Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0213, written 6 May 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 May 2025 |
|---|---|
| Reference | 2025-0213 |
| Deceased | Charlotte Avis |
| Coroner | Rachael Griffin |
| Coroner area | Dorset |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Secretary of State for Transport 2. Chief Executive Officer of Dorset Council 1 CORONER I am Rachael Clare Griffin, Senior Coroner, for the Coroner Area of Dorset. 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 12th December 2022, I commenced an investigation into the death of Charlotte Katie Mae Avis, born on the 20th April 1992 who was aged 30 years at the time of her death. The investigation was suspended under paragraph 2 of Schedule 1 of the Coroners and Justice Act 2009 on the 16th April 2024 as I was notified an individual had been appeared before Weymouth Magistrates Court having been charged with offences under the Road Traffic Act 1988 relating to her death. Following the individual’s conviction and sentence, I held a hearing on the 1st May 2025 where I determined that there was insufficient evidence to resume the Inquest following the suspension. 4 CIRCUMSTANCES OF THE DEATH At approximately 16.49 hours on the 1st December 2022 Charlotte was driving her Silver Ford Focus along the A30 dual carriageway in an easterly direction towards Sherborne, Dorset at the crossroad junction with Marl Lane, when her vehicle was struck head on by another vehicle that was being driven in the opposite direction which had lost control and crossed over into the opposite carriageway. Charlotte sustained fatal injuries and died at the scene of the collision. 5 CORONER’S CONCERNS During the course of the investigation the evidence provided 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. – (1) Evidence has been provided that between 01.01.2014 and 24.03.2025 there have been 8 road traffic collisions at the site of Charlotte’s death which is referred to as Loscombe Crossroads, near Sherborne, Dorset. Those collisions have resulted in slight, serious and fatal injuries being sustained by those involved. There have been 4 fatalities from 3 of the collisions in a 4 year period. These fatalities occurred on 21.01.2020, 01.12.22 and 20.02.24.The last of these fatalities occurred after Charlotte’s death. (2) Although the speed of the road was reduced by Dorset Council on 11th October 2024 from 70mph to 60mph, I have concerns around the layout of the road and the number of collisions in the area, and that there could be future deaths that occur. “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 1st July 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 Persons via their legal representatives: (1) Charlotte’s Mother (2) Charlotte’s Partner (3) (4) Axa Insurance (5) Questgates Insurance 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 Signed Rachael C Griffin, HM Senior Coroner for Dorset 6th May 2025
2 responses 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.
From the Parliamentary Under Secretary of State Great Minster House 33 Horseferry Road London SW1P 4DR Tel: 0300 330 3000 E-Mail: Web site: www.gov.uk/dft Our Ref: 16 July 2025 Rachael C Griffin Senior Coroner for Dorset Civic Centre Bourne Avenue Bournemouth BH2 6DY Dear Ms Griffin, Thank you for your report of 6 May made under the Coroners and Justice Act 2009 and the Coroners (Investigations) Regulations 2013, following the inquest you conducted into the death of Charlotte Katie Mae Avis. I am responding as Minister for the Future of Roads. I am deeply saddened by the circumstances of Charlotte Katie Mae Avis’s death, and I would like to extend my condolences to her family. I want to assure you that the Government treats road safety with the utmost seriousness. Whilst UK roads are among the safest in the world, there is no room for complacency, and I have carefully considered your report and its recommendations. You expressed concerns regarding the layout of the road as a factor in the collision. Responsibility for making decisions about the roads under its care rests with the traffic authority, based on its knowledge of the area and taking into account local needs and circumstances. Local authorities, in this case Dorset Council, are free to make their own decisions about the design of the roads and streets under their care, provided they take account of the relevant legislation. This includes setting local speed limits and introducing traffic calming measures such as speed cameras and speed activated warning signs. It is up to the authority to decide what work to undertake, although it may well take into account the severity, causes and frequency of crashes in deciding what to