Prevention of Future Deaths reports · 2026

Phillip Tetley

Regulation 28 report to prevent future deaths, reference 2026-0293, written 1 Jun 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report1 Jun 2026
Reference2026-0293
DeceasedPhillip Tetley
CoronerNathanael Hartley
Coroner areaNottingham and Nottinghamshire
Sourcejudiciary.uk record
Responses published1

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

REGULATION 28:  REPORT TO PREVENT FUTURE DEATHS

REPORT TO PREVENT FUTURE DEATHS
REGULATION 28 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013

Please do not include any living persons’ names in this document, in accordance
with the Chief Coroner’s PFD Publication Policy (2026).

1.

CORONER

I am Nathanael Hartley, Assistant Coroner for the coroner area of Nottingham and
Nottinghamshire.

2.

DATE OF REPORT

1 June 2026

3.

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.

4.

THIS REPORT IS BEING SENT TO

1.  Cabinet Member for Transport and Environment at Nottinghamshire County

Council

2.  Head of District Highways Management, VIA – East Midlands

You are under a duty to respond to this report within 56 days of the date of this
report, namely by 28 July 2026. I, the coroner, may extend the period if an
appropriate application is made

5.

YOUR RESPONSE

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.

I have a duty to send a copy of your response to the Chief Coroner.

In accordance with the Chief Coroner’s Publication Policy, you should send me any
representations regarding publication of your response. These representations
should be made at the same time as the response is provided. I will pass any
representations received to the Chief Coroner for a decision.

Please note any links to webpages included in the response will not be checked for
sensitive information prior to publication, as the information is already online.

1

 The names of those who do not respond to PFD reports are regularly published on
the Chief Coroner’s webpages Non-responses to Prevention of Future Death (PFD)
reports - Courts and Tribunals Judiciary.

6.

SUMMARY OF CORONER’S CONCERN

Risk of death to those crossing between HMP Ranby prison estates on A620
Straight Mile in Ranby.

7.

ACTION SHOULD BE TAKEN

In my opinion unless action is taken to address the above concerns then there is a
significant risk of future deaths and I believe each of you have the power to take
such action.

8.

INVESTIGATION AND INQUEST

On 26 March 2026 an inquest was opened into the death of Phillip Tetley, aged 42.
The inquest concluded on 1 June 2026. I made a determination at inquest that he
died from multiple injuries.

The record of inquest recorded the following: Phillip Tetley died on 1 December 2025
at the A620 Straight Mile in Ranby from injuries received when he was struck by a
vehicle whilst crossing the road.

Conclusion: Road traffic collision.

9.

CIRCUMSTANCES OF DEATH

Mr Tetley was employed at HMP Ranby and had parked in the overflow carpark on 1
December 2025 on his way in to work. HMP Ranby’s main site is across the A620
Straight Mile, a 50mph road with no provision to assist those crossing between each
site. Concerns had been raised by HMP Ranby in 2023 and traffic calming measures
had been requested, but due to there being no recorded injury collisions at the
location there was insufficient evidence to support the installation of such measures.
Mr Tetley crossed the road into the path of an oncoming vehicle and was struck by it,
and another vehicle, causing fatal injuries.

10. CORONER’S CONCERNS

During the course of the inquest I heard evidence 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:

The court heard evidence that the possibility of a crossing is being considered by the
council. The overflow carpark to the south of the A620 has been increased in size
and there is an increase in the number of people crossing the road to get to the
prison estate. Many of those crossing expressed concern about crossing the road
safely. The court is concerned that if nothing is done to assist those crossing the
road there is a risk of future deaths.
The court also received initial evidence from VIA in the form of a written statement
that warning signs had been installed on the approach to the carpark, but then heard
evidence that only “SLOW” signage had been installed, and planned
“PEDESTRIANS IN THE ROAD/CROSSING” signage had not. As a result, drivers
may be unaware of the risks posed at the car park location.

2

 SIGNATURE

Nathanael Hartley
HM Assistant Coroner
For Nottingham and Nottinghamshire

3

Responses

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.

Response from Nottingham County Council
##MAILMERGE - Do not delete this text or change the colour from white 

This matter is being dealt with by: 

W nottinghamshire.gov.uk 

Private and Confidential 
To be opened by addressee only 

Assistant Coroner Nathanael Hartley 
HM Coroner's Office 
Nottingham and Nottinghamshire 

Dear Assistant Coroner Hartley 

24 July 2026 

Re: Regulation 28 Report to Prevent Future Deaths – Phillip Tetley (Deceased)  

Thank you for your Regulation 28 Report to Prevent Future Deaths dated 1 June 2026 concerning 
the death of Mr Phillip Tetley.  

Nottinghamshire  County  Council  and  Via East  Midlands have carefully  considered  the matters of 
concern identified by the Court and welcome the opportunity to respond.  The Council recognises 
the concerns raised regarding pedestrian safety on the A620 Straight Mile adjacent to HMP Ranby 
and has undertaken a review of the location following the fatal collision on 1 December 2025.  

