Michael Arthur Warren · Prevention of Future Deaths report

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.

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.

(1) The evidence at the Inquest revealed that Bracknell Forest 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 Forest Council to Highway Inspectors to ensure that they are properly trained in tree issues; that they have an appropriate system of work that ensures that they drive at a speed appropriate to maximise the chances of identifying tree hazards and that there should be a series of inspections which are limited to only the inspection of trees.
(5) The evidence also revealed that there was very little by way of clear, detailed guidance available to Local Authorities as regards the appropriate systems of highway inspection of trees abutting the highway. There is a potential need for clear direction from a suitably qualified source to assist Local Authorities in this crucial role.
(6) The owner of the land on which the relevant oak tree stood lived abroad and had no arrangements for professional review of the trees on his property, in particular those that were close to the highway and therefore a potential hazard to road users. It was of concern that the lack of active management of the owner’s land continued some two and a half years after Mr Warren’s death.