Prevention of Future Deaths reports · 2025
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 report | 4 Sep 2025 |
|---|---|
| Reference | 2025-0449 |
| Deceased | Cheryl Edwards |
| Coroner | Geoffrey Sullivan |
| Coroner area | Hertfordshire |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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
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.
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
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.
See every Prevention of Future Deaths report matching Road (Highways Safety) related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.