Freddie Slater
PFD Report
Partially Responded
Ref: 2025-0204
288 days overdue · 1 response outstanding
Sent To
Response Status
Responses
1 of 2
56-Day Deadline
12 Jun 2025
288 days past deadline — 1 response outstanding
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
(1) The grass verge which separates the M20 and M25/ M20 slip road does not have erected upon it any physical barriers to prevent traffic crossing the verge from either of the 2 roads referred to and entering a parallel lane the opposite side of the verge.
(2) The evidence received from National Highways confirmed that under the present policy guidance, barriers would not normally be required as there are no features such as an incline on the slip road, bridge supports or trees requiring physical protection between the two merging roads of traffic travelling at similar speeds in the same direction.
(3) The facts of the present case illustrate that in the event of a loss of control of a vehicle travelling on either the M20 or in the slip road there is the potential for that vehicle, without any warning to drivers travelling at or about the same area in the coastbound direction, cross the grass verge to their side and enter their lane of travel. As both the material roads are subject to the same national speed limit of 70MPH, the risk of a high speed collision and fatality arises.
(2) The evidence received from National Highways confirmed that under the present policy guidance, barriers would not normally be required as there are no features such as an incline on the slip road, bridge supports or trees requiring physical protection between the two merging roads of traffic travelling at similar speeds in the same direction.
(3) The facts of the present case illustrate that in the event of a loss of control of a vehicle travelling on either the M20 or in the slip road there is the potential for that vehicle, without any warning to drivers travelling at or about the same area in the coastbound direction, cross the grass verge to their side and enter their lane of travel. As both the material roads are subject to the same national speed limit of 70MPH, the risk of a high speed collision and fatality arises.
Responses
National Highways states that no further action is planned as their existing barrier provision meets current requirements and they do not intend to update policy regarding barriers at merges as a direct result of this incident, arguing that circumstances are uncommon and barriers themselves pose risks.
AI summary
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REGULATION 28 RESPONSE TO PREVENT FUTURE DEATHS
THIS RESPONSE IS BEING SENT TO:
The Assistant Coroner for North West Kent, His Honour Alan James Blunsdon of Oakwood House, Oakwood Park, Maidstone, Kent, ME16 8AE.
National Highways
I am , Head of the Vehicle Restraint Systems Team at National Highways Limited of Viables 3, Jays Close, Basingstoke RG22 4BS.
CORONER’S MATTERS OF CONCERN
The MATTERS OF CONCERN are as follows: –
(1) The grass verge which separates the M20 and M25/ M20 slip road does not have erected upon it any physical barriers to prevent traffic crossing the verge from either of the 2 roads referred to and entering a parallel lane the opposite side of the verge.
(2) The evidence received from National Highways confirmed that under the present policy guidance, barriers would not normally be required as there are no features such as an incline on the slip road, bridge supports or trees requiring physical protection between the two merging roads of traffic travelling at similar speeds in the same direction.
(3) The facts of the present case illustrate that in the event of a loss of control of a vehicle travelling on either the M20 or in the slip road there is the potential for that vehicle, without any warning to drivers travelling at or about the same area in the coastbound direction, cross the grass verge to their side and enter their lane of travel. As both the material roads are subject to the same national speed limit of 70MPH, the risk of a high speed collision and fatality arises.
DETAILS OF ACTION TAKEN
This note has been prepared in response to a Regulation 28 report, received from the North West Kent Coroner’s Service by National Highways in response to a fatal road traffic collision on 16 October 2024. The incident occurred in the proximity of the link road connecting the M25 junction 3 southbound carriageway to the M20 eastbound carriageway.
Nature of the current barrier provision at the material location
The current barrier provision at the incident location is unchanged from the time of the incident; prior to the Button Street overbridge, there is a barrier in the nearside verge of the entry slip road to the M20 from the Farningham roundabout (i.e. located between the Farningham roundabout entry slip road and the M25 entry slip road).
