Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2026-0089, written 28 Nov 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 28 Nov 2025 |
|---|---|
| Reference | 2026-0089 |
| Deceased | Gurkirat Singh |
| Coroner | Zafar Siddique |
| Coroner area | Black Country |
| 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Highways Department, Sandwell Local Authority 2. Family- Represented by SM Lawson Solicitors 1 CORONER I am Mr Zafar Siddique, Senior Coroner for the Black Country. 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 https://www.legislation.gov.uk/uksi/2013/1629/part/7 3 INVESTIGATION and INQUEST On 17 December 2024, I commenced an investigation into the death of the child, Gurkirat Singh, born on the 7 March 2020, who died on the 6 December 2024. The investigation concluded at the end of the inquest on 12 November 2025. The inquest was heard before me and the conclusion at inquest was Road Traffic Collision. The medical cause of Gurkirat’s death was recorded as: 1a Extensive Intracranial & Thoracic Injuries 1b Collison with a Bus 4 1. A fatal road traffic collision occurred on the north-east bound lane of High Street, Tipton, West Midlands. At the time of the collision, it was dark with street lighting in the vicinity of the collision which was illuminated. 2. It was a cold winter evening, and the road surface was damp but in good overall condition. Gurkirat was in the company of his mother, and two sisters aged 5 and 2. 3. The collision involved a single decker bus that struck Gurkirat causing him fatal injuries. Gurkirat was pronounced deceased at the scene by hours. at 17:30 4. The collision occurred on the north-east bound lane of High Street, Tipton which is designated the B4517. This is approximately 50 metres from a roundabout junction with Park Lane West and Sedgley Road West. 5. At the collision location, the road is a single carriageway with a lane in each direction. However, there are no lane lines painted upon the road surface on the section of High Street where the collision occurred. The edges of the road are lined with footpaths on both sides that lead to a mixture of both commercial and residential properties. Parked vehicles were located on both sides of the road however there was room for vehicles to pass on the main carriageway side by 1 side. The speed limit at the location is 30mph. 6. The bus driver described it was dark and doesn’t recall seeing anyone on the footpaths. He described seeing a flash across the road from my right to left literally right in front of the bus. There was then a bang at the front of the bus followed by his front right wheel jumping up as if it had gone over something. It was very quick between the two happening (less than a second) and he applied his brakes rapidly. Sadly, he had collided with Gurkirat who ran out from the path. 7. There were no bus defects found when the bus was later examined by the Police. 5 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 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. During the course of the inquest, I heard evidence from the Police Collision investigator and the bus driver. 2. My concern is that in the last five years there have been six incidents including this fatality on this stretch of road and within half a mile approaching the roundabout. Evidence at the inquest emerged indicating there are no pedestrian crossings on this stretch of the High Street and visibility to drivers is obscured due to vehicles parked on ither side. 3. In addition, there are no central road markings with poor street lighting resulting in the building line creating shadows on the footpath, which all add to the lack of visibility for drivers. 4. Given the number of incidents, you may wish to consider reviewing the road layout including street lighting. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has 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 26 January 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: Family and Solicitors. 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 other person who I believe may find it 2 useful or of interest. 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. 9 Mr Zafar Siddique Senior Coroner Black Country Area 28 November 2025 3
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.
Mr Zafar Siddique Senior Coroner Black Country Area Dear Mr Siddique Date: 26th January 2026 Prevention of Future Deaths Report – Inquest into the Death of Gurkirat Singh - 17th December 2024 Thank you for your email dated 8th December 2025. Following receipt of the Senior Coroner’s report, Sandwell Council has noted the contents of the report and undertaken an investigation into the concerns raised in relation to the prevention of future deaths on High Street, Tipton. In response to concerns regarding the number of road traffic incidents recorded within half a mile of the roundabout, a road safety and public realm improvement scheme is already proposed for B4517 Owen Street, Tipton, to the north-east of the roundabout junction with Sedgley Road West. This scheme includes the introduction of three new pedestrian crossings, modernised street lighting, traffic-calming measures, and the implementation of a 20mph speed zone. Public consultation for this scheme has been completed, and works are programmed to commence on site in February 2026. Following further investigation, it is now proposed to extend the principles and objectives of this scheme to include B4517 High Street, where this tragic incident occurred. Although existing street lighting levels have been assessed and are compliant with the standards in place at the time of installation, it has been identified that opportunities exist to enhance lighting to the next level of standard and to improve the overall layout. These improvements will now be designed and delivered as part of a wider package of safety measures for the area. This will be further supported by the introduction of a new scheme incorporating improved centre-line markings and parking bays where feasible, and the introduction of a new 20mph zone for High Street and surrounding roads. This will complement the 20mph zone currently being implemented in the Owen Street area. In addition, it is proposed to pursue the introduction of a new zebra crossing in the vicinity of the shop and café at the north-eastern end of High Street. This proposal will be subject to statutory public consultation, as the installation of a crossing would require the displacement of some residential and business parking. The proposed work will now be progressed through detailed design and will be subject to an independent road safety audit. Subject to the audit findings and the outcomes of the required statutory public consultations, works on site are anticipated to commence in summer 2026. While Sandwell Council is committed to considering and implementing appropriate safety improvements as outlined above, this response is provided without any admission of liability for the tragic incident or for any accidents occurring in the area. The proposed works form part of our ongoing commitment to improving road safety across the borough. Yours Sincerely Executive Director - Place [IL0: UNCLASSIFIED] Directorate of Place Sandwell Council House, Freeth Street, Oldbury, West Midlands, B69 3DE www.sandwell.gov.uk
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