Recurring concern

Inadequate safety controls at high-risk road junctions

First to latest report 2 Dec 2013 — 11 Dec 2025

Reports that mention this concern
55
Times this concern has been raised
85
Stated actions linked to this concern
126

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.

What is 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 and published responses 55 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Hertfordshire

    AI-generated summary

    Jan Bodnar · 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

    Jan Bodnar died after his motorcycle collided with a car crossing the A505 near Ashwell on 12 July 2015. The report raised concerns that plant growth in the central reservation severely restricted visibility for drivers and that similar risks might exist at other junctions on the road.

    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 regularly cut back plant growth at road junctions

    Wider context from the report

    “(1) That the state of the central reservation at this junction was dangerous in that the plant growth severely restricted the view for a driver of traffic approaching from the left. (2) The evidence showed that the growth had been cut back a week or so after this incident, but the risk of danger to motorists will only be avoided if the growth at this junction is regularly cut back. (3) The evidence showed that similar risks may well be present at other similar junctions on this road. ”

    Source location

    Jan Bodnar · 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

    Plant growth severely restricting drivers’ view at a junction

    Wider context from the report

    “(1) That the state of the central reservation at this junction was dangerous in that the plant growth severely restricted the view for a driver of traffic approaching from the left. (2) The evidence showed that the growth had been cut back a week or so after this incident, but the risk of danger to motorists will only be avoided if the growth at this junction is regularly cut back. (3) The evidence showed that similar risks may well be present at other similar junctions on this road. ”

    Source location

    Jan Bodnar · 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

    Clear vegetation at the A505 Slip End Farm junction within the central reserve safety barrier.

    Verbatim wording from the response

    “• Cleared the vegetation (tree, shrubs and other plant growth) at the A505 Slip End Farm junction (inside the safety barrier within the central reserve) on 25 and 27 July 2015.”

    Source location

    2016-0166-Response-by-Hertfordshire-Council
    Page 1 · response
    Published 29 April 2016

    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

    Assess similar junctions between Baldock and Royston to identify locations requiring additional vegetation clearance.

    Verbatim wording from the response

    “• Carried out an assessment of similar junctions on this section of road between Baldock and Royston. This has revealed that of the 11 junctions, 6 require further vegetation clearance over and above what is covered by our cyclical grass cutting maintenance programme. This work is planned to be undertaken in July 2016, subject to weather and other factors outside of our control.”

    Source location

    2016-0166-Response-by-Hertfordshire-Council
    Page 1 · response
    Published 29 April 2016

    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

    Clear vegetation at six identified junctions between Baldock and Royston beyond cyclical grass-cutting maintenance.

    Verbatim wording from the response

    “• Carried out an assessment of similar junctions on this section of road between Baldock and Royston. This has revealed that of the 11 junctions, 6 require further vegetation clearance over and above what is covered by our cyclical grass cutting maintenance programme. This work is planned to be undertaken in July 2016, subject to weather and other factors outside of our control.”

    Source location

    2016-0166-Response-by-Hertfordshire-Council
    Page 1 · response
    Published 29 April 2016

    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

    Revise highway safety inspectors’ remit to identify vegetation requiring corrective action on this length of road.

    Verbatim wording from the response

    “• Revised the remit for our highway safety inspectors for this length of road to ensure that vegetation of this nature is identified, enabling corrective action to be programmed.”

    Source location

    2016-0166-Response-by-Hertfordshire-Council
    Page 1 · response
    Published 29 April 2016

    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

    Revise the vegetation maintenance regime so tree, shrub and plant-growth cutting is coordinated annually with grass cutting on this length of road.

    Verbatim wording from the response

    “• Revised the maintenance regime for vegetation for this length of road, so that the cutting of trees, shrubs and other plant growth will be carried out in co-ordination with grass cutting on an annual basis.”

