Darryl Johnson

Ordnance Survey 
Explorer House, Adanac Drive,  
Southampton, SO16 0AS. 

+

Senior Coroner Emma Whitting 
Central Bedfordshire Council 
Coroner's Office 
The Court House, Woburn Street, Ampthill, Bedfordshire  
MK45 2HX 

Via email:  

19 May 2026 

Ref // NB/JOM/CW (8681.1) 

Dear Senior Coroner Whitting  

Subject: Regulation 28 report to prevent future deaths dated 10 March 2026 
Inquest into the death of Darryl Johnson (Deceased) 

Introduction 

I refer to the Regulation 28 report referenced above which Ordnance Survey 
Limited ('Ordnance Survey') received on 13 March 2026.   This letter sets out 
Ordnance Survey’s response as required under section 7 of the Regulation 28 
report.    

Firstly, on behalf of Ordnance Survey and GeoPlace LLP (‘GeoPlace’, who I describe 
below) I would like to take this opportunity to extend our sympathies to Darryl 
Johnson's family and friends. This is a tragic matter and we are grateful to you for 
bringing it to our attention and for the opportunity to review the matters of concern 
identified within your Regulation 28 report.          

Ordnance Survey and GeoPlace are taking the matters of concern very seriously. 
We have undertaken an extensive fact-finding investigation into the circumstances 
giving rise to your concerns and carefully considered the actions that we can take 
in response, which we believe will support Emergency Service response in relation 
to location queries and therefore help prevent future deaths.  

As part of our investigation, we have worked closely with GeoPlace, whose role we 
explain in detail in Schedule 1, and made enquiries with other relevant stakeholders 
involved in the compilation and use of the address data supplied by Ordnance 
Survey. In consultation with GeoPlace, we have also identified a number of 

Registered in England and Wales under number 09121572 
Registered Office: Explorer House, Adanac Drive, Southampton, SO16 0AS 

  
  
 
 
 
 
 
 
 
 
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corrective and improvement actions which I detail below, as well as a timetable for 
completion of these actions (see Schedule 2).    

Matters of concern 

I note the matters of concern set out in your report as follows: 

'The East of England Ambulance Services Trust confirmed that their CAD system 
utilises an address and map database supplied by Ordnance Survey but that 
postal addresses listed in this database along with mapping coordinates to locate 
the property are not always accurate. Whilst it is it is accepted that it is not 
feasible for the database to be 100% accurate and up to date because it will take 
time for the system to be updated (as for example in the following situations: 

• 

• 

• 

New builds 

Change of property name/number 

Change of use for a property/dwelling) 

the Deceased had purchased his property over 11 years ago and had been paying 
Council Tax since that time. It is, therefore, of concern why the database still did 
not have full details of his address.'' 

Executive summary of our response to the matters of concern 

The key points to note from our detailed fact-finding investigation set out in 
Schedule 1 are as follows:  

-  Ordnance Survey's address products that were being used by East of England 

Ambulance Services Trust did not include any address information for 27B Market 
Square, Potton, SG19 2NP ('27B') at the relevant time.  

-  Ordnance Survey’s address products rely on the provision of accurate addresses 

through an established supply chain, whereby data is provided to Ordnance Survey 
(via its associated organisation, GeoPlace) by local authorities, Royal Mail and the 
Valuation Office Agency ('VOA'). 

-  At the time of the incident, Ordnance Survey’s address products only included 

addresses that had been verified through an address matching process with the 
relevant local authority (see further details in Schedule 1). This is because local 
authorities have statutory responsibility for street naming and numbering and 
maintaining address information in the official register of addresses known as the 
Local Land and Property Gazetteer (‘LLPG’). The local authority is therefore 
considered to be the authoritative source of the address. 

-  Royal Mail had created address data for 27B in 2013 in the course of mail delivery, 

and this address was included in Royal Mail’s Postcode Address File (‘PAF’) 
database which is a key source of address data for GeoPlace and Ordnance Survey. 

Registered in England and Wales under number 09121572 
Registered Office: Explorer House, Adanac Drive, Southampton, SO16 0AS 

 
 
 
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However, whilst GeoPlace had identified 27B’s inclusion in Royal Mail PAF data and 
had notified this to Central Bedfordshire Council for investigation, the address had 
not been reviewed by Central Bedfordshire Council and not 'matched' with their 
LLPG.  

-  Central Bedfordshire Council have now confirmed that they do not hold any 

records referring to 27B Market Square in their LLPG or other internal datasets.  
This explains why 27B is 'unmatched' and was not included in the Ordnance Survey 
address products at the relevant time.   Central Bedfordshire Council have also 
confirmed that their Council Tax system holds two residential addresses at 27 
namely “27A Market Square" and "The Cottage, 27 Market Square" whilst the LLPG 
only holds "27A Market Square". 

-  Whilst 27B was included within Royal Mail’s PAF database, the property appears to 
have been identified in a number of other sources with different and inconsistent 
descriptors.  For instance, HM Land Registry do not hold any record of “27B” and 
Mr Johnson was the proprietor of a freehold title registered with the description of 
“Land to the South of 27 Market Square”, and not 27B.    

