Prevention of Future Deaths reports · 2025

Cheryl Edwards

Regulation 28 report to prevent future deaths, reference 2025-0449, written 4 Sep 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report4 Sep 2025
Reference2025-0449
DeceasedCheryl Edwards
CoronerGeoffrey Sullivan
Coroner areaHertfordshire
CategoryRoad (Highways Safety) related deaths
Sourcejudiciary.uk record · original PDF
Responses published2

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

CORONER’S OFFICE 
AREA OF HERTFORDSHIRE 

Date: 4th September 2025 

Our Ref: 20267252 

     REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 
     THIS REPORT IS BEING SENT TO:  
     Angie Ridgwell Chief Executive Hertfordshire County Council 

1.  CORONER 

I am Geoffrey Sullivan HM Senior Coroner for Hertfordshire  

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.  

http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 

http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 

3.  INVESTIGATION AND INQUEST 

On 11 October 2023 I commenced an investigation into the death of Cheryl Dawn Lorna Edwards. 

The investigation concluded at the end of the inquest on 28 August 2025. 

The conclusion of the inquest was Road Traffic Collision.  The cause of death: 

1a Multiple Traumatic Injuries   

1b    

1c    

II    

4.  CIRCUMSTANCES OF DEATH 

On 28th September 2023 Cheryl Edwards was walking her dog on Sarratt Road, Croxley Green 
when she was struck by a car. Ms Edwards was crossing the road from a driveway which leads to 
the road from her house. The driver of the car had insufficient time to respond to her presence in 
the road. Police and paramedics attended and confirmed her death at the scene. 

5.  CORONERS 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. During the course of the 
inquest, I heard evidence from an experienced collision investigator from Hertfordshire 
Constabulary that in his opinion the speed limit of 60mph on Sarratt Road is too high, the specific 
stretch of road runs from the M25 over-bridge to the speed restriction sign for Sarratt Village. He 
outlined that the road has a number of residential properties that border the road with driveways 

 
   
  
  
  
  
  
 
 accessing it and that the verges were made up of dense foliage.  This restricts the view of 
approaching drivers and any pedestrians leaving their houses or crossing the road. In his opinion 
the characteristics of the road, the speed limit and the presence of the residential properties 
present a risk of future deaths.  In the circumstances it is my statutory duty to report to you. 

6.  The MATTERS OF CONCERN are as follows.  – 

[BRIEF SUMMARY OF MATTERS OF CONCERN] 

(1) That the speed limit of 60mph is too high for the stretch of Sarratt Road between the M25 over-
bridge and the speed restriction sign for Sarratt Village.     

(2) 

(3) 

7.  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. 

8.  YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, namely by 
30th 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. 

9.  COPIES AND PUBLICATION 

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 

 (family member of the deceased).   

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. 

10.  4th September 2025 

Signature 

Mr. Geoffrey Sullivan Senior Coroner 

HM Coroner for Hertfordshire

Responses

2 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.

Response from Hertfordshire County Council (PDF)
Chief Executive: Angie Ridgwell 

Hertfordshire County 
Council CH 0238, Robertson 
House Six Hills Way, 
Stevenage, SG1 2FQ 01992 
555200 

28 November 2025 

Dear Geoffrey, 

Subject: Response to Regulation 28 Prevention of Future Deaths Notice – 
Sarratt Road Fatal Collision (September 2023) 

Thank you for your report dated 4 September, issued under Regulation 28 following 
the inquest into the tragic fatal collision on Sarratt Road in September 2023. We 
recognise the seriousness of this incident and extend our deepest sympathies to the 
family and all those affected. 

We have carefully considered the Matters of Concern raised in your report, namely: 

That the speed limit of 60mph is too high for the stretch of Sarratt Road 
between the M25 over-bridge and the speed restriction sign for Sarratt 
Village. 

In our role as Highways and Transport Authority, we have undertaken further 
investigation and held further discussions with the Police, with whom we work closely 
on all matters relating to speed limits and road safety more broadly. Together, we are 
committed to improving road safety within Hertfordshire. 

