ‘Investigatory Level’ rather than ‘Intervention Level’. These levels are 
set considering existing case law associated with personal injury claims having gone through the law 
courts. This has been introduced to ensure that defects that present a high risk are repaired ahead of 
defects that by their location may cause a lesser hazard.  

To ensure that the inspectors are correctly applying the ‘investigatory level’ risk assessment 
appropriately, all our inspectors are required to be qualified to City and Guilds 6033 Unit 301, Health 
and Safety and Unit 311 Highway Safety Inspection and have at least 3 years' experience. 

The Milton Keynes City Highway Authority Code of Practice for Highways Inspections is reviewed and 
updated annually to ensure it considers any changes to guidance, statute, or internal policies. 

In conclusion  

•  The Council will always undertake its statutory obligation as the Highway Authority to keep the 
highway safe and evidence this by its code of practice, routine inspections, and its works (either 
through urgent/reactive repairs or planned programmes).  

•  Our work is in line with the national guidance, ‘Well managed Highway Infrastructure 2016’. 
•  The core of our local code of practice, as the national guidance, is that intervention criteria 
must be applied to justify actions. Routine and reactive inspections did not reveal any 
actionable defect(s) at Menteith Close. 

 
 
 
 
 
 
 
 
 
 •  The process for inspection and determination of defect action is a risk-based approach, set out 
in national guidance, with several factors needing to be taken into consideration before a 
determination on whether a ‘defect’ requires actioning.  

•  All our inspectors are trained to national qualifications in the risk-based approach of the code 

and have the relevant experience. 

•  The Highway Authority immediately reviewed its inspection records and actions given the 

seriousness of the incident.   

•  Utilising our ‘code of practice’ and our qualified and trained inspectors, it was determined that 
in line with national guidance, during both routine inspections and the ad-hoc responsive 
inspections following the incident, that there is no actionable defect in this location.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Appendix A - Photos of footway 
Bletchley (taken 24.04.24 and 03.05.24) 

 Mentieth Close – Lakes Estate –