-  Similarly, 27B is not included in the Valuation Office Agency’s Council Tax rating 

lists (another key source dataset used by GeoPlace and Ordnance Survey). 
Although VOA does contain records for “27A Market Square” and “Flat at 27”.  We 
note that whilst Central Bedfordshire Council hold a Council Tax record for “27A 
Market Square”, they do not hold a record of “Flat at 27” for Council Tax purposes, 
but do hold “The Cottage, 27 Market Square”: we do not have confirmation that 
these two addresses are the same rateable properties.      

I wish to make it clear that I do not include this context (nor the detailed 
explanations in Schedule 1) by way of excuse or justification for 27B not being 
included in Ordnance Survey address products, rather to explain the scale and 
complexity of the task, the multiple stakeholders and sources involved, and to 
explain why addresses were only included within Ordnance Survey address 
products once matched to the local authority LLPG address.  

Further details of our fact-finding investigation can be found in Schedule 1.   

Corrective and improvement actions 

Before I set out a summary of the actions Ordnance Survey is taking in response to 
the matters of concern, it is notable that the latest version of our most recent 
Address product -  NGD Address Version 3 (‘NGD Address V3’) which was released 
in October 2025 -  already includes unmatched Royal Mail address data, including 
27B, in the 'Royal Mail Address' feature type. Since 27B remains unmatched with 
any Central Bedfordshire Council LLPG record, the product only includes the 
address of 27B and an estimated position at the beginning of Market Square, rather 
than assigning geographic co-ordinates to the specific building to which 27B relates.   

Registered in England and Wales under number 09121572 
Registered Office: Explorer House, Adanac Drive, Southampton, SO16 0AS 

 
 
 
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Regarding the actions we are taking, these fall into two categories, the first of which 
relate to Data Quality and Improvement and the second of which relate to 
Customer adoption, awareness and guidance. 

In relation to the first category of Data Quality and Improvement, the actions are 
summarised as follows:   

1. Ordnance Survey and GeoPlace will undertake a comprehensive analysis of 
unmatched address records across England and Wales, and will use the results of 
the analysis to prioritise  unmatched records for resolution by individual local 
authorities. 

2. As part of this, Ordnance Survey and GeoPlace will work with Central 
Bedfordshire Council to address unresolved and unmatched VOA and PAF records, 
including 27B.  

Ordnance Survey and GeoPlace will also seek to work with Royal Mail on how we 
could improve collaboration on national address sharing and management.  We will 
also seek to agree new resolution targets with local authorities in relation to this 
review and for future management of unmatched addresses, although this will of 
course be subject to agreement with local authorities.  

However, I must stress that whilst Ordnance Survey and GeoPlace will do 
everything they reasonably can to help facilitate the resolution process, the 
success of this review will depend on the co-operation and engagement of local 
authorities including Central Bedfordshire Council. As such, we will be seeking 
support from the Local Government Association (LGA) which is the national 
membership body for local authorities in England and Wales. 

In relation to the second category of Customer adoption, awareness and guidance, 
the actions are summarised as follows: 

1.  We will promote the adoption and use by the Emergency Services (and by our Licensed 
Partners who include Ordnance Survey data within their products and services and 
work with the Emergency Services) of NGD Address V3, which as noted above, includes 
Royal Mail addresses such as 27B which have not been matched.  

2.  We will review and update our best practice guidance to Ordnance Survey’s 

Emergency Services working group in relation to determining location and position. This 
will include guidance for situations where an emergency call handler is working with 
unmatched addresses and locations.  This guidance will be extended to local authority 
address custodians and local authority emergency planners for information and 
awareness. 

Details of the action plan, including timescales, can be found in Schedule 2. 

Registered in England and Wales under number 09121572 
Registered Office: Explorer House, Adanac Drive, Southampton, SO16 0AS 

 
 
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Conclusion 

Having conducted a thorough investigation into the matters of concern, it has 
become apparent that there were a number of complexities associated with this 
particular address, both in terms of its address data history and competing source 
information, HM Land Registry title registration, physical location, and signage, as 
detailed in Schedule 1.    

We trust this letter (and the attached schedules) provide sufficient explanation 
regarding the detail and circumstances relating to the particular address 27B, but 
also provide a clear explanation of the overall process of address data creation, 
maintenance and supply.  Although collating and maintaining address data is 
complex and relies on a number of sources, this does not reduce our regret that 
Ordnance Survey's products did not include address information for Mr Johnson’s 
residence at the relevant time.  

Moreover, this investigation has highlighted some areas for improvement from 
which we have been able to identify actions that we and other key stakeholders can 
focus on to drive improvements to the accuracy and reliability of address data for 
the benefit of Emergency Services, citizens and the nation as a whole.     

The matters of concern in your Regulation 28 report are being taken very seriously 
by Ordnance Survey and GeoPlace and we are working with relevant stakeholders 
to ensure, to the extent of our control and influence, that the issues and action 
plans identified are being addressed. Should you consider it helpful, we can provide 
you with an update on progress against the above actions at the end of September 
2026.  

Furthermore, should you require further clarification on any part of our response, I 
would be pleased to assist. 

Yours sincerely 

CEO Ordnance Survey Limited 

Registered in England and Wales under number 09121572 
Registered Office: Explorer House, Adanac Drive, Southampton, SO16 0AS