County of opportunity 

 
 
 
 
 
 
 
 
 
 
 
 Our Findings 

Speed: 
The Police Investigation Report estimated impact speed between 24–44mph; no 
evidence of excessive speed was found. Separate evidence shows that mean vehicle 
speeds on Sarratt Road are typically 30–40mph, significantly below the national 
speed limit. We acknowledge that speed has been cited as a proxy cause of the 
incident, suggesting the driver of the car had insufficient time to respond in the 
situation. 

Visibility and Vegetation: 
The sightlines between the driver and the person crossing the road were found to be 
affected by vegetation, located on third party land. Further review identified that a 
hedgerow and fencing restrict visibility. 

In light of the impact speed estimated by the Police and the sightlines, it is our view 
that the available visibility and reaction times were the key factors in this case. We 
recognise the sensitivity of this issue within the local community and will ensure any 
steps taken to improve sightlines are managed through appropriate processes 
without public attribution, to avoid conflict between neighbours. Our focus remains on 
improving safety for all road users. 

Decision and Policy Context: 
In considering any changes to speed limits, we are required to take into account 
guidance from the Department for Transport (DfT Circular 01/2013, updated March 
2024) which reinforces that speed management decisions should be evidence led, 
integrated within an overarching ‘safe system’ approach, and avoid isolated hazard-
based changes unless supported by robust data. 

After reviewing the evidence and considering your concerns, we have met with both 
the Police Investigation team and the Local Policing Traffic Management Officer. To 
inform our response, further consideration was given to the recommendation that the 
speed limit along this stretch of road is too high. 

The Police have set out their view on this and Chief Inspector 
of Roads Policing has confirmed that: 

, Head 

“...the police Traffic Management Officer opinion is that the speed limit 
does not need to be reduced and remains within the consistency and 
parameters of speed management strategies.” 

I attach Chief Inspector 

 full letter for your information. 

 In the light of this and evidence contained within the Police Investigation Report, we do 
not consider that an isolated reduction of the speed limit at this location would address 
the underlying visibility issues which we believe were key contributory factors that led 
to this tragic incident. Instead, we propose other actions to address the issues which 
the evidence now available suggests were the more likely cause of the incident. This 
approach aligns with Hertfordshire’s Speed Management Strategy and DfT Circular 
01/2013, which emphasises evidence led, network wide consistency. 

I set out below the action taken to date in response to this tragic event and 
proposed future actions. 

Actions Already Taken 

  Reviewed the Police Investigation Report and your Prevention of Future Deaths 

notice. 

Initiated internal review of vegetation management processes. 

  Checked land ownership and planning records for the affected location. 
 
  Reviewed highway faults. 
  Met with investigating officers for the case. 
  Sought Police Traffic Management Officer’s initial position on an isolated speed limit 

change – which was met with concerns. 

  Clarified a consolidated Police position on an isolated speed limit change. 

Planned Actions (Undertaken by Summer 2026) 

Speed Management: 
 

In light of the evidence in relation to speed, and in line with the Department 
for Transport Circular 01/2013 and our Speed Management Strategy, we will 
maintain the current limit, focusing on systemic improvements rather than 
changing the speed limit for an isolated hazard. 

  We will consider area wide rural speed management approaches as part of 

our Speed Management Strategy review, which is underway, and strengthen 
messaging to the public to explain speed limits and road user behaviour in a 
rural context. 

Visibility Improvements: 
  Apply targeted vegetation clearance for safety critical sightlines, while maintaining 

visual cues that discourage higher speeds. 

  Seek to highlight the requirements on property owners through the planning 

process. 

  Review frontage design constraints and address these through appropriate 
processes to ensure safety standards are met, without creating community 
conflict. 

  Strengthen our messaging to the public on third party vegetation responsibilities. 

 System Improvements: 
  Propose a regular multi-agency collision review meeting after life changing, 

serious or fatal collisions to identify systemic issues earlier. 
  Strengthen liaison with your office to improve timelines and clarity 
of recommendations as part of the initial investigation process. 

  We can confirm that the forthcoming review of our Speed Management 

Strategy will consider rural speed limit requirements. 

Please do not hesitate to contact me if you require any clarification. 

