Barry Howard
PFD Report
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Ref: 2024-0380
All 1 response received
· Deadline: 11 Sep 2024
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11 Sep 2024
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Source: Courts and Tribunals Judiciary
Coroner’s Concerns
i. While the evidence I heard was that the Council consider that the current signage is adequate & has been inspected, there was a history of incidents reported to them, and sadly the very tragic death of Barry. That suggests that, while they consider it adequate, it was not sufficiently so to prevent those incidents & Barry’s death. I have heard nothing to reassure me that appropriate action has been taken to prevent others continuing to fail to be aware of the risk of the unbridged Ford, especially after heavy periods of rain.
ii. A lack of any appropriate warning signs that this Ford is prone to flooding which may make it unsafe to cross.
iii. A lack of signs sufficiently in advance of the Ford so as to warn road users at times of extreme flooding. The current signs were well within the flooded area on the night in question and I am concerned they would not be visible, especially to those unfamiliar with the road and in the dark, until they were already in the flood water.
iv. The slippery surface of the road.
v. The insufficiency of the temporary road closed signs used and the lack of more permanent measures, in accordance with guidelines, once the closure lasted more than 24 hours. It was only a week prior to the inquest, some 7 months after this death, that action was taken. I am concerned that such lengthy delays to implement safety measures will lead to a risk in future incidents at this and possibly other locations.
vi. The evidence was that more appropriate measures for road closure should have been considered, but there was no evidence as to why they were not, or that this has been considered and action taken to address the reasons. I have not heard of any change to the way the team works, and I was repeatedly told they are a small team with a large area to cover – which means that there are risks of future issues with regards to the suitability of temporary signs and the correct procedures being followed when they need to be more permanent.
ii. A lack of any appropriate warning signs that this Ford is prone to flooding which may make it unsafe to cross.
iii. A lack of signs sufficiently in advance of the Ford so as to warn road users at times of extreme flooding. The current signs were well within the flooded area on the night in question and I am concerned they would not be visible, especially to those unfamiliar with the road and in the dark, until they were already in the flood water.
iv. The slippery surface of the road.
v. The insufficiency of the temporary road closed signs used and the lack of more permanent measures, in accordance with guidelines, once the closure lasted more than 24 hours. It was only a week prior to the inquest, some 7 months after this death, that action was taken. I am concerned that such lengthy delays to implement safety measures will lead to a risk in future incidents at this and possibly other locations.
vi. The evidence was that more appropriate measures for road closure should have been considered, but there was no evidence as to why they were not, or that this has been considered and action taken to address the reasons. I have not heard of any change to the way the team works, and I was repeatedly told they are a small team with a large area to cover – which means that there are risks of future issues with regards to the suitability of temporary signs and the correct procedures being followed when they need to be more permanent.
Responses
Norfolk County Council has already inspected all 47 fords, temporarily closed two additional fords, and installed more robust signage at Shotesham Ford, including an automatic 'Ford Flooded' sign. Shotesham Ford remains closed, and the council is evaluating the option of its permanent closure.
AI summary
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Dear Madam
Thank you for your recent email and for the Regulation 28: Report to Prevent Future Deaths following the recent Inquest relating to Mr Howard.
Please can I start with passing on my condolences onto the family of Mr Howard regarding this tragic accident.
I would also like to take this opportunity to provide more detail with regard to the weather conditions and the Council’s response to the recent tragic events, as part of the response to the Regulation 28 Report.
Recently, the weather conditions in Norfolk have been extremely challenging – it having been a very wet autumn, winter and spring period, with abnormally high levels of rainfall. This has caused water levels across the county to remain high and the usual drop we experience in spring each year did not materialise. These conditions explain why the peak flows at Shotesham Ford have not reduced as they usually would each year, resulting in the road closure being extended.
As the local highway authority for Norfolk, the Council is responsible for 47 fords across 6,200 miles of highway network. Within days of the incident on 13 December 2023, all these fords had been inspected by the local Highways teams to ensure vehicle users would encounter safe conditions. This initial review identified other locations where roads were closed due to higher than usual water levels, and replacements for any missing and damaged warning signs were also arranged. As a result of these actions, two further fords on the Norfolk network (at West Acre and Caste Acre) were closed and remain closed to ensure public safety.
Continued…/
-2-
Alongside this initial inspection work, more detailed safety reviews of all 47 fords in the Norfolk network were commissioned. The characteristics of each ford across the Norfolk highway network are different and therefore each ford requires a detailed, individual assessment. As part of this review, Engineers are considering the points you have raised in the Regulation 28 Report and are investigating other opportunities to further improve safety at each ford location.
