Recurring concern

Inadequate safety controls at high-risk road junctions

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First reported 2 Dec 2013•Latest report 11 Dec 2025

Definition

What this concern includes

Includes failures or hazards in road-junction layouts and dedicated safety controls where recurring collisions or serious collision risk indicate that the junction is not reliably made safe, including layout, signage, markings, speed or other junction-specific mitigation measures.

Not included

  • Excludes generic road-safety, highway-maintenance or collision concerns without a material road-junction safety condition.
  • Excludes failures limited to a specific road-marking, signage or inspection process where junction safety is not the shared unsafe condition.
  • Excludes pedestrian-crossing, railway, vehicle-design and non-junction hazards unless the assertion directly concerns safety of the road junction.
  • Excludes a single isolated collision or factual hazard where no continuing deficiency or recurring collision risk is identified.
Reports
55

Distinct published reports

Individual concerns
85

A report can raise multiple concerns

Date range
2013–2025

First to latest report issue date

Stated actions
126

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

National Highways8
Department for Transport6
Office of the Chief Coroner4
Transport for London4
Lincolnshire County Council3
Recipient name withheld3
A-One+2
Apple (UK) Limited2
Birmingham City Council2
Google UK Limited2
Leicester City Council2
Nottinghamshire County Council2
Slough Borough Council2
TomTom2
Wiltshire Council2

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. North Wales (East and Central)

    AI-generated summary

    David Paul Langford · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    David Paul Langford died at the scene after his motorcycle collided with a motor vehicle emerging from the Waterloo Hill junction. Concerns included restricted visibility caused by vegetation, the condition and positioning of railings and a visibility mirror, and the national speed limit at the dangerous junction.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to address obstructive and deteriorated railings at the junction

    Wider context from the report

    “Whilst these improvements are noted there remain two concerns 1. The railings to the right of the junction are old and rusty and their position provides a barrier from view down the road. It was noted that Conwy County Borough Council had noted this and no action has yet been taken; and 2. It was noted that the stretch of road in question is subject to a national speed limit and it is a concern that this high Speed does not account for the dangerous junction at Waterloo Hill. I am concerned that deaths will occur into the future and/or continue to occur as a result of these concerns. ”

    Source location

    David Paul Langford · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to set a speed limit that accounts for the dangerous junction at Waterloo Hill

    Wider context from the report

    “Whilst these improvements are noted there remain two concerns 1. The railings to the right of the junction are old and rusty and their position provides a barrier from view down the road. It was noted that Conwy County Borough Council had noted this and no action has yet been taken; and 2. It was noted that the stretch of road in question is subject to a national speed limit and it is a concern that this high Speed does not account for the dangerous junction at Waterloo Hill. I am concerned that deaths will occur into the future and/or continue to occur as a result of these concerns. ”

    Source location

    David Paul Langford · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Replace the privately owned junction railings with a more suitable boundary treatment at Council expense.

    Verbatim wording from the response

    “These railings are privately owned and located on the property known as Pentre Smithy. The Council has approached the property owner and reached agreement to replace the railing with a more suitable boundary treatment, at the Council’s expense. This will be carried out by March 31st, 2026.”

    Source location

    Response from Conwy County Borough Council
    Page 1 · response
    Published 18 December 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Complete a route speed-limit review for the A548 between Llanfair TH and Llangernyw under national guidance.

    Verbatim wording from the response

    “The Council has conducted a route speed limit review for the A548 between Llanfair TH and Llangernyw in accordance with national guidance (Setting of Local Speed Limits in Wales circular 24/2009). It is proposed to reduce the speed limit on the A548 to 40mph from a point 65 metres north of its junction with Cae Lian, Llangernyw to a point 45 metres east of the turning to Nant Mawr, a distance of approximately 4km (which includes the Waterloo Hill junction).”

    Source location

    Response from Conwy County Borough Council
    Page 1 · response
    Published 18 December 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Advertise the proposed A548 40mph speed-limit reduction as a Traffic Regulation Order and undertake the required consultation and legal process.

    Verbatim wording from the response

    “The Council has conducted a route speed limit review for the A548 between Llanfair TH and Llangernyw in accordance with national guidance (Setting of Local Speed Limits in Wales circular 24/2009). It is proposed to reduce the speed limit on the A548 to 40mph from a point 65 metres north of its junction with Cae Lian, Llangernyw to a point 45 metres east of the turning to Nant Mawr, a distance of approximately 4km (which includes the Waterloo Hill junction).”

    Source location

    Response from Conwy County Borough Council
    Page 1 · response
    Published 18 December 2025

    Open published response
  2. Birmingham and Solihull

    AI-generated summary

    Charlotte NOORDAM · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Charlotte NOORDAM died on 8 March 2025 after her motorbike collided with a car at the junction of Frederick Road and St James Road in Edgbaston. The report raises concerns about the junction's safety, noting at least 27 other road traffic incidents there and an ongoing risk to life despite existing signage and road markings.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of the junction layout, signage and road markings to mitigate incident risk at the stop junction

    Wider context from the report

    “3. Whilst the road layout, including signage and road markings, complies with the legal requirements this does not appear to have mitigated against the prevalence of incidents at the stop junction. 4. There have been at least 27 other road traffic incidents at the same junction during the period 23rd May 2014 to the 8th March 25. 5. The police investigator gave evidence that, in his experience, the number of collisions at the stop junction raises questions about the safety of the junction. 6. Evidence from Birmingham City Council suggested that there were potentially additional measures that could be considered to mitigate any safety risks so far as reasonably practicable. 7. I am concerned that there is still a risk to life for users of the junction. ”

    Source location

    Charlotte NOORDAM · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement the Fatal Collision Response Protocol to assess site conditions and identify locally appropriate safety interventions.

    Verbatim wording from the response

    “In accordance with the statutory timeframe, the Council is implementing its Fatal Collision Response Protocol to assess the specific site conditions to identify locally appropriate interventions which we intend to deliver in two phases. The first of these will be implementation of vertical traffic calming measures and additional signage to better alert drivers to the presence of the junction. We will deliver these measures within a six-month period of the date of this letter.”

