Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0605, written 1 Dec 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Dec 2025 |
|---|---|
| Reference | 2025-0605 |
| Deceased | John Hickmott |
| Coroner | Adam Smith |
| Coroner area | Milton Keynes |
| 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.
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 Assistant Director of Highways and Transportation, Milton Keynes Council
1
CORONER
I am : Adam Smith, Assistant Coroner for Milton Keynes
Civic Offices
1 Saxon Gate East
Milton Keynes
MK9 3EJ
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 24 February 2025, Dr Sean Cummings, Assistant Coroner, commenced an investigation
into the death of John Charles HICKMOTT aged 63. The investigation concluded at the end of
the inquest on 21 November 2025.
My conclusion at the inquest was that Mr Hickmott died by road traffic collision. The medical
cause of death was:
1(a) Multiple fractures and cardiogenic shock.
4
CIRCUMSTANCES OF THE DEATH
On 19 February 2025, at around 19:15 hours, Mr Hickmott crossed the road (V11 Tongwell
Street, Northfield, Milton Keynes) near to the Audi garage. There was a pedestrian footpath at
either side of the road where he crossed and a pedestrian island in the middle of the road so
that pedestrians could stop midway. The road at this point is a single carriageway road, with
a 60mph limit. It was dark and the weather was dry, although the road was damp. A number
of nearby streetlights, including one immediately above the site of the collision, were not
working at the time. The nearest lit streetlights were 75m and 105m respectively in opposite
directions from the site of the collision.
Mr Hickmott stepped from the pedestrian island in front of a moving car. On the evidence, he
was probably intoxicated at the time. He had been seen a few minutes earlier stumbling on
the grass verge and into the road. He was struck by the car and died at the scene from the
injuries he sustained.
The driver of the vehicle that collided with Mr Hickmott was following all rules and regulations,
including driving well below the speed limit. He was not impaired by drugs or alcohol. Mr
Hickmott would only have become visible to him at the last moment. The driver reacted
appropriately and took evasive action, but once Mr Hickmott stepped into the road, the collision
was sadly unavoidable.
Regulation 28 – After Inquest
Document Template Updated 30/07/2021
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)
I received evidence from witnesses who had attended the scene of the collision soon afterwards
or driven past shortly beforehand, commenting on how dark it was and how difficult it would
have been to see a pedestrian.
I also received evidence from a Highways Strategic Asset Manager at Milton Keynes City
Council, together with documents, indicating that a number of streetlights on this stretch of
road had previously been reported as not working. These included a streetlight almost
immediately above where the collision with Mr Hickmott took place and other adjacent/nearby
streetlights. Specifically, there had been reports on 6 October 2024 of three individual
streetlights not working, then on 20 November 2024 a report of a block of five more streetlights
not working. It was stated in the Council's enquiry document that, "Several lamps on both
sides of V11 are permanently out between the two Northfield Drive turnings" and that, "This is
making this already accident-prone stretch of road more dangerous as the turnings are very
dark." According to the Council's procedure at the time, the block of five lights should have
been repaired within 14 days of having been reported defective and the three individual lights
within 28 days. These lights had not been repaired at the time of the collision involving Mr
Hickmott, nor when the Forensic Collision Investigator undertook a reconstruction 21 days later
(see below). The evidence from the Highways Strategic Asset Manager was that six of the
streetlights were repaired on 19 March 2025 and two more on 16 April 2025.
I received a Collision Investigation Report from a Forensic Collision Investigator at Thames
Valley Police's Forensic Collision Investigation Unit. This included detailed evidence about
conspicuity, and how Mr Hickmott would have been especially inconspicuous in the dark, in the
absence of working streetlighting proximate to the incident. This evidence included
photographs from a reconstruction undertaken at the site in hours of darkness 21 days after
the incident. The streetlights were still not working at that time. This evidence was striking in
demonstrating how a pedestrian would be almost invisible to a driver (even when one knows
they are present and are looking for them) until the driver is within 20 - 30 metres of the
pedestrian, at which point they would start to be illuminated by car headlights.
The Council’s Highways Strategic Asset Manager also stated that, following an inspection of the
same stretch of road, undertaken on 19 November 2025 following questions received from me,
six streetlights were found not to be working (not previously reported to the Council as faulty).
This may suggest a more fundamental technical problem with the streetlights on this stretch
of road.
The evidence of the Highways Strategic Asset Manager was that the priorities and timescales
for repairs of faulty streetlights were already, as at November 2024, set out in the Council's
contract with its principal highway services contractor, as well as the Code of Practice for
Highways Electrical Maintenance. Despite this, the faults reported on 6 October and 20
November 2024 were not repaired until 19 March and 16 April 2025.
I am concerned at:
1) The timeliness of repairs being undertaken when streetlights are reported as not being
lit;
2) The extent of monitoring of scheduled repairs to ensure timely repair;
3) The extent to which proactive inspections are undertaken by the Council to identify
faulty streetlights, or blocks of lights, that may not have been reported to the Council.
Regulation 28 – After Inquest
Document Template Updated 30/07/2021
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 January 26, 2026. 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.
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:
Mr Hickmott’s next of kin
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 of
interest.
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.
9
DATE SIGNED BY ASSISTANT CORONER
1 December 2025
Regulation 28 – After Inquest
Document Template Updated 30/07/2021
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.
Formal Response to the Coroner Milton Keynes City Council – Highways & Transportation Directorate Date: 14 January 2026 To: Adam Smith Assistant Coroner for Milton Keynes Response to Regulation 28 Report to Prevent Future Deaths – Death of Mr John Charles Hickmott Dear Mr Smith, Thank you for your Regulation 28 Report dated 1 December 2025 concerning the tragic death of Mr John Charles Hickmott on 19 February 2025. Milton Keynes City Council (MKCC) offers its sincere condolences to Mr Hickmott’s family and all those affected. Coroner’s Concerns You raised the following areas of concern: 1. Timeliness of repairs when streetlights are reported as not being lit. 2. Monitoring and oversight of scheduled repairs to ensure timely action. 3. The extent of proactive inspections to identify faulty streetlights or larger-scale outages not yet reported. MKCC response and actions. 1.Timeliness of repairs when Streetlights are reported as not being lit General streetlight repair works are contractually required to be fixed by our contractor within the stated 14 days for the block faults, unless it is outside of our control, such as an electricity supply issue to our assets. The requirements of the contract have been reiterated to the contractor via formal notification. 2.Monitoring and oversight of scheduled repairs to ensure timely action MKCC now undertake a sample check inspection of 10% of the repair works carried out by the contractor. All works will be updated within the highways asset system with before and after reports and photographs. These reports will be reviewed at the regular operational lighting team meeting before being formalised into the contractual key performance indicators which form part of the overall performance framework of the contract. 3.The extent of proactive inspections to identify faulty streetlights or larger scale outages not yet reported By April 2026, most of the highways street lighting assets and all grid road and high priority lighting areas will have had a remote monitoring system installed. This enables proactive inspection and early identification of any streetlights out. This will replace most manual scouting. There will remain a minimal level manual ‘fault scouting’ and identification to check any significant or unclear fault reports from the system. From time to time there are circumstance on grid roads outside of our control where the stated streetlight repair timeline for larger outages cannot be met. MKCC have introduced a Road Safety Assessment for these instances, undertaken by an accredited Safety Auditor, who will consider temporary “Street Lights Not Working” signage as well or Temporary reduced speed limit signage, or further road safety interventions on a risk assessment basis. (end)
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