Dear Coroner Henderson, Further to the issuing of a Prevention of Future Deaths Report on 10 October 2022, please find below Surrey County Council’s (SCC) response. At the outset, Surrey County Council once again wishes to pass on our condolences to the Stringer family following this tragic incident. The Inquest concluded on 30 November 2021 and a conclusion of ‘Accident’ was reached. Following the hearing, written submissions were provided on the issue of whether a PFD Report or a Letter of Concern should be issued. SCC made submissions that neither would be appropriate in the circumstances but understands that the Coroner reached the decision that a Letter of Concern would be written. However, notwithstanding this decision a PFD Report was issued on 10 October 2022. It is to this Report that SCC now responds. SCC understands that the two issues which the Coroner would like addressed are set out within Section 5 of the PFD Report:
1. A lack of reflection by SCC following Mr Stringer’s death.
2. A lack of action and/or change to the management of potholes by SCC following Mr Stringer’s death. Lack of reflection SCC indicated to the Coroner that a witness in senior management was available to give evidence on reflection and learning following Mr Stringer’s death, once the Coroner had raised this as a concern. Prior to this, the Coroner had not requested such evidence and it was not incumbent on SCC to proffer such evidence in the absence of a direction to do so or indication that it was a concern that needed to be addressed. Once the Coroner had indicated her 1

concern in this regard, evidence was provided (in written form) by Ms Amanda Richards, addressing each of the points of concern raised by the Family. SCC maintain that a significant degree of reflection did take place following Mr Stringer’s death and is unclear about the respects in which this was deemed to be inadequate. SCC would like to reiterate that reflection did take place following Mr Stringer’s death as set out below and changes aimed at improving the service have occurred since the sad death of Mr Stringer. Lack of action and/or change to the management of potholes The Coroner has indicated that the written submissions provided (it is assumed by

refer to ‘a number of discussions…but there has been no documented changes in systems of practice’. SCC notes that the conclusion of the Inquest was Accident and that the Coroner determined that at every relevant inspection where the index defect was identified, it was classified correctly, and an appropriate repair completion date was imposed. Tragically, Mr Stringer’s accident occurred whilst the pothole was scheduled for repair (and was within the appropriate repair time window). The Inquest did not therefore determine that the current system was inadequate. However, given the tragic circumstances of Mr Stringer’s death, SCC has undertaken reviews of each of the issues raised by the Family (set out at paragraphs 1-5 in Section 5 of the PFD Report) and several changes have been made since the Inquest (albeit not all directly as a result of this Inquest). Most pertinently the main changes since Mr Stringer’s passing are:
1. We have recently reprocured our Highways Term Maintenance contract and have taken the opportunity to consider improvements to the services we deliver. For example, SCC have now increased the potential to be able to carry out larger scale pothole repairs, where conditions warrant it, which will help prevent future potholes and improve road condition for all users.
2. The highways-inspector role (for routine and reactionary) inspections has been brought in-house to SCC having previously been a function that was outsourced to our Term Maintenance Contractor. This has facilitated greater local knowledge and consistency across inspections (for example, all inspectors are more likely to know which routes are popular cycle-routes due to their local knowledge) and allows SCC to have control over all highways-inspector training.
3. The Local Transport Plan 4 (LTP4) is currently being implemented. This has prompted broad consideration of ways to improve the services we deliver. In particular, the LTP4 places greater emphasis on cyclist-use of roads within the network and steps are being taken to collect data on cycle-routes in order to inform future decisions about how best to incorporate this knowledge into the policy and systems and, if appropriate, to facilitate access to this data for highways-inspectors.
1. What steps have been taken to ensure inspectors of defects are fully informed of recent complaints including those from members of the public regarding damage to bicycles by the state of the road. 2

Inspections are based on what the Inspector sees at the point in time that the inspection takes place. SCC often gets multiple reports of what might be the same defect and there can be a variety of reasons why certain defects may be the subject of multiple reports (it is not always the case that a higher number of reports means that a defect poses a greater risk than a defect which has received only one report). For this reason, while we assess all reports from the public regarding potential safety defects, we need to ensure that limited resources are not diverted or biased based on what can be inconsistent reporting by the public. It is important that inspections that are prompted by a customer complaint are carried out to review what is reported at that point in time as an independent one-off inspection carried out by a trained Inspector. There are risks and benefits to providing historical data and not providing it. These have been carefully considered, and SCC is still giving specific consideration to whether providing historical complaint data to Inspectors would be beneficial. SCC is in the process of building a new data system and is exploring the option of having a data history available to inspectors as part of this.
2. What steps have been taken in the provision of a detailed and robust risk assessment by inspectors with all the available information available such as past complaints, the nature of the road and who uses the road to ensure a ‘holistic’ approach to decision making with regard to the necessity and the speed of road repairs. As above, Mr Stringer’s death prompted further internal discussions about whether historical complaint data should be provided to Inspectors. There are risks and benefits of providing this information and these are being carefully considered. Inspectors identify risks by visual inspection and evaluate them in terms of their significance, which means assessing the likely impact should the risk occur and the probability of it actually happening. The impact is quantified by assessing the extent of damage likely to be caused should the risk become an incident. As the impact is likely to increase with increasing speed, the level of traffic, the type of traffic, and the type of road, all of these aspects are considered in the assessment. The probability is quantified by assessing the likelihood of users, passing by or over the defect, encountering the risk. As the probability is likely to increase with increasing flows and the type of traffic, the network hierarchy and defect location are considered in the assessment. Based upon the potential impact and probability and in accordance with the guidance set out in the Highways Risk Matrix, the Inspector will determine the appropriate category for the defect. We have recently reviewed one of our key strategies, our Local Transport Plan (LTP4), which sets the policy direction for transport across Surrey. As part of that we are reviewing how to 3

