Mason Williams
PFD Report
All Responded
Ref: 2023-0442
All 1 response received
· Deadline: 5 Jan 2024
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Source: Courts and Tribunals Judiciary
Coroner’s Concerns
During the inquest, the evidence and information revealed matters giving rise to concern. In my opinion, there is a risk that future deaths will occur unless action is taken.
i. The street lighting along Trinity Road, Piccadilly, nr Kingsbury was not illuminated at the time of the Road Traffic Collision due to a fault. I am told the fault was with the underground cabling which was affecting lamp posts 16 to 21 along Trinity Road.
ii. I am aware that the cabling may have been damaged from a previous Road Traffic Collision that occurred on 20 October 2022.
i. The street lighting along Trinity Road, Piccadilly, nr Kingsbury was not illuminated at the time of the Road Traffic Collision due to a fault. I am told the fault was with the underground cabling which was affecting lamp posts 16 to 21 along Trinity Road.
ii. I am aware that the cabling may have been damaged from a previous Road Traffic Collision that occurred on 20 October 2022.
Responses
Warwickshire County Council has permanently repaired the damaged underground cabling and replaced the lighting column on Trinity Road, restoring full street lighting. They have also recruited two additional employees, enabling daily interrogation of the central management system to quickly detect faults.
AI summary
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Dear Ms Blackmore,
RE: REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
FOLLOWING INQUEST INTO THE DEATH OF MASTER MASON WILLIAMS
I refer to your report to the Chief Executive dated 10 November 2023 in which you raise concerns about faults with the street lighting on Trinity Rd, Piccadilly near Kingsbury.
You indicate that the street lighting was not illuminated at the time of the road traffic collision on 30th November 2022 that resulted in the death of Mason Williams and that this was due to a fault with the underground cabling which affected lamp posts numbered 16 to 21 along Trinity Road. Your report states that you are aware that this fault may have been caused by damage to the cabling as a result of a previous road traffic collision on 20 October 2022.
You have written to the Council because you believe that action should be taken to prevent future deaths.
The Council’s response
The Council’s records indicate that the previous road traffic collision on Trinity Road occurred on 28 October 2022 and not 20 October 2022 when a street lighting column (no.
18) was damaged by a vehicle. The Council received police incident report 108 of the 28/10/2022 notifying of a collision at the location. The Council instructed its contractors to attend as an emergency and they attended on 28 October 2022. On attending, the contractors found that lighting column no. 18 had been hit and was unsafe so took emergency action to cut down the column and prevent it from falling before a new column could be ordered and installed. Damage to the underground cabling was not detected at this time. The Council was not aware that streetlights 16, 17, 19, 20 and 21 were out until 5 December 2022 when its contractors attended following the police report of the fatality and discovered the damaged cabling. Resources Directorate Shire Hall, Warwick, CV34 4RL DX 723362 Warwick 5
Director of Strategy, Planning & Governance
When faults with street lighting are identified, officers instruct the Council’s contractor ( ) to attend and carry out a repair. The Council aims to attend and/or take action in respect of identified faults within the following timescales:
Urgent or dangerous faults Appropriate action within one hour depending on the severity of the situation General faults
• Light being out
• Dim
• Flickering/flashing
• On during the day
Attend within five working days Underground electrical cable faults Once fault has been identified - within 25 working days. Lighting with complex issues can take longer to resolve.
The Council has the facility for members of the public to report street lighting faults via a ‘Report it’ link on its home page of the website or by telephone via the Council’s Customer Service Centre.
The Council uses a central management system to monitor street lighting (known as Telensa PLANet). Where the system identifies a problem with a streetlight (such as flickering) it raises an automatic fault alert. The system does not have the functionality to raise a fault alert where there has been a complete loss of power to a streetlight column.
Streetlights 16 to 21 on Trinity Road were out in November 2022 due a complete loss of power so there was no automatic alert. No faults with the street lighting on Trinity Road had been reported to the Council via the website or the Customer Service Centre.
In order to detect a complete loss of power to a streetlight, officers have to manually interrogate the central management system to check for lights that have not communicated with the system and judge whether the problem is transient or due to an on-going issue with the power supply. This work requires a level of specialist knowledge of the central management system. In October and November 2022 the resource capacity within the street lighting team meant that it was not possible to carry out regular manual interrogation of the system.
Details of Action Taken:
1. The damaged power cabling on Trinity Road was temporarily repaired by the Council’s contractors on 5 December 2022 to restore the street lighting. The lighting column damaged on 28 October 2022 (no. 18) was replaced and a permanent repair to the cable carried out on 17 January 2023. The street lighting on Trinity Road has been fully operational since that date.
2. The Council’s street lighting team has recruited two additional employees who started work on 6 November 2023. The central management system is now interrogated by an appropriately qualified officer on a daily basis. This means that street lighting faults that are not alerted automatically (ie due to power outage) or are not reported by the public will be detected very quickly.
3. The Council continues to respond to all reports or detection of faults in line with the timescales referenced above.
4. The Council met with Telensa, its contracted supplier of the central management system, in March 2023 and highlighted the lack of an automatic systems alert in the event of a complete power loss to a street lighting column. Telensa have advised that they will consider updates and improvements that could be made to the system. The Council will continue to work with Telensa to pursue a solution to this issue.
