Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0365, written 18 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 | 18 Jul 2025 |
|---|---|
| Reference | 2025-0365 |
| Deceased | Dorothy Wagstaff |
| Coroner | John Hobson |
| Coroner area | West 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.
OFFICE OF THE SENIOR CORONER for the County of West Yorkshire (Eastern District) His Majesty’s Coroner’s Office The Coroner’s Courts Burgage Square Wakefield WF1 2TS Telephone: Email: REGULATION 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. THIS REPORT IS BEING SENT TO: 1 Leeds City Council Highways. CORONER I am John Hobson, Assistant Coroner for the Coroner Area of West Yorkshire (East). 2 3 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. INVESTIGATION and INQUEST On 15 January 2025 I commenced an investigation into the death of Dorothy Elizabeth Wagstaff who died on 11 January 2025. The investigation concluded at the end of the Inquest on 26 June 2025. The medical cause of death was 1a) Multiple Traumatic Injuries 2) Multiple Medical Comorbidities. In summary, Mrs Wagstaff died after the car she was driving collided with a post, plastic barriers, railings and a lamp post on the A660 Leeds Road at Otley. It was found to be more likely than not that the car moved towards the post, plastic barriers and railings after Mrs Wagstaff suffered a medical episode. The plastic barriers were temporary and provided little resistance to prevent the car leaving the road which then collided with railings and with the lamp post. The car came to a rest and paramedics attended but Mrs Wagstaff’s death was confirmed at the scene. CIRCUMSTANCES OF THE DEATH 4 The relevant facts pertaining to Mrs Wagstaff’s death were recorded on the Record of Inquest at Box 3 which reads as follows: ‘On 11 January 2025 Dorothy Elizabeth Wagstaff was driving towards Bramhope on the A660 Leeds Road at Otley when her car steadily moved to the left of, then off, the inside lane before colliding with a concrete post to the road barrier. The car then collided with temporary plastic barriers which provided little or no resistance before hitting a further section of the road barrier comprised of posts and poles. The car then proceeded to hit a lamp post before coming to a stop in the road. Elizabeth sustained multiple traumatic injuries. Paramedics attended but her death was confirmed at the scene at 1057 hours. It is more likely than not that Elizabeth suffered a medical episode that led to her car initially colliding with the road barrier post and the gap in the road barrier enabled the car to then proceed to collide with road barrier posts and poles and the lamp post before coming to rest’. A conclusion of Road Traffic Collision was recorded. CORONER’S CONCERNS During the course of the Inquest the evidence revealed a matter 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 MATTER OF CONCERN is as follows. – (1) The trajectory of Mrs Wagstaff’s car after the initial collision with the concrete post involved passing through temporary plastic barriers which, on the evidence heard, offered no resistance such that the car then proceeded to leave the road and collide with a lamp post before coming to rest back on the road. (2) Upon examining photographs of the scene, the road barrier/railings and sections of the road, it was noted that plastic barriers similar to those referred to in the Record of Inquest above were present in another section of the A660 Leeds Road. (3) Within the evidence adduced at the inquest, it was noted that Leeds City Council Highways Department have indicated that a schedule of works will be created with a view to replacing the old concrete and metal pole barriers with metal pedestrian railings in this area of the A660. (4) The concern that I raise is that photographs considered at the inquest indicated the on-going presence of plastic barriers in a gap in the existing barrier/railings elsewhere along the stretch of road. Plastic barriers were a factor in the circumstances of the accident in which Mrs Langstaff sadly died. If that remains the case, I am of the view that action should be taken to prevent a risk of future deaths. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you or your organisation have the power to take such action. 5 6 YOUR RESPONSE 7 You are under a duty to respond to this report within 56 days of the date of this report, namely by 12 October 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 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 8 Mrs Wagstaff’s family. 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. She may send a copy of this report to any person who she 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. Signed: 9 JOHN HOBSON Area Coroner West Yorkshire (E) Date: 18 July 2025
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.
