Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0093, written 12 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 | 12 Feb 2026 |
|---|---|
| Reference | 2026-0093 |
| Deceased | Rita Thomas and Christine Dale |
| Coroner | Robert Cohen |
| Coroner area | Cumbria |
| 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.
Miss K J Gomersal LLB | Senior Coroner | Cumbria
HM Coroner's Courts, Allerdale House, Workington, Cumbria CA14 3JY
12 February 2026
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: National Highways
1) CORONER
I am Robert Cohen, HM Assistant Coroner for Cumbria
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 1 October 2024 an investigation commenced into the deaths of Rita Margaret Thomas
and Christine Dale. The investigations concluded at the end of the inquests. The conclusion
of the inquest in each case was 'Road Traffic Collision'. In each case the medical cause of
death was associated with multiple traumatic injuries.
4) CIRCUMSTANCES OF THE DEATH
On 19th September 2024 Rita Thomas was driving, and Christine Dale was a passenger, in a
vehicle being driven northbound up the exit ramp of the M6 at Junction 37. A bus was being
driven along the A684. The car collided with the bus causing both Mrs Thomas and Mrs Dale
to sustain life-ending injuries.
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 will 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) The exit ramps at Junction 37 of the M6 are recognised to be 'high harm' spots. Several
very serious collisions have occurred at the same location. Significant efforts have been
made to address this, including by placing stop signs, increasing the visibility of signs, and
improving driver awareness. However, the A684 remains the subject of the National Speed
Limit. I was informed that no speed limit was imposed because previous investigation 'did not
highlight a speeding problem'. The evidence I heard included an observation by the driver of
the bus that: "At the point where I first saw the car, I was only a few metres away from the top
of the slip road. The dark car was travelling up the slip road from my left-hand side. I must
have only been aware of its presence for a matter of one or two seconds...I did not have any
time to react or take any evasive action. As far as I recall I did not have time to brake or steer
to try and avoid the collision."
For the avoidance of doubt, the evidence indicates that the bus was being driven at less than
the national speed limit.
I am concerned that this indicates that the speed at which vehicles are permitted to drive on
the A684, taken with the design of the junction, gives drivers insufficient time to react in the
event that a vehicle crosses into their path.
6) ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you, National
Highways 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 11th April 2024 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 Interested Persons.
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.
12 February 2026
Signature
Robert Cohen HM Assistant Coroner for Cumbria
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.
Robert Cohen HM Assistant Coroner for Cumbria hmcoroner@cumbria.gov.uk Head of Planning & Development Piccadilly Gate Store Street Manchester M1 2WD www.nationalhighways.co.uk 9 April 2026 Dear Sirs INQUEST TOUCHING THE DEATHS OF RITA MARGARET THOMAS and CHRISTINE DALE Further to the publication of your Regulation 28 Report on the Chief Coroner’s website, National Highways is able to provide the following response to your concerns regarding the prevention of future deaths at the junction of the M6 motorway with the A684 (junction 37). National Highways Regional Director for trunk roads and motorways in the North West, annual leave, I am responding on her behalf. , would normally write to you. As is currently away on National Highways is the Highway Authority in respect of the M6 motorway, including the entry and exit slip roads at junction 37, and Westmorland and Furness Council are the Highway Authority for the A684 at this location. To clarify, any changes to the current National Speed Limit along this section of the A684 would be the responsibility of Westmorland and Furness Council and not National Highways. Notwithstanding that, the junction has historically been the scene of several serious collisions resulting from vehicles exiting the motorway and failing to give way at the interface with the A684 and continuing into the path of vehicles being driven along the local road. National Highways has undertaken a number of site assessments and evaluations, in conjunction with partners and stakeholders, including Cumbria Police, Westmorland and Furness Council and local politicians. These have failed to identify any specific reason as to why some drivers fail to react to the warning signs and carriageway markings. As a direct result, the already substantial, approach signing has been upgraded and improved, ‘STOP’ signing and approach lane delineation markings have been installed Registered office National Highways, Three Snowhill, Snowhill Queensway, Birmingham, B4 6GA National Highways Limited registered in England and Wales number 09346363 and more recently, transverse yellow markings have been laid along the direct approach from the M6 exit slip roads to the A684. These measures greatly increase the visibility of the junctions and their approaches. We will continue to monitor the junction within our area of responsibility to monitor the performance of the improvements we have installed and react accordingly should that be necessary. I trust the above is of assistance. Yours sincerely Head of Planning & Development Email: Registered office National Highways, Three Snowhill, Snowhill Queensway, Birmingham, B4 6GA National Highways Limited registered in England and Wales number 09346363
