Lee Marsden
PFD Report
All Responded
Ref: 2021-0084
All 2 responses received
· Deadline: 21 May 2021
Response Status
Responses
2 of 1
56-Day Deadline
21 May 2021
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner's Concerns
(at the the the
There was a in activating the warning signals to reduce the speed of traffic travelling along the M66 motorway between junctions 2 and 3 to 3Omph: The efficacy of communication between Highways England and North West Motorway Police Group in that there was a failure to appreciate the significance of the prefix numbers 08/8126 No internal review of the circumstances of this fatal accident has been undertaken by Highways England with the consequent loss of an opportunity for learning
There was a in activating the warning signals to reduce the speed of traffic travelling along the M66 motorway between junctions 2 and 3 to 3Omph: The efficacy of communication between Highways England and North West Motorway Police Group in that there was a failure to appreciate the significance of the prefix numbers 08/8126 No internal review of the circumstances of this fatal accident has been undertaken by Highways England with the consequent loss of an opportunity for learning
Responses
Response received
View full response
1
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS RESPONSE IS BEING SENT TO:
1. The Assistant Coroner for the Coroner area of Manchester North, Matthew Cox of Newgate House, Newgate, Rochdale OL16 1AT in response to a ‘Regulation 28 Report to Prevent Future Deaths’ following an inquest hearing into the death of Lee David Marsden that concluded on 15 March 2021.
1 HIGHWAYS ENGLAND
I am Superintendent of Cheshire Constabulary, responsible for the North West Motorway Police Group Regional Control Centre.
2 CORONER’S MATTERS OF CONCERN
The MATTER OF CONCERN for this report:–
The language and manner of communication between Highways England and North West Motorway Police Group in that there was a failure to appreciate the significance of the prefix numbers 06/8126.
3 DETAILS OF ACTION TAKEN
Prefix numbers 06/8126
Prior to the incident on 20 December 2019, Highways England Regional Operations Centre staff were not aware of the significance and meaning of the prefix numbers transferred from the North West Motorway Police Group (NWMPG) incident logging system via an automatic, electronic interface into the Highways England Incident Management System. Highways England operate a tiered response to reports of incidents on the network, giving a higher degree of priority to information from a ‘trusted source’ (including police officers) than that received from other sources. In this case, the police operator used ‘06’ the police force identifier for Greater Manchester Police, and ‘8126’ the police officer’s force identification or ‘collar’ number. The prefix numbers were included within the electronic transfer of information to the Highways England incident log however, the textual description did not state that the information had come from a (off-duty) police officer. The Highways England operator has not recognised this as information from a ‘trusted’ source. Highways England has a national policy and a work instruction in relation to the activation of motorway variable signs and signals. The notification of ‘unconfirmed pedestrian’ on the carriageway initially results in the setting of signs and signals to indicate an advisory 60mph speed limit supported by ‘unconfirmed’ signing, where available. Once the presence of a pedestrian has been confirmed by an approved, trusted source such as a Highways England Traffic Officer or Highways Inspector, or the police, the advisory speed limit is lowered further and supported by ‘confirmed’ signing, where available.
Highways England and the NWMPG have agreed that going forward details relating to the source of information will be clearer and a free text description will be added to the log to identify the source of information in clear language.
Police operators and supervisors within NWMPG will be briefed to add this plain language to logs.
4 TIMETABLE FOR ACTION
2
Date Action
25/05/2021 Briefing note for North West Motorway Police Group staff circulated advising of the need to use ‘plain language’ when identifying Police or other Emergency services employees who are referred to on a log corroborating an incident report.
6 SAFETY OF ROAD USERS
The safety of our road users is an imperative for our business in what we set out to achieve, and a core value of our organisation. We are working hard to make our entire network safer, and consider that the action we have taken will improve safety through enhanced communication.
7
25 May 2021 Signed:
Superintendent.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS RESPONSE IS BEING SENT TO:
1. The Assistant Coroner for the Coroner area of Manchester North, Matthew Cox of Newgate House, Newgate, Rochdale OL16 1AT in response to a ‘Regulation 28 Report to Prevent Future Deaths’ following an inquest hearing into the death of Lee David Marsden that concluded on 15 March 2021.
1 HIGHWAYS ENGLAND
I am Superintendent of Cheshire Constabulary, responsible for the North West Motorway Police Group Regional Control Centre.
