Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0353, written 10 Jul 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Jul 2025 |
|---|---|
| Reference | 2025-0353 |
| Deceased | Paul Ransom |
| Coroner | Henry Charles |
| Coroner area | Hampshire, Portsmouth and Southampton |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
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: 1 , Minister for the Future of Roads, Department for Transport (DfT), Great Minster House, 33 Horseferry Road, London SW1P 4DR 2 Association of Directors of Environment, Economy, Planning & Transport (ADEPT), 83 Ducie Street, Manchester M1 2JQ 3 The Road Surface Treatments Association (RSTA), Technology Centre, Wolverhampton Science Park, Glaisher Drive, Wolverhampton WV10 9RU 1 CORONER I am Henry CHARLES, HM Assistant Coroner for the coroner area of Hampshire, Portsmouth and Southampton 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 01 June 2023 I commenced an investigation into the death of Paul David RANSOM aged 25. The investigation concluded at the end of the inquest on 18 June 2025. The conclusion of the inquest was that: See narrative conclusion 4 CIRCUMSTANCES OF THE DEATH Narrative Conclusion: Mr Paul Ransom sadly died on 24th May 2023 on the A272 between Meon Hut and Petersfield, approaching the village of Langrish, Hampshire. A 40mph speed limit applied. He lost control of his motorcycle whilst doing up to around 45mph and crossed into the oncoming carriageway, colliding with a lorry and sustaining the multiple injuries that caused his death. Conditions were excellent: full daylight, sunny and dry. Surfacing work had been completed less than six hours before the collision. The surface was very slippery and this caused or at least substantially contributed to the collision. 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: (brief summary of matters of concern) The resurfacing that had been carried out was an asphalt preservation treatment known as a “thin surface treatment” wherein a bituminous solution is cold sprayed onto the surface, overlaid with a silicate grit. This is a commonly used method. I heard evidence that in the initial period after laying thin surface treatment has a particular property (“early life Regulation 28 – After Inquest Document Template Updated 30/07/2021 effects”)in dry conditions the level of friction available can be akin to that of a wet road. There is no guidance that signage be provided. There is also the potential for unpredictable vehicle behaviour, particularly at lower speeds or when road surface temperatures are high, by reason of a change in the level of fiction available to a vehicle during a steering manoeuvre or braking. This may have a greater effect on motorcycles. The newly applied surface looks like an ordinary tarmac road albeit pristine. There has been research into accident rates following application of thin surface treatments. The research had the effect of allaying concerns but I was informed that the research may not have been able to look specifically at motorcycle accidents, and further informed that the issue of signage has been the subject of discussion in at least some highways authorities. Thin surface treatments are to be distinguished from surface dressing wherein aggregates are applied, following which loose chipping warning signs are usually erected and a reduced speed limit applied for the days following application. Following thin surface treatment the drivers of vehicles, including motorycles are likely to assume that in dry conditions the road surface is going to have the same properties as any established dry asphalt road surface. I am concered that where the road is, for example, downhill and/or twisting and/or with limited sight lines then it may be a particular problem if speeds are not adapted for the early life properties of thin surface treatments: particularly in the case of motorcycles. I recommend review of actions to be taken for the safety of road users, particularly motorcyles, following application of thin surface treatments, during the early life phase following thin surface treatment. 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 11th September 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 Hampshire County Council (Hampshire Highways) I have also sent it to 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 Regulation 28 – After Inquest Document Template Updated 30/07/2021 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: 10/07/2025 Henry CHARLES HM Assistant Coroner for Hampshire, Portsmouth and Southampton Regulation 28 – After Inquest Document Template Updated 30/07/2021
3 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.