    Source location

    2016-0166-Response-by-Hertfordshire-Council
    Page 1 · response
    Published 29 April 2016

    Open published response

  2. South Lincolnshire

    AI-generated summary

    Sheila Slater · 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

    Sheila Slater died at the scene of a road traffic collision at the staggered junction of the A16 and B1166 near Crowland, while travelling as a passenger in a car driven by her husband. The report raised concerns about the safety of this junction and other staggered junctions in Lincolnshire, including their history of fatalities and injury-producing collisions.

    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

    Unsafe staggered road-junction layouts

    Wider context from the report

    “1 The staggered junction of the A16 with the B1166 is part of the Crowland Bypass which was opened in 2010. As with all of the other staggered junctions in Lincolnshire it was built to DFT specifications. Since it was opened there have been 3 fatalities associated with this junction (2 at the junction and one on the approach to the south bound island) and 10 injury producing collisions. There have been fatalities at the other staggered junctions in Lincolnshire. DFT and Highways England have been made aware of the problems associated with these junctions both by S.28 reports and correspondence from officers of Lincolnshire County Council. At the inquest, into Mrs Slater's death evidence was given to the effect that this particular junction could be made safer if it were to be replaced by a roundabout but that local funding was not available for this purpose. Witnesses also were concerned about the safety record of other staggered junctions in Lincolnshire. ”

    Source location

    Sheila Slater · 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

    Undertake a scoping study to inform potential updates to design guidance for major and minor junctions and accesses, including staggered junctions.

    Verbatim wording from the response

    “Highways England regional and area teams monitor local and specific safety issues and there does not appear to be a pattern of similar issues occurring at this type of junction. Highways England have been undertaking a scoping study with a view to updating the design guidance covering major and minor junctions and accesses, including this type of junction, subject to evidence and funding. The relevant team have been informed of these concerns.”

    Source location

    Response from Department for Transport
    Page 1 · response
    Published 31 March 2016

    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

    Lincolnshire County Council is responsible for local road safety and deciding whether to install a roundabout on the local road.

    Verbatim wording from the response

    “The Design Manual for Roads and Bridges, a publication sponsored by my department sets out the national standards for such junctions, however local authorities are responsible for road safety on the local road network, in this case Lincolnshire County Council. Section 39 of The Road Traffic Act 1988 puts a 'statutory duty' on local authorities to deliver an appropriate road safety education service and for the provision of a safe local road network. This includes road construction, accident investigation and analysis, traffic calming, setting speed limits and facilities for pedestrians and cyclists. It is up to individual authorities to determine how they meet their ‘statutory duty’ and any decision about installing a roundabout on a local road is entirely a matter for Lincolnshire County Council.”

    Source location

    Response from Department for Transport
    Page 1 · response
    Published 31 March 2016

    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

    Highways England found no apparent pattern of similar safety issues at this type of junction.

    Verbatim wording from the response

    “Highways England regional and area teams monitor local and specific safety issues and there does not appear to be a pattern of similar issues occurring at this type of junction. Highways England have been undertaking a scoping study with a view to updating the design guidance covering major and minor junctions and accesses, including this type of junction, subject to evidence and funding. The relevant team have been informed of these concerns.”

    Source location

    Response from Department for Transport
    Page 1 · response
    Published 31 March 2016

    Open published response

  3. Leicester City and South Leicestershire

    AI-generated summary

    Kian Singh GILL · 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

    Kian Singh GILL, aged 15, died at the scene of a road traffic accident while cycling into the path of a car at a junction in Gilmorton, Leicestershire, on 5 May 2015. Concerns included overgrown hedgerows obscuring visibility, a lack of junction signage, and the national speed limit remaining in place despite the 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

    Lack of signage indicating the junction

    Wider context from the report

    “(2) There is no signage to indicate that there is a junction there and ”

    Source location

    Kian Singh GILL · 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

    Place give-way road markings on Bonehams Lane.

