Allan Stevenson

Mr Nigel Parsley 
HM Senior Coroner for Suffolk 
HM Coroners Court 
Beacon House 
White House Road 
Ipswich 
Suffolk 

Dear Mr Parsley 

Anglian Water Services Limited 
The Legal Department 
Lancaster House  
Lancaster Way 
Ermine Business Park 
Huntingdon  
Cambridgeshire  
PE29 6XU 

Your ref:  

Regulation 28 Report to Prevent Future Deaths following the inquest touching upon the death 
of Mr Allan Stevenson 

1.  I am writing to you on behalf of Anglian Water (Anglian) in response to you Regulation 28 Report dated 
6  April  2026  (the  PFD  Report),  following  the  inquest  into  the  death  of  Mr  Allan  Stevenson  (the 
Inquest). I wish to express our deepest sympathy and sincere condolences to the family and friends 
of Mr Stevenson.  

2.  By way of background, Anglian is a water and recycling company which operates throughout England 
and  Wales.  We  supply  essential  water  and  water  recycling  services  to  around  7  million  people, 
covering 14 counties across the East of England and Hartlepool. Our group employs around 6,000 
people and work alongside 3,000 alliance partners and contractors. We are constantly striving to be 
the best company we can be, which reflects a company that makes a real and meaningful impact for 
our customers, communities, colleagues and environments. 

3.  The  health,  safety,  and  wellbeing  of  our  employees,  contractors,  and  all  those  affected  by  our 
operations is Anglian’s highest priority. We are fully committed to creating and maintaining a safe 
working  environment,  and  our  approach  to  health  and  safety  is  embedded  at  every  level  of  the 
organisation.  We  foster  a  culture  of  continuous  improvement  and  encourage  open  reporting  of 
hazards, near misses, and safety concerns. 

4.  As  an  Interested  Party  (IP)  to  the  Inquest,  Anglian  was  requested  to  provide  witness  statements 
addressing  both  the  status  of  the  permit  application  for  the  relevant  works  and  further  details 
regarding the operation of Anglian’s ‘defect line’. In response, Anglian submitted two statements to 
the Coroner, in May 2024 and December 2025. 

Registered Office: Anglian Water Services Ltd.  
Lancaster House, Lancaster Way, Ermine Business Park,  
Huntingdon, Cambridgeshire, PE29 6XU.  
Registered in England No. 02366656. An AWG Company. 

 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 5.  To the best of our knowledge, the witness statements submitted by Anglian were not included in the 
final Inquest bundle, nor were they read into evidence by the Coroner. In view of this, we consider it 
helpful to reiterate the position set out in those statements, with the aim of addressing any concerns 
relating to Anglian as highlighted in the PFD Report. 

‘Defects Line’ 

6.  Anglian operates a system for the notification and rectification of site defects identified during works, 
primarily managed through the Street Manager online reporting platform in collaboration with Suffolk 
County Council (SCC).  

7.  As digital logging into Street Manager can occasionally result in a “time lag”, there is also a dedicated 
telephone  line  available  for  the  immediate  reporting  of  defects.  This  line  is  used  for  multiple 
purposes,  with  one  of  the  menu  options  specifically  relating  to  defect  reporting.  If  a  call  to  this 
dedicated line is not answered directly, an automated answering system records the message. Two 
administrators are responsible for checking for new messages every 15 to 20 minutes and ensuring 
prompt action is taken. 

8.  At the time of the incident in October 2022, notifications received via the dedicated phone line were 

managed as follows:  

• 

• 

• 

the administrator would manually compile the details of each notification into an email, which 
was then circulated to a location-specific distribution list; 

this  distribution  list  comprised  Area  Managers,  Field  Performance  Managers,  and,  where 
applicable, Traffic Management companies; and 

the  relevant  individuals  on  the  distribution  list  would  then  assume  responsibility  for 
addressing and rectifying the reported defect. 

9.  Whilst Anglian operates both a system for the notification of defects and a dedicated phone line to 
ensure  reporting,  when  SCC  identifies  a  defect  during  inspection,  the  risk  level  of  the  non-
compliance determines the communication protocol: 

a)  For low-risk non-compliances, such as those identified at the relevant site on 24 October 
2022, SCC records the defect on Street Manager and issues a notification to Anglian’s Street 
Works Compliance Team. There is no expectation for SCC to make a direct telephone call to 
Anglian Water in these circumstances. The Compliance Team monitors these notifications 
every 15 – 20 minutes both via automated prompts and through manual checks. 

b)  For high-risk non-compliances, SCC notifies Anglian Water through both Street Manager and 
a direct telephone call to the general number for the Street Works Compliance Team, which 
is provided in the permit application and is known to SCC. 