As part of that review, the Council examined the available collision history for this location.  Analysis 
of casualty data supplied by Nottinghamshire Police confirmed that, prior to the collision involving Mr 
Tetley, there had been no recorded pedestrian injury collisions of any severity outside HMP Ranby 
during the period for which records are held.  Notwithstanding that collision history, the Council has 
carefully considered the concerns identified by the Court and has undertaken further investigation of 
pedestrian activity at the location.  Those investigations identified sufficient pedestrian demand to 
justify  progression  of  a  formal  pedestrian  crossing  facility  and  the  Council  has  consequently 
commenced the work set out below with a view to reducing risk and improving pedestrian safety at 
the site.  

The actions taken and proposed in response to each matter of concern are set out below.  

Matter of Concern 1  

"The court heard evidence that the possibility of a crossing is being considered by the council. The 
overflow car park to the south of the A620 has been increased in size and there is an increase in the 
number of people crossing the road to get to the prison estate. Many of those crossing expressed 
concern about crossing the road safely. The court is concerned that if nothing is done to assist those 
crossing the road there is a risk of future deaths." 

Response  

Following the fatal collision on 1 December 2025, Nottinghamshire County Council commissioned a 
review of pedestrian movements and road safety conditions on the A620 Straight Mile adjacent to 
HMP Ranby.  

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The Council is committed to protecting your privacy and ensuring all personal information is kept confidential and safe. For more details 
see our general and service specific privacy notices at: https://www.nottinghamshire.gov.uk/global-content/privacy 

Nottinghamshire County Council, County Hall, West Bridgford, Nottingham NG2 7QP 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Traffic and pedestrian surveys were subsequently undertaken.  The results demonstrated sufficient 
pedestrian demand to warrant further investigation into the provision of a formal pedestrian crossing 
facility.  

A feasibility study was then commissioned to assess the suitability of a signal-controlled pedestrian 
crossing.    The  study  was  completed  in  April  2026  and  identified  a  preferred  location  for  a  puffin 
crossing adjacent to the prison's overflow car park.  

As a result, the Council has instructed Via East Midlands to progress the detailed design and delivery 
of a signal-controlled pedestrian crossing at this location.  The current anticipated programme is as 
follows:  

•  Completion  of  detailed  design,  site  investigations  and  associated  technical  work  by  30 

September 2026 

•  Commencement of public consultation and any required statutory procedures by 14 October 

2026 

•  Completion of consultation by 11 November 2026  

•  Determination of objections and approvals required to proceed by December 2026 

•  Anticipated commencement of construction by February 2027 

•  Anticipated  completion  of  the  crossing  by  March  2027,  subject  to  completion  of  statutory 
procedures,  procurement  requirements  and  any  matters  arising  through  consultation  or 
detailed design.  

The Council considers that the proposed crossing will provide a significant improvement in safety for 
staff, visitors and other pedestrians required to cross between the prison estate and overflow parking 
facilities.  

Matter of Concern 2  

"The court  also received  initial  evidence from  VIA  in the form  of  a  written statement that  warning 
signs had been installed on the approach to the car park, but then heard evidence that only 'SLOW' 
signage had been installed, and planned 'PEDESTRIANS IN THE ROAD/CROSSING' signage had 
not. As a result, drivers may be unaware of the risks posed at the car park location." 

Response  

Following notification of the fatal collision by Nottinghamshire Police on 3 December 2025, Via East 
Midlands commissioned the  installation  of  temporary  warning  signage  consisting  of  both "SLOW" 
signs and "Pedestrians in Road" warning signs on the approaches to HMP Ranby.  

Whilst  the  "SLOW"  signs  were  installed,  it  subsequently  became  apparent  that  the  temporary 
"Pedestrians in Road" warning signs had not been erected as intended.  This omission was identified 
following evidence heard during the inquest proceedings.  

Upon becoming aware of the omission, Via East Midlands immediately investigated the matter and 
arranged  for  the  warning  signs  to  be  installed.    Two  "Pedestrians  in  Road"  warning  signs  were 
subsequently erected on 19 June 2026.  

The  Council  and  Via  East  Midlands  acknowledge  that  the  intended  signage  should  have  been 
installed earlier and regret that this did not occur.  The matter has been reviewed internally and steps 
have  been  taken  to  ensure  that  highway  safety  measures  commissioned  in response  to  collision 
investigations are appropriately monitored and verified following instruction and implementation.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The Council considers that the installation of the warning signs, together with the progression of the 
proposed signal-controlled crossing scheme, directly addresses the concerns raised by the Court 
regarding driver awareness and pedestrian safety at this location.  

Conclusion  

Nottinghamshire County Council and Via East Midlands have carefully considered the matters raised 
within the Regulation 28 Report and remain committed to improving pedestrian safety on the A620 
adjacent to HMP Ranby.  

Immediate  action  has  been  taken  through  the  installation  of  pedestrian  warning  signs  and  a 
programme is  now  underway to design  and deliver  a signal-controlled  pedestrian  crossing  at the 
location.  

The  Council  and  Via  East  Midlands  will  continue  to  progress  the  scheme  in  accordance  with  the 
timetable  set  out  above  and  will  work  with  relevant  stakeholders  to  deliver  the  proposed 
improvements as soon as reasonably practicable.  

We trust that this response addresses the concerns identified by the Court.  

Yours sincerely 

Director Highways, Transport & Waste Management 
Nottinghamshire County Council 

Enc: 
Appendix 1 – Chronology of Events and Actions Taken  
Appendix 2 – Pedestrian Crossing Delivery Programme and Key Milestones

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