The deaths of two boys on a motorway has led to an shake-up to combat "Chinese Whispers" that led to confusion over the way calls were relayed to police patrols.
North Cheshire Coroner Nicholas Rheinberg recorded accident verdicts on the deaths of Kieran Coupe, six, and his pal Guy Davies, seven, who were mown-down on the M56 in Cheshire in October 2007.
The coroner had spoken of his dismay that the importance of the danger to the boys was relegated from top priority "Grade One" to the least important "Grade 5".
Inspector Stephen Jones of Cheshire Police told how there had, effectively, been a second risk assessment as the call was passed to patrols on the motorway because of miscommuniications
In a three-day inquest Warrington Coroner's Court had heard that scores of motorists made frantic 999 calls warning there were two boys with toy scooters trying to cross the road in pitch darkness.
But the message received by a police patrol said there were "two young males with scooters or bikes" on a stretch of motorway at Runcorn.
PC Simon Jordan said that he sped to the scene at 120mph expecting to find two teenagers pushing motorbikes or scooters along the hard shoulder.
In fact he arrived at the place where the boys had been killed when they tried to double-back across three lanes of traffic from the central reservation.
Inspector Stephen Jones of Cheshire Police said there had effectively been a "second risk assessment" in the process of passing the information to motorway patrols.
However, the court heard the "Chinese Wispers" had no impact on the speed at which PC Jordan arrived at the scene and the coroner praised his diligence.
Mr Rheinberg said: "The incident deserved the most serious rather than the most benign treatment.
"It’s almost like Chinese Whispers as it goes through a whole lot of processes because the person on the ground assumes someone has just broken down on the hard shoulder."
The the pals had become disorientated when darkness fell after the spent an afternoon playing in woodland at Runcorn, Cheshire, on 24th October 2007.
The probably strayed onto the motorway, in trying to head home, through a missing section of perimeter fencing that had been removed by contractors.
The first 999 called was taken at 7.01 pm and the boys both died at 7. 22pm as a result of multiple injuries including skull fractures.
Recording an accident verdict Mr Rheinberg said: "The deaths of Kieran Coupe and Guy Davies were unintentional, but valuable lessons can be learned by all parties to prevent a re-occurrence of this tragic event.
"The fact that it was two young children was not communicated due an error and lessons need to be learned so that officers on the ground are provided with the most accurate and up-to-date information.
"These were very young children, probably absolutely terrified and acting in the spare of the moment without thought or consideration.
"There is no evidence as to why they turned back from the central reservation, the whole motorway is unlit and it is quite possible that they were drawn to the lights of the nearby pub.
"It is incredibly difficult for the families to revisit these tragic events two years on.
"Lessons can be learned and it is my hope that this tragedy is never repeated."
Speaking outside Warrington Coroner's Court Supt Guy Hindle said: "We acknowledge that there were mistakes made by ourselves in the way that emergency calls were taken.
"In respect of this, we have implemented a number of recommendations including the recording of telephone calls and greater facilities are now available to call handlers to help with locating the scene of an incident.
"There are many messages to take from this, the carriageways are clearly not a place for adults, let alone for children. As the coroner rightly said, the terror which went through these boys' minds is impossible to comprehend.
"Clearly, it is likely that the children accessed the carriageway in an area where fencing was minimal. and the new fencing now in place should provide a far greater deterrent to pedestrians.
"Additionally, parents must take on board the important lessons which have been learnt from this tragedy and pass on these important safety messages to their children."
Guy Davies' mother and father, and Kieran Coupe's father, Colin Lambert, 33, were present throughout the hearing.
Outside the court heartbroken father Guy Davies snr choked back tears as he said: "On behalf of my family and myself I would like to thank everybody who has supported us through this terrible ordeal.
"Yesterday was road traffic accident awareness day which highlights how important road safety is.
"And I hope many other children have taken these lesson on board.
"I am a HGV lorry driver and very experienced motorway user, and more should be done to prevent accidents on the motorway.
"If a sign says 60 mph then 70mph is too high."
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