Initially, this barrier takes the form of two single sided lengths of Tensioned Corrugated Beam (TCB) barrier. These have been installed to reduce the risk of injury to a road user from impacting the trees between the barriers and to reduce the risk of injury posed by the difference in height between the two carriageways.
When there are no trees between the two slip roads, and the difference in height between the two slip roads presents no/little risk of injury, the barrier transitions into a double sided TCB barrier to close the gap which would otherwise have been left between the two lengths of single sided barrier, and the next length of barrier.
Shortly, prior to the bridge pier supporting Button Street, the double sided TCB bifurcates (forming a Y-shape) into two single sided lengths of TCB.
These lengths of single sided TCB are then transitioned into two lengths of single sided Open Box Beam (OBB) barrier which are then aligned around each side of the bridge pier. This is to reduce the risk of injury to a road user from impacting the bridge pier.
Each length of the single sided OBB is then terminated after the bridge pier with an end terminal.
Additional lengths of barrier are not provided after the bridge pier at the material location as there are no further hazards after the bridge pier; the height difference between the two carriageways is negligible, and there are no physical hazards present within the grass strip, such as a bridge pier, tree, lighting column or sign post.
A review of the current barrier provision at this locality with reference to current requirements
National Highways’ current requirements for road restraint systems (including barriers) are contained within the document CD 377 – Requirements for Road Restraint Systems. These were first published in March 2020, with the latest revision (revision 4) published in January 2021 (https://www.standardsforhighways.co.uk/search/1fe48581-82ba-4b6f-95a1-ee93309bd1b5).
As identified in paragraph 5(2) of the Regulation 28 report, current design requirements would not require a barrier to be erected within the grassed medium between the M25 link and the M20 link.
An assessment using the National Highways’ Road Restraint Risk Assessment Process (RRRAP) has been undertaken, and that has confirmed the merge arrangements do not constitute a hazard that would require protection by a barrier as traffic travelling down the M25 entry slip road and the main carriageway of the M20 are travelling in the same direction.
The RRRAP identified that current design requirements would require a full height barrier to extend
7.5 metres beyond the Button Street bridge pier (as the bridge pier is identified as the hazard requiring protection).
The existing length of barrier at full height beyond the Button Street bridge pier is approximately
16.8 metres in the nearside verge of the M20, and approximately 9.6 metres in the offside verge of the M25 entry slip road. Hence both lengths of barrier beyond the Button Street bridge pier exceed the minimum requirement of National Highways’ current design requirements.
It is also confirmed that the containment level of the barrier in front of the Button Street bridge pier is compliant with current requirements. If it had been identified that a greater level of containment was required, this would have required longer lengths of barrier after the bridge pier (in order to accommodate the containment level of the system). Again, this is not the case and both lengths of barrier beyond the Button Street bridge pier exceed the minimum requirement of National Highways’ current design requirements.
Barriers present a level of injury risk to road users and are therefore only installed in locations where a hazard cannot be removed, relocated, or made frangible, and the level of injury risk from the barrier is lower than the level of injury risk posed by the hazard located behind the barrier.
Barriers also require installation, inspection, maintenance, repair and removal, all of which present a level of risk to our roadworkers, but also to the travelling public whilst temporary lane closures and speed restrictions may be in place to undertake such works.
A review of similar incidents on the National Highways Strategic Road Network (SRN).
A review of fatal incidents on the whole of the SRN in England has been undertaken to identify any other incidents where a vehicle has crossed over a strip at the end of the nosing at an on-slip road and impacted a vehicle on the adjacent slip road. This search has been limited to fatal incidents as there is typically insufficient detail available for serious, slight and damage-only incidents in order to make a detailed assessment of the circumstances of the incident.
The review of fatal incidents has identified a single event between 2014 and 2022 on the SRN, however in that incident, the fatality occurred to a member of the public who had left their vehicle due to a previous minor incident on the main carriageway.
