Charlotte Noordam
PFD Report
All Responded
Ref: 2025-0422
All 1 response received
· Deadline: 7 Oct 2025
Coroner's Concerns (AI summary)
A high-incident crossroads junction is inherently confusing due to its non-signalised, historic design, posing an ongoing safety risk despite current legal compliance.
View full coroner's concerns
1. The junction is a crossroads in Edgbaston between Frederick Road (running North South) and St James Road (running East West). Both roads are two way priority. Traffic flow priority is along St James Road. Access northwards to St James row from Frederick Road is controlled by a GIVE WAY. Access southwards to St James row from Frederick Road is controlled by a STOP. Both roads are the subject of a 20mph speed limit Traffic Regulation Order.
2. Birmingham City Council stated that if a new junction being designed from new (i.e. it was not a preexisting historic arrangement), they would oppose the use of a non-signalised crossroad junction because of the inherent confusion around priority of movement at the crossroad. However, this is a historic highway arrangement.
3. Whilst the road layout, including signage and road markings, complies with the legal requirements this does not appear to have mitigated against the prevalence of incidents at the stop junction.
4. There have been at least 27 other road traffic incidents at the same junction during the period 23rd May 2014 to the 8th March 25.
5. The police investigator gave evidence that, in his experience, the number of collisions at the stop junction raises questions about the safety of the junction.
6. Evidence from Birmingham City Council suggested that there were potentially additional measures that could be considered to mitigate any safety risks so far as reasonably practicable.
7. I am concerned that there is still a risk to life for users of the junction.
2. Birmingham City Council stated that if a new junction being designed from new (i.e. it was not a preexisting historic arrangement), they would oppose the use of a non-signalised crossroad junction because of the inherent confusion around priority of movement at the crossroad. However, this is a historic highway arrangement.
3. Whilst the road layout, including signage and road markings, complies with the legal requirements this does not appear to have mitigated against the prevalence of incidents at the stop junction.
4. There have been at least 27 other road traffic incidents at the same junction during the period 23rd May 2014 to the 8th March 25.
5. The police investigator gave evidence that, in his experience, the number of collisions at the stop junction raises questions about the safety of the junction.
6. Evidence from Birmingham City Council suggested that there were potentially additional measures that could be considered to mitigate any safety risks so far as reasonably practicable.
7. I am concerned that there is still a risk to life for users of the junction.
Responses
Action Planned
Birmingham City Council intends to take steps to address the volume of vehicular traffic using the junction of Frederick Road and St James Road. The first phase will be implementation of vertical traffic calming measures and additional signage, with further traffic management measures to follow. (AI summary)
Birmingham City Council intends to take steps to address the volume of vehicular traffic using the junction of Frederick Road and St James Road. The first phase will be implementation of vertical traffic calming measures and additional signage, with further traffic management measures to follow. (AI summary)
View full response
Dear Ana,
Thank you for your Regulation 28 Report dated 12 August 2025 concerning the tragic death of Charlotte Noordam at the junction of Frederick Road and St James Road in Edgbaston.
Birmingham City Council acknowledges the serious concerns raised in your report, particularly the longstanding safety issues associated with this historic, non-signalised crossroad junction of residential, unclassified roads. While the current road layout, signage, and markings comply with legal standards, we recognise that these measures have not sufficiently mitigated the risks posed to road users. The frequency and severity of incidents at this location, including the 27 recorded collisions between May 2014 and March 2025, underscore the need for more decisive intervention.
As meaningful redesign in alignment with the Safe System approach would require significant demolition of the surrounding built environment, this approach is wholly inappropriate for this setting. Therefore, the Council confirms its intention to take decisive steps to address the volume of vehicular traffic using this junction.
This decision reflects our commitment to prioritise public safety and prevent future loss of life, as set out in our adopted Road Harm Reduction Strategy. Vehicular traffic will be redirected away from residential areas towards the city’s classified road network, which is better equipped to handle higher vehicular traffic volumes safely.
In accordance with the statutory timeframe, the Council is implementing its Fatal Collision Response Protocol to assess the specific site conditions to identify locally appropriate interventions which we intend to deliver in two phases. The first of these will be implementation of vertical traffic calming measures and additional signage to better alert drivers to the presence of the junction. We will deliver these measures within a six- month period of the date of this letter.
As set out above, our further intention is to deliver traffic management measures to direct traffic away from this junction. However, as this could have impacts across the wider road network, this will require further design and assessment work to be undertaken before proceeding to implementation.
Thank you for your Regulation 28 Report dated 12 August 2025 concerning the tragic death of Charlotte Noordam at the junction of Frederick Road and St James Road in Edgbaston.
Birmingham City Council acknowledges the serious concerns raised in your report, particularly the longstanding safety issues associated with this historic, non-signalised crossroad junction of residential, unclassified roads. While the current road layout, signage, and markings comply with legal standards, we recognise that these measures have not sufficiently mitigated the risks posed to road users. The frequency and severity of incidents at this location, including the 27 recorded collisions between May 2014 and March 2025, underscore the need for more decisive intervention.
As meaningful redesign in alignment with the Safe System approach would require significant demolition of the surrounding built environment, this approach is wholly inappropriate for this setting. Therefore, the Council confirms its intention to take decisive steps to address the volume of vehicular traffic using this junction.
This decision reflects our commitment to prioritise public safety and prevent future loss of life, as set out in our adopted Road Harm Reduction Strategy. Vehicular traffic will be redirected away from residential areas towards the city’s classified road network, which is better equipped to handle higher vehicular traffic volumes safely.
In accordance with the statutory timeframe, the Council is implementing its Fatal Collision Response Protocol to assess the specific site conditions to identify locally appropriate interventions which we intend to deliver in two phases. The first of these will be implementation of vertical traffic calming measures and additional signage to better alert drivers to the presence of the junction. We will deliver these measures within a six- month period of the date of this letter.
As set out above, our further intention is to deliver traffic management measures to direct traffic away from this junction. However, as this could have impacts across the wider road network, this will require further design and assessment work to be undertaken before proceeding to implementation.
Sent To
- Birmingham City Council
Response Status
Linked responses
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56-Day Deadline
7 Oct 2025
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
Report Sections
Investigation and Inquest
On 18 March 2025 I commenced an investigation into the death of Charlotte NOORDAM. The investigation concluded at the end of the inquest . The conclusion of the inquest was; Road traffic collision
Circumstances of the Death
On the 8th March 2025 at around 14.12 the deceased was riding a black Yamaha Tracer 700 motorbike registration number down Frederick Road in Edgbaston towards the junction with St James Road. Upon reaching the junction she failed to comply with the stop sign and crossed into the path of and into collision with an MG 3 motor vehicle registration number , which was travelling with right of way along St James Road. Death was certified at 14.48 at the junction of Frederick road and St James Road. Following a post mortem the medical cause of death was determined to be: 1a Multiple Injuries 1b Road Traffic Collision 1c 1d II
Copies Sent To
West Midlands Police
driver of
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.