Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2025-0287, written 16 Sep 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Sep 2022 |
|---|---|
| Reference | 2025-0287 |
| Deceased | Nargis Begum |
| Coroner | Nicola Mundy |
| Coroner area | South Yorkshire (East) |
| 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 (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Chief Executive Highways England, 1 CORONER I am Nicola Jane Mundy, Senior Coroner for the coroner area of South Yorkshire East District. 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 11th September 2018 I commenced an investigation into the death of Nargis Begum, age 62. The investigation concluded at the end of the inquest on 9th September 2022. The conclusion of the inquest was Road Traffic Collision. 4 CIRCUMSTANCES OF THE DEATH On the 9th September 2018, Nargis Begum was a front seat passenger in a vehicle being driven by her husband. They were travelling in a homeward bound direction along the northbound M1 motorway which includes a stretch of All Lanes Running SMART motorway. The vehicle had been MOT’d and serviced and was not known to have any mechanical defects. Shortly after passing a service station, the vehicle began to lose power and despite the efforts of the driver continued to lose power before coming to a halt in the live running lane. The driver pulled the vehicle as far as possible to the left hand side but the offside wheels of the vehicle remained over the white line and were in the running lane (Lane 1). Although Mrs Begum exited the vehicle, she was physically incapable of climbing over the barrier and thus rested on the barrier in close proximity to the stationary vehicle. Some 16 minutes and 21 seconds elapsed before a Mercedes motor vehicle travelling in lane 1 crashed into the rear of the stationary vehicle causing this to collide with Mrs Begum and the injuries she received as a consequence proved to be rapidly fatal. 153 drivers had passed the stationary vehicle and none had alerted Highways England /National Highways or any of the emergency services. One of the witnesses that I had heard from said that he and his passenger had discussed calling National Highways but he reached the view that given the presence of cameras on the motorway, the stationary vehicle would be detected by the cameras. I also heard evidence regarding the rollout of stationary vehicle detection technology On all All Lane Running motorways by the end of September 2022 and it was anticipated that 80% plus of stationery vehicles would be detected by this technology in a timely fashion. 1 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 will 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) The lack of public understanding regarding the need for them to call National Highways should they identify a problem on the motorway network such as a stationary vehicle. (2) Despite television, radio and social media campaigns regarding SMART motorways, the lack of emphasis on the importance of road users responsibility to alert the authorities to any such problems. (3) Despite public information referred to during the course of the evidence, the above message does not appear to have been a priority and does not appear to have effectively reached the public. 6 ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and I believe you Mr Jim O’Sullivan and 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 Friday 4th November 2022. 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 The family of Mrs Begum via Kennedys Solicitors. 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 16th September 2022 Ms N J Mundy, LL.B (hons) Senior Coroner, South Yorkshire (East District) 2
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.
REGULATION 29 RESPONSE TO A REPORT ON ACTION TO PREVENT FUTURE DEATHS THIS RESPONSE IS BEING SENT TO: NICOLA JANE MUNDY, Senior Coroner for the coroner area of South Yorkshire (East District) of Coroner’s Court and Office, Crown Court, College Road, Doncaster DN1 3HS in response to a ‘Regulation 28 Report to Prevent Future Deaths’ following an inquest hearing into the death of NARGIS BEGUM that concluded on 9th September 2022. 1. NATIONAL HIGHWAYS I am Walnut Tree Close, Guildford, Surrey, GU1 4LZ. , Chief Executive of National Highways Limited, Bridge House, 1 2. CORONER’S MATTERS OF CONCERN The MATTERS OF CONCERN are as follows:– 1. The lack of public understanding regarding the need for them to call National Highways should they identify a problem on the motorway network such as a stationary vehicle 2. Despite television, radio and social media campaigns regarding smart motorways, the lack of emphasis on the importance of road users’ responsibility to alert the authorities to any such problems 3. Despite public information referred to during the course of the evidence, the above message does not appear to have been a priority and does not appear to have effectively reached the public 3. DETAILS OF ACTION TAKEN Mrs Begum’s death was a tragedy, and our sympathies remain with her family and friends. is the Government-owned company, sponsored by the National Highways for Transport (DfT), charged with operating, maintaining and Department improving England's motorways and major A-roads. Responsibility for local roads rests with local highway authorities and the road network in other parts of the UK rests with the devolved administrations. In March 2020 the Government published a comprehensive Smart Motorway Safety Evidence Stocktake and Action Plan which sought to further raise the bar on smart motorway safety. National Highways has published two progress reports, one in 2021 and a second in 2022, setting out the progress we have made towards achieving the commitments set out in the 2020 Stocktake. This response sets out the actions we have taken, and plan to take, which relate to the three matters of concern stated in the Regulation 28 report. It recognises, as did the Coroner during the hearing, that to fully address her concerns, wider consultation is required with other parties. This response therefore also sets out how we plan to approach that wider engagement. We have an ongoing programme of road safety campaign activity, intended to provide important guidance to drivers to make journeys safer, easier and more reliable. This ongoing campaign work includes a specific section on breakdown advice. 