10. The distinction between ‘low-risk’ and ‘high-risk’ non-compliance can be subjective and may vary 
between different authorities. For example, ‘low-risk’ non-compliance may include issues such as 

Registered Office: Anglian Water Services Ltd.  
Lancaster House, Lancaster Way, Ermine Business Park,  
Huntingdon, Cambridgeshire, PE29 6XU.  
Registered in England No. 02366656. An AWG Company. 

 
 fallen  down  signs,  or  incorrect  traffic  management  arrangements.  In  contrast,  ‘high-risk’  non-
compliance may involve more serious matters, such as missing safety zones or exposed excavations 
in  the  carriageway.  While  the  classification  of  these  defects  may  differ  between  authorities,  the 
critical consideration is the manner and urgency with which they are addressed, according to their 
categorisation. 

11. On 24 October 2022, SCC identified two low risk non-compliance areas relating to signage and traffic 
management  at  the  site.  These  were  communicated  to  Anglian  via  Street  Manager  only,  in 
accordance with established assignment and reporting procedures.  

12. Following additional internal investigation, we were able to confirm in the witness evidence that no 
phone call was made or expected, as the issues were not classified as high risk. Our Compliance 
Team  received  and  acted  upon  the  notifications  as  required,  in  accordance  with  Anglian’s 
established assignment and reporting procedures and SCCs assessment of the risk profile.  

13. In light of this, we would like to respectfully confirm that there was no failure in the operation of the 
defect line on the day in question. The process functioned as intended for the risk level identified, 
and Anglian responded to the notification in line with established procedures.  

14. We trust this clarification addresses the concern raised and confirms that the defect line was not at 

any stage unresponsive or the cause of any delay. 

Post-Inquest 

15. As outlined above, Anglian is committed to maintaining the highest standards of health and safety 
across  all  its  operations.  As  a  responsible  business,  we  recognise  the  importance  of  regularly 
reviewing and enhancing our processes and procedures to ensure they remain robust, effective, and 
in line with industry best practice.  

16. Since  the  Inquest,  we  have  taken  the  opportunity  to  reflect  on  our  systems  and  identify  further 
measures to strengthen our approach, with a view to continually improving the safety and efficiency 
of our operations. 

17. Since early 2023, Anglian has tested and implemented the SKEWB Permit Manager System, which 
interfaces directly with the Street Manager platform and automatically imports incoming defect data 
into  its  database.  Within  the  SKEWB  system,  Automated  Working  Groups  are  mapped  to  specific 
business cohorts, enabling the system to relay any identified failures or defects to the appropriate 
teams. While this represents a significant improvement over previous processes, the effectiveness 
of the system remains contingent upon the timely upload of defect information by the inspector to 
the Street Manager system. Consequently, the overall success of the system continues to depend on 
the SCC inspector’s ability to upload defects promptly to the Street Manager platform. 

18. In order to ensure a rapid response to urgent issues and to prevent delays that could compromise 
safety, Anglian continues to accept direct telephone notifications from the Highway Authority. If a 
telephone notification is received before the corresponding digital permit update is available in Street 

Registered Office: Anglian Water Services Ltd.  
Lancaster House, Lancaster Way, Ermine Business Park,  
Huntingdon, Cambridgeshire, PE29 6XU.  
Registered in England No. 02366656. An AWG Company. 

 Manager, the administrative team manually enters the relevant information into the SKEWB system 
to initiate the necessary notifications and actions.  

19. When the formal Street Manager notification is subsequently received, the system may, on occasion, 
issue a duplicate notification. While this duplication is unintentional, it is considered to be a safe and 
precautionary measure designed to ensure that no necessary actions are missed, thereby reducing 
the risk of further incidents. 

20. We remain committed to ongoing learning and improvement, and we are grateful for the opportunity 

to address the matters raised in your report. 

21. If you require any further information or clarification, please do not hesitate to contact me. 

Yours sincerely,  

Group Director of Health and Safety  
Anglian Water  

Registered Office: Anglian Water Services Ltd.  
Lancaster House, Lancaster Way, Ermine Business Park,  
Huntingdon, Cambridgeshire, PE29 6XU.  
Registered in England No. 02366656. An AWG Company.

From the Parliamentary  
Under Secretary of State 

Great Minster House 
33 Horseferry Road 
London 
SW1P 4DR 

Web site: www.gov.uk/dft 

          27 May 2026 

Nigel Parsley 
H M Area Coroner 
Suffolk 
Beacon House 
Whitehouse Road 
Ipswich, Suffolk 
IP1 5PB 

Dear Mr Parsley, 

Thank you for your letter enclosing a Regulation 28 Report following the 
conclusion of your inquest into the death of Allan Stevenson.  

I was very sorry to hear of Mr Stevenson’s tragic death, and my thoughts are 
with his family and friends. I would also like to thank you for your investigation 
and for setting out your concerns. 

I note the issues you have raised in relation to the temporary traffic 
management arrangements in place at the time of the incident, including the 
design and implementation of the layout, the clarity of the arrangements for 
road users, and the oversight of changes made on site. 