As a result, it is concluded that such incidents are uncommon on the SRN.
A review of incidents at this locality
A review of incidents in this locality has identified a single unrelated incident within the five year period from 1 October 2019 to 30 September 2024. The incident recorded was a ‘slight’ personal injury and from the description provided by the police, the road infrastruture (or lack of) was not a factor in this incident, and occurred in advance of the link road merge.
TIMETABLE FOR PLANNED ACTION
No further action is planned.
SAFETY OF ROAD USERS
The safety of our road users is an imperative for our business, and safety is a core value of our organisation. We are working hard to make our entire network safer.
We consider that the action we have taken to date has confirmed that the length of barrier after the Button Street bridge piers meets current requirements.
We have also identified that the circumstances witnessed in this incident are uncommon elsewhere on the SRN.
Furthermore, we have also identified a single unrelated incident (of a slight personal injury) at this location (albeit in advance of the link road merge) within the five year period from 1 October 2019 to 30 September 2024.
We have also highlighted that barriers present a level of injury risk to road users and are therefore only installed in locations where a hazard cannot be removed, relocated, or made frangible, and the level of injury risk from the barrier is lower than the level of injury risk posed by the hazard located behind the barrier.
All improvements to the SRN are required to be progressed in a considered and controlled fashion so that the consequences of changes to the SRN are fully understood and any linked safety risks are eliminated or reduced as far as possible. Furthermore, works to the SRN are required to demonstrate value for money, in accordance with the Highways England: Licence (April 2015), and our duty to manage public funds.
As a result, it is not our intention to take any further action at this location, nor is it our intention to update the requirements for barriers at merges within CD 377 as a direct result of this incident.
7 Signed and dated
, 11th June 2025
THIS RESPONSE IS BEING SENT TO:
The Assistant Coroner for North West Kent, His Honour Alan James Blunsdon of Oakwood House, Oakwood Park, Maidstone, Kent, ME16 8AE.
National Highways
I am , Head of the Vehicle Restraint Systems Team at National Highways Limited of Viables 3, Jays Close, Basingstoke RG22 4BS.
CORONER’S MATTERS OF CONCERN
The MATTERS OF CONCERN are as follows: –
(1) The grass verge which separates the M20 and M25/ M20 slip road does not have erected upon it any physical barriers to prevent traffic crossing the verge from either of the 2 roads referred to and entering a parallel lane the opposite side of the verge.
(2) The evidence received from National Highways confirmed that under the present policy guidance, barriers would not normally be required as there are no features such as an incline on the slip road, bridge supports or trees requiring physical protection between the two merging roads of traffic travelling at similar speeds in the same direction.
(3) The facts of the present case illustrate that in the event of a loss of control of a vehicle travelling on either the M20 or in the slip road there is the potential for that vehicle, without any warning to drivers travelling at or about the same area in the coastbound direction, cross the grass verge to their side and enter their lane of travel. As both the material roads are subject to the same national speed limit of 70MPH, the risk of a high speed collision and fatality arises.
DETAILS OF ACTION TAKEN
This note has been prepared in response to a Regulation 28 report, received from the North West Kent Coroner’s Service by National Highways in response to a fatal road traffic collision on 16 October 2024. The incident occurred in the proximity of the link road connecting the M25 junction 3 southbound carriageway to the M20 eastbound carriageway.
Nature of the current barrier provision at the material location
The current barrier provision at the incident location is unchanged from the time of the incident; prior to the Button Street overbridge, there is a barrier in the nearside verge of the entry slip road to the M20 from the Farningham roundabout (i.e. located between the Farningham roundabout entry slip road and the M25 entry slip road).
Initially, this barrier takes the form of two single sided lengths of Tensioned Corrugated Beam (TCB) barrier. These have been installed to reduce the risk of injury to a road user from impacting the trees between the barriers and to reduce the risk of injury posed by the difference in height between the two carriageways.
