Prevention of Future Deaths reports · 2026
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 report | 1 Jun 2026 |
|---|---|
| Reference | 2026-0293 |
| Deceased | Phillip Tetley |
| Coroner | Nathanael Hartley |
| Coroner area | Nottingham and Nottinghamshire |
| Source | judiciary.uk record |
| Responses published | 1 |
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
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.
##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. 4 2 0 2 h c r a M d a e h r e t t e L e t a r o p r o C 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
See every Prevention of Future Deaths report matching Nathanael Hartley, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.