Charlotte Saunders

The report

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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.

2.

3.

CORONER
I am Lindsey TONKS, H M Assistant Coroner, for the coroner area of
Staffordshire and Stoke-on-Trent.

DATE OF REPORT
08 June 2026

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. Staffordshire County Council
2. National Highways

You are under a duty to respond to this report within 56 days of the date of this
report, namely by August 02, 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.

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

 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 19 January 2026 I commenced an investigation into the death of Charlotte
Marie SAUNDERS aged 52. The investigation concluded at the end of the
inquest on 03 June 2026. The conclusion of the inquest was 'Road Traffic
Collision'

9.

CIRCUMSTANCES OF DEATH

On the afternoon of 27 August 2024, Charlotte Marie Saunders was struck by
a tipper lorry whilst attempting to cross Christchurch Way in Stone,
Staffordshire. She sustained multiple injuries including a severe traumatic
brain injury which resulted in prolonged disorder of consciousness, requiring
24-hour care for all her needs. Mrs Saunders’ condition deteriorated on 25
December 2025 and she died in a specialist neurological care centre on 13
January 2026.

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 location of the road traffic collision involves a one-way carriageway,
consisting of two lanes of traffic. This is a busy section of road that serves as
a bypass around Stone town centre. At the section in question, there is a
large supermarket on the outer part of the ring road and the main shopping
area of Stone is located within the inner part of the ring road.

There is a purpose-built pedestrian walkway leading from the supermarket car
park to a bus stop, with metal pedestrian guardrails at the edge of the road to
the north of the walkway preventing pedestrians from crossing the
carriageway. There is no similar fencing to the south.

On the inner side of that section of the ring road, there is an alleyway that
leads directly into the town centre. There are metal pedestrian guardrails at
the edge of the carriageway on that side also, running north from opposite the
bus stop. Again, however, there is no similar fencing running to the south.

 There is a pedestrian crossing to either side of the collision location – one to
the north and one to the south - each of which is traffic light controlled and
each being said to be at a distance “within less than 100m” of Mrs Saunders’
crossing point.

Police inquiries revealed that Mrs Saunders had walked from the car park of
Morrisons and had been attempting to cross the furthest lane carriageway,
heading towards the town centre, at the time that she was struck. The Police
Report stated that this route “is often used by pedestrians to cross over in to
the town, rather than walking to one of the crossings”. A police officer who
gave evidence also described having visited the site for the purposes of his
investigation and having observed at least ten pedestrians crossing at the
same location during a period of no more than thirty minutes.

I have concern that there is a risk of future deaths as a result of the current
layout of this location, given the following:

The ring road is a busy road with heavy, consistent traffic flow, this

There is a busy supermarket with a large car park on one side of the

1.
being a bypass around the town centre
2.
ring road and the town centre on the other
There is a purpose-built pedestrian walkway leading to the pavement
3.
on the outer side of the carriageway and an alleyway leading directly into the
town centre on the other side
4.
There are no pedestrian guardrails either side of the carriageway at
what appears to be a primary location used by people for their speed and
convenience, to avoid the need to walk further to use the pedestrian crossings

11. COPIES AND PUBLICATION OF THIS REPORT

I have a duty to send a copy of my report to every Interested Person who in
my opinion should receive it.

I also may send a copy of the report to any other person who I believe may
find it useful or of interest.

I can confirm I have sent the report to:
[please do not use individual’s names, but instead roles/titles]

 Husband of deceased
 Staffordshire Police

I also have a duty to send a copy of the report to the Chief Coroner.

You may make representations to me, the coroner, about the publication of the
contents of this report in line with Chief Coroner’s PFD Publication Policy
(2026). Any representations will be sent to the Chief Coroner alongside the
report. Please refer to box 4 above for additional information relating to the
publication of reports and responses.

 12. SIGNATURE

Lindsey TONKS
H M Assistant Coroner for
Staffordshire and Stoke-on-Trent

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.

Lindsey Tonks
Assistant Coroner for
Staffordshire and Stoke-on-Trent
Coroners Service
Stoke Town Hall
Stoke on Trent
ST4 1HH

Dear Lindsey Tonks

                  Road Safety Team
Staffordshire County Council
Staffordshire Place 1
Tipping Street
Stafford
ST16 2DH

10/08/2026

Re: Regulation 28 Report to Prevent Future Deaths Report – Charlotte Marie SAUNDERS
00161 - 2026

I refer to your Regulation 28 report regarding the inquest into the tragic death of Charlotte Marie
SAUNDERS following a road traffic collision on 27/08/2024 on Christchurch Way in Stone.