    Verbatim wording from the response

    “a) It is proposed to place give way road markings on Bonehams lane;”

    Source location

    Response from Leicestershire County Council
    Page 12 · response
    Published 22 June 2015

    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

    Place “Slow” road markings on Ullesthorpe Road to encourage drivers to reduce speed near the junction.

    Verbatim wording from the response

    “b) It is proposed to place “Slow” markings on Ullesthorpe Road to advise drivers of the presence of a junction with a view to encouraging them to reduce their speed.”

    Source location

    Response from Leicestershire County Council
    Page 12 · response
    Published 22 June 2015

    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

    Additional junction signage was considered unnecessary because existing visual cues should alert reasonably careful road users to the junction.

    Verbatim wording from the response

    “34. Although the Council is prepared to take further measures to enhance road safety, the Council does not believe that the presence of additional signage was necessary to alert a reasonably careful road user on Bonehams Lane of the existence of a junction.”

    Source location

    Response from Leicestershire County Council
    Page 7 · response
    Published 22 June 2015

    Open published response

  4. West Yorkshire (West)

    AI-generated summary

    Nicholas Gary Stocks · 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

    Nicholas Gary Stocks was struck and fatally injured by a vehicle after a collision at the junction of Dry Hill Lane and the A635 Barnsley Road in Huddersfield on 27 September 2012. The report raised concerns about damaged and poorly maintained give-way signs and road markings, inadequate reporting and repair systems, highway inspection practices, risk assessment, and coordination between West Yorkshire Police and Kirklees Council.

