David Walsh

Ms Marianne Johnson
HM Assistant Coroner for Greater
Lincolnshire
Greater Lincolnshire Coroner’s Service
Myles Cross Centre
Macaulay Drive
Lincoln
LN2 4EL

Legal Services Lincolnshire
County Offices
Newland
Lincoln
LN1 1YS

Date:

12/08/2025

Dear Ms Johnson

Re: Response to Regulation 28 (Report to Prevent Future Deaths) - Inquest in
relation to the deaths of David Walsh and Cameron Walsh

We write in response to the Regulation 28 Report issued on the 23 June 2025 following
the  inquest  into  the  deaths  of  David  Walsh  and  Cameron  Walsh.  This  is  a  joint
response submitted on behalf of Lincolnshire County Council and Lincolnshire Police.

The conclusion of the inquest was that both David Walsh and Cameron Walsh were
travelling in a Mercedes GLC300 motor vehicle on the 6 January 2024 when it left the
road  at Whitegates Farm, Tetney Lock Road, Tetney and entered the Louth Canal.
Despite rescue attempts both were announced deceased at the scene of the collision.

The Regulation 28 Report follows as a result of evidence provided during the inquest
on  behalf  of  Lincolnshire  County  Council’s  Highway’s  Department  that  road  traffic
collisions, where there are injuries or fatalities that may have been contributed to by
the  condition  of  the  highway,  are  not  immediately  reported  to  the  Highways
Department  by  the  Police.  The  evidence  provided  was  that  the  Police  complete  a
STATS19 Form which is then sent to the Lincolnshire Road Safety Partnership. The
information  from  the  STATS19  Form  is  then  collated  and  placed  onto  the  WINGS
software programme which is a Council owned software programme. This information
is reviewed on an annual basis where the types of incidents are considered along with
the traffic flow on that road and it gives a score. Based on the score there is then a
ranking of sites where there has been more than one collision within a set area (known

 as a Cluster). The score is used to decide where the Highways Department should
intervene first on looking at potential safety improvements. The Accident Investigation
Team and the Road Safety Partnership then look at each of those Cluster Sites and
investigate those sites. Consideration will then be given to what improvements could
be made to the highway to reduce the risk of future incidents.

It is the view of the Coroner that as these reports are only considered annually there
is the possibility that other incidents can occur prior to the annual review that could
have  been prevented  had  a  report been  made  to  the  Highway’s  Department  at  the
time of the incident and as such action should be taken.

The below response provides further information in respect of the current processes
already in place between Lincolnshire County Council and Lincolnshire Police, as well
as additional actions that have been agreed to further mitigate any future risks.

Lincolnshire is uniquely positioned  to ensure that  the Local Authority receives early
notification  of  potential  highway  issues  reported  by  Lincolnshire  Police.  The  co-
location of Lincolnshire County Council (LCC) Accident Investigation and Prevention
(AIP) staff and Lincolnshire Police Forensic Collision Investigation Unit (FCIU) at the
Lincolnshire Road Safety Partnership (LRSP) ensures that timely sharing of pertinent
information occurs. The LRSP Senior Manager and the FCIU Inspector and Sergeants
meet regularly to discuss cases where information sharing is appropriate.

Additionally, Lincolnshire Police can, and do, submit P199 forms to LCC where they
consider there may be highway related safety issues. The P199 form is used to advise
of road engineering or signing problems that may be contributory to an accident and
suggested improvements where applicable.

Regarding the case of David Walsh and Cameron Walsh, LCC were notified about the
collision on the date it occurred. However, at that early stage the road condition was
not highlighted as an area of investigation and no P199 form was submitted. This is
not uncommon and Lincolnshire Police will generally provide further updates / request
information as an investigation progresses. The road undulations were noted at the
time  of  the  collision;  however,  they  were  not  considered  to  be  a  primary  causation
factor and it was agreed to await the outcome of the investigation, although a safety
inspection did take place as scheduled on the 9 January 2024 and identified no safety
defects.

On the 24 June 2024 LCC were notified that 'surface undulations are being explored
as a possible causation factor.' This information was disseminated accordingly.

Regarding the reporting of potential highway issues in fatal collisions more widely, I
am pleased to confirm that LCC systems have recently been improved to ensure that
any possible highway issues are identified at the earliest opportunity.

The following now occurs after every fatal collision:

LCC Fatal Notification Process

  Unmodified Police Fatal Report without private and sensitive data distributed to
Highways Managers and relevant interested parties as soon as it is received in

 LCC  from  Lincolnshire Police.  This  provides  a  general  overview  of what  has
occurred.

  LRSP create a record on SharePoint adding the Police Fatal Report and a Fatal
liaise  with  Police  Forensic  Collision
Notification  Spreadsheet.  LRSP 
Investigation  Officer  to  record  any  likely  highway  issues  that  may  be  a
contributory factor to this collision.

  LRSP  update  spreadsheet  Tab  One.  LRSP  search  records  to  identify  if  any
issues  have  been  raised  at  this  location  by  /  to  LRSP.  LRSP  update
spreadsheet Tab two.

  LRSP email to relevant Highways Managers and LCC Legal Services, notifying

them that the spreadsheet has been created.

  Relevant Highways Managers search all systems and records and add relevant

information to the spreadsheet.

  Any  actions  identified  that  could  prevent  a  future  collision  can  then  be

considered.

As such, every fatal collision reported to LCC is considered at the earliest opportunity.

In addition, two additional actions have been agreed. The Lincolnshire Police Serious
Collision  Investigation  Unit  (SCIU)  and  FCIU  hold  monthly  operational  update
meetings to discuss progress on open cases. In addition to the informal discussions
outlined above, the LRSP Senior Manager and FCIU Inspector have formally agreed
to  meet  every  month  after  the  SCIU/FCIU  meeting  to  ensure  any  relevant  data  is
shared that may help prevent future collisions occurring.

Every STATS19 collision form that has R1-R5 (Roads) listed as a possible causation
factor will be highlighted within the wider LCC Highways Team. This will allow for any
review or action to be taken at the earliest opportunity where necessary. The actions
to be taken will be graded based on the severity of the collision and the weighting of
the causation factor. For example, a road related causation factor rated as the most
likely  issue  in  a  fatal/serious  collision  will  indicate  a  more  significant  issue  than  a
causation factor ranked third in likelihood for a slight collision.

Finally,  as  noted  during  the  inquest,  LCC  AIP  staff  undertake  an  annual  collision
cluster  run  and  route  study  programme.  The  ensures  that  every  collision  in  the
preceding five-year period, regardless of severity is also reviewed, to identify patterns
or issues, highlighting locations that require further investigation. This is a risk-based
assessment that factors in the number of collisions, the severity, and the presence of
vulnerable road users. This generates a work programme of 30 or more sites and three
or more routes for review every year. I can confirm that whilst this work forms a vital
part  of  LCC's  activity  to  prevent  future  death  and  injury,  it  is  not  the  only  relevant
programme,  and  LCC  do  not  wait  for  the  annual  review  before  investigating  fatal
collisions.

We  hope  that  the  above  information  provides  reassurance  in  terms  of  the  current
processes  already  in  place  and  that  the  additional  actions  agreed  provide  further
reassurance in relation to the commitment of all agencies to ensure that the highway
in Lincolnshire is safe for all users.

 Both LCC and Lincolnshire Police would like to extend their sincere condolences to
the family and friends of both David Walsh and Cameron Walsh.

If we can be of any further assistance, please do not hesitate to contact us.

Yours sincerely

Principal Lawyer

For Legal Services Lincolnshire