Mr Robert Cohen HM Assistant Coroner- Cumbria HM Coroner’s Courts Allerdale House Workington Cumbria CA14 3JY 09 April 2026 Dear HM Assistant Coroner, Westmorland and Furness Council and the Cumbria Road Safety Partnership, acknowledge receipt of the Regulation 28 Prevention of Future Death Report issued following the inquest into the tragic deaths of Rita Margaret Thomas and Christine Dale at Junction 37 of the M6 and the A684 on 19th September 2024. We recognise the seriousness of this incident and wish to extend our deepest sympathies to the families and all those affected. Westmorland and Furness Council (WAF) submit this response to set out the actions we have taken, together with our partners; Cumbria Constabulary, Cumbria Fire and National Highways (Cumbria Road Safety Partnership, ‘the Partnership’), and outline the further work currently underway following this tragic road traffic collision 1. Identification of Junction 37 as a High-Harm Location The classification of junction 27 as a high harm location initiated multi-agency reviews involving Westmorland and Furness Council, Cumbria Constabulary, Cumbria Fire and Rescue Service, and National Highways. These discussions led to a coordinated package of safety improvements implemented in December 2024. 2. Measures Implemented by National Highways (Slip Roads) As highlighted in the Prevention of Future Death Report, National Highways have undertaken significant upgrades to both the northbound and southbound exit slip roads since the fatal collision. South Lakeland House, Lowther Street, Kendal, Cumbria LA9 4UF westmorlandandfurness.gov.uk 3. Measures Implemented by Westmorland and Furness Council (A684) In parallel, the Council conducted a full speed review of the A684 in partnership with the Cumbria Constabulary Safety Camera Unit in November 2024. Traffic data was collected by Cumbria Constabulary Safety Camera Unit across several months; • A684 both direction; 29th May – 4th June 2024 • J37 Entry slip roads; 30th May – 4th June 2024 • J37 Exit slip roads; 16th – 23rd October 2024 A comprehensive series of improvements along approximately 500 metres of carriageway and implemented between November and December 2024. These were designed to highlight the presence of the approaching junction to improve driver awareness and reduce approaching speeds. These improvements and upgrades, included: • Installation of double-white centre lines to restrict overtaking – to improve safety by preventing overtaking • Upgraded road studs – to improve visibility especially at night and in poor weather conditions • Yellow rumble strips – to highlight and reduce approach speed • Red high-friction surfacing- reduce perception of lane width to reduce approach speed • Additional “SLOW” markings – highlight an approaching hazard and reduce speed Below are images showing the significant improvements on the A684 South Lakeland House, Lowther Street, Kendal, Cumbria LA9 4UF westmorlandandfurness.gov.uk Prior to improvements A684 (Sept 2024) South Lakeland House, Lowther Street, Kendal, Cumbria LA9 4UF westmorlandandfurness.gov.uk Image of A684 After works February 2025 4. Speed-Limit Concern We recognise the specific concern contained within the Regulation 28 report in respect of permitted speed on the A684 as below: The MATTERS OF CONCERN are as follows. – .. “, the A684 remains the subject of the National Speed Limit. I was informed that no speed limit was imposed because previous investigation 'did not highlight a speeding problem'. The evidence I heard included an observation by the driver of the bus that: "At the point where I first saw the car, I was only a few metres away from the top of the slip road. The dark car was travelling up the slip road from my left-hand side. I must have only been aware of its presence for a matter of one or two seconds...I did not have any time to react or take any evasive action. As far as I recall I did not have time to brake or steer to try and avoid the collision." South Lakeland House, Lowther Street, Kendal, Cumbria LA9 4UF westmorlandandfurness.gov.uk For the avoidance of doubt, the evidence indicates that the bus was being driven at less than the national speed limit. I am concerned that this indicates that the speed at which vehicles are permitted to drive on the A684, taken with the design of the junction, gives drivers insufficient time to react in the event that a vehicle crosses into their path. “ Prior monitoring by Cumbria Constabulary Safety Camera Group as part of the partnership in May/June 2024 and October 2024, recorded average speeds on the A684 to be below the permitted speed (on average 40-50mph). Nonetheless, the question of a reduced speed limit is still being considered by the Partnership and has been incorporated into an independent Engineering Safety Study which is being commissioned by Westmorland and Furness Council. 5. Ongoing Statutory Duties and Further Investigation An independent consultancy has been commissioned to undertake the full Engineering Safety Study, which will fully review: • Existing conditions along the route • Evaluate the impact of works completed to date • Assess whether additional engineering, enforcement, or educational measures are required • Examine specifically whether a change to the current speed limit would be appropriate, practicable, and effective We therefore hope to offer assurance that the concern raised is being addressed through the study commissioned. Of note national guidance Setting Local Speed Limits 2024 from the Department for Transport (DfT) requires a full analytical process when proposing a reduced limit. Additional Review and Emerging Issues since December 2024 In addition to the commissioning of the engineering safety study, a follow-up multi-agency through the Cumbria Road Safety Partnership of Westmorland and Furness Council, National Highways, Cumbria Constabulary and Cumbria Fire held on 2 May 2025 examined the impact of the December 2024 improvements. South Lakeland House, Lowther Street, Kendal, Cumbria LA9 4UF westmorlandandfurness.gov.uk Video evidence reviewed during the meeting highlighted ongoing issues with driver non-compliance at the STOP signs. The Partnership therefore agreed to some ongoing actions which are reviewed at monthly operational Cumbria Road Safety Partnership meetings with no end date currently set. A further review will now be set after National Highways most recent completed works in February/March 2026 to resurface and increase skid resistance of the exit slip roads has been completed and given time to be monitored. The current ongoing actions are as follows: • Undertake targeted police engagement and enforcement • Explore options for remote digital enforcement • Increase public communication to reinforce awareness of the new measures 7. Expected Timescales The Engineering Safety Study is now underway. We expect its findings later this year and will be able to provide a further update upon completion and review by the Council and the Cumbria Road Safety Partnership. We reiterate that the tragic deaths of Rita Margaret Thomas and Christine Dale at Junction 37 of the M6 and the A684 on 19th September 2024 has been taken extremely seriously by Westmorland and Furness council and our partners. In accordance with our statutory obligations under Section 39 of the Road Traffic Act 1988, the Council will continue to review road traffic collisions and assess the need for further safety measures We hope to offer assurance that the A684 from Kendal through to (and including) Junction 37 has been prioritised for further detailed assessment. Assistant Director Sustainable Transport and Highways Westmorland and Furness Council South Lakeland House, Lowther Street, Kendal, Cumbria LA9 4UF westmorlandandfurness.gov.uk
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