Concerns raised 2
Failure to address obstructive and deteriorated railings at the junction View source Failure to set a speed limit that accounts for the dangerous junction at Waterloo Hill View source
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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.
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× 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
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
Open source report
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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 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
Open published response
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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 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
Open published response
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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 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
Open published response
12 Aug 2025 Charlotte NOORDAM · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1
Failure of the junction layout, signage and road markings to mitigate incident risk at the stop junction View source
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 3
Birmingham City Council
Implement the Fatal Collision Response Protocol to assess site conditions and identify locally appropriate safety interventions.
View source
Birmingham City Council
Implement vertical traffic-calming measures and additional junction warning signage within six months.
View source
Birmingham City Council
Design and assess traffic-management measures to redirect vehicles away from the junction before proceeding to implementation.
View source
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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.
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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
Open source report
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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 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
Open published response
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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 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
Open published response
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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 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
Open published response
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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
Open published response
6 May 2025 Charlotte Katie Mae Avis · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 2
Hazardous road layout at Loscombe Crossroads View source Continuing risk of road traffic collisions at Loscombe Crossroads View source
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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.
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× 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
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
Open source report
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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 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
Open published response
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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
Open published response
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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
Open published response
6 Feb 2025 Jane BENNETT · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 1
Hazardous difficulty manoeuvring at the junction of St Johns Road, Tiffield and the A43 Northamptonshire View source
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
National Highways
Carry out planned summer 2025 minor surfacing works, including refreshed eastbound road markings and reflective road studs through the junction.
View source
National Highways
Investigate including vegetation clearance in the summer 2025 works to improve visibility at the junction.
View source
National Highways
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.
View source
National Highways
Investigate potential junction improvements, such as signage, as part of the A43 renewals scheme scoping.
View source See 1 more action
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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.
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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
Open source report
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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 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
Open published response
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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
Open published response
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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 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
Open published response
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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 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
Open published response
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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
Open published response
23 Aug 2024 Amal Mohamed AHMED · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 4
Inadequate positioning and visibility of No Entry signage for wrong-way slip-road entry View source Frequent wrong-way driving down the slip road into oncoming traffic View source Slip-road geometry allowing wrong-way vehicles to enter and build up considerable speed View source
Failure to maintain adequate visibility of road-surface No Entry markings at the slip-road junction View source See 1 more concern
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
Apple (UK) Limited Google UK Limited Milton Keynes City Council National Highways TomTom International B.V.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 11
National Highways
Install temporary large No Entry signs on A-frames at both sides of the A5 off-slip exit.
View source
National Highways
Complete a full safety review of the junction against the current Wrong Way Driving: Mitigation Toolkit.
View source
National Highways
Continue developing enhanced A5 off-slip mitigation options and establish which measures will be progressed, including improved signage and road markings.
View source
National Highways
Undertake further work to assess junction capacity and whether the A5 off-slip bell-mouth width can be reduced with hatched markings.
View source
Milton Keynes City Council
Inspect the junction and assess signage and road markings for safety defects.
View source
Milton Keynes City Council
Review the junction situation later as part of the planned work programme.
View source
TomTom International B.V.
Review navigation instructions near the junction by simulating driver-speed scenarios and assessing instruction timing.
View source
TomTom International B.V.
Implement safeguards that time verbal navigation commands closer to the exit and after drivers pass the off-slip road.
View source
Google UK Limited
Investigate and develop improvements to the timing of Google Maps audio guidance.
View source
Apple (UK) Limited
Add special voice guidance directing westbound drivers to continue straight at the overpass and turn right onto the A5 toward Milton Keynes and Bletchley.
View source
Milton Keynes City Council
Reinspect the site after the incident and investigate whether an immediate safety hazard exists.
View source See 8 more actions
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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.
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× 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
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
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
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
Open source report
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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 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
Open published response
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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 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
Open published response
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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 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
Open published response
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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 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
Open published response
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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 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
Open published response
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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 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
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
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
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
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
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
Open published response
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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
Open published response
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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
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
Open published response
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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
Open published response
22 Aug 2024 Tracey Julie HAYBITTLE · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 1
Failure of commonly used satnav applications to provide safe verbal directions at the junction View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
Apple (UK) Limited Google UK Limited National Highways TomTom International B.V.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
TomTom International B.V.
Review navigation instructions and simulate speed scenarios near the junction.
View source
TomTom International B.V.
Implement safeguards that time verbal commands closer to the exit and after the off-slip road.
View source
National Highways
Deploy temporary ‘Do not follow Sat Nav’ and customer-information signs at the junction.
View source
National Highways
Investigate Sat Nav routing and liaise with Google Maps, Apple Maps and WAZE regarding potentially confusing audible instructions.
View source
Google UK Limited
Liaised with National Highways and reviewed dashcam footage of the junction to inform investigation of Google Maps audio guidance.
View source
Google UK Limited
Investigate and develop improvements to the timing of Google Maps audio guidance.
View source
Apple (UK) Limited
Add special voice guidance instructing drivers to continue straight at the overpass and turn right onto the A5 toward Milton Keynes, Bletchley.
View source See 4 more actions
×
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
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
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
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
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
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
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
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
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
Open published response
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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
Open published response
16 Aug 2023 Absolom Adolphus Abraham Zephaniah DUFFY · Prevention of Future Deaths report Lincolnshire
View report summary
Concerns raised 1
Failure of junction signage to require stopping where visibility of the major road is restricted View source
×
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
Open source report
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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 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
Open published response
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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
Open published response
Concerns raised 1
Visibility deficiencies between downhill traffic and cars exiting the roundabout View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
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
Open source report
Concerns raised 5
Failure to provide adequate speed control within the junction series View source Inadequate junction capacity for traffic volume View source Failure to assess junction improvements across the junction series View source
Delays in implementing junction safety improvements View source Insufficient junction safety improvements View source See 2 more concerns
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 2
Durham County Council
Secure funding to bring forward signal-control improvements at the West Rainton and Pittington Lane junctions.
View source
Durham County Council
Implement signal control at the West Rainton and Pittington Lane junctions.
View source
×
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
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
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
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
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
Open source report
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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 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
Open published response
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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 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
Open published response
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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
Open published response
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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
Open published response
8 Dec 2022 Mervyn Charles Gladstone Leonard HOLBROOK · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1
Failure to maintain the kerb at the junction to prevent it appearing to be an official crossing point View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 2
Birmingham City Council
Amend the kerb height at the footpath outside 214 Alcester Road South at the Livingstone Road junction.
View source
Birmingham City Council
Review network kerb-defect information and intervention criteria to identify similar locations and incorporate necessary maintenance processes.
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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.
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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
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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 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
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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 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
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.