Julie Davies Coroner's Officer Hampshire, Portsmouth & Southampton Coroner's Service Portsmouth Office The Coroner’s Court 1 Guildhall Square Portsmouth PO1 2GJ By email Dear Julie ADEPT President / Director of Thriving Places Westmorland & Furness Council South Lakeland House Lowther Street Kendal LA9 4DQ 2nd September 2025 Thank you for your letter and Regulation 28 “Report to Prevent Future Deaths” dated 10th July 2025, concerning the death of Mr Paul David Ransom. In advance of responding to the concerns raised in your report, ADEPT would like to express our deep condolences to Paul’s family and loved ones. We note that your report has also been addressed to Minister for the Future of Roads, Department for Transport (DfT) and The Road Surface Treatments Association (RSTA). It is appropriate that these organisations address the matters of concern, namely around the issues relating to any research and the safety of road users, following application of thin surface treatments. The Association of Directors of Environment, Economy, Planning & Transport (ADEPT) is a voluntary membership organisation representing place directors in local authorities, focusing on services like highways, waste and recycling, and planning. We collaborate with our members, including our corporate partners drawn from the private sector, through various channels to help drive innovation, develop and influence policies and work closely with government departments, including the Department for Transport. We facilitate the sharing of best practice and technical research with our members through technical working groups, regional boards and specific work programmes. Whilst the association does not have a direct role in the design, specification, safety testing or the execution of road surface treatments, we regularly collaborate with the RSTA and provide technical commentary on their work. We do not engage with or comment on individual councils’ highways maintenance contractual requirements / specifications nor do we act as an enforcement body in any way. Whilst we are not aware of the research you referenced in the report, as a member organisation we will commit to working with the Department for Transport and industry experts such as the RSTA. We will share with our members any relevant research, learning, best practice and technical guidance relating to the application of thin surface treatments and safety of road users. ADEPT is concerned with the safety of all road users, with a focus on the more vulnerable road users like pedestrians, cyclists and motorcyclists. Thank you for bringing this matter to our attention. Yours sincerely ADEPT President
Henry Charles HM Assistant Coroner for Hampshire, Portsmouth and Southampton Coroner’s Office From the Parliamentary Under Secretary of State Great Minster House 33 Horseferry Road London SW1P 4DR Web site: www.gov.uk/dft 31 October 2025 Dear Mr Charles I am writing to address the recommendations and concerns raised in your report of 10 July following the inquest into the death of Paul David Ransom. May I first express my deep sadness at learning of Paul Ransom’s death and offer my condolences to his family and friends. I am grateful to you for extending the date by when I should respond to 31 October. My and I officials have studied the report’s findings: that in the initial period of laying the “thin surface treatment” to a road’s surface, it has a particular property “early life effects” which can cause the dry road surface to respond akin to a wet road surface and affect vehicle behaviours; and may have a greater effect on motorcycles. I felt it would be useful to explain how highways maintenance is managed and, in that context, suggest how best the report’s recommendations and concerns can be addressed. This government takes the condition of our country’s roads very seriously and is committed to supporting local highway authorities in maintaining the local highway network and keeping it safe. Responsibility for highways maintenance is devolved; the local highway authorities have a duty under Section 41 of the Highways Act 1980 to maintain the highways network in their area. The Act does not set out specific standards of maintenance, as it is for each local highway authority to assess which parts of its network need repair and to what standards based upon local knowledge and circumstance. However, I recognise the seriousness of what has occurred regarding the road surfacing which your report cites as having caused or substantially contributed to the collision involving Mr Ransom, and the need to ensure, as far as possible, there is no recurrence. For that reason, I have committed to undertaking several measures, described below. My officials and ADEPT (Association of Directors of Environment, Economy, Planning & Transport), to whom your Report was also sent, are working closely to determine the best approach for ensuring awareness of this issue and the effect on motorcyclists, within the wider transport sector, including among local highways authorities. The issue will be discussed at ADEPT’s next Board meeting. Further, the guidance on highways maintenance which is offered to local highways authorities in the publication ‘Well Managed Highways Infrastructure: A Code of Practice’, will be reviewed and updated to address and take account of your report’s recommendations and concerns. We are planning to comprehensively review and update the Code by November 2026 but where possible we will incorporate and issue the guidance related to this case before then. Finally, on the need for adequate road signage, currently, signage exists for slippery roads and for loose chippings but not for the specific “thin surface treatment” road surfacing highlighted in your report. As part of the update to the Code of Practice, I have asked my officials to consider the appropriateness of signing to highlight locations where thin surface treatments have been applied. I hope these measures assure you of what I am doing to address your report and to ultimately ensure safety on our roads, in light of this tragic case. Best wishes, MINISTER FOR LOCAL TRANSPORT
Technology Centre, Glaisher Drive Wolverhampton Science Park Wolverhampton, WV10 9RU 9th September 2025 Julie Davies HM Coroner for Hampshire, Portsmouth and Southampton Coroner's Service Portsmouth Office The Coroner’s Court 1 Guildhall Square Portsmouth PO1 2GJ Dear Julie Thank you for your letter dated 10th July 2025, with the accompanying ‘Regulation 28: Report to Prevent Future Deaths’ in relation to the very sad death of Paul David RANSOM on the 24th May 2023. The RSTA would like to express our condolences to Paul’s family and friends. I acknowledge the themes identified by the Coroner as cause for concern, to include: Early life skid resistance, post treatment / change in the level of friction Study into accidents rates - not specific to motorbikes Guidance on post treatment signage Site categories gradients, bends, limited site lines – particularly for motorcycles The RSTA and its supplier and contracting specialist member representatives held a meeting to review the Specification, Codes of Practice and processes associated with the application of preservation systems. Our response to this