John Bass
PFD Report
All Responded
Ref: 2024-0251
All 1 response received
· Deadline: 3 Jul 2024
Sent To
Response Status
Responses
1 of 1
56-Day Deadline
3 Jul 2024
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
When the footpath was inspected in November 2022, just weeks before the accident, the highway inspector did not consider the narrowing of pathway as a safety concern and or met an intervention level which required action. It is noted in the policy that there is reference to trees and vegetation, but no clear guidance in terms of vegetation which encroaches on pavements. I am concerned that there is a risk to future pavement users if clear guidance is not provided to inspectors to identify safety concerns regarding vegetation growth on footpaths. The Highways current inspection of the pavement is only yearly albeit in evidence given at inquest by the family, this road is used frequently by cyclists next to a busy road. I am therefore concerned that the frequency of the inspections need to be reviewed.
Responses
Surrey County Council disputes the need for changes to its inspection guidance for encroaching vegetation, stating pavements are for pedestrians and their policy reflects this. They also maintain that the footway's Category 4 classification (annual inspection) is correct and does not require review based on cyclist use. They have provided further reminders to inspectors on considering risk from debris.
AI summary
View full response
Dear Assistant Coroner Hayes,
Further to the issuing of a Prevention of Future Deaths (PFD) Report on 8 May 2024, please find below Surrey County Council’s (SCC) response.
At the outset, Surrey County Council wishes to pass on our condolences to the Bass family following this tragic incident.
We note that the Inquest took place in the Spring of 2024 and confirm that SCC provided a witness statement to the Assistant Corner detailing the Inspection history of the site, however SCC were not classed as an “interested party” at the inquest and so were not invited to attend the inquest to give evidence.
SCC understands that the two matters of concern which the Assistant Coroner would like SCC to consider are set out within Section 5 of the PFD Report:
1. There is a risk to future pavement users if clear guidance is not provided to inspectors to identify safety concerns in terms of vegetation which encroaches on pavements
2. The current inspection regime whereby the pavement is inspected yearly needs to be reviewed based on the evidence provided at the inquest by the family of Mr Bass that the pavement is used frequently by cyclists
Risk to future pavement users
Background – Highway Authority responsibilities for pavements
SCC understands that at the time of the accident Mr Bass was cycling on the pavement of the A217 Brighton Road Tadworth in a southbound direction north of Vicarage Close.
Krestina Hayes HM Coroner’s Court Station Approach Woking Surrey GU22 7AP Woodhatch Place 11 Cockshot Hill Woodhatch Reigate RH2 8EF
3rd July 2024
2 Section 72 of the Highways Act 1835 and Rule 64 of the Highway Code state that pavements are for the use of pedestrians not cyclists and accordingly, SCC’s Highway Safety Inspection policy only considers the safety of pavements with regards to pedestrians and not cyclists.
Further to the receipt of the PFD report, SCC requested and received from the Coroners Service a copy of the Forensic Collision Report prepared for the Inquest and photos taken for the report. The photos show the mud/grass, twigs and acorns described in Section 4 of the PFD report. Highway case law from Rollinnson -v- Dudley Metropolitan Borough Council (judiciary.uk) found that that the duty upon Highway Authorities under s.41(1) of the Highways Act 1981 to maintain did not extend to a duty to remove surface-lying material, obstructions or spillages, whether or not they resulted in danger. The Court of Appeal upheld the Judge’s decision. The Judge in the Rollinson vs Dudley Metropolitan Borough Council case described the conclusion as inescapable as the law had been established and further stated in his judgement that “The duty imposed by s.41 is a duty to maintain the fabric of the road, including its substructure such as its drains. The removal of surface-lying material which creates a danger is not within the section.” National Guidance on types of surveys
Well Managed Highway Infrastructure – A code of practice, provides guidance to local authorities on developing a risk-based approach to maintenance of highway infrastructure. The Code identifies a number of different types of inspections and surveys that Highway Authorities may carry out which are summarised below;
1. Safety inspections are designed to identify all defects likely to create danger or serious inconvenience to users of the network or the wider community. The risk of danger is assessed on site and the defect identified with an appropriate priority response
2. Service inspections mainly comprise detailed inspections tailored to the requirements of particular highway assets and elements to ensure that they meet requirements for serviceability. The scale and scope of these inspections will be determined by the authority’s approach to asset management
3. Condition surveys are primarily intended to identify deficiencies which, if untreated, are likely to adversely affect long term performance, serviceability and safety.
4. Reports from members of the public provide a further source of information on the condition of all aspects of the highway network.