On behalf of the Council I would like to offer our deepest condolences to Mason’s family and friends. I hope that this letter will give some assurance about the steps taken to make Warwickshire’s roads safer for all who use them.
Please do not hesitate to contact me if you have any queries about the content of the Council’s response.
RE: REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
FOLLOWING INQUEST INTO THE DEATH OF MASTER MASON WILLIAMS
I refer to your report to the Chief Executive dated 10 November 2023 in which you raise concerns about faults with the street lighting on Trinity Rd, Piccadilly near Kingsbury.
You indicate that the street lighting was not illuminated at the time of the road traffic collision on 30th November 2022 that resulted in the death of Mason Williams and that this was due to a fault with the underground cabling which affected lamp posts numbered 16 to 21 along Trinity Road. Your report states that you are aware that this fault may have been caused by damage to the cabling as a result of a previous road traffic collision on 20 October 2022.
You have written to the Council because you believe that action should be taken to prevent future deaths.
The Council’s response
The Council’s records indicate that the previous road traffic collision on Trinity Road occurred on 28 October 2022 and not 20 October 2022 when a street lighting column (no.
18) was damaged by a vehicle. The Council received police incident report 108 of the 28/10/2022 notifying of a collision at the location. The Council instructed its contractors to attend as an emergency and they attended on 28 October 2022. On attending, the contractors found that lighting column no. 18 had been hit and was unsafe so took emergency action to cut down the column and prevent it from falling before a new column could be ordered and installed. Damage to the underground cabling was not detected at this time. The Council was not aware that streetlights 16, 17, 19, 20 and 21 were out until 5 December 2022 when its contractors attended following the police report of the fatality and discovered the damaged cabling. Resources Directorate Shire Hall, Warwick, CV34 4RL DX 723362 Warwick 5
Director of Strategy, Planning & Governance
When faults with street lighting are identified, officers instruct the Council’s contractor ( ) to attend and carry out a repair. The Council aims to attend and/or take action in respect of identified faults within the following timescales:
Urgent or dangerous faults Appropriate action within one hour depending on the severity of the situation General faults
• Light being out
• Dim
• Flickering/flashing
• On during the day
Attend within five working days Underground electrical cable faults Once fault has been identified - within 25 working days. Lighting with complex issues can take longer to resolve.
The Council has the facility for members of the public to report street lighting faults via a ‘Report it’ link on its home page of the website or by telephone via the Council’s Customer Service Centre.
The Council uses a central management system to monitor street lighting (known as Telensa PLANet). Where the system identifies a problem with a streetlight (such as flickering) it raises an automatic fault alert. The system does not have the functionality to raise a fault alert where there has been a complete loss of power to a streetlight column.
Streetlights 16 to 21 on Trinity Road were out in November 2022 due a complete loss of power so there was no automatic alert. No faults with the street lighting on Trinity Road had been reported to the Council via the website or the Customer Service Centre.
In order to detect a complete loss of power to a streetlight, officers have to manually interrogate the central management system to check for lights that have not communicated with the system and judge whether the problem is transient or due to an on-going issue with the power supply. This work requires a level of specialist knowledge of the central management system. In October and November 2022 the resource capacity within the street lighting team meant that it was not possible to carry out regular manual interrogation of the system.
Details of Action Taken:
1. The damaged power cabling on Trinity Road was temporarily repaired by the Council’s contractors on 5 December 2022 to restore the street lighting. The lighting column damaged on 28 October 2022 (no. 18) was replaced and a permanent repair to the cable carried out on 17 January 2023. The street lighting on Trinity Road has been fully operational since that date.
2. The Council’s street lighting team has recruited two additional employees who started work on 6 November 2023. The central management system is now interrogated by an appropriately qualified officer on a daily basis. This means that street lighting faults that are not alerted automatically (ie due to power outage) or are not reported by the public will be detected very quickly.
3. The Council continues to respond to all reports or detection of faults in line with the timescales referenced above.
4. The Council met with Telensa, its contracted supplier of the central management system, in March 2023 and highlighted the lack of an automatic systems alert in the event of a complete power loss to a street lighting column. Telensa have advised that they will consider updates and improvements that could be made to the system. The Council will continue to work with Telensa to pursue a solution to this issue.
On behalf of the Council I would like to offer our deepest condolences to Mason’s family and friends. I hope that this letter will give some assurance about the steps taken to make Warwickshire’s roads safer for all who use them.
Please do not hesitate to contact me if you have any queries about the content of the Council’s response.
Report Sections
Investigation and Inquest
On 16 December 2022, I commenced an investigation into the death of Master Mason Williams (aged 13 years). The investigation concluded at the end of the inquest on 10 November 2023 at Warwick Coroners Court and my conclusion was a Road Traffic Collision.
Circumstances of the Death
On the 30 November 2022, at about 5.00pm Mason Williams was walking with three friends along the footpath next to Trinity Road, Piccadilly near Kingsbury. A car was travelling along Trinity Road, in the same direction as the boys. At this time, it was dark and the street lighting were not working. Mason and two of his friends decide to hide from a friend who has walked on ahead. As a group they crossed the road onto the opposite verge. Mason attempted to cross the carriageway back to his friend and was struck by a car. He died in hospital 3 days later. The conclusion of the Inquest was a Road Traffic Collison.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.