Matthew Scott
PFD Report
All Responded
Ref: 2024-0355
All 1 response received
· Deadline: 29 Aug 2024
Coroner's Concerns (AI summary)
A lengthy, defective, and subsided section of road, prone to holding standing water that could freeze, created a significant hazard for drivers, leading to loss of vehicle control.
View full coroner's concerns
At 6 weeks post Mr Scott's death - on the 28th of April 2023 - a discussion took place between collision investigator officers, a traffic management officer (all of Derbyshire police) with the Project Engineer of the Highways Authority of Derbyshire County Council. The officers raised their concerns that at the place where Mr Scott lost control of his vehicle (Station Road, Melbourne Derbyshire) there was a lengthy, defective and subsided stretch of road. Further that at the time of Mr Scott's death the subsided section of road was some 4 metres in width, 37 metres in length and 5 cms in depth. Further, that it was deep enough to have had standing water in it which at the time of Mr Scott's death had turned to ice. Ice in the said defect would likely cause a vehicle to lose grip on the road surface. At that section of road, the road starts to bend to the right such that losing control on the ice could cause a vehicle to veer to the offside of the road, either into the path of an oncoming vehicle, into the opposite field or as in Mr Scott’s case, a tree. The Project Engineer of the Highways Authority discussed his concerns and the concerns Regulation 28 – After Inquest
Responses
Action Planned
Derbyshire County Council will undertake full width road surfacing work to be completed by 31 October 2024 to level deviations in the road surface. (AI summary)
Derbyshire County Council will undertake full width road surfacing work to be completed by 31 October 2024 to level deviations in the road surface. (AI summary)
View full response
CONTROLLED RESPONSE TO REGULATION 28 NOTICE FROM DERBYSHIRE COUNTY COUNCIL
This is the response to the Regulation 28 Report to Prevent Future Deaths issued by Assistant Coroner for Derbyshire and Derby, Sabyta Kaushal dated 7th May 2024.
It is noted in section 5 – Coroner’s Concerns that reference is made to the site visit on 28th April 2023 that the discussions that took place were that officers stated that “there was a lengthy, defective and subsided stretch of road. Further that at the time of Mr Scott's death the subsided section of road was some 4 metres in width, 37 metres in length and 5 cms in depth. Further, that it was deep enough to have had standing water in it which at the time of Mr Scott's death had turned to ice”. This appears to be information contained in the site report which appeared at section 6 page 19 of 38 in the redacted reconstruction report prepared by . It is however expressed somewhat differently in the actual site report than in the Coroners’ Regulation 28 Report. The site report states as follows “Large patch of ice on the road surface measuring 4 metres in diameter and 37 meters in length. Commencing the in the centre of the carriageway, 4 metres prior to the entrance of the Melbourne Hotel, and terminating in the south-east bound lane. The area predominantly covered the south-east bound lane. It must be noted that this had reduced in size during my attendance due to weather conditions”. This does not say that there was a defect in the road but ice formation. There were some minor differences in level within the carriageway which allowed water to stand, such minor differences in level would be typical of an evolved road network in similar settings such as this and other areas of road across the county.
Due to the inconsistency between the site report carried out by and the concerns raised by the Coroner Derbyshire County Council have undertaken a laser survey dated 26/04/2024. The results of the survey also clearly shows there was not an actionable safety defect that measured 4m wide by 37 meters in length, as that was the ice formation.
The largest depth of pooled water was 30mm in a small, isolated area of subsided carriageway. We can only conclude that the 50mm depth of water was a pothole within this localised subsidence.
Ice also forms on flat surfaces, where water has been tracked, and it is the ice area that is referring to and not a defect.
Further in order to consider the issue of pooled water we have had photographs taken over the area referenced by the coroner on two separate dates following periods of rain fall – these were dated 29th May 2024 and 4th June 2024. Although there is some pooling which is normal it is not evident that there are any large areas of concern. It should be noted that these investigations post date the issue of the Regulation 28 Report and some pothole areas have already been repaired.
CONTROLLED As referenced above the road in question, Station Road, Melbourne is subject to quarterly inspections. We have noted the following from records; 13 January 2023 – 2 customer reports of pot hole received on the same day – area put in for ad hoc inspection 17 January 2023 - ad hoc inspection – a number of separate pot holes put in for repair ref. 50186345 works completed 1 March 2023 17 February 2023 routine inspection – defect noted – 28 day repair requested ref. 50189695 - completed 20 February 2023 9 May 2023 – routine inspection – jobs raised outside Melbourne view repair requested ref 50197481– completed 30 May 2023 ] 17 August 2023 – routine inspection – potholes repairs requested ref. 50204692 and 50204693 completed 04 September 2023. 22 November 2023 – routine inspection – potholes repairs requested ref. 50210507 completed on 21 December 2023.