Safety Inspections carried out by Highway Safety Inspectors are regular focused inspections where any immediate risks are identified and rectified within a limited time period of either 2 hours, 5 working days or 20 working days depending on the Inspectors’ assessment of severity and risk which takes account of considerations such as the location and volume of use. It should be noted that the time periods quoted are for SCC, other authorities may use different time periods for rectification of defects. This service ensures that our Highway Safety Inspection resources are deployed to the highest risk locations and situations, however as shown above, other methods are employed to deal with less immediate risks with longer timescales for resolutions.
Issues with regards to debris on the carriageway would generally be dealt with under the fourth item above, in response to reports from members of the public. The resolution to this type of
3 enquiry could either be that SCC will arrange clearance of the debris or they may liaise with the local borough council who provide street cleansing activities.
Guidance to Inspectors
As stated in our witness statement, the pavement on the A217 where the incident occurred, had been inspected by foot on 22nd November 2022, just prior to the accident and no safety defects meeting our intervention level were identified.
Within SCC’s Highway Safety Inspection standards and procedures policy, there is a “Trees and Vegetation” defect category which relates to “Fallen debris causing obstruction to passage or vision”. The inspection carried out on 22/11/22 did not identify any defect under this category because the Highway Safety Inspection Team interpret the policy reference to ‘fallen debris’ as being an instance of an individual substantial tree, branch or hedge that has recently fallen and causing a definitive obstruction.
Instances such as the situation on the pavements of the A217 in November/December 2022 where there has been a narrowing of the footway due to seasonal vegetation growth/detritus, are considered as street cleansing or general maintenance issues rather than as “safety defects” which require an immediate response. These situations are generally identified through reports from the public.
Where members of the public report issues to us, a Highways Customer Officer will attend and may report issues such as this as “maintenance issues” which are passed on to our maintenance team to carry out routine maintenance. This location was reported by a member of the public in January 2023 and following a review by the Highways Customer Officer, work was requested to remove debris and cut any encroaching vegetation overhanging the footway. This is the work which was carried out in January 2023, as mentioned during the Inquest.
SCC believes that our current inspection processes are in line with the legal requirements and with the risk-based approach encouraged by national guidance. Following the receipt of the Prevention of Future Deaths report however, we have reminded our inspectors to consider the risk that narrowing/obstruction situations may pose, particularly to vulnerable users of pavements, such as wheelchair users or those with push chairs etc and to request maintenance works where needed, or to raise as an immediate risk for a quicker response where they consider such a risk to be very serious or life threatening.
The current inspection regime
The footway Hierarchy, which determines the inspection frequency, is established through a data led exercise and footways (pavements) are assessed according to the Council’s Hierarchy Definition Policy which can be found here.
As outlined in the policy document the datasets used to determine hierarchy include shops, businesses, transport hubs, schools, industrial areas and other community facilities. Once the data exercise has been undertaken, each area is reviewed by local engineers to sense
4 check the outcomes of the data exercise and to recommend any amendments based on their local knowledge.
Footways have four levels of hierarchy. The highest is a primary walking route (Category 1) which is inspected monthly, then a secondary walking route (Category 2) which is inspected every three months, link footways (Category 3) which are inspected every 6 months and finally local access footways (Category 4) which are inspected annually.
The footway running along Brighton Road has been assigned as a Category 4 (link footway) in our policy because it does not meet any of the criteria for a higher category. For this footway to have its hierarchy increased it would have to provide access to 5+ shops in the local vicinity, which it does not, and there are no other drivers to warrant it being recategorised as a Category 3 footway; namely – Linking local access footways, small retail shopping outlets typically +5 shops, large schools and Industrial outlets, +500 pupils or equivalent pedestrian movements.
SCC considers the footway hierarchy for this section of the A217 Brighton Road to have been correctly assessed as Category 4 which is subject to an annual walked inspection, however we will respond to any reports of issues from the public at any point during the year.
SCC hopes that the above demonstrates that SCC is managing our pavements in line with our legal responsibilities and national guidance. As described, we have mechanisms in place to respond to issues with debris on pavements outside of our Highway Safety Inspection process, and we have given due consideration to the recommendations made by providing further reminders to our Inspection Team around consideration of risk to vulnerable users posed by debris on pavements.
Further to the issuing of a Prevention of Future Deaths (PFD) Report on 8 May 2024, please find below Surrey County Council’s (SCC) response.
At the outset, Surrey County Council wishes to pass on our condolences to the Bass family following this tragic incident.