The Department’s role is to set the overarching legal and policy framework for 
road safety and to provide guidance. Responsibility for the design, approval 
and monitoring of temporary traffic management arrangements sits with those 
undertaking the works and the relevant highway authority. These parties are 
responsible for ensuring that arrangements are appropriate for the specific 
circumstances on site.  

Existing guidance, including the Safety at Street Works and Road Works 
Code of Practice, sets out clear requirements for the planning, design and 
implementation of temporary traffic management. A failure to comply with the 
Safety Code could be used as evidence of a failure to fulfil legal obligations to 
sign, light and guard works.  

The Code includes requirements to plan site layouts in advance and to 
implement those arrangements on site (Part 1, p.9–10), and to ensure that 
the full extent of the works area, working space and safety zone is 
appropriately protected, including through the correct placement of cones and 
barriers (Part 2, p.19–22). 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The Code also requires that temporary traffic management arrangements 
remain compliant and safe as works progress, including where changes are 
made on site and where risk assessments must be reviewed accordingly 
(Part 1, p.9–10). 

The Code further requires that arrangements are clearly signed and designed 
so that road users can readily understand the layout and what is expected of 
them, with signs correctly positioned, visible and set out in the appropriate 
sequence (Part 2, p.16–18). It also requires that arrangements are monitored 
and maintained, and that any issues identified through inspection are 
addressed promptly (Part 2, p.81–82; Part 3, p.93–94). These requirements 
are intended to ensure that traffic management remains safe and effective 
throughout the duration of the works. 

In addition, the Code places strong emphasis on the safety of vulnerable road 
users, including pedestrians and cyclists, requiring that their needs are 
considered as part of site-specific planning and risk assessment, and that 
suitable provisions are made for their safe passage through or around works 
(Part 1, p.5; Part 2, p.35). 

The Department considers that, when applied effectively, this framework 
provides a robust basis for the safe management of works on the highway. 
We are currently reviewing the Code of Practice and intend to consult on 
proposed updates later this year. This work will build on the existing 
framework, including strengthening expectations in relation to cyclists and 
improving the clarity of temporary traffic arrangements, and will take into 
account the concerns raised in your report. 

The code does not set out a specific procedural framework for managing 
last-minute changes to traffic management plans. Instead, the code 
establishes a principles-based approach, requiring works to be properly 
planned, risk assessed, and delivered by competent personnel, with traffic 
management adapted to actual site conditions to ensure safety at all times.  

More generally, the regulatory framework for street works requires close 
coordination between works promoters and highway authorities, and for traffic 
management arrangements to be appropriate for the circumstances on the 
ground. It also provides for inspection by highway authorities to ensure 
compliance with requirements. Decisions on the specific design and 
implementation of such arrangements rest with works promoters and highway 
authorities. 

While it would not be appropriate for me to comment on the specific 
operational decisions taken in this case, I will ensure that the concerns you 
have raised are carefully considered as part of our ongoing work to support 
safe management of work. 

 
 
 
 
 
 
 
 
 
 
 Thank you again for bringing these matters to my attention. 

Yours sincerely, 

MINISTER FOR ROADS AND BUSES

HM Senior Coroner Parsley 
Suffolk Coroner’s Service  
Beacon House 
Whitehouse Road 
Ipswich 
Suffolk 
IP1 5PB 

Clyde & Co LLP 

2 New Bailey Square 

Stanley Street 

Salford, M3 5GS  

United Kingdom 

www.clydeco.com 

                   Our Ref 

     Your Ref                                                          Date 

  2026-0207                                                       29/05/2026 

Dear HM Senior Coroner Parsley, 

Inquest touching upon the death of Allan Stevenson 

We are instructed on behalf of Core Highways (Southeast) Limited, formerly MLP Traffic 

Limited (‘‘CHSEL’’) and write on its behalf in response to your report dated 6 April 2026.  

CHSEL extends its condolences to Mr Stevenson’s family and friends.  

Prevention of Future Deaths (‘‘PFD’’) report 

We note the matters of concern set out in your PFD report and deal with these in turn below, 

which we were surprised to see directed at our client. At the conclusion of the Inquest, 

following submissions from Interested Persons, three recipients of the report were named, 

which did not include CHSEL.  

Prior to making a report you were respectfully invited to set out any concerns in respect of 

CHSEL which you chose not to do. As indicated during submissions at the Inquest, policies, 

controls, and procedures in place at the time of the Inquest were, and have been for some 

time, materially different from those in place in 2022.  

CHSEL 

Following any serious incident involving CHSEL, the business takes the opportunity to reflect 

and learn lessons, and where appropriate, implement improvements. 

Clyde  &  Co  Claims  LLP  is  a  limited  liability  partnership  registered  in  England  and  Wales  under  number  OC344148  and  is  authorised  and  regulated  by  the  Solicitors 
Regulation  Authority.   A  list  of  members  is  available  for  inspection  at  its  registered  office  The  St  Botolph  Building,  138  Houndsditch,  London  EC3A  7AR.  Clyde  &  Co 
Claims LLP uses the word 'partner' to refer to a member of the LLP, or an employee or consultant with equivalent standing and qualifications. 

