Kevin O’Reilly
PFD Report
All Responded
Ref: 2025-0088
All 1 response received
· Deadline: 14 Apr 2025
Coroner's Concerns (AI summary)
All lanes open motorways present a significant hazard due to insufficient emergency stopping areas spaced 1.6 miles apart and a lack of continuous monitoring.
View full coroner's concerns
i. It was accepted at inquest that Mr O’Reilly was on an all lanes open motorway. This type of motorway has all lanes open for vehicles to use, and areas for vehicles to stop every 1.6 miles, but not areas in between.
ii. It was accepted that there was no area for vehicles to stop should they need to, unless they were near to the refuse areas spaced 1.6 miles apart, and the all lanes open motorways were not monitored.
ii. It was accepted that there was no area for vehicles to stop should they need to, unless they were near to the refuse areas spaced 1.6 miles apart, and the all lanes open motorways were not monitored.
Responses
Action Taken
National Highways details actions regarding all lane running motorways including stopped vehicle detection technology and emergency areas, and outlines a communications plan including multiple campaigns in Autumn and Winter 2025. (AI summary)
National Highways details actions regarding all lane running motorways including stopped vehicle detection technology and emergency areas, and outlines a communications plan including multiple campaigns in Autumn and Winter 2025. (AI summary)
View full response
1 REGULATION 29 RESPONSE TO PREVENT FUTURE DEATHS THIS RESPONSE IS BEING SENT TO: The Area Coroner for Staffordshire, Emma Serrano, of Stoke Town Hall, Stoke on Trent, ST4 1HH.
1. NATIONAL HIGHWAYS
I am , Regional Director for the Midlands, National Highways Limited, The Cube, 199 Wharfside Street, Birmingham, B1 1RN.
National Highways was not an Interested Person at the inquest hearing held on 12 February 2025 and had not been invited to provide any evidence to assist the Area Coroner in her investigation prior to receiving the Regulation 28 PFD report.
On behalf of National Highways, I would like to express my deepest condolences to Mr O’Reilly’s family and friends and those affected by his tragic death.
2. CORONER’S MATTERS OF CONCERN
The MATTERS OF CONCERN are as follows:
1. It was accepted at inquest that Mr O’Reilly was on an all lanes open motorway. This type of motorway has all lanes open for vehicles to use, and areas for vehicles to stop every 1.6 miles, but not areas in between.
2. It was accepted that there was no area for vehicles to stop should they need to, unless they were near to the refuge [sic] areas spaced 1.6 miles apart, and the all lanes open motorways were not monitored.
3. DETAILS OF ACTION TAKEN
1. All lane running motorways and places to stop in an emergency
All lane running (ALR) motorways add variable mandatory speed limits to control the speed and smooth the flow of traffic and increase capacity by permanently converting the hard shoulder into a running lane. ALR motorways feature emergency areas, which are places to stop in an emergency. These are in addition to motorway service areas and sections of hard shoulder, for example on slip roads. Radar stopped vehicle detection (SVD) technology is also in place on all operational ALR motorways.
This incident occurred on the M6 northbound between junction 11a and junction 12 which is a section of ALR motorway. It was constructed as part of the M6 junction 10a to junction 13 ALR scheme completed in February 2016.
This location complied with the design standards at the time (IAN/161) which required places to stop in an emergency at a maximum spacing of 2.5km (1.6 miles).
On this section of the M6 between junction 11a and junction 12 the distance between places to stop is 1.9km (1.2 miles).
In October 2020, a new standard was published (GD 3011) which requires places to stop to be provided at a maximum spacing of 1.6km (1 mile), and where possible
1.2km (0.75 miles). This standard would be used for all new ALR schemes from this date forward.
1 https://www.standardsforhighways.co.uk/search/d908f9c2-cd47-4e96-b015-97b51e24c588
2 When a new standard is produced, National Highways is not funded to retrofit the Strategic Road Network (SRN) but to apply the new standard in any new works/designs. Currently, there are no plans for the addition of more emergency areas to this section of the M6 motorway.
Over the last 2 years, National Highways has been adding additional emergency areas to some ALR sections of motorway. We recently completed a nationwide programme to construct and install more than 150 additional emergency areas2. We prioritised locations where emergency areas could make the most difference and bring benefits to drivers. The M6 junction 10a to 13 was not included as one of the locations for additional emergency areas because after looking at the frequency of live lane stops alongside safety data, other locations were determined to be higher priority as emergency areas could make the most difference and bring benefits to drivers as soon as possible.
In addition to these formal places to stop in an emergency, in some locations it is possible for drivers, in the event of a breakdown, to access the verge to position their vehicle out of the live carriageway. There was approximately 180 metres of accessible verge prior to the collision location.