Yours sincerely 

Chief Executive
Response from Road Policing Unit (PDF)
Mr R. Surridge 

Technical lead Road Safety / Highways team 

Herts County Council 

Dear Rob 

29th October 2025 

As the head of department for the collaborated Bedfordshire, Cambridgeshire and 
Hertfordshire Roads Policing portfolio, encompassing road death investigations and Traffic 
Management Officers, I wish to make comment surrounding the  Regulation 28 Prevention 
Of Future Deaths Order directed towards Hertfordshire County Council, dated the 4th 
September ( 
death of Cheryle Edwards pursuant to a road collision  on the 28th September 2023 on 
Sarratt Road , Croxley ,Green Hertfordshire. 

) by MR Sullivan regarding the sad and tragic road 

In preparation of the case and during verbal presentation of the evidence to Mr Sullivan my 
detectives made commentary that speed was a likely causation of the collision, and the 
national speed limit at the location represented a risk of future collisions. The commentary 
about future road user risk is unusual for my detectives to make and is not the norm, 
however they are entitled to make an informed opinion under oath to assist the Coroner. The 
detectives presenting from the Serious Collision Investigation Collision Unit are very 
experienced and professional officers having completed hundreds of such investigations and 
can be classed as Subject Matter Experts in their field. However, this field would be for 
investigation purposes and not the wider design of the road, road safety best 
practice/principles regarding influence/compliance of road users. It is my opinion that the 
detectives have acted in good faith in presenting their evidence, have been open with their 
opinion to assist the Coroner and deliver public protection, they have not acted with any 
intentional or unconscious bias to any party. 

I have subsequently discussed the matter with my Traffic Management Officers who are 
Subject Matter Experts in the wider field of road deign signage and maintenance. These 
officers have rightly referred to Sarratt Road as being a national speed limit in a rural 
location with relatively low vehicle use compared to high density town centre / urban 
locations. In this regard , due consideration needs to be made to the  detailed documents 
from  Government – Setting local speed limits 1and the HCC speed management strategy.2  

1 Setting local speed limits - GOV.UK 
2 Speed Management Strategy 2020 

                                                             
 
 
 
 
 
 
 Both documents seek to ensure consistency across similar road types and speed setting 
should not be a singular solution to any safety concerns for a road where road death and 
injury rates are known to be high. Therefore, the refined, considered and nuanced Roads 
Policing position, on behalf of Hertfordshire Constabulary, is this that any determination on 
road safety solutions, if any, should be at the considered direction of HCC as the responsible 
authority utilising their own expert assessment and being consistent with local and national 
strategy. Furthermore this  road has had  only 1 fatality /serious  collision in the last 5 years , 
speed limit was not evidenced as a key issue within the forensic collision report ,albeit 
analysis was difficult due to  the nature of the collision and relying on pedestrian throw 
distance  , therefore the police Traffic Management Officer opinion  is that the speed limit 
does not need to be reduced and remains within the consistency and parameters of  speed 
management strategies.  

Police Traffic Management Officers work very closely with HCC and key stakeholders with 
the Hertfordshire Speed Management Group assessing bespoke local sites and aligning 
practical interpretation to national speed strategy parameters.  

The Police Traffic Management Officers would normally be part of a multi-agency post 
collision review process , this did not take place for this collision as it was not originally felt  
that there was any highway issues as a factor to consider in this case ,as result there was no 
bespoke Subject Matter Experts present at the Coroner’s hearing to support the Coroner 
and respond to questions. 

I would also highlight that some differing professional views and opinions is a healthy 
position under strong partnerships to enable open conversations on a range of solutions to a 
problem, to protect the public professionally, pragmatically and proportionally to the risk. 
However, I am very conscious on how a differing initial views may be perceived by both the 
Coroner and Cheryle Edwards’ family and I would be happy to speak to either or both in 
person to explain this further. 

In summary the response to the Coroner’s question as to what considerations as to how the 
road could be made safer, holistically, now sits with HCC colleagues, but I hope the above 
provides some assistance with this. 

I am happy for this letter to be shared in full or in part within your formal response to the 
Regulation 28 notice. 

Yours sincerely 

 
 
 
 
 
 
 
 
 Chief Inspector 

Head of Roads Policing. 

Specialist Operations.

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