 
 
 
  
 
 
 
                  
 
 
 
 
 Since October 2022, the business has undergone a name change from MLP Traffic 

Management to CHSEL. This occurred in 2024 as part of a wider group restructuring to 

rebrand smaller regional businesses as Core Highways companies.  

A central Group Head of Safety, Health, Environment and Quality (SHEQ) was appointed to 

review and implement standardised policies across the group with a focus on continual 

improvement in health and safety. 

The business is also now part of the National Highways Stakeholder Advisory Forum and the 

Traffic Management Contractors Association, supporting health and safety innovation and 

sector-wide best practice.  

CHSEL  notes  the  content  of  the  evidence  heard  during  the  Inquest.  This  included 

confirmation  that  the  Operative  who  installed  the  traffic  management  (“TM”)  plan  had 

implemented arrangements that differed from the agreed plan.  

The Operative was unable to provide any evidence that such changes had been authorised 

in  accordance  with  the  accepted  process  and  CHSEL  also  found  no  evidence  of 

authorisation  having  been  given.  Furthermore,  the  Inquest  heard  that  none  of  the 

documentation that would accompany an agreed change had been produced. 

The TM as implemented was inspected by a Network Inspector. The Inspector did not 

consider that the TM plan required significant change or that it ought to have been closed 

(which was an option available to him). 

The Forensic Collision Investigator concluded that the LGV driver had sufficient opportunity 

to observe Mr  Stevenson prior to the  collision.  The  Investigator’s view  was that,  once both 

Mr Stevenson and the LGV were on the roundabout, the primary contributing factor was the 

inherent blind spots associated with the LGV’s design, rather than the TM layout. 

Response to concerns raised 

1.  Complex schemes being ‘flipped’ on site; 

Previous position: 

The Inquest heard evidence that trained Planners designed TM plans based upon customer 

instructions and in accordance with the Red Book. Plans were checked by senior team 

members before being issued to customers in advance of the requested works for approval. 

Qualified Operatives then installed the temporary TM works in accordance with the TM plan.  

 
 
 
 The TM plan in question was sent to the customer 12 days prior to the works commencing 

and no issues were noted or changes requested.  

Evidence  was  also  heard  that  changes  to  the  TM  plan  required  appropriate  authorisation 

from  suitably  qualified  personnel  (Planners).  Accordingly,  any  requests  by  Operatives  to 

amend  the  plan,  whether  arising  from  customer  requests  or  initiated  by  the  Operatives 

themselves,  were  required  to  be  referred  to  Planners.  The  Planners  assessed  the  request 

and determined if a job could be continued or needed to be cancelled. 

Authorised changes would prompt the creation of further documents for ‘job packs’ where 

required. This included revised risk assessments and a new TM plan which would be issued 

to the Operative to implement. If the requested changes were not practical, the job would not 

proceed. 

Whilst it is disputed whether the Operative who amended the TM plan received the required 

authorisation, evidence indicated that he was aware of a ‘review system’ or ‘process’ being 

in place at the time.  

Updated position: 

CHSEL now requires written customer confirmation that TM plans meet requirements before 

work commences which significantly reduces the potential for changes to be required on the 

day. In the absence of such confirmation, the job will not proceed.  

Any requested changes prompt the plan to be reviewed and if necessary redrawn. Customer 

approval of the revised TM plan is required before the job can proceed. This requirement 

cannot apply to emergency response work where different considerations apply.  

Material revisions to TM arrangements and schematics are now recorded in a Central Issues 

Register and monitored internally. Revisions are reviewed by the Group Head of Technical 

Standards, allowing updates to existing processes where necessary.  

Further, CHSEL has formalised its established processes around changes to TM on site, 

clarifying permissible on-site changes and the appropriate level of documented approval 

required for changes to plans. It also reinforces that, if in any doubt, staff should contact their 

supervisor. A failure to follow the process as set out in the policy document will result in 

disciplinary action.  

This policy has been communicated to operational staff and is available to Operatives via a 

QR code present within all company vehicles. 

 
 
 
 
 
 Additionally, TM sites are now subject to random audits by supervisors to ensure compliance 

with plans and safe implementation. Whilst audits are random, they are generally completed 

based on the risk profile of the set up. A formal target is in place for site audits to ensure 

compliance with policies. 

2.  Escalation where an operative identifies a safety concern; 

Previous position: 

Processes dealing with requested changes (regardless of who made the request) are set out 

above.  

Those responsible for planning and implementing the TM held relevant qualifications to 

undertake their roles. In relation to the material works, the changes suggested by the 

‘‘relatively junior TM operative’’ were considered by the trained and qualified Operative 

during the Inquest. The Operative did not feel the suggested changes would have been 

practical.  

Updated position: 

As in 2022, suitably qualified and trained personnel plan, design, and implement temporary 

TM works. As part of the commitment to continual improvement, CHSEL’s WorkSafe (refusal 

to work) policy has been reviewed and updated. This confirms the circumstances in which 

work should not be completed if there are safety concerns and details what actions 

Operatives should take.  