    Source location

    Response from Birmingham City Council
    Page 1 · response
    Published 14 August 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement vertical traffic-calming measures and additional junction warning signage within six months.

    Verbatim wording from the response

    “In accordance with the statutory timeframe, the Council is implementing its Fatal Collision Response Protocol to assess the specific site conditions to identify locally appropriate interventions which we intend to deliver in two phases. The first of these will be implementation of vertical traffic calming measures and additional signage to better alert drivers to the presence of the junction. We will deliver these measures within a six-month period of the date of this letter.”

    Source location

    Response from Birmingham City Council
    Page 1 · response
    Published 14 August 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Design and assess traffic-management measures to redirect vehicles away from the junction before proceeding to implementation.

    Verbatim wording from the response

    “This decision reflects our commitment to prioritise public safety and prevent future loss of life, as set out in our adopted Road Harm Reduction Strategy. Vehicular traffic will be redirected away from residential areas towards the city’s classified road network, which is better equipped to handle higher vehicular traffic volumes safely.”

    Source location

    Response from Birmingham City Council
    Page 1 · response
    Published 14 August 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Meaningful Safe System redesign is not feasible because it would require significant demolition of the surrounding built environment.

    Verbatim wording from the response

    “As meaningful redesign in alignment with the Safe System approach would require significant demolition of the surrounding built environment, this approach is wholly inappropriate for this setting. Therefore, the Council confirms its intention to take decisive steps to address the volume of vehicular traffic using this junction.”

    Source location

    Response from Birmingham City Council
    Page 1 · response
    Published 14 August 2025

    Open published response
  3. Dorset

    AI-generated summary

    Charlotte Katie Mae Avis · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Charlotte Katie Mae Avis died at the scene after her car was struck head-on by a vehicle that had lost control and crossed into the opposite carriageway on 1 December 2022. The report raises concerns about the layout of Loscombe Crossroads and the number of collisions and fatalities at the site, with concern that future deaths could occur.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Hazardous road layout at Loscombe Crossroads

    Wider context from the report

    “(1) 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. (2) Although the speed of the road was reduced by Dorset Council on 11th 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. ”

    Source location

    Charlotte Katie Mae Avis · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Continuing risk of road traffic collisions at Loscombe Crossroads

    Wider context from the report

    “(1) 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. (2) Although the speed of the road was reduced by Dorset Council on 11th 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. ”

    Source location

    Charlotte Katie Mae Avis · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Conduct a feasibility study for introducing average speed cameras on the A30 between Yeovil and Sherborne, collaborating with relevant stakeholders including Dorset Police.

    Verbatim wording from the response

    “2. Records show a high number of collisions along the entire length of the A30 dual carriageway between Yeovil and Sherborne, with many vehicles significantly exceeding the speed limit. Therefore, we are conducting a feasibility study to introduce Average Speed Cameras to ensure compliance with the recent change in speed limit to 60mph. This work will involve close collaboration with stakeholders, including Dorset Police.”

    Source location

    Response from Dorset Council
    Page 2 · response
    Published 19 May 2025

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Reduce the speed limit at the relevant road site from 70mph to 60mph.

    Verbatim wording from the response

    “(2) Although the speed of the road was reduced by Dorset Council on 11th 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.”

    Source location

    Response from Dorset Council
    Page 1 · response
    Published 19 May 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Dorset Council, as the traffic authority, is responsible for decisions about road design, speed limits, traffic calming and road network management.

    Verbatim wording from the response

    “You expressed concerns regarding the layout of the road as a factor in the collision. Responsibility for making decisions about the roads under its care rests with the traffic authority, based on its knowledge of the area and taking into account local needs and circumstances. Local authorities, in this case Dorset Council, are free to make their own decisions about the design of the roads and streets under their care, provided they take account of the relevant legislation. This includes setting local speed limits and introducing traffic calming measures such as speed cameras and speed activated warning signs.”

    Source location

    Response from Department for Transport
    Page 1 · response
    Published 19 May 2025

    Open published response
  4. Northamptonshire

    AI-generated summary

    Jane BENNETT · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mrs Bennett was involved in a road traffic collision at the junction of St Johns Road, Tiffield and the A43 on 13 March 2024 and was later confirmed deceased on 15 March 2024. The report raises concern that the junction is very difficult to manoeuvre and that, without changes, further accidents or fatalities are likely.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Hazardous difficulty manoeuvring at the junction of St Johns Road, Tiffield and the A43 Northamptonshire

    Wider context from the report

    “The junction of St Johns Road, Tiffield and the A43 Northamptonshire is very difficult to manoeuvre. Witnesses who attended at the inquest gave evidence to the effect that unless some changes are made there are likely to be further accidents/or fatalities. I concur with this view. ”

    Source location

    Jane BENNETT · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Carry out planned summer 2025 minor surfacing works, including refreshed eastbound road markings and reflective road studs through the junction.

    Verbatim wording from the response

    “In advance of the 2026/2027 planned carriageway renewals scheme, National Highways is planning minor surfacing works for Summer 2025. This will include refreshing road markings and reflective road studs on the A43 eastbound mainline through the junction. We are currently investigating the possibility of including the vegetation clearance in these works.”

    Source location

    Response from National Highways
    Page 2 · response
    Published 7 February 2025

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Investigate including vegetation clearance in the summer 2025 works to improve visibility at the junction.

    Verbatim wording from the response

    “In advance of the 2026/2027 planned carriageway renewals scheme, National Highways is planning minor surfacing works for Summer 2025. This will include refreshing road markings and reflective road studs on the A43 eastbound mainline through the junction. We are currently investigating the possibility of including the vegetation clearance in these works.”

    Source location

    Response from National Highways
    Page 2 · response
    Published 7 February 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Develop and construct the 2026 A43 renewals scheme, including carriageway resurfacing, line-marking repainting and replacement reflective road studs through to St John’s Road junction.

    Verbatim wording from the response

    “National Highways currently have a renewals scheme programmed for 2026/2027 which includes resurfacing, road markings, road studs, vegetation clearance, and drainage for sections of the A43 including St John’s junction.”

    Source location

    Response from National Highways
    Page 2 · response
    Published 7 February 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Investigate potential junction improvements, such as signage, as part of the A43 renewals scheme scoping.