Competent inspectors have inspected the road and some defects have been noted and put in for repair. There have been no significant repairs requested and a defect as large as 37m long, 4 meters wide and a depth of 40mm or greater would certainly have been identified during a routine safety inspection.
Nonetheless Derbyshire County Council take road safety very seriously and the area from Melbourne View Hotel to a point approximately 200 metres in an easterly direction has been put in for full width road surfacing work to be undertaken. This will be completed by 31 October 2024 and will level some of the deviations in the road surface caused by various pot hole repairs.
It should however be noted that this road will continue to be treated as part of our Secondary salting network during the winter season, as per the Derbyshire County Council - Winter Service Policy. The resurfacing work will not prevent the formation of ice on the road surface should winter weather conditions be such that ice formation conditions are met.
Director of Highways Derbyshire County Council
28 June 2024
This is the response to the Regulation 28 Report to Prevent Future Deaths issued by Assistant Coroner for Derbyshire and Derby, Sabyta Kaushal dated 7th May 2024.
It is noted in section 5 – Coroner’s Concerns that reference is made to the site visit on 28th April 2023 that the discussions that took place were that officers stated that “there was a lengthy, defective and subsided stretch of road. Further that at the time of Mr Scott's death the subsided section of road was some 4 metres in width, 37 metres in length and 5 cms in depth. Further, that it was deep enough to have had standing water in it which at the time of Mr Scott's death had turned to ice”. This appears to be information contained in the site report which appeared at section 6 page 19 of 38 in the redacted reconstruction report prepared by . It is however expressed somewhat differently in the actual site report than in the Coroners’ Regulation 28 Report. The site report states as follows “Large patch of ice on the road surface measuring 4 metres in diameter and 37 meters in length. Commencing the in the centre of the carriageway, 4 metres prior to the entrance of the Melbourne Hotel, and terminating in the south-east bound lane. The area predominantly covered the south-east bound lane. It must be noted that this had reduced in size during my attendance due to weather conditions”. This does not say that there was a defect in the road but ice formation. There were some minor differences in level within the carriageway which allowed water to stand, such minor differences in level would be typical of an evolved road network in similar settings such as this and other areas of road across the county.
Due to the inconsistency between the site report carried out by and the concerns raised by the Coroner Derbyshire County Council have undertaken a laser survey dated 26/04/2024. The results of the survey also clearly shows there was not an actionable safety defect that measured 4m wide by 37 meters in length, as that was the ice formation.
The largest depth of pooled water was 30mm in a small, isolated area of subsided carriageway. We can only conclude that the 50mm depth of water was a pothole within this localised subsidence.
Ice also forms on flat surfaces, where water has been tracked, and it is the ice area that is referring to and not a defect.
Further in order to consider the issue of pooled water we have had photographs taken over the area referenced by the coroner on two separate dates following periods of rain fall – these were dated 29th May 2024 and 4th June 2024. Although there is some pooling which is normal it is not evident that there are any large areas of concern. It should be noted that these investigations post date the issue of the Regulation 28 Report and some pothole areas have already been repaired.
CONTROLLED As referenced above the road in question, Station Road, Melbourne is subject to quarterly inspections. We have noted the following from records; 13 January 2023 – 2 customer reports of pot hole received on the same day – area put in for ad hoc inspection 17 January 2023 - ad hoc inspection – a number of separate pot holes put in for repair ref. 50186345 works completed 1 March 2023 17 February 2023 routine inspection – defect noted – 28 day repair requested ref. 50189695 - completed 20 February 2023 9 May 2023 – routine inspection – jobs raised outside Melbourne view repair requested ref 50197481– completed 30 May 2023 ] 17 August 2023 – routine inspection – potholes repairs requested ref. 50204692 and 50204693 completed 04 September 2023. 22 November 2023 – routine inspection – potholes repairs requested ref. 50210507 completed on 21 December 2023.
Competent inspectors have inspected the road and some defects have been noted and put in for repair. There have been no significant repairs requested and a defect as large as 37m long, 4 meters wide and a depth of 40mm or greater would certainly have been identified during a routine safety inspection.