When there are no trees between the two slip roads, and the difference in height between the two slip roads presents no/little risk of injury, the barrier transitions into a double sided TCB barrier to close the gap which would otherwise have been left between the two lengths of single sided barrier, and the next length of barrier.
Shortly, prior to the bridge pier supporting Button Street, the double sided TCB bifurcates (forming a Y-shape) into two single sided lengths of TCB.
These lengths of single sided TCB are then transitioned into two lengths of single sided Open Box Beam (OBB) barrier which are then aligned around each side of the bridge pier. This is to reduce the risk of injury to a road user from impacting the bridge pier.
Each length of the single sided OBB is then terminated after the bridge pier with an end terminal.
Additional lengths of barrier are not provided after the bridge pier at the material location as there are no further hazards after the bridge pier; the height difference between the two carriageways is negligible, and there are no physical hazards present within the grass strip, such as a bridge pier, tree, lighting column or sign post.
A review of the current barrier provision at this locality with reference to current requirements
National Highways’ current requirements for road restraint systems (including barriers) are contained within the document CD 377 – Requirements for Road Restraint Systems. These were first published in March 2020, with the latest revision (revision 4) published in January 2021 (https://www.standardsforhighways.co.uk/search/1fe48581-82ba-4b6f-95a1-ee93309bd1b5).
As identified in paragraph 5(2) of the Regulation 28 report, current design requirements would not require a barrier to be erected within the grassed medium between the M25 link and the M20 link.
An assessment using the National Highways’ Road Restraint Risk Assessment Process (RRRAP) has been undertaken, and that has confirmed the merge arrangements do not constitute a hazard that would require protection by a barrier as traffic travelling down the M25 entry slip road and the main carriageway of the M20 are travelling in the same direction.
The RRRAP identified that current design requirements would require a full height barrier to extend
7.5 metres beyond the Button Street bridge pier (as the bridge pier is identified as the hazard requiring protection).
The existing length of barrier at full height beyond the Button Street bridge pier is approximately
16.8 metres in the nearside verge of the M20, and approximately 9.6 metres in the offside verge of the M25 entry slip road. Hence both lengths of barrier beyond the Button Street bridge pier exceed the minimum requirement of National Highways’ current design requirements.
It is also confirmed that the containment level of the barrier in front of the Button Street bridge pier is compliant with current requirements. If it had been identified that a greater level of containment was required, this would have required longer lengths of barrier after the bridge pier (in order to accommodate the containment level of the system). Again, this is not the case and both lengths of barrier beyond the Button Street bridge pier exceed the minimum requirement of National Highways’ current design requirements.
Barriers present a level of injury risk to road users and are therefore only installed in locations where a hazard cannot be removed, relocated, or made frangible, and the level of injury risk from the barrier is lower than the level of injury risk posed by the hazard located behind the barrier.
Barriers also require installation, inspection, maintenance, repair and removal, all of which present a level of risk to our roadworkers, but also to the travelling public whilst temporary lane closures and speed restrictions may be in place to undertake such works.
A review of similar incidents on the National Highways Strategic Road Network (SRN).
A review of fatal incidents on the whole of the SRN in England has been undertaken to identify any other incidents where a vehicle has crossed over a strip at the end of the nosing at an on-slip road and impacted a vehicle on the adjacent slip road. This search has been limited to fatal incidents as there is typically insufficient detail available for serious, slight and damage-only incidents in order to make a detailed assessment of the circumstances of the incident.
The review of fatal incidents has identified a single event between 2014 and 2022 on the SRN, however in that incident, the fatality occurred to a member of the public who had left their vehicle due to a previous minor incident on the main carriageway.
As a result, it is concluded that such incidents are uncommon on the SRN.
