Stephen John COOMBES · Prevention of Future Deaths report

On 7ᵗʰ September 2021 I commenced an investigation into the tragic death of
Stephen John COOMBES

The investigation concluded at the end of the inquest on 22ⁿᵈ July 2022. The
conclusion of the inquest was that:-

Stephen ‘John’ Coombes died on the 3ʳᵈ September 2021, at the Addenbrookes
Hospital, in Cambridge.

John had been admitted to the Addenbrookes Hospital on the 29ᵗʰ August 2021
following a single vehicle road traffic collision on the A1101, Burnt Fen, near
Mildenhall in Suffolk.

Immediately after the road traffic collision, John was trapped upside down in
his vehicle, and initially could not be extracted from it. Due to the position he
was in, John’s airway was closed, inducing postural asphyxia.

The medical cause of death was confirmed as:

1a Complications arising from traumatic and hypoxic-ischaemic brain injury
1b Head injury in association with postural asphyxia.

Stephen ‘John’ Coombes died on the 3ʳᵈ September 2021, at the Addenbrookes
Hospital, in Cambridge.

John had been admitted to the Addenbrookes Hospital on the 29ᵗʰ August 2021
following a single vehicle road traffic collision on the A1101, Burnt Fen, near
Mildenhall in Suffolk.

The convertible Porsche John was driving left the road and came to rest upside down
in a ditch. John was originally trapped in the upside-down car pinned to the ground.

Attending police officers and ambulance crew were able to release John and extricate
him from the vehicle.

John was taken to Addenbrookes, but due to the injuries he had received, he
continued to deteriorate until he passed away on the 3ʳᵈ September 2021.

Subsequent police investigation identified that a deep depression in the road surface
contributed to John losing control of the vehicle he was driving.

This depression was known to be present by the Highways authority, and a temporary
30 mph speed limit (instead of the usual 50mph) had been put in place.

Inadequate road signage, did not reflect the temporary 30mph limit and John hit the
depression at approximately 50mph, his vehicle being forced off the road as a result.

Had John known to negotiate the depression at 30 mph, this tragic incident would not
have occurred.

The court heard that the depression was known to be present by the Highways
Authority, and a temporary 30 mph speed limit (instead of the usual 50mph) had been
put in place.

Evidence was heard from the Forensic Crash Investigation Officer from Suffolk
Constabulary, who conducted an investigation into the road traffic collision which
caused John’s death.

This officer told the court, how he and a colleague drove a police vehicle over the
depression in the road at various speeds to observe the reaction the vehicle had to
damaged road surface.

At 30 mph the police vehicle negotiated the depression in the road with relative ease.

At 50 mph, the police vehicle reacted significantly when negotiating the depression.

At the time of Johns collision, he had just overtaken another vehicle and therefore
crossed the depression a slight angle as he returned to his own side of the carriage
way.

When the police officers replicated this vehicle movement at 50 mph, the police
vehicle reacted violently, with one of the wheels leaving the surface of the road.
The officer driving that vehicle was not prepared to attempt the same manoeuvre at
any higher speed due to the risk involved.

The police officer then told the court that the attending officers themselves were
unaware of 30 mph speed limit on this stretch of road. The officer told the court that
the main 50 mph signs, the smaller repeater 50 mph signs and the 50 mph roundels
painted on the road surface were all clearly visible on this stretch of road.

Prior to the depression the officer saw one temporary 30mph partially obscured in the
verge, but assumed it was left over from previous works, as all of the 50mph signs
remained in view.

Evidence was heard that in the normal course of events, when a temporary reduction
in a speed limit is imposed on a stretch of road, any signage indicating a higher speed
limit should be covered by either securing a dark bag or sack over each sign, or spray
painting it out.

On the basis of the police officers’ evidence, that clearly did not occur in this case,
and this, coupled to there being only one 30mph temporary sign in place prior to the
depression in the road, left road users (and attending police officers) unaware of the
reduced speed limit in place.

I am therefore concerned that should further identified road defects require a
reduction in the speed limit, that any repeat of the provision of inadequate signage
and/or a failure obscure higher speed limits may result in further fatalities.