    Verbatim wording from the response

    “The A43 renewals scheme is currently being developed and scheduled for construction in the later part of 2026. This scheme involves resurfacing of the A43 eastbound and westbound carriageway, repainting of the line markings and replacing the reflective road studs from the M1 motorway through to St John’s Road junction. While the physical layout of the junction will not change, as part of our scoping we are investigating potential improvements for the junction of St John’s Road, such as signage.”

    Source location

    Response from National Highways
    Page 2 · response
    Published 7 February 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The junction does not rank highly as a safety problem location, so detailed investigations for a potential safety improvement scheme have not been prioritised.

    Verbatim wording from the response

    “Following the fatal incident National Highways has referred to this assessment list and the junction of the A43 / St John’s Road does not appear within the top 100 sites in the Midlands. Although this data does not include the recent fatality it does reveal that this junction has a relatively good safety record in relation to the Midlands trunk and motorway network, with only two ‘slight’ injury collisions recorded here within that 5 year period. Based on this, the junction of the A43 and St John’s Road does not rank highly as a safety problem location, and for this reason we have not prioritised this junction as a location to undertake detailed investigations for a potential safety improvement scheme.”

    Source location

    Response from National Highways
    Page 1 · response
    Published 7 February 2025

    Open published response
  5. Milton Keynes

    AI-generated summary

    Amal Mohamed AHMED · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Amal Mohamed Ahmed died at the scene after entering the A5 southbound off slip road in the wrong direction and colliding head-on with another vehicle. The other vehicle’s driver later died in hospital, and a passenger suffered life-threatening injuries. The principal concern was that inadequate, poorly positioned and poorly visible signage and the unlit, wide junction allowed drivers to enter the slip road incorrectly; other drivers were observed making the same manoeuvre.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inadequate positioning and visibility of No Entry signage for wrong-way slip-road entry

    Wider context from the report

    “The exit point of the A5 "off" slip road at the Little Brickhill junction is wide. The signage indicating No Entry appears to be inadequate as there are two No Entry signs which are widely spaced at the junction. One is positioned to appear to forbid entry to the road over the bridge leading over the A5 and does not obviously relate to the slip road. The second is positioned such that it obliquely faces the road over the bridge and would not be visible to a driver turning right onto the slip road until they had completed the manoeuvre placing them at risk. There is a No Right Turn sign as the junction is approached. There is also No Entry in large white letters at the mouth of the slip road junction, however, this may be (1) obscured by vehicles leaving the slip road and (2) the junction is unlit and was said by a witness as being "pitch black". After the collision attention police officers saw three further vehicles perform exactly the same manoeuvre as Ms Ahmed and attempt to travel down the slip road in the wrong direction. Local residents have contacted police and claimed that it is a very common occurrence for drivers to mistakenly travel down the slip road in the wrong direction. The slip road is long and allows for the build up of considerable speed in turn facilitating what the police describe as a high energy impact. Following the collision, large temporary No Entry signs were positioned at the slip road junction. They were quickly removed apparently because the original signs were deemed to comply with necessary regulations. That seems wholly irrelevant to me because drivers are clearly commonly not seeing the signs because of the large numbers who mistakenly drive the wrong way onto the slip road. In my opinion, consideration should be given to alternative arrangements to prevent vehicles entering and travelling along the slip road in the wrong direction. ”

    Source location

    Amal Mohamed AHMED · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Frequent wrong-way driving down the slip road into oncoming traffic

    Wider context from the report

    “I have made observations regarding the slip road at this junction in my initial pre-Inquest Report To Prevent Future Deaths dated the 21st December 2023. National Highways undertook a number of immediate remedial measures to try to prevent drivers turning and travelling the wrong way down this slip road, including narrowing the "mouth" of the slip road to one lane, placement of very large temporary "No Entry" signs and placement of signs indicating "Do Not Use Satnav" at the site. CCTV monitoring of driver behaviour was commenced. Police activity and monitoring by National Highways showed that despite these measures, drivers were still turning early and attempting to drive the wrong way down the slip road. Further enquiries by the police and information volunteered by members of the public who made the same incorrect manoeuvre led to the finding that while the visual map display on commonly used satnav applications at this junction displayed the correct information, the verbal commands gave information likely to confuse and direct drivers down the wrong slip road into the path of oncoming traffic. This was observed to happen frequently. ”

    Source location

    Amal Mohamed AHMED · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Slip-road geometry allowing wrong-way vehicles to enter and build up considerable speed

    Wider context from the report

    “The exit point of the A5 "off" slip road at the Little Brickhill junction is wide. The signage indicating No Entry appears to be inadequate as there are two No Entry signs which are widely spaced at the junction. One is positioned to appear to forbid entry to the road over the bridge leading over the A5 and does not obviously relate to the slip road. The second is positioned such that it obliquely faces the road over the bridge and would not be visible to a driver turning right onto the slip road until they had completed the manoeuvre placing them at risk. There is a No Right Turn sign as the junction is approached. There is also No Entry in large white letters at the mouth of the slip road junction, however, this may be (1) obscured by vehicles leaving the slip road and (2) the junction is unlit and was said by a witness as being "pitch black". After the collision attention police officers saw three further vehicles perform exactly the same manoeuvre as Ms Ahmed and attempt to travel down the slip road in the wrong direction. Local residents have contacted police and claimed that it is a very common occurrence for drivers to mistakenly travel down the slip road in the wrong direction. The slip road is long and allows for the build up of considerable speed in turn facilitating what the police describe as a high energy impact. Following the collision, large temporary No Entry signs were positioned at the slip road junction. They were quickly removed apparently because the original signs were deemed to comply with necessary regulations. That seems wholly irrelevant to me because drivers are clearly commonly not seeing the signs because of the large numbers who mistakenly drive the wrong way onto the slip road. In my opinion, consideration should be given to alternative arrangements to prevent vehicles entering and travelling along the slip road in the wrong direction. ”

    Source location

    Amal Mohamed AHMED · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to maintain adequate visibility of road-surface No Entry markings at the slip-road junction