Nonetheless Derbyshire County Council take road safety very seriously and the area from Melbourne View Hotel to a point approximately 200 metres in an easterly direction has been put in for full width road surfacing work to be undertaken. This will be completed by 31 October 2024 and will level some of the deviations in the road surface caused by various pot hole repairs.
It should however be noted that this road will continue to be treated as part of our Secondary salting network during the winter season, as per the Derbyshire County Council - Winter Service Policy. The resurfacing work will not prevent the formation of ice on the road surface should winter weather conditions be such that ice formation conditions are met.
Director of Highways Derbyshire County Council
28 June 2024
Sent To
Response Status
Linked responses
1 of 1
56-Day Deadline
29 Aug 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
Report Sections
Investigation and Inquest
On 21 March 2023 I commenced an investigation into the death of Matthew SCOTT aged
24. The investigation concluded at the end of the inquest on 22 April 2024. The conclusion of the inquest was that: Matthew James Scott died on 11th March 2023 whilst travelling east on Station Road, Melbourne. The road had a speed limit of 40mph. He was travelling to his place of work at East Midlands airport when he hit a lengthy defective and subsided stretch of road which was filled with ice. That combined with his speed, which was likely to be in excess of 40mph, caused him to lose control, impact with a tree and sadly resulted in his death.
24. The investigation concluded at the end of the inquest on 22 April 2024. The conclusion of the inquest was that: Matthew James Scott died on 11th March 2023 whilst travelling east on Station Road, Melbourne. The road had a speed limit of 40mph. He was travelling to his place of work at East Midlands airport when he hit a lengthy defective and subsided stretch of road which was filled with ice. That combined with his speed, which was likely to be in excess of 40mph, caused him to lose control, impact with a tree and sadly resulted in his death.
Circumstances of the Death
5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) At 6 weeks post Mr Scott's death - on the 28th of April 2023 - a discussion took place between collision investigator officers, a traffic management officer (all of Derbyshire police) with the Project Engineer of the Highways Authority of Derbyshire County Council. The officers raised their concerns that at the place where Mr Scott lost control of his vehicle (Station Road, Melbourne Derbyshire) there was a lengthy, defective and subsided stretch of road. Further that at the time of Mr Scott's death the subsided section of road was some 4 metres in width, 37 metres in length and 5 cms in depth. Further, that it was deep enough to have had standing water in it which at the time of Mr Scott's death had turned to ice. Ice in the said defect would likely cause a vehicle to lose grip on the road surface. At that section of road, the road starts to bend to the right such that losing control on the ice could cause a vehicle to veer to the offside of the road, either into the path of an oncoming vehicle, into the opposite field or as in Mr Scott’s case, a tree. The Project Engineer of the Highways Authority discussed his concerns and the concerns Regulation 28 – After Inquest CONTROLLED Document Template Updated 30/07/2021
that had been raised by the police, with the highway maintenance department in early May 2023. As at the date of the inquest into Mr Scott' death (22 April 2024) this stretch of road had not been surveyed, no consideration had been given to the concerns of the police and no decisions taken to repair the defect so as to prevent any further accidents.
that had been raised by the police, with the highway maintenance department in early May 2023. As at the date of the inquest into Mr Scott' death (22 April 2024) this stretch of road had not been surveyed, no consideration had been given to the concerns of the police and no decisions taken to repair the defect so as to prevent any further accidents.
Copies Sent To
PROJECT ENGINEER HIGHWAYS AUTHORITY
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Revise signal sighting standard to explicitly consider signal readability
Ladbroke Grove Inquiry
Hazardous road design
Define additional time required for reading gantry-mounted and complex signals
Ladbroke Grove Inquiry
Hazardous road design
Clarify "very short duration" definition within the signal sighting standard
Ladbroke Grove Inquiry
Hazardous road design
Identify and retrospectively review locations affected by "very short duration" ambiguity
Ladbroke Grove Inquiry
Hazardous road design
Clarify "overhead line equipment" in signal sighting standard to mean wires and droppers
Ladbroke Grove Inquiry
Hazardous road design
Define acceptable limits for temporary signal obscuration in sighting standards
Ladbroke Grove Inquiry
Hazardous road design
Explicitly define cab sight lines for signal positioning based on driver's eye
Ladbroke Grove Inquiry
Hazardous road design
Railtrack to conduct safety examination of Paddington station layout and operations.
Ladbroke Grove Inquiry
Hazardous road design
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.