1 We worked with stakeholders to launch England’s first major campaign, in 2021, to raise awareness of the eCall or 'SOS' button function, which increasing numbers of newer cars come with and which can be used to call for help, by the driver or someone else needing help, if a situation requires emergency services. This was on digital channels, including a dedicated campaign page on our external website. The Highway Code, which was updated in September 2021, also now advises the use of eCall to contact police and communicate a location directly to a 999 operator under The Highway Code current rules 277, 279 and 283. In November 2021, we delivered the second wave of the eCall awareness campaign. The eCall explainer highlighted the safety messages to raise awareness of how and when to use eCall in newer vehicles. This is available on YouTube. Overall, the campaign has seen an increase in the correct use of the eCall system of connected emergency services calls from 22% in 2020 to 59% in 2022. This statistic was verified by the British Association of Public Safety Communications Officials. We worked with DfT and the Driver and Vehicle Standards Agency (DVSA) to enable The Highway Code to be updated on 14 September 2021. This will help improve driver understanding and confidence when driving on a motorway. We launched a ‘Driving on motorways' hub on our website in January 2022, which provides a central point for all our information and advice on motorway driving. The hub was launched alongside a multimedia campaign and radio day, with content featured on over 450 stations reaching over 6 million listeners. These activities were designed to reach drivers up and down the country to help provide a better understanding, and help increase their confidence, when travelling on all types of roads. We are committed to providing even more information that is highly accessible to drivers. Our aim is to help them feel safe and be safer on all our roads, including smart motorways. We have listened to the concerns raised by the Coroner at the inquest and subsequently via this Regulation 28 report. Following the inquest, on 21 September 2022, I wrote to DfT on two matters. - Firstly, as DfT has responsibility for The Highway Code, I shared the Coroner’s view that a further update to The Highway Code may be beneficial to help the public know what actions to take should they identify a problem when driving, such as a stationary vehicle. We understand DfT are currently giving this consideration. - Secondly, the letter also confirmed a commitment to conduct a study to explore additional actions that could be taken to further increase awareness among the public of what they can do if they spot someone in difficulty on any road. This study, on which work started in September 2022, will, amongst the other actions stated in this response, cover the three areas of concern raised by the Coroner. 4. DETAILS OF FURTHER ACTION PROPOSED National Highways remains committed to helping drivers and their passengers be even safer and feel safe on all our roads, including smart motorways. As stated above, we have an ongoing programme of road safety campaign activity, intended to provide important guidance to drivers to make journeys even safer, easier and more reliable. 2 We will include an update on the eCall campaign and include that the function can be used to help both the driver of the vehicle which has the function, and to help others in difficulty. We will do this via a further campaign, ‘Driving for Better Business’ programme1 and through our own staff. As the Coroner recognised, to fully address her concerns, wider consultation is required with other parties. The study we have initiated envisages input from a wide range of organisations including, at the outset, DfT, DVSA, and the police. It could also involve bodies including devolved administrations, local highway authorities, and safety organisations. In line with our smart motorway stocktake annual progress reports, we will also continue to analyse the safety performance of smart motorways (including all lane running and dynamic hard shoulder smart motorways) as part of our ongoing assessment of risks. Based on the findings we will consider whether we need to take additional action to further improve the safety of smart motorways. 5. TIMETABLE FOR ACTION DATE ACTION Before the end of 2022 We will include an update on the eCall campaign and emphasise that the function can be used to help both the driver of the vehicle which has the function, and to help others in difficulty. January 2023 Spring 2023 National Highways to provide the Coroner with an update on the study (which started in September 2022), progress and next steps, including an update on the planned completion date, which is currently expected by summer 2023. Planned publication of a smart motorways stocktake third year progress report, providing the latest safety data (2017 to 2021). As part of this report preparation, we will consider whether we need to take additional action to further improve the safety of smart motorways. Summer 2023 At this early stage we are working to a planned completion date of summer 2023 to complete the study, subject to the wider engagement with external parties who we will shortly approach. As a result of the study, we are looking to prepare a shortlisted set of options that could be implemented after the end of the study. 2025 Complete the installation of over 150 additional emergency areas on all lane running smart motorways in operation and construction. 6. SAFETY OF ROAD USERS 1 Driving for Better Business is a government-backed National Highways programme to help employers in both the private and public sectors reduce work-related road risk, control the associated costs and improve compliance with current legislation and guidance 3 Every road death is a tragic loss of life. We are determined to reduce the number of fatal incidents, and injuries, on our roads and we want everyone who travels or works on any of our roads to feel confident and safe. Although roads, especially high-speed roads, can never be risk-free environments, our absolute priority is the reduction of road deaths and injuries on our network. This is why we invest in road safety initiatives and public awareness campaigns, to help prevent death and injury and to help give drivers the information they need, to have safe journeys. This is in addition to information provided in other areas, for example The Highway Code. The Smart Motorway Safety Evidence Stocktake and Action Plan published by the Government in March 2020 set out 18 measures to improve safety and build greater public confidence in smart motorways. We welcomed the stocktake and action plan as an opportunity to further improve the safety of smart motorways. We are constantly listening to motorists, continually assessing how we can make motorways safer for those who use them. Since 2020 we have published two reports2 setting out our progress in delivering commitments from the Stocktake. We urge road users to act safely and sensibly, including by informing themselves about what to do in an emergency3, who to contact, and how to avoid dangerous situations where possible, thereby minimising the risks to themselves and other road users. In 2021 we launched our biggest ever, high profile multi-media road safety campaign to help drivers know what to do if they break down on any motorway, including one without a hard shoulder. The death of Mrs Begum was tragic, and our deepest sympathies remain with her loved ones. We remain committed to improving communication with road users and to taking steps to further improve the safety of smart motorways. 8 8th November 2022 Signed: , Chief Executive 2 Smart Motorways stocktake first year progress report Smart Motorways stocktake second year progress report 3 The National Highways website provides guidance on what to do in case of a breakdown on any motorway: https://nationalhighways.co.uk/road-safety/breakdowns/ 4
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