It makes clear that staff are not expected to work when: 

•  They are not competent to perform tasks; 

•  The correct equipment is not available;  

•  There is no safe system of work; 

•  The site conditions have changed impacting the planned method of work; or 

•  The correct PPE is not available. 

In summary, the policy requires staff to cease work if they feel their safety or that of others 

may be at risk and to contact a supervisor to allow the work and method to be reassessed. 

Additionally, CHSEL has introduced nine TM life-saving rules that form part of employees’ 

inductions and are reinforced through briefings as well as visible posters. The rules include: 

 
 
 
 
 
 
 
 
 •  Ensure we are both qualified and competent to complete tasks; 

•  Stop work if anything changes and seek guidance; and 

•  Report all safety concerns to our supervisor/manager. 

These sit alongside the overarching golden rule of ‘‘Stop, think, check – we never put 

ourselves in harm’s way … a two second pause could prevent a lifetime of regret.’’  

3.  Special signage and cyclist-specific considerations; 

Previous position: 

All TM plans were designed in accordance with customer requirements and the Red Book. 

As  such  special  consideration  for  cyclists  within  TM  plans  was  already  incorporated  into 

CHSEL’s design process in 2022.  

The  Inquest  heard  evidence  that  the  specific  TM  plan,  as  designed  in  line  with  the 

customer’s  request,  included  instructions  for  cycle  lanes  to  be  closed  and  ‘special’,  or 

bespoke signs to be used on site. These were set out on the plan as equipment required to 

be taken to site. This requirement was also detailed in the ‘front sheet’ or cover letter, of the 

‘job pack’ provided to the Operative. They were not collected.  

The signs would have been created at the depot where the Operative would collect all other 

required  equipment.  This  process  would  have  taken  a  short  period  of  time.  However,  after 

the  TM  had  been  altered  by  the  Operative  on  site  the  special  signs  would  have  been 

redundant. Had the Planner been notified new special signs could have been considered.  

Updated position: 

Planners share TM plans to Operatives directly via an application on their digital tablets in 

advance of the job.  On every job, the ‘job pack’ now includes a separate ‘equipment list’ 

detailing all the required signage needed to implement the approved plan. This lists the 

equipment required which was available previously on the plan itself. 

When plans require special signage, the Planners will share this request with the relevant 

local depot in advance of the job. The local depot considers if the signs are in stock or if they 

need to be ordered in advance of the works. If they are, they will be ordered.  

 
 
 
 
 
 
 
 
 Further, CHSEL has implemented the Design Guide for ‘Cycle Safety in TTM Design’ which 

sets  out  the  specific  considerations  regarding  cyclists  for  Planners  when  designing  TM 

plans. This guide is easily accessible to all Planners when drafting TM plans.  

4.  Signage availability, spare equipment loaded onto vehicles; 

Previous position: 

The Inquest heard that a Local Authority Network Inspectors’ role is to ensure that TM plans, 

as physically set out, comply with the Red Book. They do not receive or review the TM plans 

themselves. If the Network Inspector feels the TM arrangements on the ground do not 

comply with the Red Book they can raise their concern with the permitholder for the relevant 

works.  

CHSEL does not consider it safe or appropriate to require operatives or Network Inspectors 

to utilise ‘spare signage’ to re-design TM schemes on site. It would be impossible to select 

the correct signs in advance as any issue with the TM is unclear until operatives are at site. 

This presents practical difficulties in terms of vehicle weight limits which may necessitate 

further operatives and vehicles increasing the footprint of the TM set up itself. 

As noted above, both the Planner and TM Operative hold relevant qualifications. We 

respectfully submit it would be unsafe for Network Inspectors, who may not hold such 

qualifications, to request that signs are moved, added or changed, as this would amount to 

redesigning a TM plan which they may not be trained to do. This would likely necessitate a 

wholesale retraining of Network Inspectors nationwide.  

Updated position: 

As mentioned above, TM plans are approved in advance by customers to ensure they fit the 

requirements  and  equipment  lists  are  prepared  and  shared  in  advance of  jobs.  As  per  the 

WorkSafe  (refusal  to  work),  change  management  policies  and  life-saving  rules  Operatives 

should not work unless it is safe to do so, as such, it is not anticipated that a situation should 

arise where the TM plan is amended, changed or redesigned with ‘spare signage’. 

Further,  the  powers  of  Network  Inspectors  are  set  by  Central  Government  and  outside  of 

CHSEL’s control.  

5.  Communication with customers, permit holders and, where relevant, network inspectors; 

Any  system  around  Network  Inspectors’  access  to  information  is  a  matter  for  Central 

Government.  

 
 
 
 CHSEL  will  continue to share best  practice and look  to  improve health and  safety  practice 

across the sector.  