    Wider context from the report

    “The exit point of the A5 "off" slip road at the Little Brickhill junction is wide. The signage indicating No Entry appears to be inadequate as there are two No Entry signs which are widely spaced at the junction. One is positioned to appear to forbid entry to the road over the bridge leading over the A5 and does not obviously relate to the slip road. The second is positioned such that it obliquely faces the road over the bridge and would not be visible to a driver turning right onto the slip road until they had completed the manoeuvre placing them at risk. There is a No Right Turn sign as the junction is approached. There is also No Entry in large white letters at the mouth of the slip road junction, however, this may be (1) obscured by vehicles leaving the slip road and (2) the junction is unlit and was said by a witness as being "pitch black". After the collision attention police officers saw three further vehicles perform exactly the same manoeuvre as Ms Ahmed and attempt to travel down the slip road in the wrong direction. Local residents have contacted police and claimed that it is a very common occurrence for drivers to mistakenly travel down the slip road in the wrong direction. The slip road is long and allows for the build up of considerable speed in turn facilitating what the police describe as a high energy impact. Following the collision, large temporary No Entry signs were positioned at the slip road junction. They were quickly removed apparently because the original signs were deemed to comply with necessary regulations. That seems wholly irrelevant to me because drivers are clearly commonly not seeing the signs because of the large numbers who mistakenly drive the wrong way onto the slip road. In my opinion, consideration should be given to alternative arrangements to prevent vehicles entering and travelling along the slip road in the wrong direction. ”

    Source location

    Amal Mohamed AHMED · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Install temporary large No Entry signs on A-frames at both sides of the A5 off-slip exit.

    Verbatim wording from the response

    “Further temporary signing has been put in place at the exit point of the A5 off slip at the Little Brickhill junction in the form of two large 1200mm ‘No Entry’ signs on A-frames on each side of the carriageway (Traffic Signs Regulations and General Directions (TSRGD), Diagram 616 No entry for vehicular traffic). These signs are intended to provide mitigation against further wrong way driving incidents while a full safety review of the junction has been undertaken.”

    Source location

    Response from Highways
    Page 1 · response
    Published 29 December 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Complete a full safety review of the junction against the current Wrong Way Driving: Mitigation Toolkit.

    Verbatim wording from the response

    “The site visit has informed a full safety review of the junction, including an assessment of the junction against the latest version of National Highways’ Wrong Way Driving: Mitigation Toolkit (v1.2 January 2021). The junction had previously been assessed against the previous version of the toolkit (first issued in 2017).”

    Source location

    Response from Highways
    Page 1 · response
    Published 29 December 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Continue developing enhanced A5 off-slip mitigation options and establish which measures will be progressed, including improved signage and road markings.

    Verbatim wording from the response

    “• The site assessment has established that, when measured against the Wrong Way Driving Toolkit, the junction has all the required ‘standard’ mitigation measures in place. However, potential improvements to road markings and signage on both National Highways and Milton Keynes City Council’s network have been identified.”

    Source location

    Response from Highways
    Page 2 · response
    Published 29 December 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Undertake further work to assess junction capacity and whether the A5 off-slip bell-mouth width can be reduced with hatched markings.

    Verbatim wording from the response

    “○ Width of the junction bell mouth at the end of the A5 off slip – the A5 off slip and junction bell mouth is two lanes wide. The bell mouth is effectively widened by the concrete overrun area along the eastern edge of the bell mouth. Reducing the width of the junction with hatched road markings may increase the conspicuity of the ‘No Entry’ measures. Further work will be undertaken to understand the capacity of the junction and whether the junction width can be reduced.”

    Source location

    Response from Highways
    Page 2 · response
    Published 29 December 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Inspect the junction and assess signage and road markings for safety defects.

    Verbatim wording from the response

    “We received a ‘Report-It’ made on 28 May 2023. The records show that in this case a highways inspector visited the location on 2 June 2023 and made the following note ‘Inspection on 02/06/23 enough signage and road marking on road saying no entry. No safety defects found all below investigatory levels’. This reflects his remit to consider the condition of those assets in respect of safety. A standardised response was sent to the customer.”

    Source location

    Response from Milton Keynes City Council
    Page 2 · response
    Published 29 December 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review the junction situation later as part of the planned work programme.

    Verbatim wording from the response

    “We have another ‘Report-It’ made on 21 November 2023 which was made following the incident. The same inspector visited the site again and again found no immediate safety hazard based on condition (of the asset) and highlighted to the resident on 13 January 2024 that we have investigated and intend to review the situation at a later date as part of our planned work programme. A standardised response was sent to the customer.”

    Source location

    Response from Milton Keynes City Council
    Page 2 · response
    Published 29 December 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review navigation instructions near the junction by simulating driver-speed scenarios and assessing instruction timing.

    Verbatim wording from the response

    “Following the report, we reviewed our navigation systems’ verbal instructions provided near the junction at hand. We have simulated different scenarios, including speed variations of 60mph and 30mph, to better understand how our navigation systems presented instructions based on driver speed. The scenarios assumed that the driver would either (i) maintain maximum speed until the junction; or (ii) slow down when approaching it. The outcome of the review revealed that instructions were given either (i) right when passing by the off-slip road; or (ii) after passing by the off-slip road, when on the overpass towards the exit.”

    Source location

    Response from TomTom
    Page 1 · response
    Published 29 December 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement safeguards that time verbal navigation commands closer to the exit and after drivers pass the off-slip road.

    Verbatim wording from the response

    “As part of our ongoing efforts to enhance road safety, we recently implemented additional safeguards, to limit drivers’ confusion where possible, regardless of their speed behavior on the road, by timing the verbal commands closer to the actual exit, and in any event after passing the off-slip road. However, please note that in order for these changes to be effective and visible by end users, they need to use the latest map and therefore in certain circumstances need to update their systems/devices.”

    Source location

    Response from TomTom
    Page 1 · response
    Published 29 December 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Investigate and develop improvements to the timing of Google Maps audio guidance.

    Verbatim wording from the response

    “• We have liaised with National Highways and reviewed their helpful dashcam footage of the relevant junction. This has assisted our product and engineering teams in carefully investigating the audio guidance provided by Google Maps. Our teams are working on improvements to the timing of the audio guidance.”

