Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0051, written 3 Feb 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Feb 2026 |
|---|---|
| Reference | 2026-0051 |
| Deceased | Nathan Cyster |
| Coroner | Daniel Howe |
| Coroner area | Staffordshire and Stoke on Trent |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
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 Department of Transport 2 National Highways 3 Moss Farm 1 CORONER I am Daniel HOWE, H M Area Coroner for the coroner area of Staffordshire and Stoke-on- Trent 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 31 March 2025 I commenced an investigation into the death of Nathan Thomas CYSTER aged 28. The investigation concluded at the end of the inquest on 27 January 2026. The conclusion of the inquest was 'Road Traffic Collision". 4 CIRCUMSTANCES OF THE DEATH On 29 March 2025, Nathan Thomas Cyster passed away at the A5 Watling Street, following a collision between his Suzuki GSX8-S motorcycle and a BMW X5 motor car. The BMW X5 had pulled out from Moss Farm car park onto the A5 intending to turn towards Cannock and the Turf Island roundabout. In doing so it needed to enter a lane of traffic travelling from it’s right from the direction of Cannock and Turf Island roundabout, across double white lines, over a turn right lane for vehicles to enter the Farm shop from the direction of Brownhills, before joining the carriageway towards Cannock. The BMW X5 commenced the manoeuvre after the driver of a Suzuki Swift car travelling from the Turf Island roundabout flashed its headlights. At this time two motorcycles, including that ridden by the deceased, overtook the slower moving traffic, including the Suzuki swift, by crossing solid white double lines and white diagonally lined hatched area. The lead motorcycle avoided the BMW X5 which had pulled onto the carriageway, however the deceased’s motorcycle collided with the offside of the BMW causing him to be thrown from his motorcycle and sustain fatal injuries which resulted in him passing away at the scene. 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: 1. Hazardous Right-Turn Manoeuvre Across Multiple Lanes and Road Markings Vehicles exiting Moss Farm Shop are currently required to cross a lane of traffic approaching from their right, traverse double solid white lines, and pass through a right- turn filter lane before entering the main carriageway. This configuration necessitates crossing areas specifically marked to restrict overtaking and protect turning movements, creating a complex and potentially hazardous manoeuvre for drivers. Regulation 28 – After Inquest Document Template Updated 30/07/2021 2. Absence of Left-Turn Only Signage at Moss Farm Shop There is no “left turn only” signage—either in the form of a mandatory highway sign or an advisory sign positioned by the Farm itself—at the Moss Farm Shop exit. This is in contrast to other nearby businesses along the A5, which display such signage to discourage or prohibit right turns across the carriageway. 3. Ineffectiveness of Road Markings in Preventing Prohibited Overtaking Although the road markings at this location—including double solid white lines and hatched areas—are intended to prohibit overtaking by vehicles (including motorcycles) travelling from Cannock and the Turf Island towards the Moss Farm junction, available evidence demonstrates that these markings are not effective in practice. CCTV analysis from the day of the collision and a separate 3-hour review period revealed that, within that window, 31 vehicles (28% of all vehicles exiting) turned right out of the Moss Farm Shop, and 7 motorcycles and 1 car overtook on the prohibited section prior to the junction. 4. Ambiguity in Legal Guidance Regarding Right Turns Across Double White Lines The inquest was told that there is ambiguity and contradiction in the guidance regarding the legality of turning right out of premises across double solid white lines at the location of Moss Farm Shop. As per the police report: “It would appear that the rules surrounding crossing double white lines to enter and exit junctions and premises is a little more ambiguous. The Highway Code mentioning only entry into, whilst a government website states entry and exit.” This contradiction may lead to different drivers having different understandings of the law and whether they would anticipate vehicles turning right out of the farm shop across double white lines. In summary, the current road layout, lack of clear signage, ineffective enforcement of road markings, and legal ambiguities potentially create a hazardous environment for road users at the Moss Farm Shop exit. 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 March 27, 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. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons I have also sent it to Staffordshire Police 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. Regulation 28 – After Inquest Document Template Updated 30/07/2021 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. 9 Dated: 02/02/2026 Daniel HOWE H M Area Coroner for Staffordshire and Stoke-on-Trent Regulation 28 – After Inquest Document Template Updated 30/07/2021
3 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.
