Charlotte Avis: Prevention of Future Deaths Report

1. Secretary of State for Transport
2. Chief Executive Officer of Dorset Council

I am Rachael Clare Griffin, Senior Coroner, for the Coroner Area of Dorset.

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

On 12^th December 2022, I commenced an investigation into the death of Charlotte Katie Mae Avis, born on the 20^th April 1992 who was aged 30 years at the time of her death.

The investigation was suspended under paragraph 2 of Schedule 1 of the Coroners and Justice Act 2009 on the 16^th April 2024 as I was notified an individual had been appeared before Weymouth Magistrates Court having been charged with offences under the Road Traffic Act 1988 relating to her death.

Following the individual’s conviction and sentence, I held a hearing on the 1^st May 2025 where I determined that there was insufficient evidence to resume the Inquest following the suspension. 

At approximately 16.49 hours on the 1^st December 2022 Charlotte was driving her Silver Ford Focus along the A30 dual carriageway in an easterly direction towards Sherborne, Dorset at the crossroad junction with Marl Lane, when her vehicle was struck head on by another vehicle that was being driven in the opposite direction which had lost control and crossed over into the opposite carriageway. Charlotte sustained fatal injuries and died at the scene of the collision.

During the course of the investigation the evidence provided 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.  –

Evidence has been provided that between 01.01.2014 and 24.03.2025 there have been 8 road traffic collisions at the site of Charlotte’s death which is referred to as Loscombe Crossroads, near Sherborne, Dorset. Those collisions have resulted in slight, serious and fatal injuries being sustained by those involved. There have been 4 fatalities from 3 of the collisions in a 4 year period. These fatalities occurred on 21.01.2020, 01.12.22 and 20.02.24.The last of these fatalities occurred after Charlotte’s death.
 
Although the speed of the road was reduced by Dorset Council on 11^th October 2024 from 70mph to 60mph, I have concerns around the layout of the road and the number of collisions in the area, and that there could be future deaths that occur.

In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.

You are under a duty to respond to this report within 56 days of the date of this report, namely by 1^st July 2025. I, the coroner, may extend the period.

Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons via their legal representatives:

(1) Charlotte’s Mother
(2) Charlotte’s Partner
(3) [REDACTED]
(4) Axa Insurance
(5) Questgates Insurance
 
I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.