    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

    50 mph speed limit at the incident junction approaches

    Wider context from the report

    “West Yorkshire Police (1) I am concerned with the system that was in place to ensure that matters of concern identified by Officers of West Yorkshire Police who attend the scene of Road Traffic Collision in November 2011 were not fully reported to Kirklees Council. I would ask you to review the system presently in place to ensure that all future reports are made and fully reported (2) On the afternoon of the 27th September 2012 following the earlier road traffic incident, a Police Officer identified the need for a repair to the Give Way sign which had been demolished. The Police Officer in attendance would have been able to also identify that the road markings at the scene were no longer visible and therefore any road user who was travelling along Dry Hill Lane would have had no visible signs or road markings on the approaching Give Way junction. In essence the Officer would have been able to undertake a risk assessment and identify the level of urgency for remedial repair works to be undertaken. I would invite West Yorkshire Police to liaise with the relevant department of Kirklees Council and undertake a new review and consider whose responsibility it should be to undertake a risk assessment at the scene of a road traffic collision in order to determine the level of urgency of remedial work which is required to be carried out so as to ensure the safety of road users and to develop a system so as to ensure that risk assessment process is implemented and carried out. (3) I would also ask you to liaise with the relevant departments of Kirklees Council in order to carry out investigations to determine which departments of Kirklees Council was contacted on the afternoon on 27th September 2012 to report the damage to the give way sign. I heard evidence that Kirklees Council Customer Services, the relevant department which should have been contacted, and who are contactable between the hours of 8.00 and 18 hours. Outside of these hours an answer machine message provides an emergency contact number. If the control room unit had contacted the customer service centre then this telephone line should have been manned and a response received rather than sending an email which was acknowledged by an automated response. I wish to ensure that firstly West Yorkshire Police have the relevant contact number which needs to be used in the future and secondly if the Customer Service centre at Kirklees Council was contacted it clearly was not manned at the appropriate time, I wish to ensure this is rectified. Kirklees Council (1) I have concerns with the regard to the wide variation of how road inspections are undertaken by your Safety Inspectors. During the course of the enquiries undertaken by West Yorkshire Police a number of interviews were conducted with a number of safety inspectors. I have reviewed those interviews and note that there was a wide variation on how Safety Inspectors undertook inspections of a highway.. One Inspector indicated that they would inspect one side of the road one month, and when inspecting the road the following month would inspect the other side of the carriageway. Another Inspector indicated that they would inspect the whole of the carriageway on each inspection. Another Safety Inspector stated that the driver also had a role to place in inspecting the road in addition to driving the vehicle which transported the Safety Inspector who would be seated in the front passenger seat. (2) I have concerns with regard to how Safety Inspectors identify issues at the junction of two roads and which inspection has responsibility to consider matters at the actual junction. There appeared to have been vague and unclear responses from the Inspectors who gave evidence, as to whose responsibility it would be to actually inspect the junction of the two roads. (3) I was concerned that neither of the two Safety Inspectors who gave evidence, considered that the lack of road markings at the junction of Barnsley Road and Dry Hill Lane, and upon Dry Hill Lane itself posed a safety risk to road users and applying appropriate risk assessment should have been repaired I heard evidence from a highly qualified independent expert who was fully familiar with the Kirklees inspection policy and who stated that the lack of road markings at the junction with Barnsley Road and upon Dry Hill Lane itself, were identifiable and reportable defects applying Kirklees Council Policy criteria and should have been reported by the Safety Inspectors and repaired. In addition the independent expert stated that the poor state of the road markings would have been present for a considerable and significant period of time. Certainly, when each of the roads had last been inspected by a Safety Inspector from Kirklees Council. (4) I also have concern that there is no ongoing training and assessment of Safety Inspectors after initial training has been given so as to ensure consistency and appropriate standard levels of inspections are maintained. I would invite Kirklees Council to undertake a comprehensive review of the training of all of their Safety Inspectors and consider what further retraining requirements are required now and in the future. (5) I would refer you to the comments I have made in the West Yorkshire Police section of this report in respect of the operation of Kirklees Council’s Customer Service Centre. I would ask you to liaise directly with West Yorkshire Police and review and ensure the Customer Centre Service facility is fully operational at all relevant times (6) I would also ask you to liaise with West Yorkshire Police in respect of the comments made in the West Yorkshire Police Section of this report concerning risk assessments when a road traffic collision occurs and West Yorkshire Police in attendance and identify the need for repair works to be undertaken, so as to ensure that an immediate risk assessment is undertaken to safeguard members of the public. (7). From details provided in the course of this investigation, it appears that remedial work was required to be undertaken by Yorkshire Water at the junction with Barnsley Road and Dry Hill Lane. This work was to identified on 13th March 2010 and the 5th March 2012, but there was no record that such work had been undertaken, and no follow up was implemented by Kirklees Council, so as to ensure that this work was carried out. I would invite you to review your systems so as to ensure that work is undertaken by other agencies and checks made to ensure that all necessary works are completed. (8) Evidence at the inquest also revealed that members of the public had reported the lack of road markings to Kirklees Council, some months prior to this incident occurring. Although Kirklees Council records show no further action required. I am concerned with regard to this finding in light of the evidence provided to me by the independent expert who confirmed that the lack of road markings was clearly a defect which fell within the Councils existing guidance as an identifiable defect which required rectification. I would invite you to review the present system that Kirklees Council has in place with addressing complaints made by members of the public in respect of the roads and highways which fall within your designated area. 9. I understand that major road works have been undertaken by Kirklees Council at the scene of this incident. However, at the inquest it was clear that the speed limit still remains to be 50 mph. I would invite you to review the speed limit not only on Dry Hill Lane, but also Barnsley Road and Lower Denby Lane. I would request you to review the street lighting along Lower Denby Lane and Dry Hill Lane at their approach to the junction with Barnsley Road and whether any additional lighting is required. ”

    Source location

    Nicholas Gary Stocks · Prevention of Future Deaths report
    Page 4 · 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