6.  Operation of Anglian Water’s ‘Defect Line’ 

CHSEL has no involvement in the operation or use of Anglian Water’s ‘Defect Line’ and is 
therefore unable to comment on its functionality or use at the material time. 

However, CHSEL does and will continue to respond to any defects reported to it in a 
proportionate and timely manner. 

Conclusion 

The safety of CHSEL staff and the public remains its highest priority. The business remains 

committed to ongoing learning and continual improvement to raise health and safety 

standards across the business and the wider industry.  

We hope this letter helps to alleviate any concerns and demonstrates that significant 

changes were already in force prior to the Inquest. Such changes have been embedded 

through training, accessible documentation and are subject to ongoing audit and review to 

allow for ongoing improvements where opportunities for these are identified.  

Thank you for taking the time to consider this response.  

Yours faithfully 

Clyde & Co Claims LLP

OFFICIAL-SENSITIVE PERSONAL 

Date: 01st June 2026  

PRIVATE AND CONFIDENTIAL  
Suffolk Coroners Court 
FAO Coroner Parsley  
Beacon House 
IP1 5PB  

Dear Coroner Parsley, 

Investigation into the death of Allan Stevenson 

Suffolk County Council (“SCC”) writes in response to your Regulation 28 Report dated 06 
April 2026.   

SCC acknowledges it is a recipient organisation of the Report, however, wishes to clarify its 
statutory and operational remit in relation to the specific issues raised. 

Concerns raised: 

1.  Concern 1: ‘I am concerned that what was agreed by witnesses to be a complex 

temporary road traffic plan, can be ‘flipped’ on the ground on the day it is installed 
without any identifiable process being in place to ensure the scheme is 
subsequently safe. The court heard that some schemes (such as a single carriage 
way scheme controlled by only two sets of traffic lights) were straight forward to flip 
if required, but that no additional or enhanced review system was in place when a 
complex scheme needed to be flipped at short notice’.  

Concern  1  appears  to  relate  to  the  installation  of  temporary  traffic  management  and  the 
processes followed by Core Highways Group Ltd and Anglian Water where arrangements were 
altered  on  the  day  of  installation.  These  matters  principally  concern  the  internal  operational 
arrangements  of  the  Statutory  Undertaker  and  its  specialist  traffic  management  contractor, 
rather  than  matters  within  SCC’s  direct  control.  SCC  is  therefore  not  able  to  speak  for  those 
organisations but sets out below its own role and the relevant statutory framework. 

For the purposes of this response, the terms “street authority” and “highway authority” are used 
interchangeably,  reflecting  the  terminology  used  within  the  New  Roads  and  Street  Works  Act 
1991 (“NRSWA”) and the Traffic Management Act 2004. 

As outlined in the Witness Statement of 
Council’s role is to: 

 dated 15 January 2026, Suffolk County 

 
                                                                                                                                          
 
 
 
 
   
 OFFICIAL-SENSITIVE PERSONAL 

1.  Coordinate works on the network, primarily through its Permit Scheme; and 

2.  Undertake compliance checks, where appropriate, against the Safety at Street Works and 
Road Works Code of Practice (“the Red Book”) through network inspections once works 
are in place. 

Statutory framework and undertaker responsibility 

Under Section 48 of NRSWA, “street works” include not only the placement and maintenance of 
apparatus  but  also  works  required  for  or  incidental  to  those  activities,  which  includes  the 
provision and management of temporary traffic management necessary to undertake the works 
safely. 

The Act identifies the undertaker (in this case, Anglian Water) as the party authorised to carry out 
those works. Responsibility for the planning, design, implementation, and ongoing operation of 
temporary traffic management therefore rests with the Statutory Undertaker and any specialist 
contractor it appoints. 

This is reinforced by Section 65 NRSWA, which places a duty on undertakers to ensure that works 
are adequately guarded, lit, and signed, and that appropriate traffic signs are provided for the safe 
guidance of road users. 

Temporary traffic management is inherently dynamic. The Red Book permits adjustments to be 
made on site to reflect prevailing conditions (for example, site constraints, parked vehicles, or 
other operational factors), with responsibility for ensuring that those arrangements remain safe 
and compliant resting with the undertaker at all times. 

Role of the highway authority 

The role of the highway authority is distinct from that of the undertaker. Suffolk County Council is 
responsible for coordinating works and managing the network,  but it is not responsible for the 
detailed design or approval of traffic management layouts, nor does it provide a safety “sign-off” 
of those arrangements. 

Highway authorities must take care not to become involved in the design or specification of traffic 
management  measures.  The  design  and  delivery  of  compliant  traffic  management  therefore 
remain the responsibility of the undertaker and its appointed, competent contractors. 

Permit scheme 

Suffolk County Council operates a Permit Scheme under the Traffic Management Act 2004 and 
the Traffic Management Permit Scheme (England) Regulations 2007. 

The purpose of the Permit Scheme is to enable the highway authority to: 

•  Coordinate works across the network, and 

•  Manage the impact of those works, particularly in relation to congestion and disruption. 

