Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0422, written 12 Aug 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Aug 2025 |
|---|---|
| Reference | 2025-0422 |
| Deceased | Charlotte Noordam |
| Coroner | Ana Samuel |
| Coroner area | Birmingham and Solihull |
| 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.
1 2 3 4 5 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Birmingham City Council CORONER I am Ana Samuel Assistant Coroner for Birmingham and Solihull 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 18 March 2025 I commenced an investigation into the death of Charlotte NOORDAM. The investigation concluded at the end of the inquest . The conclusion of the inquest was; Road traffic collision CIRCUMSTANCES OF THE DEATH On the 8th March 2025 at around 14.12 the deceased was riding a black Yamaha Tracer 700 motorbike registration number St James Road. Upon reaching the junction she failed to comply with the stop sign and crossed into the path of and into collision with an MG 3 motor vehicle registration number which was travelling with right of way along St James Road. Death was certified at 14.48 at the junction of Frederick road and St James Road. down Frederick Road in Edgbaston towards the junction with , Following a post mortem the medical cause of death was determined to be: 1a Multiple Injuries 1b Road Traffic Collision 1c 1d II 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 junction is a crossroads in Edgbaston between Frederick Road (running North South) and St James Road (running East West). Both roads are two way priority. Traffic flow priority is along St James Road. Access northwards to St James row from Frederick Road is controlled by a GIVE WAY. Access southwards to St James row from Frederick Road is controlled by a STOP. Both roads are the subject of a 20mph speed limit Traffic Regulation Order. 2. Birmingham City Council stated that if a new junction being designed from new (i.e. it was not a preexisting historic arrangement), they would oppose the use of a non-signalised crossroad junction because of the inherent confusion around priority of movement at the crossroad. However, this is a historic highway arrangement. 3. Whilst the road layout, including signage and road markings, complies with the legal requirements this does not appear to have mitigated against the prevalence of incidents at the stop junction. 4. There have been at least 27 other road traffic incidents at the same junction during the period 23rd May 2014 to the 8th March 25. 5. The police investigator gave evidence that, in his experience, the number of collisions at the stop junction raises questions about the safety of the junction. 6. Evidence from Birmingham City Council suggested that there were potentially additional measures that could be considered to mitigate any safety risks so far as reasonably practicable. 7. I am concerned that there is still a risk to life for users of the junction. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 7 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: • The family of Mrs Noordam • West Midlands Police • The driver of 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. 12 August 2025 6 7 8 9 Signature: Ana Samuel Assistant Coroner for Birmingham and Solihull
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.
Ana Samuel, Assistant Coroner for Birmingham and Solihull Coroner’s Court, Steelhouse Lane, Birmingham, West Midlands, B4 6BJ 7th October, 2025 Formal Response to Regulation 28 Report to Prevent Future Deaths – Death of Charlotte Noordam Dear Ana, Thank you for your Regulation 28 Report dated 12 August 2025 concerning the tragic death of Charlotte Noordam at the junction of Frederick Road and St James Road in Edgbaston. Birmingham City Council acknowledges the serious concerns raised in your report, particularly the longstanding safety issues associated with this historic, non-signalised crossroad junction of residential, unclassified roads. While the current road layout, signage, and markings comply with legal standards, we recognise that these measures have not sufficiently mitigated the risks posed to road users. The frequency and severity of incidents at this location, including the 27 recorded collisions between May 2014 and March 2025, underscore the need for more decisive intervention. As meaningful redesign in alignment with the Safe System approach would require significant demolition of the surrounding built environment, this approach is wholly inappropriate for this setting. Therefore, the Council confirms its intention to take decisive steps to address the volume of vehicular traffic using this junction. This decision reflects our commitment to prioritise public safety and prevent future loss of life, as set out in our adopted Road Harm Reduction Strategy. Vehicular traffic will be redirected away from residential areas towards the city’s classified road network, which is better equipped to handle higher vehicular traffic volumes safely. In accordance with the statutory timeframe, the Council is implementing its Fatal Collision Response Protocol to assess the specific site conditions to identify locally appropriate interventions which we intend to deliver in two phases. The first of these will be implementation of vertical traffic calming measures and additional signage to better alert drivers to the presence of the junction. We will deliver these measures within a six- month period of the date of this letter. As set out above, our further intention is to deliver traffic management measures to direct traffic away from this junction. However, as this could have impacts across the wider road network, this will require further design and assessment work to be undertaken before proceeding to implementation. Yours sincerely, Deputy Chief Executive Executive Director for Strategy, Insight & Governance Birmingham City Council Page 2 of 2
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