    Absence of visible signs or road markings at an approaching Give Way junction

    Wider context from the report

    “West Yorkshire Police (1) I am concerned with the system that was in place to ensure that matters of concern identified by Officers of West Yorkshire Police who attend the scene of Road Traffic Collision in November 2011 were not fully reported to Kirklees Council. I would ask you to review the system presently in place to ensure that all future reports are made and fully reported (2) On the afternoon of the 27th September 2012 following the earlier road traffic incident, a Police Officer identified the need for a repair to the Give Way sign which had been demolished. The Police Officer in attendance would have been able to also identify that the road markings at the scene were no longer visible and therefore any road user who was travelling along Dry Hill Lane would have had no visible signs or road markings on the approaching Give Way junction. In essence the Officer would have been able to undertake a risk assessment and identify the level of urgency for remedial repair works to be undertaken. I would invite West Yorkshire Police to liaise with the relevant department of Kirklees Council and undertake a new review and consider whose responsibility it should be to undertake a risk assessment at the scene of a road traffic collision in order to determine the level of urgency of remedial work which is required to be carried out so as to ensure the safety of road users and to develop a system so as to ensure that risk assessment process is implemented and carried out. (3) I would also ask you to liaise with the relevant departments of Kirklees Council in order to carry out investigations to determine which departments of Kirklees Council was contacted on the afternoon on 27th September 2012 to report the damage to the give way sign. I heard evidence that Kirklees Council Customer Services, the relevant department which should have been contacted, and who are contactable between the hours of 8.00 and 18 hours. Outside of these hours an answer machine message provides an emergency contact number. If the control room unit had contacted the customer service centre then this telephone line should have been manned and a response received rather than sending an email which was acknowledged by an automated response. I wish to ensure that firstly West Yorkshire Police have the relevant contact number which needs to be used in the future and secondly if the Customer Service centre at Kirklees Council was contacted it clearly was not manned at the appropriate time, I wish to ensure this is rectified. Kirklees Council (1) I have concerns with the regard to the wide variation of how road inspections are undertaken by your Safety Inspectors. During the course of the enquiries undertaken by West Yorkshire Police a number of interviews were conducted with a number of safety inspectors. I have reviewed those interviews and note that there was a wide variation on how Safety Inspectors undertook inspections of a highway.. One Inspector indicated that they would inspect one side of the road one month, and when inspecting the road the following month would inspect the other side of the carriageway. Another Inspector indicated that they would inspect the whole of the carriageway on each inspection. Another Safety Inspector stated that the driver also had a role to place in inspecting the road in addition to driving the vehicle which transported the Safety Inspector who would be seated in the front passenger seat. (2) I have concerns with regard to how Safety Inspectors identify issues at the junction of two roads and which inspection has responsibility to consider matters at the actual junction. There appeared to have been vague and unclear responses from the Inspectors who gave evidence, as to whose responsibility it would be to actually inspect the junction of the two roads. (3) I was concerned that neither of the two Safety Inspectors who gave evidence, considered that the lack of road markings at the junction of Barnsley Road and Dry Hill Lane, and upon Dry Hill Lane itself posed a safety risk to road users and applying appropriate risk assessment should have been repaired I heard evidence from a highly qualified independent expert who was fully familiar with the Kirklees inspection policy and who stated that the lack of road markings at the junction with Barnsley Road and upon Dry Hill Lane itself, were identifiable and reportable defects applying Kirklees Council Policy criteria and should have been reported by the Safety Inspectors and repaired. In addition the independent expert stated that the poor state of the road markings would have been present for a considerable and significant period of time. Certainly, when each of the roads had last been inspected by a Safety Inspector from Kirklees Council. (4) I also have concern that there is no ongoing training and assessment of Safety Inspectors after initial training has been given so as to ensure consistency and appropriate standard levels of inspections are maintained. I would invite Kirklees Council to undertake a comprehensive review of the training of all of their Safety Inspectors and consider what further retraining requirements are required now and in the future. (5) I would refer you to the comments I have made in the West Yorkshire Police section of this report in respect of the operation of Kirklees Council’s Customer Service Centre. I would ask you to liaise directly with West Yorkshire Police and review and ensure the Customer Centre Service facility is fully operational at all relevant times (6) I would also ask you to liaise with West Yorkshire Police in respect of the comments made in the West Yorkshire Police Section of this report concerning risk assessments when a road traffic collision occurs and West Yorkshire Police in attendance and identify the need for repair works to be undertaken, so as to ensure that an immediate risk assessment is undertaken to safeguard members of the public. (7). From details provided in the course of this investigation, it appears that remedial work was required to be undertaken by Yorkshire Water at the junction with Barnsley Road and Dry Hill Lane. This work was to identified on 13th March 2010 and the 5th March 2012, but there was no record that such work had been undertaken, and no follow up was implemented by Kirklees Council, so as to ensure that this work was carried out. I would invite you to review your systems so as to ensure that work is undertaken by other agencies and checks made to ensure that all necessary works are completed. (8) Evidence at the inquest also revealed that members of the public had reported the lack of road markings to Kirklees Council, some months prior to this incident occurring. Although Kirklees Council records show no further action required. I am concerned with regard to this finding in light of the evidence provided to me by the independent expert who confirmed that the lack of road markings was clearly a defect which fell within the Councils existing guidance as an identifiable defect which required rectification. I would invite you to review the present system that Kirklees Council has in place with addressing complaints made by members of the public in respect of the roads and highways which fall within your designated area. 9. I understand that major road works have been undertaken by Kirklees Council at the scene of this incident. However, at the inquest it was clear that the speed limit still remains to be 50 mph. I would invite you to review the speed limit not only on Dry Hill Lane, but also Barnsley Road and Lower Denby Lane. I would request you to review the street lighting along Lower Denby Lane and Dry Hill Lane at their approach to the junction with Barnsley Road and whether any additional lighting is required. ”