The Scheme does not provide for the approval of detailed traffic management design. 

 
 
 
 
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Undertakers are required to submit information about their works, including duration and general 
method.  The  authority  may  apply  conditions  where  appropriate,  and  undertakers  may  submit 
variations  where  there  are  material  changes  affecting  duration,  traffic  management  type  (for 
example, signals or road closure), or network impact. 

However, on-site operational adjustments, including changes to the positioning or orientation of 
traffic management (such as the “flipping” of a layout), would not necessarily require a formal 
permit variation where: 

• 

• 

the nature of the works remains the same; and 

the  impact  on  the  network  and  road  users,  particularly  in  terms  of  congestion,  is  not 
materially altered. 

Such  operational  decisions  sit  within  the  undertaker’s  responsibility  for  delivering  the  works 
safely. 

Inspections 

The Code of Practice for Street Works Inspections provides statutory guidance on how highway 
authorities may undertake inspections. These inspections are typically risk-based and sample-
based, and authorities are not required to inspect every site. 

  undertook  a  Category  A  (live  site)  sample  inspection.  Network  Inspectors  are 

responsible for selecting sites as part of this inspection regime. 

During an inspection, the Network Inspector assesses the traffic management arrangements as 
implemented  on  site  at  the  time  of  inspection,  measuring  compliance  against  the  Red  Book. 
Where non-compliance is identified, defects may be raised against the undertaker. 

Inspections represent a snapshot in time. Site conditions may change after an inspection due to 
ongoing activity or operational adjustments. 

Application to this concern 

The  concern  raised  suggests  that  the  absence  of  a  process  to  notify  the  highway  authority  of 
changes  to  a complex  scheme  (including the “flipping” of the layout)  compromised the safety 
assessment. However: 

•  Responsibility  for  ensuring  that  traffic  management  remains  safe  and  compliant  at  all 

times rests with the Statutory Undertaker. 

• 

The inspection regime is designed to assess what is physically present on site, rather than 
to verify compliance against an original or proposed plan. 

•  Whilst advance notification (of a layout change) may assist contextual understanding, the 
Network  Inspector’s  task  remains  to  assess  the  arrangements  actually  in  place  set 
against the requirements of the Red Book. 

As set out in the evidence of 
inspection and was raised with the undertaker in accordance with established procedures. 

, incorrect signage was observed on site during the 

 
 
 
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2.  Concern 2: ‘I am concerned that there is no apparent safety escalation process, 
when as in this case a relatively junior Traffic Management Operative identifies a 
safety issue with a scheme once it has begun operations’.  

Concern 2 principally relates to the internal escalation arrangements of Anglian Water and Core 
Highways Group Ltd. SCC has reinforced its procedures for identifying relevant issues to those 
responsible for the temporary traffic management. 

3.  Concern 3: ‘I am concerned that the correct ‘special signage’ that would have 

undoubtedly made this scheme safer, was not even considered in this case (as a 
direct result of the flipping of the original plan).  
I am further concerned that Network Inspectors have no power to declare a special 
sign (or the lack of a special sign) as a defect, as these signs fall outside the 
mandatory signage shown in the Red Book.  
As such, even if a Network Inspector identified what they believed to be a 
dangerous temporary traffic management scheme, any danger being caused by the 
lack of special signage (or caused by special signage on site that is incorrect), there 
is no mechanism available for a Network Inspector to issue a defect notice to raise 
their concern’. 

This concern appears to arise from the present scope of the statutory inspection framework and 
the guidance currently available to highway authorities and inspectors.  

As highlighted in the concern, ‘special signage’ is not considered mandatory signage as per the 
Red Book and other advisory material and is therefore not something which a Network Inspector 
could raise a defect for in the same way as mandatory signage. However, SCC recognises the 
importance of ensuring that wider safety concerns can still be escalated promptly to the 
undertaker where identified. 

4.  Concern 4: ‘I am concerned of that the only recourse for a Network Inspector to get 

temporary traffic management signage replaced, is an apparently protracted 
procedural route involving multiple individuals remote from the site, with the 
Network Inspector having limited or no contact with the Traffic Management 
Operatives at the site itself.  
I am further concerned that there is no requirement for spare signage to be carried 
on vehicles used for setting up the schemes, for obvious or frequently occurring 
errors identified on temporary road traffic schemes (such as in this case the road 
narrow signs being the wrong way around)’. 

Concern 4 primarily concerns the operational arrangements and equipment practices of Core 
Highways Group Ltd and Anglian Water, rather than matters determined by SCC. 

 
 
 
 
 
 
 
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Local Authorities are required to report any identified defects to the statutory undertaker as the 
holder of the street works licence.  

As covered in the evidence, 
 verbally reported the defect to the traffic management 
operative on site following completion of his inspection on 24 October 2022. He also reported 
the defect to Anglian Water via the English national online system (Street Manager) and via 
telephone, as the Code of Practice of Inspections requests.  The Network Inspector can take the 
steps available to him/ her within the limits of the statutory inspection role. 