2 CORONER’S MATTERS OF CONCERN
The MATTER OF CONCERN for this report:–
The language and manner of communication between Highways England and North West Motorway Police Group in that there was a failure to appreciate the significance of the prefix numbers 06/8126.
3 DETAILS OF ACTION TAKEN
Prefix numbers 06/8126
Prior to the incident on 20 December 2019, Highways England Regional Operations Centre staff were not aware of the significance and meaning of the prefix numbers transferred from the North West Motorway Police Group (NWMPG) incident logging system via an automatic, electronic interface into the Highways England Incident Management System. Highways England operate a tiered response to reports of incidents on the network, giving a higher degree of priority to information from a ‘trusted source’ (including police officers) than that received from other sources. In this case, the police operator used ‘06’ the police force identifier for Greater Manchester Police, and ‘8126’ the police officer’s force identification or ‘collar’ number. The prefix numbers were included within the electronic transfer of information to the Highways England incident log however, the textual description did not state that the information had come from a (off-duty) police officer. The Highways England operator has not recognised this as information from a ‘trusted’ source. Highways England has a national policy and a work instruction in relation to the activation of motorway variable signs and signals. The notification of ‘unconfirmed pedestrian’ on the carriageway initially results in the setting of signs and signals to indicate an advisory 60mph speed limit supported by ‘unconfirmed’ signing, where available. Once the presence of a pedestrian has been confirmed by an approved, trusted source such as a Highways England Traffic Officer or Highways Inspector, or the police, the advisory speed limit is lowered further and supported by ‘confirmed’ signing, where available.
Highways England and the NWMPG have agreed that going forward details relating to the source of information will be clearer and a free text description will be added to the log to identify the source of information in clear language.
Police operators and supervisors within NWMPG will be briefed to add this plain language to logs.
4 TIMETABLE FOR ACTION
2
Date Action
25/05/2021 Briefing note for North West Motorway Police Group staff circulated advising of the need to use ‘plain language’ when identifying Police or other Emergency services employees who are referred to on a log corroborating an incident report.
6 SAFETY OF ROAD USERS
The safety of our road users is an imperative for our business in what we set out to achieve, and a core value of our organisation. We are working hard to make our entire network safer, and consider that the action we have taken will improve safety through enhanced communication.
7
25 May 2021 Signed:
Superintendent.
Response received
View full response
1
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS RESPONSE IS BEING SENT TO:
1. The Assistant Coroner for the Coroner area of Manchester North, Matthew Cox of Newgate House, Newgate, Rochdale OL16 1AT in response to a ‘Regulation 28 Report to Prevent Future Deaths’ following an inquest hearing into the death of Lee David Marsden that concluded on 15 March 2021.
1 HIGHWAYS ENGLAND
I am , Regional Director for the North West, Highways England Company Limited of Piccadilly Gate, Store Street, Manchester M1 2WD.
2 CORONER’S MATTERS OF CONCERN
The MATTERS OF CONCERN are as follows:–
a. There was a delay in activating the warning signals to reduce the speed of traffic travelling along the M66 motorway between junctions 2 and 3 to 30mph.
b. The efficacy of communication between Highways England and North West Motorway Police Group in that there was a failure to appreciate the significance of the prefix numbers 06/8126.
c. No internal review of the circumstances of this fatal accident has been undertaken by Highways England with the consequent loss of an opportunity for learning.
3 DETAILS OF ACTION TAKEN
a. Activating warning signals
Please see paragraph 5a. below.
b. Prefix numbers 06/8126
Prior to the incident on 20 December 2019, Highways England Regional Operations Centre staff were not aware of the significance and meaning of the prefix numbers transferred from the North West Motorway Police Group (NWMPG) incident logging system via an automatic, electronic interface which allows the log to be edited and confidential information redacted prior to being transferred, into the Highways England Incident Management System.
In this case, ‘06’ is the police force identifier for Greater Manchester Police, and ‘8126’ is the police officer’s ‘collar’ number. The prefix numbers were included within the electronic transfer of information from the NWMPG to the Highways England incident log however, the textual description did not state that the information had come from a (off-duty) police officer. If it had, the information could have been treated as an approved ‘trusted’ source confirming the presence of a pedestrian on the motorway.
In discussions with the NWMPG it has been agreed that the use of prefix numbers as numerical identifiers in such circumstances could lead to relevant information not being considered, and could lead to a delay in confirming the presence of a pedestrian on the Strategic Road Network and the signing of a further reduced advisory speed limit in accordance with our company policy and work instruction.