This letter is in response to the matters of concern recorded in section 10 of your report, which
states:

The location of the road traffic collision involves a one-way carriageway,
consisting of two lanes of traffic. This is a busy section of road that serves as
a bypass around Stone town centre. At the section in question, there is a
large supermarket on the outer part of the ring road and the main shopping
area of Stone is located within the inner part of the ring road.

There is a purpose-built pedestrian walkway leading from the supermarket car
park to a bus stop, with metal pedestrian guardrails at the edge of the road to
the north of the walkway preventing pedestrians from crossing the
carriageway. There is no similar fencing to the south.

On the inner side of that section of the ring road, there is an alleyway that
leads directly into the town centre. There are metal pedestrian guardrails at
the edge of the carriageway on that side also, running north from opposite the
bus stop. Again, however, there is no similar fencing running to the south.
There is a pedestrian crossing to either side of the collision location – one to
the north and one to the south - each of which is traffic light controlled and
each being said to be at a distance “within less than 100m” of Mrs Saunders’
crossing point.

Police inquiries revealed that Mrs Saunders had walked from the car park of
Morrisons and had been attempting to cross the furthest lane carriageway,
heading towards the town centre, at the time that she was struck. The Police
Report stated that this route “is often used by pedestrians to cross over in to
the town, rather than walking to one of the crossings”. A police officer who

 gave evidence also described having visited the site for the purposes of his
investigation and having observed at least ten pedestrians crossing at the
same location during a period of no more than thirty minutes.

I have concern that there is a risk of future deaths as a result of the current
layout of this location, given the following:

1. The ring road is a busy road with heavy, consistent traffic flow, this being a bypass

around the town centre

2. There is a busy supermarket with a large car park on one side of the ring road and

the town centre on the other

3. There is a purpose-built pedestrian walkway leading to the pavement  on the  outer
side of the carriageway and an alleyway leading directly into the town centre on the
other side

4. There are no pedestrian guardrails either side of the carriageway at what appears to
be a primary location used by people for their speed and convenience, to avoid the
need to walk further to use the pedestrian crossings

As part of our statutory function and commitment to road safety, Staffordshire County Council
routinely  monitors  personal  injury  collision  data  reported  on  the  public  highway  to  identify
collision clusters and trends. Any treatable pattern of collisions identified will have proportionate
remedial measures put forward for funding and will be prioritised against other locations around
Staffordshire.

A  review  of  the  collision  history  at  the  location  of  concern,  (Christchurch  Way  between  the
Supermarket access and the Lichfield Street/High Street junction) has been undertaken. No
other personal injury collisions have been recorded by Staffordshire Police at this location since
before 1 January 2020. A site visit and an assessment of the highway layout have also been
completed.

From the pedestrian exit point behind the bus stop, measurements have been taken to each
of the nearest formal pedestrian crossing points (north and south) providing access to the inner
pavement  of  the  ring  road,  and  High  street.  Both  pedestrian  crossing  facilities  are  at
equidistance from the bus stop, being approximately 107 metres.  However, it is recognised
that pedestrians  will choose not to use formal crossing points if alternative routes provide a
perception of time and/or distance saving.

The provision of additional pedestrian guardrail, to encourage pedestrians to use the formal
crossing points, has been considered.  However, initial observations have identified that the
addition of pedestrian guard rail on the southern side of the carriageway may impede visibility
for vehicles exiting the private business vehicle access; and the addition of pedestrian guardrail
on the northern side of the carriageway may encourage pedestrians to enter the carriageway
at either the bus stop or private driveway access that is situated approximately 47 metres away.

Notwithstanding the above, the County Council has a scheme in this year’s capital programme
to consider active travel and structural maintenance at a number of locations in Stone; and,
following receipt of the Prevention of Future Deaths Report, the study area has been extended

 to  include  the  Christchurch  Way  pedestrian  desire  line  crossing  location.   The  study  will
consider  the  current  national  guidance  on  pedestrian  guardrails  and  whether  alternative
measures or interventions may be appropriate to encourage safer pedestrian crossing routes
at this location.

I hope the information provided within this letter is useful. Please let me know if you require
anything further.

Yours sincerely,

Road Safety Manager
Staffordshire County Council

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