notice make reference specifically to the asphalt preservation treatment and does not relate to other road surface treatments or resurfacing. Early life skid resistance Asphalt preservation systems are preventive surface treatments certified under a Highway Authority Product Approval Scheme, in which an independent, accredited laboratory will have undertaken robust testing, including that of post treatment skid resistance, deeming the systems suitable for use on UK roads. Following the application of the preservation treatment, a grit is applied as a sacrificial layer which serves to manage initial skid resistance, and to re-abrade the aggregate through the effects of trafficking, to remove any remaining film on the road surface. Asphalt preservation treatments typically take from 30 minutes to two hours to ‘cure’ depending on conditions, which on the day of the collision, were reported to be good. The treated surface is not reopened to traffic until such time that the application of grit has been completed and the treatment has fully cured. My understating is that the collision occurred approximately six hours, post treatment, having been fully inspected and deemed suitable to be reopened to traffic. The site was closed following the collision and Police conducted testing of skid resistance during the closure as part of their collision investigation. Therefore without any vehicle actions, the surface properties would be very similar to that at the time of the collision. The skid testing results confirmed that both skid resistance values and grip levels were satisfactorily above the minimum investigatory values required, which is contrary to the testimonies of some of the witnesses who had described the road as being slippery. The site was therefore reopened by the Police, without any post-treatment signage, indicating that there were no further safety concerns. Through the HAPAS testing process, we are confident that quality products and systems are applied to roads, and by trained and competent installers, which ensures post preservation treatment skid resistance values will meet the required investigatory levels. Accident Rate Studies not being motorcycle-specific The RSTA is unable to offer any comment on any statistics or studies relating to collisions involving motorcycles, specifically. The Department for Transport may have a more detailed breakdown of collision data, involving motorcycles. Post-Treatment Signage Guidance Currently, there is no requirement for post-treatment signage on sites treated with asphalt preservation. Asphalt preservation systems undergo rigorous independent testing and accreditation under the Highway Authorities Product Approval Scheme (HAPAS), including: A Type Approval Installation Trial (TAIT), involving comprehensive independent testing to UK and European standards covering both pre- and post-treatment skid resistance, grip, and surface texture. Manufacturing under ISO 9001 quality standards. Annual installation audits by independent bodies such as the British Board of Agrément (BBA), ensuring treatments are applied according to approved methods. Mike Hansford - Chief Executive & Director. Registered office: Technology Centre, Glaisher Drive, Wolverhampton Science Park, Wolverhampton, WV10 9RU. RSTA is a trading name of The Road Surface Treatments Association Limited, a Company Limited by guarantee No. 375993 London This independent testing confirms that by the time a treated road is reopened to traffic, skid resistance values will be restored to the specified investigatory levels, therefore the process for these systems, do not require any signage. Preservation treatments are only recommended for sites where SCRIM data is above investigatory levels. Sites falling below this threshold are deemed unsuitable for preservation treatment. All RSTA members confirm that pre treatment skid resistance data is routinely requested, which forms an essential part of site suitability considerations. A site-specific survey and risk assessment is completed for all sites prior to treatment, whereby any additional risk factors and mitigation measures that may be required, including that of any signing, are identified. Site Categories – Gradients, Bends, and Limited Sight Lines The site-specific survey and risk assessment which is completed for all sites prior to treatment, would incorporate any risk factors linked to gradients, bends and sight lines, and may also include any collision history on the section of road being treated. This would be a discussion between the specialist contractor and the client / principal designer or designer and would involve consideration of any requirement for warning signs on completion of works prior to reopening to traffic. Further evidence for clarification I understand there was reference in one of the testimonies at the inquest, to slippery road warning signs once being required to be put out on new ‘thin surfacing’ type materials (which is a term used to reference a type of asphalt surface course product). These materials have a thicker binder film. The national guidance on management of these thin surfacing materials removed the requirement for slippery roads signs to go out on these sites. These thin surfacing materials, unlike asphalt preservation systems, do not have an application of grit applied post treatment to manage skid resistance, so the two treatments / processes cannot be compared. My understanding is that there was also reference to surface dressing, where signing is placed on the highway, post treatment. This is an entirely different process and this signing manages the potential risk associated with loose chippings and therefore reduces the speed of traffic, until such time the final sweep has been completed and loose chippings have been removed. This process is not required for preservation treatments. Next steps The specifications (Specification for Highway Works) and design manual documents (Design Manual for Roads and Bridges) are compiled by National Highways as part of their Manual of Contract Documents for Highway Works (MCHW), and these documents are often used by local highway authorities. Mike Hansford - Chief Executive & Director. Registered office: Technology Centre, Glaisher Drive, Wolverhampton Science Park, Wolverhampton, WV10 9RU. RSTA is a trading name of The Road Surface Treatments Association Limited, a Company Limited by guarantee No. 375993 London We are due to meet National Highways to discuss the newly revised specification documents, which will be published in late September/early October. We will specifically discuss the concerns set out by the Coroner in this Notice, relating to asphalt preservation systems. I will respond to you again, with an update of the outcomes of that meeting. In the meantime, if you have any further questions or require any clarifications, please get in contact with me. Yours sincerely Chief Executive Officer Mike Hansford - Chief Executive & Director. Registered office: Technology Centre, Glaisher Drive, Wolverhampton Science Park, Wolverhampton, WV10 9RU. RSTA is a trading name of The Road Surface Treatments Association Limited, a Company Limited by guarantee No. 375993 London
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