prioritise. Local authorities are also responsible for day-to-day management of their road networks, including any necessary road and street works, and ensuring that their actions are within the law and are accountable to local people for their decisions and their performance. Local councillors are responsible for ensuring that local decisions about street infrastructure take account of the needs and opinions of local people. The Department for Transport has published guidance on the design of traffic calming measures in Local Transport Note (LTN) 1/07 ‘Traffic Calming’ which is available at: www.gov.uk/government/publications/local-transport-notes. I hope you will understand why I consider that the Department does not need to take any action regarding this incident. Best wishes, MINISTER FOR THE FUTURE OF ROADS
Senior Leadership Team Dorset Council, County Hall, Colliton Park, Dorchester, Dorset DT1 1XJ 01305 251010 www.dorsetcouncil.gov.uk Date: 30 June 2025 Ref: Officer: , Interim Chief Executive Rachael C Griffin HM Senior Coroner for Dorset The Coroner’s Office Civic Centre Bourne Avenue BOURNMOUTH BH2 6DY Sent via email to: and copied to Dear Ms Griffin Regulation 28: Prevention of Future Deaths Report Response Deceased: Charlotte Avis (DOB 20 April 1992, DOD 1 December 2022) Thank you for your Regulation 28 Report, received on 22 May 2025, following the hearing on 1 May 2025. I was deeply saddened to learn of the tragic death of Charlotte Avis and would like to extend my sincere condolences to her family and friends. This is a response to the Regulation 28 report which sets out the following concerns affecting Dorset Council: (1) Evidence has been provided that between 01.01.2014 and 24.03.2025 there have been 8 road traffic collisions at the site of Charlotte’s death which is referred to as Loscombe Crossroads, near Sherborne, Dorset. Those collisions have resulted in slight, serious and fatal injuries being sustained by those involved. There have been 4 fatalities from 3 of the collisions in a 4 year period. These fatalities occurred on 21.01.2020, 01.12.22 and 20.02.24. The last of these fatalities occurred after Charlotte’s death. (2) Although the speed of the road was reduced by Dorset Council on 11th October 2024 from 70mph to 60mph, I have concerns around the layout of the road and the number of collisions in the area, and that there could be future deaths that occur. Response to Concerns A wide variety of factors influence the occurrence of road traffic collisions, many of which are beyond the direct control of Dorset Council, such as human error and behaviour. Road safety is one of the Council's highest priorities, and we follow the Safe System model considered to be international best practice in road safety by the World Health Organisation, which aims to implement mitigations that address common human errors or consider significant highway improvements when necessary. Following the collision, we have investigated whether there are opportunities to improve road safety at this junction. We have carefully considered your report and can outline our proposed response: 1. We plan to implement a temporary traffic regulation order under Section 14(1)(b) of the Road Traffic Regulation Act 1984. This order will prohibit all right-turn, U-turn, and straight-over movements for vehicular traffic entering and exiting Marl Lane and Old Compton Lane at the Over Compton junction. These measures are scheduled to come into effect this summer. As with all temporary orders, we will closely monitor the situation to ensure that we do not inadvertently disperse risk. This measure will be regularly reviewed for a maximum of 18 months, during which time we will consult on the possibility of making these measures permanent. 2. Records show a high number of collisions along the entire length of the A30 dual carriageway between Yeovil and Sherborne, with many vehicles significantly exceeding the speed limit. Therefore, we are conducting a feasibility study to introduce Average Speed Cameras to ensure compliance with the recent change in speed limit to 60mph. This work will involve close collaboration with stakeholders, including Dorset Police. A key element of the Safe System model is the recognition of the need for safe speeds. If we do not see the required reduction in the number of excessively speeding vehicles and a decrease in overall collisions and their severity, further calming measures will be considered. These options require a significant capital outlay, underscoring Dorset Council's commitment to improving road safety on the A30 and particularly at the Loscombe Crossroads. Yours sincerely Interim Chief Executive
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