Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0029, written 16 Jan 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Jan 2025 |
|---|---|
| Reference | 2025-0029 |
| Deceased | Alexander Thomas |
| Coroner | Adrian Farrow |
| Coroner area | Manchester South |
| Category | Road (Highways Safety) related deaths · Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. THE CHIEF EXECUTIVE, NATIONAL HIGHWAYS 1 CORONER I am Adrian Farrow, Hm Assistant Coroner, for the coroner area of Greater Manchester South 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 15th August 2024 an investigation was commenced into the death of Alexander Charles Edward Thomas, aged 42. The investigation concluded at the end of the inquest on 13th January 2025. The conclusion of the inquest was that he died from multiple injuries consistent with a road traffic collision when he committed suicide. 4 CIRCUMSTANCES OF THE DEATH Mr Thomas died on 14th August 2024 when he entered the eastbound carriageway of the M56 motorway between junctions . A heavy goods vehicle collided with him when he deliberately stood in its path and he sustained fatal injuries. He had a longstanding diagnosis of depressive disorder. The location of the collision was close to where motorway and the nearby premises and car parks of the and the evidence was that Mr Thomas had entered the motorway from the area. CORONER’S CONCERNS passes under the M56 5 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. – is a pedestrian walkway running 1. During the inquest, I heard that underneath the M56 motorway. On the northern side of the motorway (eastbound carriageway side) the entrance to the walkway tunnel is constructed so that the buttress walls form a ramp-like structure which has a shallow gradient topped with a waist-high railing which provides an easily accessible and walkable route from the footpath to the Armco crash barrier bordering the hard shoulder of the eastbound motorway carriageway. 2. Also leading from is an established track through undergrowth running west parallel to the motorway. That path leads directly to a fixed bespoke metal ladder which appears to be specifically positioned so as to enable a person to climb up to the Armco crash barrier bordering the hard shoulder of the eastbound carriageway. 3. There is no fencing to prevent access over the Armco crash barrier onto the motorway itself along this stretch of the eastbound carriageway, in contrast to the substantial fencing positioned behind the Armco crash barrier along the opposite stretch of the westbound carriageway. 1 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has 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 13th March 2025. 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 Person Mr Thomas’ brother on behalf of Mr Thomas’ family. I have also sent it to Chief Superintendent, Greater Manchester Police Roads Policing Unit, 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 Adrian Farrow HM Assistant Coroner 16th January 2025 2 3
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.
Our ref: Your ref: Adrian Farrow HM Assistant Coroner HM Coroner Manchester South Coroners Court 11 Mount Tabor Street Stockport SK1 3AG Operations Regional Director Piccadilly Gate Store Street Manchester M1 2WD www.nationalhighways.co.uk 13 March 2025 Dear Mr Farrow Regulation 28 Report into the death of Alexander Charles Edward Thomas Thank you for your correspondence dated 16/01/2025. The M56 motorway at this point spans Hasty Lane which forms an underpass to facilitate access by cyclists and pedestrians. The structural supports and cast concrete wing walls mirror the profile of the embankments on either side of the motorway and are located within the highway boundary. This design of ‘bridge’ complies with the design requirements outlined within the Design Manual for Roads and Bridges and includes tubular railings to protect against falls from the structure. It is accepted that this type of design does not deter determined attempts by pedestrians to gain access to the motorway but when combined with timber boundary fence provides some deterrence and security. By the very nature of the Strategic Road Network, it is impossible to fully deny access. Whilst there are no requirements for highway authorities to fence their boundaries, as this responsibility generally rests with landowners, National Highways recognises the specific hazards associated with the operation of motorways and provides boundary fencing generally located to reflect the legal separation of adjacent land. This normally takes the form of 1 metre high timber post and rail fencing although more specialised types of fence are used for specific purposes for example, to address the presence of deer or other hazards and minimise environmental impacts. To the east of the motorway, along the southbound carriageway, the extents of the boundary line are clearly marked by timber fencing as outlined above. This extends along the wing walls of the structure and this would be the ideal, and normally achieved, layout. Additionally, along this section, a timber environmental barrier is installed at the top of the Registered office Bridge House, 1 Walnut Tree Close, Guildford GU1 4LZ National Highways Limited registered in England and Wales number 09346363 embankment/verge. We believe this is the substantial wooden fence referred to in the Coroner’s concerns. Along the northbound carriageway and to the south of Hasty Lane, the M56 carriageway is some 3 metres higher than the adjacent ground level and initially has a ramped profiled embankment. After a distance of 12 metres, the profiled verge area becomes a near vertical retaining wall which continues for some distance. This also creates a level area of ground, running parallel to the motorway between the retaining wall and boundary fence. Between the retaining wall on one side and the boundary fence and mature vegetation on the other, this gives the visual impression of a pathway. The M56 at this point is lit with lighting columns located within the area of carriageway immediately behind the hard shoulder. This includes columns installed within the top of the verge/embankment and the top of the retaining structure. The electrical supply required to operate this system is distributed from electrical feed cabinets located at the foot of the retaining wall. Maintenance personnel require unhindered access to, not only the individual lighting columns, but also these supply cabinets to safely work on the systems when needed. A set of metal steps (ladder) allow access for maintenance personnel to and from carriageway level and the flat ground some 2 metres below. This is within the fenced highway boundary. The boundary fence alongside the northbound carriageway to the south of Hasty Lane has suffered some level of vandalism in the immediate area of the underpass and although there is some dense vegetation, this affords access to the side of the carriageway and metal steps outlined above. Additionally, it appears that a boundary fence line has never been in place along the wing walls on this side of the structure and Hasty Lane. Further investigation has identified some minor vandalism at the edge of the car park for the Marriot Hotel, 100 yards south of Hasty Lane. This indicates the section of lane between the retaining wall and boundary fence has been used as short cut or cut through although the usage appears to be light. Our current incident recording system was implemented during April 2019. Since this time we are not aware of any similar, pedestrian related, incidents having been recorded at this site. We will repair the boundary fence both at the edge of the hotel car park and Hasty Lane, extending this to cover the wing walls of the structure to increase the security and reduce access to the area along the carriageway. This work will be completed by the 30 June 2025. In addition, we are in discussion with our Electrical team and Maintenance contractors to establish if it is feasible to maintain a more remote access to the electrical cabinets and whether direct access from the mainline carriageway, via the ladder is essential. This includes the relevant health and safety requirements and if this can be resolved we will take steps to remove the ladder from the retaining wall. Again, if this is feasible the work will be completed by 30 June 2025. Registered office Bridge House, 1 Walnut Tree Close, Guildford GU1 4LZ National Highways Limited registered in England and Wales number 09346363 If this is not a realistic way forward, we will undertake to design and install a bespoke fence assembly to secure the access point, cabinets and ladder. If this course of action is necessary, the work will be completed by the 31 August 2025. I hope that you find this information helpful. Yours sincerely Operations Regional Director Email: Registered office Bridge House, 1 Walnut Tree Close, Guildford GU1 4LZ National Highways Limited registered in England and Wales number 09346363
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