more positively accommodate more sustainable modes of transport on our network, including cyclists, into our network management regimes. Implementation of the LTP4 has specifically focused efforts on factoring in use by cyclists of particular routes and data is currently being gathered on this issue. The main sources of information we have identified for mapping cycle movements is Propensity to Cycle data, the SCC Better Points app, Strava, and cycle counting technology such as image recognition from CCTV cameras. Following analysis of the data, decisions will be made on whether changes to maintenance polices are needed. In particular, consideration is currently being given to creating a cycle hierarchy similar to the existing carriageway and footway hierarchies. A bespoke hierarchy focussed on cycle routes will enable interventions on routes that are used by cyclists to be more clearly based on the usage and risks for cyclists. In terms of Inspections, this will give the Inspectors valuable information about the cycle usage of the routes they are inspecting, rather than relying on their local knowledge. This work is ongoing with data gathering and consultation taking place with relevant stakeholders including Council officers, Members, other authorities and cycling groups. Outputs are due to be reported within the next 6 months with any recommendations for changes then going through council governance processes. Also relevant is the change in our Highways Maintenance Contractor which although not related to the inquest, it has allowed us to make changes to how the service is delivered. SCC has moved all highways-inspector roles (routine and reactionary) in-house (from 2022) which enables enhanced and better use of ‘local knowledge’ and continuity to inspections. All Inspectors will now have access to SCC asset data including street history information (details of works or defects that have previously occurred on the section of road), and all officers will have a clear understanding of the inspection process and points of contact though regular meetings and training.
3. What, if any, changes have been made to the pictorial guide and the matrix given to inspectors to ensure training there is not an ‘overly mechanistic’ assessment of a road defect. All highway authorities have their own guidance and processes to provide guidance to staff in carrying out their role. The pictures are helpful to give an indication of the types of defect that may fall into each category and as an aide-mémoire. The document clearly states that it is there to “assist” with identification and classification and that it should be used in conjunction with other information. Comparing the visual characteristics of a defect against the pictures in the guide provides a good starting point for Inspectors when assessing the risk posed by a defect. The pictorial guide is periodically reviewed and following this inquest SCC has reviewed it in detail and a new draft has been produced with a number of pictures updated along with updates to reflect the changes introduced as part of the new contact arrangements. SCC maintains that the pictures provide suitable supplementary assistance for classification of defects in accordance with the policy. The most recent review aligns the guide with the changes made as part of the new contract arrangements in terms of repairing the area 4

surrounding the defect if the surrounding surface is not sound rather than repairing just the defect itself. SCC has also re-emphasised to Inspectors that the pictorial guide and matrix are to be used as only part of their dynamic risk assessment for each defect, with the visual characteristics of each defect (and comparison to the pictures in the guide) being only one aspect of that assessment. In addition to the pictorial guide and matrix, the training that Inspectors receive continues to emphasise that the situational and wider characteristics of a defect are important – as described in point 2 above. Refresher training happens regularly for SCC Inspectors which covers the risk assessment process and how a dynamic risk assessment is to be conducted without placing over-reliance on the dimensions of a defect in an overly mechanistic way. Recent changes to the organisational structure have meant that all the highway inspectors now work directly for SCC (as above). This will improve the control and consistency in training and also SCC’s ability to ensure that regular training is undertaken for all highways-inspectors. SCC also has a team dedicated to carrying out internal audits of the quality of repairs and of the assessment of defects to ensure that an ‘overly mechanistic’ approach is not adopted. All stages of the safety defect process from identification and categorisation through to the repair are monitored and scrutinised continuously. Issues are reviewed and, where necessary, discussed with relevant officers. Trends and performance are reported through a monthly performance board and as a result processes are continuously evolving across the teams involved.
4. What steps have been taken to ensure there is appropriate and timely communication between the SCC contact centre and the highways department such as a standard operating procedure in place when complaints must be forwarded on and responded to? The primary method for contacting the Highways service is by using the on-line web-portal which is where the vast majority of highway concerns are reported and which go directly to the Highways Service. Customers are also able to phone the SCC contact centre to raise issues and the contact centre will log issues with the Highways Service on their behalf. The corporate standard response time is 5 days. Performance with regards to response times for enquiries is monitored regularly and any issues with processes or systems are addressed. Regular discussions take place between the Highways Service and the Customer Contact Centre. Discussions took place following this case and Customer Care Centre operatives were subsequently instructed to make direct and immediate contact with Highways if there is anything they are unsure about.
5. What steps have been taken to ensure repairs are completed in a timely fashion after serious injuries and deaths have occurred, as a result of a road defect? We have reviewed the timeline of notification to repair a defect following incidents on the road network. We have reinforced the process to both Surrey Police and the Surrey Contact Centre 5

of the requirement to notify the Highways Service immediately in these circumstances to enable a timely response. SCC hopes that the above demonstrates that significant reflection and action has occurred since Mr Stringer’s sad passing and that work is ongoing to improve the service.