5.  Concern 5: ‘I am concerned that there is no apparent system in place to inform 

Network Inspectors that a traffic scheme has been laid out, contrary to the original 
plan that was in place (as in this case when a plan has been flipped).   
As a result of the Network Inspector having no access to, or sight of the original 
plan, he was unaware that the original plan had been flipped, unaware of the 
suspension of the cycle lanes approaching the roundabout and unaware that the 
special signage deemed necessary in the original plan, was completely absent in 
the flipped scheme that was put in place.  
As such the Network Inspector’s ability to check the safety of the flipped scheme 
was seriously compromised’.  

As set out under Concern 1 above, highway authorities have powers to investigate and monitor 
street works activity, including through the use of network inspections where appropriate. These 
inspections  can  be  undertaken  on  a  random  sample  basis  and  are  focused  on  assessing 
compliance with relevant safety requirements. 

The role of the Network Inspector is to assess whether the traffic management arrangements as 
implemented on site at the time of inspection comply with the requirements of the  Red Book. 
Inspections are not intended to verify detailed design intent or confirm whether a scheme has 
been implemented in accordance with a previously submitted plan. 

Statutory  Undertakers  may  appoint  specialist  traffic  management  contractors  to  design  and 
implement  appropriate measures.  Responsibility for  ensuring that traffic management is safe, 
compliant, and responsive to changing circumstances rests with the statutory undertaker and its 
appointed contractors. Temporary traffic management is inherently dynamic, and the Red Book 
allows  for  adjustments  to  be  made  on  site  to  reflect  conditions  such  as  parked  vehicles,  site 
constraints, or nearby activity. 

The  statutory  framework  draws  a  clear  distinction  between  the  undertaker’s  responsibility  to 
design and implement safe traffic management, and the highway authority’s role in coordination 
and inspection. SCC must therefore avoid stepping into the undertaker’s operational function. 

The  duty  to  design  and  deliver  compliant  traffic  management  remains  with  the  organisation 
undertaking the works, supported by appropriately qualified and competent personnel. 

Non-compliance was identified by 
 during his inspection and raised with both the on-
site operative and Anglian Water in accordance with the established inspection and enforcement 
process. The absence of advance notice of the change did not prevent the identification of this 
defect or appropriate action being taken. 

 
 
 
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It  should  also  be  noted  that,  under  the  present  framework,  the  presence  or  absence  of  non-
prescribed or advisory signage is not necessarily in itself, a matter that can give rise to a defect 
under the Red Book where such signage is not a mandatory requirement. 

In  addition,  the  presence  of  advisory  cycle  lanes  at  this  location  does  not  create  a  statutory 
restriction, as these are not supported by a Traffic Regulation Order. Their temporary obstruction 
or absence during works is therefore not subject to a formal suspension process. 

While permit applications submitted via the DfT’s Street Manager system require undertakers to 
describe their works and associated traffic management, there is currently no specific mandatory 
field to explicitly identify impacts on cycle routes (advisory or not), in contrast to provisions such 
as footway closures. Any such impacts are typically conveyed through supporting information, 
drawings, or permit conditions. 

A Network Inspector, in their role, is to assess compliance based on the arrangements in place 
on site at the time of inspection. 

6.  Concern 6: ‘I am concerned that the ‘defect line’ operated by Anglian Water was not 
answered or responded to on the day of this incident, adding unnecessary delay to 
the changes required to the scheme signage. It is acknowledged that the signage 
defect identified on the 24 October 2022 would not have affected the tragic 
outcome of this case, however that may not be the case in future incidents’. 

Concern 6 relates primarily to the responsiveness of Anglian Water’s own defect reporting 
arrangements. SCC cannot comment on the internal operation of those systems. 

Conclusion 

SCC has carefully considered the Coroner’s concerns. For the reasons set out above, and 
following specific review, it does not consider that the statutory role of the highway authority 
should extend to approving or redesigning temporary traffic management laid out by 
undertakers. Responsibility for the safe design, implementation and operation of such 
arrangements rests with the undertakers and their appointed contractors. 

However, SCC has reviewed its own procedures and has taken active steps to reinforce the 
inspection and escalation processes applicable to Network Inspectors. In particular, SCC has 
delivered a toolbox talk to Network Inspectors to reaffirm the correct application of established 
inspection and escalation processes and will continue to do so as appropriate. SCC has also 
provided, and will continue to provide, refresher learning to both Network Inspectors and 
Network Coordinators. 

In addition, SCC has been in contact with the Department for Transport with a view to 
discussion as to the findings of the inquest and the extent to which any aspect of national 
guidance or the wider regulatory framework may merit further consideration. Whilst SCC can 
contribute its views and respond to any such consultation or discussion, responsibility for 

 
 
 
 
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changes to national guidance or the regulatory framework rests with the relevant national 
bodies. 

Yours sincerely, 

Suffolk County Council Legal Services (on behalf of SCC)