Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0228, written 16 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 | 16 May 2025 |
|---|---|
| Reference | 2025-0228 |
| Deceased | Patricia Bushell |
| Coroner | Louise Pinder |
| Coroner area | Rutland and North Leicestershire |
| Category | Road (Highways Safety) related deaths |
| 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: Secretray of Sate for Transport 1 CORONER I am Miss Louise PINDER, His Majesty's Senior Coroner for the coroner area of Rutland and North Leicestershire. 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 28 September 2023 I commenced an investigation into the death of Patricia Heidi BUSHELL aged 56. The investigation concluded at the end of the inquest on 14 May 2025. The conclusion of the inquest was that: Mrs Bushell was a pillion passenger on a motorcycle being driven by her husband, when at just before 1.20pm on 9th September 2023 they were struck by a car which failed to stop at the junction on Stapleford Road and entered the carriageway of the A606. Mrs Bushell was thrown from the motorbike and came to rest on the road, sustaining fatal injuries. She was taken as an emergency to Queens Medical day. There were multiple missed opportunities to identify a significant risk to road users during a period of resurfacing work. At the time of the collision, there was no advanced warning of white line removal at the junction and the permanent “Give Way” sign was not visible. As a result, the driver of the car which struck Mrs Bushell had not identified the junction and failed to stop. Nottingham where Centre same sadly died that she The cause of death was established as: I a Chest and Abdominal Injuries I b I c II 4 CIRCUMSTANCES OF THE DEATH The driver of a car which struck the motorbike on which Mrs Bushell was travelling, did not identify the junction ahead and was given very little opportunity to do so. The words “SLOW” were painted on the road 70 metres prior to the junction. There were permanent centre white lines/warning lines painted on the road commencing approximately 60 metres from the junction. Neither of these hazard Regulation 28 – After Inquest Document Template Updated 16/05/2023 warnings alerted the driver to the junction ahead. The topography gave the impression that the road continued ahead. A temporary sign with a red background and white writing displaying the words “No road markings at junction” was in situ at the junction and attached to the base of the permanent Give Way sign, this permanent sign was leaning over and obscured by foliage. The permanent white lines at the junction had all been removed including some of the centre/warning lines. There was inadequate signage on the road to assist the driver in identifying the approaching junction. There is no evidence that the driver was distracted prior to the collision. He was using the Waze satellite navigation application on his phone and whilst I am not critical of its use or design, it contributed to the impression that there was no junction ahead. There were multiple missed opportunities to identify that there was a significant risk to road users during a period of resurfacing work particularly from 4th September to 9th September 2023. Despite numerous dynamic risk assessments over these six days, it was not identified that the permanent Give Way sign was obscured by vegetation. No drive or walk through along the road had been conducted which would have afforded the four traffic marshals and their supervisor a drivers view of the junction and highlighted the associated risks. A witness gave evidence on behalf of Leicestershire County Council (LCC) and accepted that they are responsible for the signage at this junction. LCC also accepted that there were missed opportunities to identify that the permanent Give Way sign was obscured. Reference was made to The Road Traffic Regulations and the Traffic Signs Manual and it remains the view of LCC that the single temporary sign in place on the road was appropriate and complied with the guidance. It was accepted however that the processes that existed at the time of the collision required review and more robust and specific written risk assessments are now in place locally together with more comprehensive training for those involved in traffic management, using the circumstances of this collision as a learning and retraining exercise. Further suggestions made by the police in court including giving consideration to additional temporary warning signs well ahead of the junction, the introduction of a lower temporary speed limit and introduction of a drive or walk through of the approach to the area from a road users’ perspective and these will be included in a new written risk assessment. 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 circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: I indicated at the conclusion of the inquest that I will not be making a report in respect of the missed opportunities identified in relation to Leicestershire County Council employees. Significant changes have been made. I am however concerned that in respect of the national regulations, I am told that the temporary signage installed at the collision site was compliant with the guidance. Reference was made to The Road Traffic Regulations and the Traffic Signs Manual and it remains the view of LCC that the single temporary sign in place on the road was appropriate and complied with the guidance. It was nevertheless inadequate. I refer specifically to Chapter 16 paragraph 20 of the Coroners Bench Book, ”Where the identified risk to life has already been ameliorated by local changes the coroner may wish to consider whether the matter is an issue that only affects the relevant local organisation or is a wider or national issue. In the latter case then directing a report to a national, professional or regulatory body might enable them to also consider relevant changes that might protect lives.” I conclude that this is potentially a Regulation 28 – After Inquest Document Template Updated 16/05/2023 wider national issue and I am writing to you, as you have responsibility for ensuring the transport network is safe and I wish to highlight the issues raised during this investigation and at the inquest particularly in relation to the current regulations with regard to temporary signage. 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 09, 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. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Mrs Bushell’s family The driver’s family Leicestershire County Council I have also sent it to: Leicestershire Constabulary 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: 16/05/2025 Miss Louise PINDER His Majesty's Senior Coroner for Rutland and North Leicestershire Regulation 28 – After Inquest Document Template Updated 16/05/2023
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.
Louise Pinder
HM Senior Coroner for Rutland and North
Leicestershire
County Hall, Leicester
LE3 8RA
From the Parliamentary
Under Secretary of State
Great Minster House
33 Horseferry Road
London
SW1P 4DR
Tel:
E-Mail:
Web site: www.gov.uk/dft
Our Ref:
9 July 2025
Dear Miss Pinder,
Thank you for your report of 16 May made under the Coroners and Justice
Act 2009 and Regulations 28 and 29 of the Coroners (Investigations)
Regulations 2013, following the inquest you conducted into the death of
Patricia Bushell. I was very sorry to hear of her death and wish to extend my
condolences to her relatives.
I am writing regarding your concern about the guidance around temporary
signage during maintenance works.
The Department’s role is to set the overarching legal and policy framework,
and to provide guidance to local highway authorities. All local highway
authorities are required to ensure that traffic signs are maintained so that they
can be seen by motorists. This stems from their general duty of care
contained in Section 122 of the Road Traffic Regulation Act 1984, together
with their statutory responsibility for maintaining the highway conferred in
Section 41 of the Highways Act 1980.
The Department gives guidance through the Traffic Signs Manual to local
highway authorities on sign maintenance, to ensure that they are clean and
clearly visible, but it is for the individual authorities to decide how to carry out
their statutory duty.
The Department is part of the UK Roads Leadership Group which has
published ‘Well Managed Highway Infrastructure: A Code of Practice’. This
provides advice on highway maintenance for local highway authorities,
including on resurfacing works. This sets out that during resurfacing works,
‘no road markings’ signs should be placed until all road markings have been
replaced.
The Department considers that with the guidance provided, and local
authorities’ responsibility to undertake risk assessments, this should be
sufficient to ensure the local authority can provide a safe road network.
However, my Department is currently undertaking work to update the Code of
Practice and we will ensure that the issue you highlight is considered as part
of that work.
Best wishes,
MINISTER FOR THE FUTURE OF ROADS
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