Michael Warren
PFD Report
Historic (No Identified Response)
Ref: 2014-0330
Coroner's Concerns (AI summary)
Highway Inspectors received inadequate training and guidance for identifying road hazards, particularly from trees, and conducted superficial "drive-by" inspections, increasing risk to road users.
View full coroner's concerns
(1) The evidence at the Inquest revealed that Bracknell Forest Borough Council employ Highways Inspectors to carry out driven and walked inspections in order to attempt to identify any potential hazards that might impact adversely on road users.
(2) The Highway Inspectors were expected to identify a range of potential problems including potholes in the road, damaged or obscured signage and potential hazards from trees abutting the highway which were often of considerable height. There was little by way of guidance given to Highways Inspectors who had developed their own system of drive-by investigations conducted at a speed rarely less than thirty miles per hour.
(3) The evidence highlighted the limited nature of training provided to Highway Inspectors in identifying potential hazards from trees. The two Inspectors who conducted a drive-by survey two days before the branch fell and killed Mr Warren and who had noted nothing of concern, had not completed any form of tree training since a two day course some seven years earlier. Another Highway Inspector who gave evidence at the Inquest, had never attended a formal training course with regard to tree hazards.
(4) There is therefore a need for appropriate guidelines to be provided by Bracknell
(2) The Highway Inspectors were expected to identify a range of potential problems including potholes in the road, damaged or obscured signage and potential hazards from trees abutting the highway which were often of considerable height. There was little by way of guidance given to Highways Inspectors who had developed their own system of drive-by investigations conducted at a speed rarely less than thirty miles per hour.
(3) The evidence highlighted the limited nature of training provided to Highway Inspectors in identifying potential hazards from trees. The two Inspectors who conducted a drive-by survey two days before the branch fell and killed Mr Warren and who had noted nothing of concern, had not completed any form of tree training since a two day course some seven years earlier. Another Highway Inspector who gave evidence at the Inquest, had never attended a formal training course with regard to tree hazards.
(4) There is therefore a need for appropriate guidelines to be provided by Bracknell
Sent To
- Bracknell Forest Borough Council
Response Status
Linked responses
0 of 2
56-Day Deadline
11 Sep 2014
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 9th October 2012 I commenced an investigation into the death of Michael Arthur Warren. The investigation concluded at the end of the inquest on 10th July 2014. The conclusion of the inquest was a narrative as attached.
Circumstances of the Death
Michael Arthur Warren died from serious head injuries suffered when the car he was driving was struck on its roof by the large branch of a mature oak tree that unexpectedly fell without warning as he drove beneath it on 5th October 2012.
Copies Sent To
Bracknell Forest Borough Council, The Chartered Institution of Highways and Transportation and Mr
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Training for IPC professionals engineers and clinicians
Scottish Hospitals Inquiry
Staff training and development
IPC role specifications and staffing levels
Scottish Hospitals Inquiry
Staff training and development
Balancing vulnerability with professional curiosity
Southport Inquiry
Staff training and development
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.