Advice regarding breakdowns and places to stop in an emergency is covered in the Highway Code rules 275 to 2793.
2. Roadside technology in place on ALR motorways
The roadside technology currently used on ALR motorways, is made up of a system of different features so that there is no over-reliance on a single feature.
It includes:
Stopped Vehicle Detection (SVD). Variable mandatory speed limits. Motorway Incident Detection and Automatic Signalling (MIDAS) to monitor traffic for changes in flows and speeds and automatically set signs and signals (speed limits). CCTV cameras to assist our operators to manage congestion and incidents, when notified. Signs and signals to alert drivers to hazards ahead and display Red X signals to close a lane(s), including when a stopped vehicle is identified. Enforcement cameras to enforce the mandatory speed limit and Red X compliance. Emergency areas set back from the road, with emergency telephones linking directly to our Regional Operations Centres.
All of the above features (including SVD) were in place on the M6 northbound between junction 11a and junction 12 at the time of this incident in June 2023. SVD detects stopped vehicles and alerts our Regional Operations Centres. The operators in the control room can then respond by taking actions to help to reduce the risks associated with live lane stops, such as setting Red X signals to close lanes, accompanied by reduced mandatory speed limits and deploying National Highways Traffic Officers.
2 https://nationalhighways.co.uk/press/national-highways-completes-programme-to-install- more-than-150-additional-emergency-areas-on-smart-motorways/ 3 https://www.gov.uk/guidance/the-highway-code
3 Once we are notified of an incident, we can use CCTV to locate the incident and take appropriate actions. Notification can arise from various sources including the police, members of the public, SVD alerts and our traffic officers. Actions in response may include setting signs and signals and deploying resources, such as traffic officers. When resources allow, we carry out “virtual patrolling”. This is the proactive use of technology to provide an overview of smart motorway sections, including emergency areas. Virtual patrolling is not a routine activity conducted in our control rooms.
Having reviewed our CCTV footage after the incident, we determined that Mr O’Reilly’s vehicle was slow moving until approximately 30 seconds before the collision. Once stopped, SVD operated correctly in detecting the vehicle and triggered the automatic “Report of obstruction” message just after the HGV, that collided with Mr O’Reilly’s car, passed the variable message sign. Therefore the HGV driver was not presented with this warning message.
3. Road safety / driver campaigns (including topping up fuel)
In March 2021 we launched our biggest ever road safety campaign, ‘Go left’, to give drivers clear information about what to do in a breakdown on a high-speed road, including smart motorways. This campaign ran until January 2023.
We have also co-ordinated a wider programme of road safety campaigns including our ‘Top up, Rest, Inspect, Prepare’ (T.R.I.P.) campaign which was launched in July 2023 where ‘Top up’ refers specifically to topping up fuel/charge prior to a journey on the Strategic Road Network. These campaigns are delivered seasonally with the messaging tailored specifically for the time of year. The media channel mix is integrated with traditional media such as radio and out of home (roadside billboards etc), digital and social media.
4. DETAILS OF FURTHER ACTION PROPOSED
We will continue the public education campaigns – pending government approvals, T.R.I.P and ‘Know the HGV zones’ will continue to be included in the paid media road safety communications investment in the 2025/26 financial year.
5. TIMETABLE FOR ACTION
DATE ACTION
July 2025 T.R.I.P. – summer campaign. Focus will be on R (Rest) but all four messages will be communicated. October 2025 T.R.I.P. – autumn campaign. Focus will be on I (Inspect tyres) but all four key messages will be communicated. October 2025 Know the HGV zones. December 2025 T.R.I.P. – winter campaign. Focus will be on P (Prepare) but all four key messages will be communicated. Ongoing T.R.I.P. – regular journey planning and incident prevention campaign. Working with partners including Halfords and Kwik Fit
Please note: paid for marketing is subject to government approval.
6. SAFETY OF ROAD USERS
4
The safety of everyone on all roads matters; it is an imperative for our business in what we set out to achieve and a core value of our organisation.
Every death on our roads is a tragic loss of life and we again offer our deepest sympathies to all those affected by Mr O’Reilly’s death.
Although roads, especially high-speed roads, can never be risk-free environments, our priority is the reduction of road deaths and injuries on our network, and we want everyone who travels or works on any of our roads to feel confident and safe.
This is why we invest in road safety initiatives and public awareness campaigns, to help prevent death and injury and to help give drivers the information they need to have safer journeys. This is in addition to information provided by other external stakeholders, for example The Highway Code.
Our latest analysis in our Fourth year progress report4 continues to show that overall, in terms of deaths or serious injuries, smart motorways remain our safest roads. This is in line with the findings of our Second year and Third year progress reports.
National Highways remains committed to continuing to improve safety and providing even more information that is accessible to drivers.