Moss Farm shop Wattling Street WS119ND 1st April 2026 Having read the report I can see that I can do very little to enforce the road layout and the guidance given to road users, as this is down to the highways department and the police to prevent motorists from breaking the rules of the road that are signed and have the appropriate road markings. I have taken away from the report that it is probably best if drivers leaving Moss Farm shop are advised not to turn right. I have asked Midland signs to prepare a sign with no right turn to go at the exit of the car park. I will get this done as soon as practically possible
From the Parliamentary Under Secretary of State Simon Lightwood MP Great Minster House 33 Horseferry Road London SW1P 4DR Tel: 0300 330 3000 Web site: www.gov.uk/dft Our Ref: 60795 March 2026 Daniel Howe HM Area Coroner Staffordshire and Stoke-on-Trent Floor 1, Swann House Boothen Road Stoke-on-Trent ST4 4SY Dear Daniel, Thank you for your letter of 3 February enclosing a Regulation 28 Report following the conclusion of your inquest into the death of Nathan Thomas Cyster. I was very sorry to hear of his death. I am writing regarding your concern about the current road layout, signage, road markings, and legal ambiguities potentially creating a hazardous environment for road users at the Moss Farm Shop exit. The Department’s role is to set the overarching legal and policy framework, and to provide guidance to local highway authorities on how to provide various traffic management measures. National Highways is a government-owned company, established under the Infrastructure Act 2015, and operates at arm’s length from ministers. It is responsible for the day-to-day operation, maintenance and improvement of the strategic road network. It is for National Highways to consider what road markings and signing are appropriate at this specific site as this road forms is part of their network. I note you have also sent a copy of the report to them. With regard to the absence of left-turn only signage, this is a matter for National Highways to consider, taking into account the context of the site and what this could mean in terms of diversions for traffic prohibited from turning right. The Department provides advice on the use of hatch markings and double white line systems in Chapter 5 of the Traffic Signs Manual, available at: www.gov.uk/government/publications/traffic-signs-manual. In relation to your comments on the double white line markings’ effectiveness to prevent overtaking in practice, the road marking has been prescribed in the Traffic Signs Regulations and General Directions, 2016 (TSRGD) and included in the Highway Code (Rule 129) for many decades. The Department believes that the meaning of this marking is well understood by drivers. Regarding the evidence provided, this does not necessarily translate to a lack of understanding of the road marking. There could be a specific site factor that causes the prohibition not to cross the white line marking to be disregarded. Thank you for flagging your concerns about an apparent ambiguity and contradiction between guidance in the Highway Code and information on a government webpage. The Department’s position is that there is no contradiction. The Department acknowledges that ‘Know Your traffic Signs’ (KYTS) refers to turning movements into or out of a side road, while the Highways Code refers only to the entry into a side road. This difference arises because the statutory marking requirements captured in the Highway Code apply only to traffic on the road on which the marking is placed, while the KYTS webpage provides broader explanatory guidance covering both the main road and the side road. We will consider the coroners’ concerns about this ambiguity at a future reprint of Know Your Traffic Signs. Yours sincerely, SIMON LIGHTWOOD MP MINISTER FOR ROADS AND BUSES
REGULATION 29 RESPONSE TO A REPORT TO PREVENT FUTURE DEATHS THIS RESPONSE IS BEING SENT TO: The Area Coroner for the coroner area of Staffordshire and Stoke-on-Trent, Daniel Howe, of Swann House, Boothen Road, Stoke-on-Trent, ST4 4SY in response to a Regulation 28 Report to Prevent Future Deaths following an inquest into the death of Nathan Cyster that concluded on 27 January 2026. 1. NATIONAL HIGHWAYS I am Snowhill Queensway, Birmingham, B4 6GA. , Regional Director for the Midlands, National Highways Limited, Three Snowhill, National Highways was not made aware of the inquest, so we did not have an opportunity as the highway authority to assist you by answering questions at the time. However, we welcome the opportunity to address your concern relating to the highway and we hope our response assists. On behalf of National Highways, I would like to express my deepest condolences to Mr Cyster’s family and friends and those affected by his tragic death. 2. CORONER’S MATTERS OF CONCERN The MATTERS OF CONCERN raised are as follows:– 1. Hazardous right-turn manoeuvre across multiple lanes and road markings for vehicles exiting Moss Farm Shop when turning right. 2. Absence of left-turn only signage positioned at the exit of Moss Farm Shop. 3. Ineffectiveness of road markings at this location including double solid white lines and hatched areas in preventing prohibited overtaking by vehicles (including motorcycles) travelling from Cannock and the Turf Island towards the Moss Farm junction. 4. Ambiguity in legal guidance regarding right turns across double white lines. 5. In summary, the current road layout, lack of clear signage, ineffective enforcement of road markings, and legal ambiguities potentially create a hazardous environment for road users at the Moss Farm Shop exit. 3. DETAILS OF ACTION TAKEN 1. Right turn manoeuvre exiting Moss Farm Shop - To be answered by Moss Farm Shop. National Highways is not responsible for the control of traffic exiting a private business and is therefore unable to assist on this point. 2. Signage at exit of Moss Farm Shop - To be answered by Moss Farm Shop. National Highways is not responsible for signing located within private premises and is therefore unable to assist on this point. 3. Road markings on the A5 All Purpose Trunk Road (APTR) – National Highways Road Safety Engineers conducted a site visit to this location on 9th February 2026 to observe traffic movements, particularly any occurrences of overtaking in contravention of the double white line system. Further to this site visit engineers have undertaken an initial discussion of the results of the site observations on the 10th February 2026. 4. Legal guidance regarding right turns across double white lines - To be answered by the Department for Transport. National Highways is not responsible for the Traffic Signs Regulations and General Directions (TSRGD) traffic signs guidance or the Highway Code. 4. DETAILS OF FURTHER ACTION PROPOSED 1 3 – Road Markings on the A5 All Purpose Trunk Road at the location We will investigate the location to establish if any measures can be identified to reduce the occurrence of injudicious overtaking by drivers in contravention of the double white line system. This investigation will be restricted to the A5 within our jurisdiction and will cover road markings, signing and carriageway layout. The implementation of any potential mitigation measures identified is subject to internal funding being made available based on the prioritised need of the Midlands Region as a whole. The responsibility for enforcement of the double white line system sits with Staffordshire Police. 5. TIMETABLE FOR ACTION DATE ACTION By 30/06/2026 Complete the investigation into the road markings, signing and carriageway layout with a view to identifying any mitigation measures. FY 2026-27 Implement any identified measures, subject to internal funding being made available based on the prioritised need of the Midlands Region. 6. SAFETY OF ROAD USERS The safety of everyone on our road network matters; it is an imperative for our business in what we set out to achieve and a core value of our organisation. Every death on our roads is a tragic loss of life and we again offer our deepest sympathies to all those affected by Mr Cyster’s death. 23rd March 2026 Signed: Regional Director for the Midlands 2
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