    Source location

    Response from Google
    Page 2 · response
    Published 29 December 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Add special voice guidance directing westbound drivers to continue straight at the overpass and turn right onto the A5 toward Milton Keynes and Bletchley.

    Verbatim wording from the response

    “However, to ensure we were following the very best approach we are taking an additional measure to add the following special voice guidance for drivers heading past the A5 offramp toward the A5 onramp, which we intend will be live by the start of next week. - Drivers heading past the A5 offramp toward the A5 onramp would be instructed to “Continue straight at the overpass” (that will happen as they are traveling westward from the offramp). - While on the overpass, drivers would be instructed to “Turn right onto A5 toward Milton Keynes, Bletchley.””

    Source location

    Response from Apple
    Page 1 · response
    Published 29 December 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Reinspect the site after the incident and investigate whether an immediate safety hazard exists.

    Verbatim wording from the response

    “City highways officials visited the site on 20 November after the fatal incident with Thames Valley Police (TVP). TVP then conveyed a video call with MKCC and National Highways on 21 November and National Highways took subsequent actions on their junction. We would”

    Source location

    Response from Milton Keynes City Council
    Page 1 · response
    Published 29 December 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The junction already has all standard wrong-way-driving mitigation measures required by the current toolkit.

    Verbatim wording from the response

    “• The site assessment has established that, when measured against the Wrong Way Driving Toolkit, the junction has all the required ‘standard’ mitigation measures in place. However, potential improvements to road markings and signage on both National Highways and Milton Keynes City Council’s network have been identified.”

    Source location

    Response from Highways
    Page 2 · response
    Published 29 December 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Existing signage and road markings appeared adequate under applicable regulations, although illumination might improve the no-entry signage.

    Verbatim wording from the response

    “agree with National Highways that the signage appeared adequate to regulations, although we would suggest that the National Highways no-entry signage at the slip road junction may benefit from illumination (although the Traffic Signs Regulations and General Directions guidance does not require this).”

    Source location

    Response from Milton Keynes City Council
    Page 2 · response
    Published 29 December 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The council has no powers to improve the junction mouth, signage or road markings because these are outside its highway authority functions.

    Verbatim wording from the response

    “The slip road, its junction with the local road, and the signage and road markings at the end of the slip road are part of the National Highways asset and they are therefore the responsible highway authority.”

    Source location

    Response from Milton Keynes City Council
    Page 1 · response
    Published 29 December 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    National Highways is responsible for the slip road junction, its signage and road markings, so it must undertake related improvements.

    Verbatim wording from the response

    “The slip road, its junction with the local road, and the signage and road markings at the end of the slip road are part of the National Highways asset and they are therefore the responsible highway authority.”

    Source location

    Response from Milton Keynes City Council
    Page 1 · response
    Published 29 December 2023

    Open published response
  6. Milton Keynes

    AI-generated summary

    Tracey Julie HAYBITTLE · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Tracey Julie Haybittle died at the John Radcliffe Hospital after a head-on collision when another driver entered the wrong slip road at the Little Brickhill junction. The report raised concerns that verbal commands from commonly used satnav applications could confuse and direct drivers down the wrong slip road into oncoming traffic, and that this occurred frequently despite remedial measures.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of commonly used satnav applications to provide safe verbal directions at the junction

    Wider context from the report

    “I have made observations regarding the slip road at this junction in my initial pre-Inquest Report To Prevent Future Deaths dated the 21st December 2023 in respect of the linked case of Amal Mohamed Ahmood. National Highways undertook a number of immediate remedial measures to try to prevent drivers turning and travelling the wrong way down this slip road, including narrowing the "mouth" of the slip road to one lane, placement of very large temporary "No Entry" signs and placement of signs indicating "Do Not Use Satnav" at the site. CCTV monitoring of driver behaviour was commenced. Police activity and monitoring by National Highways showed that despite these measures, drivers were still turning early and attempting to drive the wrong way down the slip road. Further enquiries by the police and information volunteered by members of the public who made the same incorrect manoeuvre led to the finding that while the visual map display on commonly used satnav applications at this junction displayed the correct information, the verbal commands gave information likely to confuse and direct drivers down the wrong slip road into the path of oncoming traffic. This was observed to happen frequently. ”

    Source location

    Tracey Julie HAYBITTLE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review navigation instructions and simulate speed scenarios near the junction.

    Verbatim wording from the response

    “Following the report, we reviewed our navigation systems’ verbal instructions provided near the junction at hand. We have simulated different scenarios, including speed variations of 60mph and 30mph, to better understand how our navigation systems presented instructions based on driver speed. The scenarios assumed that the driver would either (i) maintain maximum speed until the junction; or (ii) slow down when approaching it. The outcome of the review revealed that instructions were given either (i) right when passing by the off-slip road; or (ii) after passing by the off-slip road, when on the overpass towards the exit.”

    Source location

    Response from TomTom
    Page 1 · response
    Published 30 August 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement safeguards that time verbal commands closer to the exit and after the off-slip road.

    Verbatim wording from the response

    “As part of our ongoing efforts to enhance road safety, we recently implemented additional safeguards, to limit drivers’ confusion where possible, regardless of their speed behavior on the road, by timing the verbal commands closer to the actual exit, and in any event after passing the off-slip road. However, please note that in order for these changes to be effective and visible by end users, they need to use the latest map and therefore in certain circumstances need to update their systems/devices.”

    Source location

    Response from TomTom
    Page 1 · response
    Published 30 August 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Deploy temporary ‘Do not follow Sat Nav’ and customer-information signs at the junction.

    Verbatim wording from the response

    “Again, on the 29 April 2024, the location was visited by National Highways and Thames Valley Police (Traffic Management Officer). During the site visit, a vehicle was observed to attempt to turn right into the slip road against the No-Entry signing. The driver was flagged down and aborted the turn. On speaking to the driver, they said that the Sat Nav app said to turn right. This raised concerns that Sat Nav instructions may have been leading to driver confusion.”

    Source location

    Response from National Highways
    Page 5 · response
    Published 30 August 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Investigate Sat Nav routing and liaise with Google Maps, Apple Maps and WAZE regarding potentially confusing audible instructions.