A specific safety review has also been undertaken by the Council at Shotesham Ford. This has involved an initial scoping of options for addressing the specific issues identified at Shotesham, which has developed into a full feasibility assessment of alternative treatments at this location.
In terms of the Matters of Concern identified in the Regulation 28 report, please note the following responses which follow the original numbering used:
i) As stated above, a detailed safety review of Shotesham Ford has been undertaken and a number of actions have already been completed, with further planned. In addition, regular inspections have been undertaken to assess the safety of reopening the ford on a weekly basis and the results of these, combined with the groundwater challenges explained above, have resulted in the ford remaining closed to traffic. Despite regular complaints from local residents and businesses, this remains the case. Given the longer than expected ongoing nature of this closure and evidence to suggest that the road closed warning signs and barriers were being ignored by motorists, the Council therefore recently improved the barriers, by way of installing immovable barriers, to ensure motorists could not continue ignoring the warning signs and barriers. ii) Your comments about lack of warning signs have been noted – please see the Actions Already Undertaken & Proposed Actions section below. iii) Your comments about lack of warning signs in advance of the ford have been noted – please see the Actions Already Undertaken & Proposed Actions section below. iv) Your comments about the slippery surface of the road have been noted – please see the Actions Already Undertaken & Proposed Actions section below.
Continued…/
-3-
v) The temporary road closed signs that have been used are the standard types of signs and barriers used across the country by highway authorities to implement closures such as these. They are usually effective. As explained above, water levels had been expected to return to their normal safe levels in spring. However, due to wider weather conditions, this has not been the case. Highway users have a statutory right to pass and repass on the highway and therefore a longer term closure requires consultation to ensure legitimate access to nearby properties and agricultural land is not impinged. Planning the measures that are currently in place, which included a localised consultation (given the complaints received that the ford was temporarily closed), was undertaken this spring and the measures installed on 9 July 2024. Regrettably, I report that since these more robust measures were installed in July 2024, the warning signs have been stolen on one side of the ford (identified on 1 August 2024) and the local Highway team have made safe with temporary signs and ordered replacement more permanent signs. vi) As outlined earlier in this response, there have been lessons learned from this tragic incident. Safety inspections of all fords in Norfolk were undertaken immediately after the event. Subsequently, more detailed site by site safety reviews have also been undertaken, with measures such as improved signage installed at a number of locations, and even some further road closures where water levels were observed to be high.
Actions Already Undertaken & Proposed Actions
In summary, given the concerns raised in the Regulation 28 Report, together with the fluctuating and higher than usual water levels at Shotesham, the Council deems it is not safe to reopen Shotesham Ford at the current time and the option of permanent closure to ensure public safety is being evaluated by the Council as part of the feasibility assessment of longer-term options at Shotesham. Until the completion of this feasibility work, which is expected later this year, the ford will remain closed.
In addition, every other ford location across the county has had an initial safety assessment, resulting in the temporary closure of a further two fords, and more detailed site-specific assessments are ongoing and, if deemed necessary, signing to improve road safety is being identified and delivered.
I hope this provides further context and reassurance around the actions that the Council has already undertaken and the further steps planned to be undertaken to help improve highway safety at not just the ford at Shotesham but also the other fords across the county.
Thank you for your recent email and for the Regulation 28: Report to Prevent Future Deaths following the recent Inquest relating to Mr Howard.
Please can I start with passing on my condolences onto the family of Mr Howard regarding this tragic accident.
I would also like to take this opportunity to provide more detail with regard to the weather conditions and the Council’s response to the recent tragic events, as part of the response to the Regulation 28 Report.
Recently, the weather conditions in Norfolk have been extremely challenging – it having been a very wet autumn, winter and spring period, with abnormally high levels of rainfall. This has caused water levels across the county to remain high and the usual drop we experience in spring each year did not materialise. These conditions explain why the peak flows at Shotesham Ford have not reduced as they usually would each year, resulting in the road closure being extended.
As the local highway authority for Norfolk, the Council is responsible for 47 fords across 6,200 miles of highway network. Within days of the incident on 13 December 2023, all these fords had been inspected by the local Highways teams to ensure vehicle users would encounter safe conditions. This initial review identified other locations where roads were closed due to higher than usual water levels, and replacements for any missing and damaged warning signs were also arranged. As a result of these actions, two further fords on the Norfolk network (at West Acre and Caste Acre) were closed and remain closed to ensure public safety.
Continued…/
-2-
Alongside this initial inspection work, more detailed safety reviews of all 47 fords in the Norfolk network were commissioned. The characteristics of each ford across the Norfolk highway network are different and therefore each ford requires a detailed, individual assessment. As part of this review, Engineers are considering the points you have raised in the Regulation 28 Report and are investigating other opportunities to further improve safety at each ford location.