A review of incidents at this locality
A review of incidents in this locality has identified a single unrelated incident within the five year period from 1 October 2019 to 30 September 2024. The incident recorded was a ‘slight’ personal injury and from the description provided by the police, the road infrastruture (or lack of) was not a factor in this incident, and occurred in advance of the link road merge.
TIMETABLE FOR PLANNED ACTION
No further action is planned.
SAFETY OF ROAD USERS
The safety of our road users is an imperative for our business, and safety is a core value of our organisation. We are working hard to make our entire network safer.
We consider that the action we have taken to date has confirmed that the length of barrier after the Button Street bridge piers meets current requirements.
We have also identified that the circumstances witnessed in this incident are uncommon elsewhere on the SRN.
Furthermore, we have also identified a single unrelated incident (of a slight personal injury) at this location (albeit in advance of the link road merge) within the five year period from 1 October 2019 to 30 September 2024.
We have also highlighted that barriers present a level of injury risk to road users and are therefore only installed in locations where a hazard cannot be removed, relocated, or made frangible, and the level of injury risk from the barrier is lower than the level of injury risk posed by the hazard located behind the barrier.
All improvements to the SRN are required to be progressed in a considered and controlled fashion so that the consequences of changes to the SRN are fully understood and any linked safety risks are eliminated or reduced as far as possible. Furthermore, works to the SRN are required to demonstrate value for money, in accordance with the Highways England: Licence (April 2015), and our duty to manage public funds.
As a result, it is not our intention to take any further action at this location, nor is it our intention to update the requirements for barriers at merges within CD 377 as a direct result of this incident.
7 Signed and dated
, 11th June 2025
Report Sections
Investigation and Inquest
On 18 October 2024 I commenced an investigation into the death of Freddie SLATER. The investigation concluded at the end of the inquest on the 9th April 2025. The conclusion of the inquest was Road Traffic Collision The medical cause of death was recorded as: 1a Hypovolemic Shock with Multiorgan Failure 1b Massive Internal Haemorrhage from Visceral Injuries 1c Polytrauma from Road Traffic Collisions
II Severe Left Ventricular Hypertrophy with Congestive Cardiac Failure
II Severe Left Ventricular Hypertrophy with Congestive Cardiac Failure
Circumstances of the Death
At about 06.19 hours on Wednesday 16th October 2024,the Deceased was driving his Smart car to work travelling coastbound on the M20 motorway in Kent. He was unaccompanied and travelling in lane 2 of the 3 lane carriageway. He was following a Vauxhall Mokka car (Mokka) also travelling in lane 2. The vehicles were at or about Junction 1 at the Swanley interchange. The Deceased was travelling slightly faster than the Mokka vehicle and upon catching up with the Mokka. There was a collision between the front and front nearside of the Smart vehicle driven by the Deceased and the rear and rear offside of the Mokka. The impact caused both vehicles to rotate at speed. The Mokka was brought under control and stopped. The Smart car driven by the Deceased continued over the grass verge which separates the main carriageway of the M20 from the M25/M20, 2 carriageway slip road. The slip road carries traffic joining the M20 southbound from the M25 and is subject to the national speed limit of 70MPH.
On crossing the grass verge the Smart car driven by the Deceased entered the slip road and was in collision with a BMW vehicle travelling in lane 2 of the slip road intending to join the M20 Motorway coastbound. The Smart car then travelled further in the eastbound direction re-entering the M20 in lane 1, stopping partly in lane 1 and the hard shoulder. As a result of injuries sustained in the collisions Mr Slater sadly died at the scene.
On crossing the grass verge the Smart car driven by the Deceased entered the slip road and was in collision with a BMW vehicle travelling in lane 2 of the slip road intending to join the M20 Motorway coastbound. The Smart car then travelled further in the eastbound direction re-entering the M20 in lane 1, stopping partly in lane 1 and the hard shoulder. As a result of injuries sustained in the collisions Mr Slater sadly died at the scene.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.