    Verbatim wording from the response

    “Investigations have been undertaken to understand the potential influence Sat Nav instructions are having on driver behaviour. Route drives were undertaken using various Sat Nav apps (Google Maps, Apple Maps and WAZE) to review route guidance given to drivers.”

    Source location

    Response from National Highways
    Page 6 · response
    Published 30 August 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Liaised with National Highways and reviewed dashcam footage of the junction to inform investigation of Google Maps audio guidance.

    Verbatim wording from the response

    “• We have liaised with National Highways and reviewed their helpful dashcam footage of the relevant junction. This has assisted our product and engineering teams in carefully investigating the audio guidance provided by Google Maps. Our teams are working on improvements to the timing of the audio guidance.”

    Source location

    Response from Google
    Page 2 · response
    Published 30 August 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Investigate and develop improvements to the timing of Google Maps audio guidance.

    Verbatim wording from the response

    “• We have liaised with National Highways and reviewed their helpful dashcam footage of the relevant junction. This has assisted our product and engineering teams in carefully investigating the audio guidance provided by Google Maps. Our teams are working on improvements to the timing of the audio guidance.”

    Source location

    Response from Google
    Page 2 · response
    Published 30 August 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Add special voice guidance instructing drivers to continue straight at the overpass and turn right onto the A5 toward Milton Keynes, Bletchley.

    Verbatim wording from the response

    “However, to ensure we were following the very best approach we are taking an additional measure to add the following special voice guidance for drivers heading past the A5 offramp toward the A5 onramp, which we intend will be live by the start of next week. - Drivers heading past the A5 offramp toward the A5 onramp would be instructed to “Continue straight at the overpass” (that will happen as they are travelling west toward the offramp). - While on the overpass, drivers would be instructed to “Turn right onto A5 toward Milton Keynes, Bletchley.””

    Source location

    Response from Apple
    Page 1 · response
    Published 30 August 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    It is not clear whether Google Maps was involved in the incidents described in the reports.

    Verbatim wording from the response

    “We recognise that the cases identified in the reports are tragic. While it is not clear whether Google Maps was involved, we have carefully considered whether there are improvements we can make to Google Maps to help ensure that similar incidents do not occur in future. We have therefore taken the following measures:”

    Source location

    Response from Google
    Page 2 · response
    Published 30 August 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Maps had no data or routing error that contributed to the deaths.

    Verbatim wording from the response

    “We immediately investigated the concerns raised and found no data or routing error on Maps which would have contributed to these tragic events.”

    Source location

    Response from Apple
    Page 1 · response
    Published 30 August 2024

    Open published response
  7. Lincolnshire

    AI-generated summary

    Absolom Adolphus Abraham Zephaniah DUFFY · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Absolom Duffy was travelling in his Land Rover Defender when he exited Sand Lane, Saxilby, onto Doddington Road and collided with another vehicle; he died from his injuries. The concern was whether the junction would be safer with a stop command rather than a give-way warning because of its restricted view.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of junction signage to require stopping where visibility of the major road is restricted

    Wider context from the report

    “The B1190 Tom Otter’s Lane junction with the C267 Sand Lane, Saxilby, Lincolnshire provides for the road user approaching from either direction on Sand Lane to give way to traffic on the major B1190 road. There is a restricted view of the B1190 as a road user approaches the junction. To be certain the B1190 road is clear a road user would be required to stop, however the road signage only requires a road user to give way. Would the junction be safer for road users if it displayed a stop command rather than a give way warning? ”

    Source location

    Absolom Adolphus Abraham Zephaniah DUFFY · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Regularly assess vegetation at the junction approaches and take enforcement action to maintain maximum visibility and unobstructed visibility splays.

    Verbatim wording from the response

    “• Vegetation at approaches to this junction will be assessed regularly by the Local Highways team, with appropriate enforcement action taken to ensure that it gives maximum visibility and does not reduce the splays when exiting onto the B1190.”

    Source location

    Response from Lincolnshire Council
    Page 3 · response
    Published 6 September 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Existing Give Way signage will not be changed because junction visibility substantially exceeds the distance at which a Stop sign might be considered.

    Verbatim wording from the response

    “The visibility distance below which a STOP sign might be considered at this location is 90m (based on using 85th percentile speed of 60mph) as specified in Table 2.1 of Traffic Signs Manual Chapter 3.”

    Source location

    Response from Lincolnshire Council
    Page 2 · response
    Published 6 September 2023

    Open published response
  8. Cornwall and Isles of Scilly

    AI-generated summary

    KAIUS JOHN PAUL TUTT · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Kaius John Paul Tutt died from multiple injuries after the motorcycle he was riding collided with a car on the A391 near St Austell on 14 October 2022. The principal concerns were faded or missing road-marking deflection arrows, visibility issues at the collision location, and the limited benefit of the downhill overtaking opportunity. The report also records a recommendation to amend the road layout, with no funding then available to facilitate it.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Visibility deficiencies between downhill traffic and cars exiting the roundabout

    Wider context from the report

    “(2) The court found that there were visibility issues for those travelling downhill viewing cars exiting roundabout and vice versa. ”

    Source location

    KAIUS JOHN PAUL TUTT · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  9. County Durham and Darlington

    AI-generated summary

    Kelly Nadine DUNNE · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Kelly Nadine DUNNE died at the Royal Victoria Infirmary in Newcastle on 4 July 2022 from fatal head injuries sustained in a road traffic collision on 2 July 2022. Concerns were raised about the adequacy and layout of the junction and other junctions on the A690, including traffic volume, traffic complexity, speed limits, and the timing and sufficiency of proposed safety improvements in light of planned development.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide adequate speed control within the junction series