A specific safety review has also been undertaken by the Council at Shotesham Ford. This has involved an initial scoping of options for addressing the specific issues identified at Shotesham, which has developed into a full feasibility assessment of alternative treatments at this location.
In terms of the Matters of Concern identified in the Regulation 28 report, please note the following responses which follow the original numbering used:
i) As stated above, a detailed safety review of Shotesham Ford has been undertaken and a number of actions have already been completed, with further planned. In addition, regular inspections have been undertaken to assess the safety of reopening the ford on a weekly basis and the results of these, combined with the groundwater challenges explained above, have resulted in the ford remaining closed to traffic. Despite regular complaints from local residents and businesses, this remains the case. Given the longer than expected ongoing nature of this closure and evidence to suggest that the road closed warning signs and barriers were being ignored by motorists, the Council therefore recently improved the barriers, by way of installing immovable barriers, to ensure motorists could not continue ignoring the warning signs and barriers. ii) Your comments about lack of warning signs have been noted – please see the Actions Already Undertaken & Proposed Actions section below. iii) Your comments about lack of warning signs in advance of the ford have been noted – please see the Actions Already Undertaken & Proposed Actions section below. iv) Your comments about the slippery surface of the road have been noted – please see the Actions Already Undertaken & Proposed Actions section below.
Continued…/
-3-
v) The temporary road closed signs that have been used are the standard types of signs and barriers used across the country by highway authorities to implement closures such as these. They are usually effective. As explained above, water levels had been expected to return to their normal safe levels in spring. However, due to wider weather conditions, this has not been the case. Highway users have a statutory right to pass and repass on the highway and therefore a longer term closure requires consultation to ensure legitimate access to nearby properties and agricultural land is not impinged. Planning the measures that are currently in place, which included a localised consultation (given the complaints received that the ford was temporarily closed), was undertaken this spring and the measures installed on 9 July 2024. Regrettably, I report that since these more robust measures were installed in July 2024, the warning signs have been stolen on one side of the ford (identified on 1 August 2024) and the local Highway team have made safe with temporary signs and ordered replacement more permanent signs. vi) As outlined earlier in this response, there have been lessons learned from this tragic incident. Safety inspections of all fords in Norfolk were undertaken immediately after the event. Subsequently, more detailed site by site safety reviews have also been undertaken, with measures such as improved signage installed at a number of locations, and even some further road closures where water levels were observed to be high.
Actions Already Undertaken & Proposed Actions
In summary, given the concerns raised in the Regulation 28 Report, together with the fluctuating and higher than usual water levels at Shotesham, the Council deems it is not safe to reopen Shotesham Ford at the current time and the option of permanent closure to ensure public safety is being evaluated by the Council as part of the feasibility assessment of longer-term options at Shotesham. Until the completion of this feasibility work, which is expected later this year, the ford will remain closed.
In addition, every other ford location across the county has had an initial safety assessment, resulting in the temporary closure of a further two fords, and more detailed site-specific assessments are ongoing and, if deemed necessary, signing to improve road safety is being identified and delivered.
I hope this provides further context and reassurance around the actions that the Council has already undertaken and the further steps planned to be undertaken to help improve highway safety at not just the ford at Shotesham but also the other fords across the county.
Report Sections
Investigation and Inquest
On 21 December 2023, I commenced an investigation into the death of Barry John HOWARD aged 75. The investigation concluded at the end of the inquest on 16 July 2024. The medical cause of death was: 1a) Drowning 1b) 1c)
2) The conclusion of the inquest was: Accident contributed to by lack of visible warning signs of flooding and road closure.
2) The conclusion of the inquest was: Accident contributed to by lack of visible warning signs of flooding and road closure.
Circumstances of the Death
On 13 December 2023, Barry Howard was travelling along Mill Lane towards Shotesham Ford, an unbridged Ford, after 10pm. He was not familiar with the road which had previously been closed at the request of police due to flooding. The temporary signs indicating that the road was closed and impassable were not visible and the signs warning of the Ford and the depth of water, were beyond the flooded section of road, and on the balance of probabilities were not visible to Mr Howard before he entered the water. After entering the water his car was swept away into the river and he was found deceased in his car, which was almost completely submerged, at the Unbridged Ford, Mill Lane, Shotesham, Norfolk on 14 December 2023. The findings at Inquest were that:
i. Based on the evidence of the police and the fact that they found road closed signs on the side of the road and face down the morning after the collision, on the night of 13 December 2023, while Barry was travelling home after 10pm in the dark, on the balance of probabilities, there were no appropriate, visible signs or barriers, leading to the Ford at Shotesham, to tell him that the road was closed and impassable.