7.
14 April 2025 Signed:
Regional Director for the Midlands
4
4ypr-120325-final.pdf
1. NATIONAL HIGHWAYS
I am , Regional Director for the Midlands, National Highways Limited, The Cube, 199 Wharfside Street, Birmingham, B1 1RN.
National Highways was not an Interested Person at the inquest hearing held on 12 February 2025 and had not been invited to provide any evidence to assist the Area Coroner in her investigation prior to receiving the Regulation 28 PFD report.
On behalf of National Highways, I would like to express my deepest condolences to Mr O’Reilly’s family and friends and those affected by his tragic death.
2. CORONER’S MATTERS OF CONCERN
The MATTERS OF CONCERN are as follows:
1. It was accepted at inquest that Mr O’Reilly was on an all lanes open motorway. This type of motorway has all lanes open for vehicles to use, and areas for vehicles to stop every 1.6 miles, but not areas in between.
2. It was accepted that there was no area for vehicles to stop should they need to, unless they were near to the refuge [sic] areas spaced 1.6 miles apart, and the all lanes open motorways were not monitored.
3. DETAILS OF ACTION TAKEN
1. All lane running motorways and places to stop in an emergency
All lane running (ALR) motorways add variable mandatory speed limits to control the speed and smooth the flow of traffic and increase capacity by permanently converting the hard shoulder into a running lane. ALR motorways feature emergency areas, which are places to stop in an emergency. These are in addition to motorway service areas and sections of hard shoulder, for example on slip roads. Radar stopped vehicle detection (SVD) technology is also in place on all operational ALR motorways.
This incident occurred on the M6 northbound between junction 11a and junction 12 which is a section of ALR motorway. It was constructed as part of the M6 junction 10a to junction 13 ALR scheme completed in February 2016.
This location complied with the design standards at the time (IAN/161) which required places to stop in an emergency at a maximum spacing of 2.5km (1.6 miles).
On this section of the M6 between junction 11a and junction 12 the distance between places to stop is 1.9km (1.2 miles).
In October 2020, a new standard was published (GD 3011) which requires places to stop to be provided at a maximum spacing of 1.6km (1 mile), and where possible
1.2km (0.75 miles). This standard would be used for all new ALR schemes from this date forward.
1 https://www.standardsforhighways.co.uk/search/d908f9c2-cd47-4e96-b015-97b51e24c588
2 When a new standard is produced, National Highways is not funded to retrofit the Strategic Road Network (SRN) but to apply the new standard in any new works/designs. Currently, there are no plans for the addition of more emergency areas to this section of the M6 motorway.
Over the last 2 years, National Highways has been adding additional emergency areas to some ALR sections of motorway. We recently completed a nationwide programme to construct and install more than 150 additional emergency areas2. We prioritised locations where emergency areas could make the most difference and bring benefits to drivers. The M6 junction 10a to 13 was not included as one of the locations for additional emergency areas because after looking at the frequency of live lane stops alongside safety data, other locations were determined to be higher priority as emergency areas could make the most difference and bring benefits to drivers as soon as possible.
In addition to these formal places to stop in an emergency, in some locations it is possible for drivers, in the event of a breakdown, to access the verge to position their vehicle out of the live carriageway. There was approximately 180 metres of accessible verge prior to the collision location.
Advice regarding breakdowns and places to stop in an emergency is covered in the Highway Code rules 275 to 2793.
2. Roadside technology in place on ALR motorways
The roadside technology currently used on ALR motorways, is made up of a system of different features so that there is no over-reliance on a single feature.
It includes:
Stopped Vehicle Detection (SVD). Variable mandatory speed limits. Motorway Incident Detection and Automatic Signalling (MIDAS) to monitor traffic for changes in flows and speeds and automatically set signs and signals (speed limits). CCTV cameras to assist our operators to manage congestion and incidents, when notified. Signs and signals to alert drivers to hazards ahead and display Red X signals to close a lane(s), including when a stopped vehicle is identified. Enforcement cameras to enforce the mandatory speed limit and Red X compliance. Emergency areas set back from the road, with emergency telephones linking directly to our Regional Operations Centres.
All of the above features (including SVD) were in place on the M6 northbound between junction 11a and junction 12 at the time of this incident in June 2023. SVD detects stopped vehicles and alerts our Regional Operations Centres. The operators in the control room can then respond by taking actions to help to reduce the risks associated with live lane stops, such as setting Red X signals to close lanes, accompanied by reduced mandatory speed limits and deploying National Highways Traffic Officers.
