Brema Virgo

Ask for/Gofynnwch am  Head of Infrastructure  

Our Ref/Ein Cyf 
Your Ref/Eich Cyf 

HMAC Mr Frazer Stuart 
Gwent Coroner’s Service 
Livingstone House 
Langstone Business Village 
Langstone Park 
Newport 
NP18 2LH 

        22 April 2026 

Infrastructure / Isadeiledd 

Civic Centre/Canolfan Ddinesig
Newport/Casnewydd
South Wales/De Cymru
NP20 4UR

Dear Mr Frazer Stuart (Assistant Coroner for Gwent) 

Regulation 28 response 

I write with the Council’s response to the Regulation 28 report to prevent deaths dated 27/2/26, 
arising out of the Investigation and Inquest into the death of Brema Elizabeth Virgo.    

I note that you considered that your duty to make a PFD report was engaged.  The concern you 
identified was:- 
‘The methods used for assessing and interpreting height of the defects in pavements allows for 
circumstances to occur whereby the actual height of the entire defect may not be reflected. 
Relevant defects may not be properly identified resulting in preventative remedial action not 
being taken, which presents a risk of future deaths’. 

I and other senior members of the Council’s highways department have given detailed 
consideration to the report and reviewed the Council’s Manual and methods with reference to 
the specific concern raised.   We have concluded that we do not consider that any immediate or 
short term changes need to be made. 

In reaching this conclusion, we have considered the following relevant factors:- 

Highway policy/Manual - The Council identifies and categorises defects on the 
highway with reference to its Highway Maintenance Manual 2022. This is the latest 
approved version used by Newport City Council.  

The Council categorises highway defects using the County Surveyors’ Society 
Wales (CSSW) Highway Asset Risk Review Method, ensuring that its standards 
meet or exceed the CSSW minimum standards. 

The CSSW Risk Review Method was developed as a collaborative approach to 
create a consistent risk-based methodology across Welsh local authorities. This risk 
based approach is applied when assessing defects. This approach, as set out in the 
CSSW Highway Asset Risk Review Method, determines how each defect is 
assessed in terms of: 

- 
- 
- 
- 

Severity 
Location and context 
Likelihood of causing a safety risk 
Potential consequences if the defect is not addressed 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
         
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 This ensures that all defects are managed proportionately, with higher risk issues 
prioritised for repair and lower risk defects managed appropriately 

Methods of identifying defects - Trained Highway inspectors carry out inspections 
on a schedule or a third party enquiry of all adopted highways based assets on the 
hierarchy as set out in the Council Highway Maintenance Manual. These inspections 
identify defects such as potholes, surface deterioration, damaged street furniture, 
drainage issues, and hazards that could cause harm to users of the highway.  

Planned routine inspections are a combination of: 
o 
and a Highway Inspector. 
o 
where the footway and carriageway are assessed 

Driven Inspections:  inspections of the carriageway undertaken with a driver 

Walked Inspections: inspections undertaken by a Highway Inspector on foot, 

Training of highways inspectors - Highway Inspectors are required to have a 
specific qualification in highway inspection. Street Works qualification, CoP 
reaccreditation and Lantra NHSS 12D (M7).   

Training and monitoring of inspectors includes the procedures set out in the 
Council’s Highway Maintenance Manual and the CSSW guidance, so that defect 
identification, measurements and risk assessment are undertaken to the expected 
professional standard.  

Measuring two potential defects located close together - In line with the Highway 
Maintenance Manual 2022 and national guidance, including the CSSW Risk Based 
Approach Method and the Highway Inspection Defect Recording Manual, Newport 
City Council applies a risk based approach to all highway inspections. These 
documents set out how defects must be assessed by severity, location, and risk, 
rather than by simply merging defects together. 

When inspectors encounter a situation where two potential defects are located close 
together, they are required to record and assess each potential defect separately. 
This ensures that every defect is evaluated on its own characteristics—such as size, 
severity, and location—while still allowing inspectors to take account of any wider 
combined risks as part of the overall assessment. 

Whilst we consider that no immediate or short term changes need to be made, in view of the 
serious nature of the incident in question, Highways intend to undertake a review of the Highway 
Maintenance Manual to consider whether any alterations to this may be necessary in view of 
your comments. Should any changes be identified, these would need to be reviewed by senior 
managers and proceed through a cabinet member approval process, before being ratified and 
implemented. 

I trust that this provides you with sufficient information. 

Yours faithfully  

Head of Infrastructure  
Newport City Council