Highways England and the NWMPG have agreed that going forward details relating to the source of information should be clearer and relayed between
2 organisations in a ‘free text’ format as part of the electronic interface of incident logs.
Highways England will brief the circumstances of this incident together with the outcome of our review to the North West Regional Operations Centre staff. The Police Operators within the NWMPG (Cheshire, Merseyside, Greater Manchester), as well as Lancashire Constabulary and Cumbria Constabulary will similarly be briefed. This joint approach will cover all the police forces operating within the North West geographic area of the Strategic Road Network.
c. Internal review of the circumstances
An internal review has been carried out into the Regional Operations Centre handling of the incident in December 2019, as requested by the Coroner. Our review concluded that on the information available to the Operations staff at the time, our staff complied with the company policy and work instructions in place, and the incident was managed appropriately. Highways England Regional Operations Centre staff were not aware that one of the entries on the log originated from a call from an off-duty police officer, or the significance and meaning of prefix numbers electronically transferred to the Highways England incident log from the NWMPG. The Coroner’s Officer brought this point to our attention shortly before the inquest. With that information, we have taken action as explained at paragraph b. above.
4 TIMETABLE FOR ACTION
Date Action
01/06/2021 Briefing for the North West Highways England Regional Operations Centre staff and police officers in relation to the use of ‘free text’ entries transferred between organisations within incident logs where appropriate. This briefing will be shared with all Highways England Regional Control Centres as best practice nationally.
5 EXPLANATION AS TO WHY NO ACTION IS PROPOSED
a. Activating warning signals
Highways England has a national policy and a work instruction in relation to the activation of motorway variable signs and signals. The notification of ‘unconfirmed pedestrian’ on the carriageway initially results in the setting of signs and signals to indicate an advisory 60mph speed limit supported by ‘unconfirmed’ signing, where available. Once the presence of a pedestrian has been confirmed by an approved, trusted source such as a Highways England Traffic Officer or Highways Inspector, or the police, the advisory speed limit is lowered further and supported by ‘confirmed’ signing, where available. We have reviewed our procedure and consider it to be robust and appropriate so no action is proposed.
6 SAFETY OF ROAD USERS
The safety of our road users is an imperative for our business in what we set out to achieve, and a core value of our organisation. We are working hard to make our entire network safer, and consider that the action we have taken will improve safety through enhanced communication.
3 7
18 May 2021 Signed:
Regional Director for North West
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS RESPONSE IS BEING SENT TO:
1. The Assistant Coroner for the Coroner area of Manchester North, Matthew Cox of Newgate House, Newgate, Rochdale OL16 1AT in response to a ‘Regulation 28 Report to Prevent Future Deaths’ following an inquest hearing into the death of Lee David Marsden that concluded on 15 March 2021.
1 HIGHWAYS ENGLAND
I am , Regional Director for the North West, Highways England Company Limited of Piccadilly Gate, Store Street, Manchester M1 2WD.
2 CORONER’S MATTERS OF CONCERN
The MATTERS OF CONCERN are as follows:–
a. There was a delay in activating the warning signals to reduce the speed of traffic travelling along the M66 motorway between junctions 2 and 3 to 30mph.
b. The efficacy of communication between Highways England and North West Motorway Police Group in that there was a failure to appreciate the significance of the prefix numbers 06/8126.
c. No internal review of the circumstances of this fatal accident has been undertaken by Highways England with the consequent loss of an opportunity for learning.
3 DETAILS OF ACTION TAKEN
a. Activating warning signals
Please see paragraph 5a. below.
b. Prefix numbers 06/8126
Prior to the incident on 20 December 2019, Highways England Regional Operations Centre staff were not aware of the significance and meaning of the prefix numbers transferred from the North West Motorway Police Group (NWMPG) incident logging system via an automatic, electronic interface which allows the log to be edited and confidential information redacted prior to being transferred, into the Highways England Incident Management System.
In this case, ‘06’ is the police force identifier for Greater Manchester Police, and ‘8126’ is the police officer’s ‘collar’ number. The prefix numbers were included within the electronic transfer of information from the NWMPG to the Highways England incident log however, the textual description did not state that the information had come from a (off-duty) police officer. If it had, the information could have been treated as an approved ‘trusted’ source confirming the presence of a pedestrian on the motorway.