ii. Anyone unfamiliar with the road, or unaware of the flooding, would not therefore have known that the road was closed.
iii. There are no warning signs that the road is liable to flooding. I heard evidence that there are many Fords across the county, many of which may not significantly flood, but this Ford is prone to deep flooding. Without a sign warning that the Ford may also flood, it is unclear how anyone unfamiliar with that particular Ford would be aware of the level of risk.
iv. The road surface was completely submerged around 40m prior to the sign for a Ford. The sign for the Ford was beyond the area that was flooded so anyone unfamiliar with the road had no notice of the close proximity of the upcoming Ford before entering the area of flood water.
v. The road slopes in the direction towards the Ford, so initially when entering the water it would not have been deep. It is not clear at what point it became so deep it was impassable or if there was a sudden change in depth. There was evidence in from reports from the Parish Counsil to Norfolk County Council that the surface of the road was very slippery. It is not possible to say whether Barry would have been able to brake and reverse easily after he entered the water and approached the Ford.
vi. I did not accept evidence that there is a gauge depth clearly visible from both approaches when the road is heavily flooded. Based on the police report & photographs the day after the accident, the gauge showing the depth of the flooded area was some way from the unflooded area of road and the road did not have street lights, and the gauge was on a bend - which, on the balance of probabilities, means that it would not have been clearly visible to Barry as he drove towards the flood, especially at night, so he had no way of knowing how deep the water was until he was some way in to the water.
vii. NCC Highways Dept were aware of difficulties with the Ford and that the signs and barriers, indicating that the road was closed were often moved and therefore not visible. They were also aware that the hinged sign to the east was damaged and inoperable.
viii. In accordance with the Traffic Signs and Regulations and General Directions 2016, when it became apparent that the road closure requested by police in October 2023 would be long lasting, there should have been an appropriate review and more permanent measures put in place including permanent and less mobile road closure signs, sufficient early warnings and a diversion. This would have prevented the issue of Barry driving down a closed and impassable road with no warning signs.
ix. It was my finding therefore on the evidence, that on the night of 13 December 2023 there was a lack of visible warning signs, before entering the flood water, of the proximity of the upcoming Ford, the impassable flooding and road closure.
i. Based on the evidence of the police and the fact that they found road closed signs on the side of the road and face down the morning after the collision, on the night of 13 December 2023, while Barry was travelling home after 10pm in the dark, on the balance of probabilities, there were no appropriate, visible signs or barriers, leading to the Ford at Shotesham, to tell him that the road was closed and impassable.
ii. Anyone unfamiliar with the road, or unaware of the flooding, would not therefore have known that the road was closed.
iii. There are no warning signs that the road is liable to flooding. I heard evidence that there are many Fords across the county, many of which may not significantly flood, but this Ford is prone to deep flooding. Without a sign warning that the Ford may also flood, it is unclear how anyone unfamiliar with that particular Ford would be aware of the level of risk.
iv. The road surface was completely submerged around 40m prior to the sign for a Ford. The sign for the Ford was beyond the area that was flooded so anyone unfamiliar with the road had no notice of the close proximity of the upcoming Ford before entering the area of flood water.
v. The road slopes in the direction towards the Ford, so initially when entering the water it would not have been deep. It is not clear at what point it became so deep it was impassable or if there was a sudden change in depth. There was evidence in from reports from the Parish Counsil to Norfolk County Council that the surface of the road was very slippery. It is not possible to say whether Barry would have been able to brake and reverse easily after he entered the water and approached the Ford.
vi. I did not accept evidence that there is a gauge depth clearly visible from both approaches when the road is heavily flooded. Based on the police report & photographs the day after the accident, the gauge showing the depth of the flooded area was some way from the unflooded area of road and the road did not have street lights, and the gauge was on a bend - which, on the balance of probabilities, means that it would not have been clearly visible to Barry as he drove towards the flood, especially at night, so he had no way of knowing how deep the water was until he was some way in to the water.
vii. NCC Highways Dept were aware of difficulties with the Ford and that the signs and barriers, indicating that the road was closed were often moved and therefore not visible. They were also aware that the hinged sign to the east was damaged and inoperable.
viii. In accordance with the Traffic Signs and Regulations and General Directions 2016, when it became apparent that the road closure requested by police in October 2023 would be long lasting, there should have been an appropriate review and more permanent measures put in place including permanent and less mobile road closure signs, sufficient early warnings and a diversion. This would have prevented the issue of Barry driving down a closed and impassable road with no warning signs.
ix. It was my finding therefore on the evidence, that on the night of 13 December 2023 there was a lack of visible warning signs, before entering the flood water, of the proximity of the upcoming Ford, the impassable flooding and road closure.
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