    Source location

    Nicholas Gary Stocks · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Wiltshire and Swindon

    AI-generated summary

    Patrick Derek Sturivant · 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

    Patrick Derek Sturivant was struck by a Mercedes while crossing the A303 near Byway 11 at Stonehenge on 29 August 2014 and died in hospital the following day from an unsurvivable brain injury. The concerns were that public use of the area near Byway 11 for parking and viewing Stonehenge created a risk of similar deaths, and that closing or modifying Byway 11 could shift the risk to Byway 12.

    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

    Foreseeable displacement of the Byway 11 safety hazard to the Byway 12 connection with the A303

    Wider context from the report

    “(2) Even if the above proposal is adopted in co-operation with the National Trust and Wiltshire Council I have however a further concern that in my view it is reasonably foreseeable that the problem currently associated with the area adjacent to the point at which Byway 11 joins the A303 will move approximately 390 metres west to the point at which Byway 12 connects to the A303. I know the area well and I can just see the problem shifting to this particular location and that concerns me from the point of view of the prevention of future deaths as if not addressed at this point could again lead to another fatality occurring in similar circumstances following the closure of Byway 11. I heard evidence from ████████ that Byway 12 is actively used as a green lane and I am fully aware that any modification to Byway 12 due to its use as a connecting green lane between the A303 and the A360 is likely to be highly controversial and political but that does not remove the concern that I have that there in my view is a reasonably foreseeable risk in the future if the terminal end of Byway 11 is closed. It is within in mind and having considered the matter further after the inquest that I have included in the list of recipients of this Regulation 28 Report, The Department of Transport and English Heritage. The reason for this is of course last year the issue of the A303 generally in this area, having regard to the A344, has prompted a review of the highway infrastructure in this area from the point of view of diverting the A303 or indeed as regards the funding of a tunnel through which the A303 would pass underground in the vicinity of the Stonehenge Monument and I would therefore like my concerns relative to the issues raised in this report relative Byway 11 and Byway 12 south of the A303 to be taken into consideration. ”

    Source location

    Patrick Derek Sturivant · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 long-term solution requires multiple agencies because responsibility for the road, land, rights of way and enforcement is distributed among them.