    Wider context from the report

    “During the course of the Inquest evidence was heard from the lead road traffic collision investigator in the case that there are significant concerns in relation to the adequacy and layout of this particular junction and the five other junctions on this stretch of road (A690). Evidence was given that since this fatality, there has been another fatal road traffic collision on the 22/12/22, at the junction directly opposite. Further that between 11/01/00 and 31/12/22 there have been 21 collisions at this junction (including this fatality and 3 other serious collisions) and that there have been 29 collisions at the other junctions on this stretch of road (including one further fatality and 6 other serious collisions). The concerns in relation to this junction, and the other junctions relate to:- 1. The volume of traffic that the junctions must manage. 2. The complexity of traffic movement at the junctions. 3. The speed limit in the vicinity of the junctions. Concerns were also raised in relation to the planned extensive expansion/development of the area in the vicinity of the junction, including increased housing development, a proposed retail park, football site, as well as developments occurring more widely in the area which will lead to increased traffic, and that any proposed improvements to the junction are not required until prior to the occupation of the 39th dwelling on the site. The concern is that the proposals to improve the safety of the junction are not sufficient nor timely, and that consideration does not appear to have been given to reducing the speed limit within the junction series. A further concern was raised that the proposed improvements to the junction considered this junction in isolation, and did not consider the series of junctions on this stretch of road. ”

    Source location

    Kelly Nadine DUNNE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inadequate junction capacity for traffic volume

    Wider context from the report

    “During the course of the Inquest evidence was heard from the lead road traffic collision investigator in the case that there are significant concerns in relation to the adequacy and layout of this particular junction and the five other junctions on this stretch of road (A690). Evidence was given that since this fatality, there has been another fatal road traffic collision on the 22/12/22, at the junction directly opposite. Further that between 11/01/00 and 31/12/22 there have been 21 collisions at this junction (including this fatality and 3 other serious collisions) and that there have been 29 collisions at the other junctions on this stretch of road (including one further fatality and 6 other serious collisions). The concerns in relation to this junction, and the other junctions relate to:- 1. The volume of traffic that the junctions must manage. 2. The complexity of traffic movement at the junctions. 3. The speed limit in the vicinity of the junctions. Concerns were also raised in relation to the planned extensive expansion/development of the area in the vicinity of the junction, including increased housing development, a proposed retail park, football site, as well as developments occurring more widely in the area which will lead to increased traffic, and that any proposed improvements to the junction are not required until prior to the occupation of the 39th dwelling on the site. The concern is that the proposals to improve the safety of the junction are not sufficient nor timely, and that consideration does not appear to have been given to reducing the speed limit within the junction series. A further concern was raised that the proposed improvements to the junction considered this junction in isolation, and did not consider the series of junctions on this stretch of road. ”

    Source location

    Kelly Nadine DUNNE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to assess junction improvements across the junction series

    Wider context from the report

    “During the course of the Inquest evidence was heard from the lead road traffic collision investigator in the case that there are significant concerns in relation to the adequacy and layout of this particular junction and the five other junctions on this stretch of road (A690). Evidence was given that since this fatality, there has been another fatal road traffic collision on the 22/12/22, at the junction directly opposite. Further that between 11/01/00 and 31/12/22 there have been 21 collisions at this junction (including this fatality and 3 other serious collisions) and that there have been 29 collisions at the other junctions on this stretch of road (including one further fatality and 6 other serious collisions). The concerns in relation to this junction, and the other junctions relate to:- 1. The volume of traffic that the junctions must manage. 2. The complexity of traffic movement at the junctions. 3. The speed limit in the vicinity of the junctions. Concerns were also raised in relation to the planned extensive expansion/development of the area in the vicinity of the junction, including increased housing development, a proposed retail park, football site, as well as developments occurring more widely in the area which will lead to increased traffic, and that any proposed improvements to the junction are not required until prior to the occupation of the 39th dwelling on the site. The concern is that the proposals to improve the safety of the junction are not sufficient nor timely, and that consideration does not appear to have been given to reducing the speed limit within the junction series. A further concern was raised that the proposed improvements to the junction considered this junction in isolation, and did not consider the series of junctions on this stretch of road. ”

    Source location

    Kelly Nadine DUNNE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Delays in implementing junction safety improvements

    Wider context from the report

    “During the course of the Inquest evidence was heard from the lead road traffic collision investigator in the case that there are significant concerns in relation to the adequacy and layout of this particular junction and the five other junctions on this stretch of road (A690). Evidence was given that since this fatality, there has been another fatal road traffic collision on the 22/12/22, at the junction directly opposite. Further that between 11/01/00 and 31/12/22 there have been 21 collisions at this junction (including this fatality and 3 other serious collisions) and that there have been 29 collisions at the other junctions on this stretch of road (including one further fatality and 6 other serious collisions). The concerns in relation to this junction, and the other junctions relate to:- 1. The volume of traffic that the junctions must manage. 2. The complexity of traffic movement at the junctions. 3. The speed limit in the vicinity of the junctions. Concerns were also raised in relation to the planned extensive expansion/development of the area in the vicinity of the junction, including increased housing development, a proposed retail park, football site, as well as developments occurring more widely in the area which will lead to increased traffic, and that any proposed improvements to the junction are not required until prior to the occupation of the 39th dwelling on the site. The concern is that the proposals to improve the safety of the junction are not sufficient nor timely, and that consideration does not appear to have been given to reducing the speed limit within the junction series. A further concern was raised that the proposed improvements to the junction considered this junction in isolation, and did not consider the series of junctions on this stretch of road. ”

    Source location

    Kelly Nadine DUNNE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Insufficient junction safety improvements

    Wider context from the report

    “During the course of the Inquest evidence was heard from the lead road traffic collision investigator in the case that there are significant concerns in relation to the adequacy and layout of this particular junction and the five other junctions on this stretch of road (A690). Evidence was given that since this fatality, there has been another fatal road traffic collision on the 22/12/22, at the junction directly opposite. Further that between 11/01/00 and 31/12/22 there have been 21 collisions at this junction (including this fatality and 3 other serious collisions) and that there have been 29 collisions at the other junctions on this stretch of road (including one further fatality and 6 other serious collisions). The concerns in relation to this junction, and the other junctions relate to:- 1. The volume of traffic that the junctions must manage. 2. The complexity of traffic movement at the junctions. 3. The speed limit in the vicinity of the junctions. Concerns were also raised in relation to the planned extensive expansion/development of the area in the vicinity of the junction, including increased housing development, a proposed retail park, football site, as well as developments occurring more widely in the area which will lead to increased traffic, and that any proposed improvements to the junction are not required until prior to the occupation of the 39th dwelling on the site. The concern is that the proposals to improve the safety of the junction are not sufficient nor timely, and that consideration does not appear to have been given to reducing the speed limit within the junction series. A further concern was raised that the proposed improvements to the junction considered this junction in isolation, and did not consider the series of junctions on this stretch of road. ”

    Source location

    Kelly Nadine DUNNE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Secure funding to bring forward signal-control improvements at the West Rainton and Pittington Lane junctions.