We note that the Inquest took place in the Spring of 2024 and confirm that SCC provided a witness statement to the Assistant Corner detailing the Inspection history of the site, however SCC were not classed as an “interested party” at the inquest and so were not invited to attend the inquest to give evidence.
SCC understands that the two matters of concern which the Assistant Coroner would like SCC to consider are set out within Section 5 of the PFD Report:
1. There is a risk to future pavement users if clear guidance is not provided to inspectors to identify safety concerns in terms of vegetation which encroaches on pavements
2. The current inspection regime whereby the pavement is inspected yearly needs to be reviewed based on the evidence provided at the inquest by the family of Mr Bass that the pavement is used frequently by cyclists
Risk to future pavement users
Background – Highway Authority responsibilities for pavements
SCC understands that at the time of the accident Mr Bass was cycling on the pavement of the A217 Brighton Road Tadworth in a southbound direction north of Vicarage Close.
Krestina Hayes HM Coroner’s Court Station Approach Woking Surrey GU22 7AP Woodhatch Place 11 Cockshot Hill Woodhatch Reigate RH2 8EF
3rd July 2024
2 Section 72 of the Highways Act 1835 and Rule 64 of the Highway Code state that pavements are for the use of pedestrians not cyclists and accordingly, SCC’s Highway Safety Inspection policy only considers the safety of pavements with regards to pedestrians and not cyclists.
Further to the receipt of the PFD report, SCC requested and received from the Coroners Service a copy of the Forensic Collision Report prepared for the Inquest and photos taken for the report. The photos show the mud/grass, twigs and acorns described in Section 4 of the PFD report. Highway case law from Rollinnson -v- Dudley Metropolitan Borough Council (judiciary.uk) found that that the duty upon Highway Authorities under s.41(1) of the Highways Act 1981 to maintain did not extend to a duty to remove surface-lying material, obstructions or spillages, whether or not they resulted in danger. The Court of Appeal upheld the Judge’s decision. The Judge in the Rollinson vs Dudley Metropolitan Borough Council case described the conclusion as inescapable as the law had been established and further stated in his judgement that “The duty imposed by s.41 is a duty to maintain the fabric of the road, including its substructure such as its drains. The removal of surface-lying material which creates a danger is not within the section.” National Guidance on types of surveys
Well Managed Highway Infrastructure – A code of practice, provides guidance to local authorities on developing a risk-based approach to maintenance of highway infrastructure. The Code identifies a number of different types of inspections and surveys that Highway Authorities may carry out which are summarised below;
1. Safety inspections are designed to identify all defects likely to create danger or serious inconvenience to users of the network or the wider community. The risk of danger is assessed on site and the defect identified with an appropriate priority response
2. Service inspections mainly comprise detailed inspections tailored to the requirements of particular highway assets and elements to ensure that they meet requirements for serviceability. The scale and scope of these inspections will be determined by the authority’s approach to asset management
3. Condition surveys are primarily intended to identify deficiencies which, if untreated, are likely to adversely affect long term performance, serviceability and safety.
4. Reports from members of the public provide a further source of information on the condition of all aspects of the highway network.
Safety Inspections carried out by Highway Safety Inspectors are regular focused inspections where any immediate risks are identified and rectified within a limited time period of either 2 hours, 5 working days or 20 working days depending on the Inspectors’ assessment of severity and risk which takes account of considerations such as the location and volume of use. It should be noted that the time periods quoted are for SCC, other authorities may use different time periods for rectification of defects. This service ensures that our Highway Safety Inspection resources are deployed to the highest risk locations and situations, however as shown above, other methods are employed to deal with less immediate risks with longer timescales for resolutions.
Issues with regards to debris on the carriageway would generally be dealt with under the fourth item above, in response to reports from members of the public. The resolution to this type of
3 enquiry could either be that SCC will arrange clearance of the debris or they may liaise with the local borough council who provide street cleansing activities.
Guidance to Inspectors
As stated in our witness statement, the pavement on the A217 where the incident occurred, had been inspected by foot on 22nd November 2022, just prior to the accident and no safety defects meeting our intervention level were identified.
Within SCC’s Highway Safety Inspection standards and procedures policy, there is a “Trees and Vegetation” defect category which relates to “Fallen debris causing obstruction to passage or vision”. The inspection carried out on 22/11/22 did not identify any defect under this category because the Highway Safety Inspection Team interpret the policy reference to ‘fallen debris’ as being an instance of an individual substantial tree, branch or hedge that has recently fallen and causing a definitive obstruction.