In discussions with the NWMPG it has been agreed that the use of prefix numbers as numerical identifiers in such circumstances could lead to relevant information not being considered, and could lead to a delay in confirming the presence of a pedestrian on the Strategic Road Network and the signing of a further reduced advisory speed limit in accordance with our company policy and work instruction.
Highways England and the NWMPG have agreed that going forward details relating to the source of information should be clearer and relayed between
2 organisations in a ‘free text’ format as part of the electronic interface of incident logs.
Highways England will brief the circumstances of this incident together with the outcome of our review to the North West Regional Operations Centre staff. The Police Operators within the NWMPG (Cheshire, Merseyside, Greater Manchester), as well as Lancashire Constabulary and Cumbria Constabulary will similarly be briefed. This joint approach will cover all the police forces operating within the North West geographic area of the Strategic Road Network.
c. Internal review of the circumstances
An internal review has been carried out into the Regional Operations Centre handling of the incident in December 2019, as requested by the Coroner. Our review concluded that on the information available to the Operations staff at the time, our staff complied with the company policy and work instructions in place, and the incident was managed appropriately. Highways England Regional Operations Centre staff were not aware that one of the entries on the log originated from a call from an off-duty police officer, or the significance and meaning of prefix numbers electronically transferred to the Highways England incident log from the NWMPG. The Coroner’s Officer brought this point to our attention shortly before the inquest. With that information, we have taken action as explained at paragraph b. above.
4 TIMETABLE FOR ACTION
Date Action
01/06/2021 Briefing for the North West Highways England Regional Operations Centre staff and police officers in relation to the use of ‘free text’ entries transferred between organisations within incident logs where appropriate. This briefing will be shared with all Highways England Regional Control Centres as best practice nationally.
5 EXPLANATION AS TO WHY NO ACTION IS PROPOSED
a. Activating warning signals
Highways England has a national policy and a work instruction in relation to the activation of motorway variable signs and signals. The notification of ‘unconfirmed pedestrian’ on the carriageway initially results in the setting of signs and signals to indicate an advisory 60mph speed limit supported by ‘unconfirmed’ signing, where available. Once the presence of a pedestrian has been confirmed by an approved, trusted source such as a Highways England Traffic Officer or Highways Inspector, or the police, the advisory speed limit is lowered further and supported by ‘confirmed’ signing, where available. We have reviewed our procedure and consider it to be robust and appropriate so no action is proposed.
6 SAFETY OF ROAD USERS
The safety of our road users is an imperative for our business in what we set out to achieve, and a core value of our organisation. We are working hard to make our entire network safer, and consider that the action we have taken will improve safety through enhanced communication.
3 7
18 May 2021 Signed:
Regional Director for North West
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe each of you respectively have the power to take such action:
Report Sections
Investigation and Inquest
On the 15 March 2021 concluded an inquest into the death of Lee David Marsden who died on 20 December 2019, reached the following conclusion: Road Traffic Collision
Circumstances of the Death
The deceased was seen accessing an area between junctions 2 and 3 of the M66 motorway on foot at 20.04 hours on 20 December 2019, The North West Motorway Police Group (NWMPG) notified Highways England of the sighting via electronic interface at 20.05.28 hours. As a result of this communication, Highways England set advisory speed limits of 60 mph between junctions 2 and 3 at 20.08.01 hours_ Two further reports of sightings were made, one of which 20.10 hours) was by an off-duty police officer who asked that consideration be given to imposing speed-limit of 3Omph at junction NWMPG updated Highways England of these reports using the prefix 06/8126 to indicate that one of the informants was a police officer. The significance of the prefix 06/8126 was not appreciated by Highways England: The evidence was that had Highways England appreciated that informant was a police officer , speed limit would have been set at 3Omph between junctions 2 and 3 with target time for implementation of 2 minutes_ This would have meant that the 30 mph speed limit would have been in place by 20.12.58 hours. At 20.16 hours, the Deceased was struck by a vehicle in the third land of the northbound carriageway: His body was projected into the southbound carriageway where other vehicles collided with him He sustained fatal injuries and his life was pronounced extinct at the scene: At 20.22:17 hours , almost six minutes after the impact; an advisory speed limit was set on both carriageways by Highways England between junctions 2 and 3 Evidence from the Forensic Collision Investigator was that had speed imit of 3Omph been in place_the_Deceased would have had a greater chance of avoiding the impact
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.