His Majesty’s Coroner’s Office The Coroner’s Courts Burgage Square Wakefield WF1 2TS Highways & Transportation Civic Hall Calverley Street Leeds LS1 1UR 9th October 2025 Dear John Hobson, Assistant Coroner for the Coroner Area of West Yorkshire (East). Subject: Mrs D Wagstaff, A660 Leeds Road. In response to your letter dated 18th July 2025. I can confirm that officers attended this location with the Police following this tragic and very sad accident. In response to the four points you raised, please see each point and our response below. (1) The trajectory of Mrs Wagstaff’s car after the initial collision with the concrete post involved passing through temporary plastic barriers which, on the evidence heard, offered no resistance such that the car then proceeded to leave the road and collide with a lamp post before coming to rest back on the road. I can confirm that the placement of temporary traffic management measures in response to incident management, with the aim to highlight a damaged area or potential hazard to other motorists is a standard industry approach, as defined in the Department for Transports, Traffic Signs Manual, Chapter 8, Traffic Safety Measures and Signs for Road Works and Temporary Situations. Options available to Local Authorities for temporary measures include the placement of traffic cones, the placement of temporary plastic red pedestrian barrier (Manchester barrier), heavy- duty provision of water filled interlocking heavy-duty barrier or temporary vehicle restraint safety barriers. It was considered appropriate for this road, that the heavy-duty water filled barriers offered the greatest visible warning of the damage to this section of fencing whilst a permanent repair was programmed. As the current historical concrete post and rail fencing acts as a demarcation, rather than vehicular restraint, between a change in level from the footway and the carriageway, the placing of temporary heavy-duty water filled interlocking plastic barriers continued to provide the demarcation where there was damage or interruption to the existing infrastructure. These temporary heavy-duty water filled plastic barriers are only an interim measure and do not offer any vehicle restraint properties. www.leeds.gov.uk General enquiries: 0113 222 4444 (2) Upon examining photographs of the scene, the road barrier/railings and sections of the road, it was noted that plastic barriers similar to those referred to in the Record of Inquest above were present in another section of the A660 Leeds Road. It is standard practice to deploy temporary plastic barriers when fencing and barriers become damaged. I can confirm that there are other sections along the A660 Leeds Road where the existing concrete post and rail demarcation has been subject to damage. Alternatives, as noted in point one, to the water filled interlocking plastic barriers were not deemed appropriate at this location. Water filled interlocking plastic barriers offer more stability. They are less susceptible to movement by the wind and the effect of passing vehicles, especially HGVs, and provide the continuous warning of the demarcation between the change of level between the carriageway and footway. (3) Within the evidence adduced at the inquest, it was noted that Leeds City Council Highways Department have indicated that a schedule of works will be created with a view to replacing the old concrete and metal pole barriers with metal pedestrian railings in this area of the A660. Each location is assessed in isolation and initially it was indicated that metal pedestrian guardrail may be a quicker solution for this location during a site visit with the Police. However, subsequent assessments by our specialist contractor and highways officers have identified several issues with this approach e.g. this approach would reduce the footway width to an unacceptable width, where wheelchair users and/or parents with push chairs would not be able to pass. This option was therefore dismissed for this location. Therefore, several alternative permanent solutions are being considered as part of an ongoing detailed options appraisal. These option appraisals have included the provision of Galvanised steel safety barrier (Arco barrier), Moorland markers post, Rebound marker posts, bollards, pedestrian guardrail and Trief (vehicle retainment) kerbing. The Trief kerb solution is currently looking the preferred option from an engineering, highway limitation and aesthetic perspective for this specific location and the other section along this length of the A660 where damage has occurred to the historical concrete post and rail fencing. Similar detailed assessments will be undertaken at other locations with defects and the appropriate solution implemented when practicable. This is to try and prevent future incidents from occurring. (4) The concern that I raise is that photographs considered at the inquest indicated the on- going presence of plastic barriers in a gap in the existing barrier/railings elsewhere along the stretch of road. Plastic barriers were a factor in the circumstances of the accident in which Mrs Langstaff sadly died. If that remains the case, I am of the view that action should be taken to prevent a risk of future deaths. Following this accident and the receipt of your letter, Leeds City Council Highways Department have commenced a detailed review of the process from when we attend site following an incident to make the location ‘safe’ for the public to continue to use the highway, through to the reinstatement of a permanent solution. This review has highlighted that we are www.leeds.gov.uk General enquiries: 0113 222 4444 now able to utilize a newly implemented computer monitoring system (AMX) to better track the location of temporary repairs, in this case the installation of heavy-duty water filled barriers and monitor progress to completion of permanent repair. Moving forward works orders will be raised immediately following an emergency site visit to allow an engineering options appraisal to take place. Once a suitable engineered solution has been determined, the works will then be issued, programmed and implemented. This improved process has the aim of ensuring permanent repairs are made within an appropriate timeframe. I trust that this information meets with your approval, but please let me know if further detail of my proposals would be helpful. Yours Sincerely Chief Officer Highways & Transportation www.leeds.gov.uk General enquiries: 0113 222 4444
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