2 https://nationalhighways.co.uk/press/national-highways-completes-programme-to-install- more-than-150-additional-emergency-areas-on-smart-motorways/ 3 https://www.gov.uk/guidance/the-highway-code
3 Once we are notified of an incident, we can use CCTV to locate the incident and take appropriate actions. Notification can arise from various sources including the police, members of the public, SVD alerts and our traffic officers. Actions in response may include setting signs and signals and deploying resources, such as traffic officers. When resources allow, we carry out “virtual patrolling”. This is the proactive use of technology to provide an overview of smart motorway sections, including emergency areas. Virtual patrolling is not a routine activity conducted in our control rooms.
Having reviewed our CCTV footage after the incident, we determined that Mr O’Reilly’s vehicle was slow moving until approximately 30 seconds before the collision. Once stopped, SVD operated correctly in detecting the vehicle and triggered the automatic “Report of obstruction” message just after the HGV, that collided with Mr O’Reilly’s car, passed the variable message sign. Therefore the HGV driver was not presented with this warning message.
3. Road safety / driver campaigns (including topping up fuel)
In March 2021 we launched our biggest ever road safety campaign, ‘Go left’, to give drivers clear information about what to do in a breakdown on a high-speed road, including smart motorways. This campaign ran until January 2023.
We have also co-ordinated a wider programme of road safety campaigns including our ‘Top up, Rest, Inspect, Prepare’ (T.R.I.P.) campaign which was launched in July 2023 where ‘Top up’ refers specifically to topping up fuel/charge prior to a journey on the Strategic Road Network. These campaigns are delivered seasonally with the messaging tailored specifically for the time of year. The media channel mix is integrated with traditional media such as radio and out of home (roadside billboards etc), digital and social media.
4. DETAILS OF FURTHER ACTION PROPOSED
We will continue the public education campaigns – pending government approvals, T.R.I.P and ‘Know the HGV zones’ will continue to be included in the paid media road safety communications investment in the 2025/26 financial year.
5. TIMETABLE FOR ACTION
DATE ACTION
July 2025 T.R.I.P. – summer campaign. Focus will be on R (Rest) but all four messages will be communicated. October 2025 T.R.I.P. – autumn campaign. Focus will be on I (Inspect tyres) but all four key messages will be communicated. October 2025 Know the HGV zones. December 2025 T.R.I.P. – winter campaign. Focus will be on P (Prepare) but all four key messages will be communicated. Ongoing T.R.I.P. – regular journey planning and incident prevention campaign. Working with partners including Halfords and Kwik Fit
Please note: paid for marketing is subject to government approval.
6. SAFETY OF ROAD USERS
4
The safety of everyone on all roads matters; it is an imperative for our business in what we set out to achieve and a core value of our organisation.
Every death on our roads is a tragic loss of life and we again offer our deepest sympathies to all those affected by Mr O’Reilly’s death.
Although roads, especially high-speed roads, can never be risk-free environments, our priority is the reduction of road deaths and injuries on our network, and we want everyone who travels or works on any of our roads to feel confident and safe.
This is why we invest in road safety initiatives and public awareness campaigns, to help prevent death and injury and to help give drivers the information they need to have safer journeys. This is in addition to information provided by other external stakeholders, for example The Highway Code.
Our latest analysis in our Fourth year progress report4 continues to show that overall, in terms of deaths or serious injuries, smart motorways remain our safest roads. This is in line with the findings of our Second year and Third year progress reports.
National Highways remains committed to continuing to improve safety and providing even more information that is accessible to drivers.
7.
14 April 2025 Signed:
Regional Director for the Midlands
4
4ypr-120325-final.pdf
Sent To
- Highways England
Response Status
Linked responses
1 of 1
56-Day Deadline
14 Apr 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 the 4th March 2024, I commenced an investigation into the death of Mr Kevin O’Reilly. The investigation concluded at the end of the inquest on 12 February 2025. The cause of death was: 1a Traumatic intracranial haemorrhage; and II Aspiration pneumonia, traumatic brain injury, polycystic kidney disease, road traffic collision
Circumstances of the Death
i) Kevin John O'Reilly was driving his black Mitsubishi motor vehicle, along the M6 northbound, heading towards Junction 12 on the 29 June 2023. he ran out of petrol and was stationary in lane three. His car was struck at 5:51, by a blue Volvo Heavy Goods vehicle. ii) The collision caused a traumatic brain injury. From the 29 June, untill he passed away he was being treated for the brain injury in many hospitals and rehabilitation facilities. iii) On the 6 February 2024 he was admitted to the Emergency Department in Warwick Hospital and diagnosed with sepsis and chest x-rays were consistent with pneumonia. He was treated for this. Later that morning he became less alert and his pupils were unequal. A CT scan revealed a large bleed inside the brain. iv) A neurosurgical referral was made and confirmed no surgical intervention. He was placed onto a palliative care pathway and passed away on the same day from a traumatic intracranial haemorrhage.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.