Instances such as the situation on the pavements of the A217 in November/December 2022 where there has been a narrowing of the footway due to seasonal vegetation growth/detritus, are considered as street cleansing or general maintenance issues rather than as “safety defects” which require an immediate response. These situations are generally identified through reports from the public.
Where members of the public report issues to us, a Highways Customer Officer will attend and may report issues such as this as “maintenance issues” which are passed on to our maintenance team to carry out routine maintenance. This location was reported by a member of the public in January 2023 and following a review by the Highways Customer Officer, work was requested to remove debris and cut any encroaching vegetation overhanging the footway. This is the work which was carried out in January 2023, as mentioned during the Inquest.
SCC believes that our current inspection processes are in line with the legal requirements and with the risk-based approach encouraged by national guidance. Following the receipt of the Prevention of Future Deaths report however, we have reminded our inspectors to consider the risk that narrowing/obstruction situations may pose, particularly to vulnerable users of pavements, such as wheelchair users or those with push chairs etc and to request maintenance works where needed, or to raise as an immediate risk for a quicker response where they consider such a risk to be very serious or life threatening.
The current inspection regime
The footway Hierarchy, which determines the inspection frequency, is established through a data led exercise and footways (pavements) are assessed according to the Council’s Hierarchy Definition Policy which can be found here.
As outlined in the policy document the datasets used to determine hierarchy include shops, businesses, transport hubs, schools, industrial areas and other community facilities. Once the data exercise has been undertaken, each area is reviewed by local engineers to sense
4 check the outcomes of the data exercise and to recommend any amendments based on their local knowledge.
Footways have four levels of hierarchy. The highest is a primary walking route (Category 1) which is inspected monthly, then a secondary walking route (Category 2) which is inspected every three months, link footways (Category 3) which are inspected every 6 months and finally local access footways (Category 4) which are inspected annually.
The footway running along Brighton Road has been assigned as a Category 4 (link footway) in our policy because it does not meet any of the criteria for a higher category. For this footway to have its hierarchy increased it would have to provide access to 5+ shops in the local vicinity, which it does not, and there are no other drivers to warrant it being recategorised as a Category 3 footway; namely – Linking local access footways, small retail shopping outlets typically +5 shops, large schools and Industrial outlets, +500 pupils or equivalent pedestrian movements.
SCC considers the footway hierarchy for this section of the A217 Brighton Road to have been correctly assessed as Category 4 which is subject to an annual walked inspection, however we will respond to any reports of issues from the public at any point during the year.
SCC hopes that the above demonstrates that SCC is managing our pavements in line with our legal responsibilities and national guidance. As described, we have mechanisms in place to respond to issues with debris on pavements outside of our Highway Safety Inspection process, and we have given due consideration to the recommendations made by providing further reminders to our Inspection Team around consideration of risk to vulnerable users posed by debris on pavements.
Report Sections
Investigation and Inquest
On 13 December 2022 I commenced an investigation into the death of John William BASS aged 80. The investigation concluded at the end of the inquest on 30 April 2024. The conclusion of the inquest was that: Mr John William Bass died of head and chest injuries, at the age of 80 years of age, on A217 Brighton Road Tadworth, following a road traffic collision with a vehicle whilst he was riding his bicycle on 6th December 2022.
Circumstances of the Death
On 6th December 2022 Mr Bass, a fit and active cyclist fell from his bicycle on 6th December 2022 from the pavement on A217 Brighton Road, Tadworth, Southbound into approaching vehicle resulting in head and chest injuries from which he died. My conclusion was Road Traffic Collision. Surrey County Council is the highway authority responsible for the maintenance of this part of the public highway (the “Highway Authority”). A subsequent police investigation identified the footpath from which Mr Bass fell measured approximately 1.4 meters in width. However, due to the encroachment of mud/grass, twigs and acorns over the pavement space where Mr Bass was able to cycle it only measured 0.6 meters wide. The Highways Authority confirmed in witness evidence, which was accepted under rule 23, that the A217 Brighton Road, Tadworth is subject to a yearly inspection. At the inquest the family advised that the footpath is used regularly by cyclists to avoid the vehicles on the busy road, where the speed limit is up to 40mph. This stretch of highway was said to have last been inspected on 14th November 2022 by car. A second scheduled inspection took place by foot on 22nd November 2022, just prior to the accident on 6th December 2022. The inspections did not identify any safety defects meeting the intervention level set out in Surrey County Council's policy. I am informed by the family shortly after the accident the pavement was cleared.
Similar PFD Reports
Reports sharing organisations, categories, or themes with this PFD
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.