    Verbatim wording from the response

    “Appraisal of the TA established that the West Rainton junction would be over capacity as the development became occupied and mitigation measures were required to alleviate traffic pressures. For this reason, a planning condition was placed on the developer to install traffic lights at the West Rainton location only upon occupancy of the 39th dwelling, and the impacts on the Pittington Road / A690 junction were assessed as being negligible. However, the Council took the opportunity to maximise improvements around this junction and made the decision to improve the Pittington Road / A690 junction in tandem with the West Rainton junction, using central government funding via the Local Transport Plan.”

    Source location

    Response from Durham County Council
    Page 2 · response
    Published 21 March 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement signal control at the West Rainton and Pittington Lane junctions.

    Verbatim wording from the response

    “Whilst the planning approval included the ‘trigger’ for signal installation, officers have worked closely with the developer and have successfully secured the necessary funding to allow the signal installation to be brought forward and a scheme to implement signal control at both the West Rainton and Pittington Lane junctions is programmed to commence 2nd May for approximately 14 weeks.”

    Source location

    Response from Durham County Council
    Page 3 · response
    Published 21 March 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    A lower speed limit would not be credible or appropriate and could increase danger because a significant proportion of motorists might ignore it.

    Verbatim wording from the response

    “A speed limit is an absolute maximum, and it is the driver’s responsibility to drive at a speed suitable to the environment and conditions. It is an intention of the Department for Transport guidance to ensure that speed limits are credible with the aim that they become self-evident and self-enforcing, by virtue of their surroundings. A limit lower than the current posted limit would not be credible or appropriate and would likely result in a significant proportion of motorists ignoring the limit. In addition, the imposition of non-credible lower limits can raise expectations that the speeds of vehicles will be reduced but seldom realised in practice, resulting in greater danger with drivers making decisions based on incorrect assumptions, and also unfair criticism of the police who have to enforce the speed limits.”

    Source location

    Response from Durham County Council
    Page 2 · response
    Published 21 March 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    No further accident investigation and prevention intervention was warranted because accident frequency remained unchanged and traffic signals were being developed.

    Verbatim wording from the response

    “However, given that the annual average accident total was remaining the same and, on the understanding that the impending traffic signals scheme was in development, it was considered that no further action was warranted in terms of AIP intervention.”

    Source location

    Response from Durham County Council
    Page 2 · response
    Published 21 March 2023

    Open published response
  10. Birmingham and Solihull

    AI-generated summary

    Mervyn Charles Gladstone Leonard HOLBROOK · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    On 16 June 2022, Mervyn Charles Gladstone Leonard Holbrook was knocked from his mobility scooter and run over at a junction after entering the carriageway where a kerb had been worn down. He suffered catastrophic thoracic injuries and was pronounced deceased at the scene. The concern was that the worn and defective kerb could be mistaken for an official crossing point by vulnerable road users, particularly mobility scooter and bicycle users, creating a risk of entering the carriageway unsafely.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to maintain the kerb at the junction to prevent it appearing to be an official crossing point

    Wider context from the report

    “1. I heard and considered evidence from West Midlands Police's Forensic Collision Unit which confirmed that where the footpath outside 214 Alcester Road South reaches the junction of Livingstone Road, it appears that there is a dropped kerb at the apex. On the opposite side of the junction, the kerbs are raised. West Midlands Police advise that this indicates that the dropped kerbs at this side of the junction are a result of vehicles mounting the kerb as they turn left from Livingstone Road to Alcester Road and therefore causing them to be eroded to be level with the road surface. There is also no tactile paving next to these kerbs, which indicate that this dropped kerb is not an "official" pedestrian crossing point - the same being situated approximately 9m from the end of Livingstone Road. 2. Mr Holbrook was able to leave the carriageway on his mobility scooter at apex/mouth of the junction due to the kerb being worn down to the road surface, and was struck in the carriageway. 3. On 12 September 2022, PC ████████ of West Midlands Police submitted a notification via Birmingham City Council's Highway Department's online portal of the defect, with the Highways responding via email on 20 September 2022 stating that it did not meet the intervention levels that require repair. 4. I am concerned that vulnerable road users - particularly users of mobility scooters or bicycles - may inadvertently consider the worn down and defective kerb to be an "official" crossing point and enter the carriageway when it is unsafe to do so. 5. Furthermore, if a mobility scooter or similar were to enter the carriageway at the mouth of the junction (as Mr Holbrook did), they would then be unable to mount the curb at the opposite side - they would have to travel West down the carriageway of Livingstone road to the official crossing point, or alternatively (and more dangerously) navigate South on the carriageway into oncoming traffic onto Alcester Road. ”

    Source location

    Mervyn Charles Gladstone Leonard HOLBROOK · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Amend the kerb height at the footpath outside 214 Alcester Road South at the Livingstone Road junction.

    Verbatim wording from the response

    “1. I confirm the height of the kerb where the footpath outside 214 Alcester Road South reaches the junction of Livingstone Road was amended by the City Council in early January 2023 as per your recommendations.”

    Source location

    Response from Birmingham City Council
    Page 1 · response
    Published 9 December 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review network kerb-defect information and intervention criteria to identify similar locations and incorporate necessary maintenance processes.

    Verbatim wording from the response

    “2. We have also commissioned to undertake a review of the available kerb defect information to identify locations similar to the incident site on the network so that the necessary processes are incorporated and similar sites are addressed as part of the Council’s maintenance activities. The scope of the study also includes a review of the intervention criteria and whether these need to be revised in the light of this incident. This study is well underway and is expected to be completed by March 2023. A copy of the report will be shared with you as soon as it is available along with details of further proposed actions.”

    Source location

    Response from Birmingham City Council
    Page 2 · response
    Published 9 December 2022

    Open published response
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Data last updated 7 September 2026