Ralph Ian Brazier · Prevention of Future Deaths report

The inquest into the death of Mr Brazier was opened on 4 March 2016 and was resumed and concluded on 2 March 2017. The cause of death was:

Fracture dislocation of the upper cervical spine.

The inquest concluded with a narrative conclusion.

Mr Brazier, a 52 year old man, was cycling along with 6 other riders as part of the Twickenham Cycling Club on 1 March 2016. They were cycling in the “through and off” formation whereby cyclists ride in two parallel lines rotating positions. As the group approached Weybridge on the A317 Mr Brazier was cycling on the inside of the through and off formation at approximately 20 mph. The cyclists would ride 0.75m-1m from the side of the kerb depending on the road surface. At a point on the A317, just past the junction with Hamm Court Road, the front wheel of Mr Brazier’s cycle hit a pot hole next to the drainage gully cover. His cycle was stopped instantly and he was thrown forwards landing on the road in front of the drain.

The pot hole and gully cover had been brought to the attention of Surrey County Council (SCC) after having been reported by a local resident on 25 January 2016. On the same day the SCC website reported the kerbside surface breaking up around the drain gully. The gully appeared to be collapsing and it was classed category 2 by a SCC Highways Inspector.

On 28 January 2016 the gully was temporarily repaired by a Kier Plc team and immediate response was placed on the defect by the Highways Inspector. On 12 February 2016 a permanent repair was made by the Kier Plc team whereby a new grating was fitted and the gully frame was re-fitted. On 25 February 2016, an inspection by ████████, a highways inspector for SCC, showed that the permanent repair had sunken and it was scheduled Priority 2 by ████████ for 5 working days. Had it been marked as Priority 2+ it would have been scheduled for repair within a much shorter time period.

A highway inspector from SCC would see the defect, assess the travelling public, the risk of harm or damage to the highway user and then classify it. All road users are taken into account when inspecting a road however a cycle path would be inspected differently in respect of cyclists with a different defect categorisation. For a highway the defect would have to be greater than 75mm for a 2+ defect, whereas for a designated cycle lane the defect would have to be only in excess of 40mm.

The planned date of repair was 2 March 2016, within the period of the P2 classification but one day after Mr Brazier’s death.

Having heard evidence from a number of members of Surrey County Council, I am concerned that insufficient consideration is taken by the Council of the increasing number of cyclists on their highways, particular in relation to the categorisation of defects on the highway. I am particularly concerned that designated cycle lanes are given higher priority relating to a defect than a highway, despite the high number of cyclists using the highway rather than cycle lanes with closer proximity to traffic including heavy goods vehicles.

- Surrey County Council has failed to take into sufficient account the fact that cyclists use the highways as well as the cycle lanes in their priority categorisations.
- That the great number of cyclists, and the risks to them using the highways, particularly the nearside section, are not specifically considered when Surrey County Council are assessing the highways for repair.

Re-consideration should be given to whether any steps, including changes to the categorisation of highway defects in light of the greater use of public highways by cyclists, can be taken to address the above concerns.