    Verbatim wording from the response

    “However as was recognised by you in your report, any potential solutions will require a multi-agency approach. Highways England own, maintain and control the surface (and verges) of the A303, and are also considering potential long term solutions in order to mitigate the continuing traffic difficulties along this section of the A303. Historic England owns the land on which Stonehenge is situated and has care and control of the stones as ancient monuments. The National Trust is a significant landowner in this area and own the land on which byway 11 is located. The Council are the local highway authority who own (on surface), control and maintain the rights of way in the area including byway 11. The Police are responsible for enforcement of the A303 clearway order and the no right turn out of byway 12.”

    Source location

    Wiltshire-Council-Response
    Page 1 · response
    Published 17 April 2015

    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

    Police enforcement of stopping restrictions and the no-right-turn order is the Police’s responsibility, rather than the Council’s.

    Verbatim wording from the response

    “However as was recognised by you in your report, any potential solutions will require a multi-agency approach. Highways England own, maintain and control the surface (and verges) of the A303, and are also considering potential long term solutions in order to mitigate the continuing traffic difficulties along this section of the A303. Historic England owns the land on which Stonehenge is situated and has care and control of the stones as ancient monuments. The National Trust is a significant landowner in this area and own the land on which byway 11 is located. The Council are the local highway authority who own (on surface), control and maintain the rights of way in the area including byway 11. The Police are responsible for enforcement of the A303 clearway order and the no right turn out of byway 12.”

    Source location

    Wiltshire-Council-Response
    Page 1 · response
    Published 17 April 2015

    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 cannot yet provide decision and implementation timescales because a multi-agency long-term solution is still being explored.

    Verbatim wording from the response

    “However as was recognised by you in your report, any potential solutions will require a multi-agency approach. Highways England own, maintain and control the surface (and verges) of the A303, and are also considering potential long term solutions in order to mitigate the continuing traffic difficulties along this section of the A303. Historic England owns the land on which Stonehenge is situated and has care and control of the stones as ancient monuments. The National Trust is a significant landowner in this area and own the land on which byway 11 is located. The Council are the local highway authority who own (on surface), control and maintain the rights of way in the area including byway 11. The Police are responsible for enforcement of the A303 clearway order and the no right turn out of byway 12.”

    Source location

    Wiltshire-Council-Response
    Page 1 · response
    Published 17 April 2015

    Open published response

  6. Leicester City and South Leicestershire

    AI-generated summary

    Anais Chantal Thouvenot · 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

    Anais Chantal Thouvenot was knocked from her bicycle by a passing vehicle at a road junction in Leicester on 9 November 2014, sustained a serious head injury, and died at Queens Medical Centre, Nottingham, on 16 November 2014. Concerns were raised about the junction’s safety, including visibility, inadequate or absent filter lanes, heavy traffic, and the road contour, with reported near misses involving cyclists.

    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 visibility at the road traffic junction

    Wider context from the report

    “During the course of the investigation I was made aware of specific concerns regarding the safety of the road traffic junction at Upper Kings Street and Regent Road, Leicester. These concerns were highlighted to me by the Leicester Cycling Campaign Group (LCCG) and a member of the public ████████ who has also raised these concerns for the attention of Councillors ████████ and ████████. The LCCG have informed me that they believe the junction to be inherently dangerous quoting a number of 'near misses' as experienced by their cycling group. The specific concerns relate to visibility at the junction and absent or inadequate filter lanes, exacerbated by heavy traffic and the contour of the road at this junction. It is also known to be on a major cycle route into the city. ”

    Source location

    Anais Chantal Thouvenot · 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

    Absence or inadequacy of filter lanes at the road traffic junction

    Wider context from the report

    “During the course of the investigation I was made aware of specific concerns regarding the safety of the road traffic junction at Upper Kings Street and Regent Road, Leicester. These concerns were highlighted to me by the Leicester Cycling Campaign Group (LCCG) and a member of the public ████████ who has also raised these concerns for the attention of Councillors ████████ and ████████. The LCCG have informed me that they believe the junction to be inherently dangerous quoting a number of 'near misses' as experienced by their cycling group. The specific concerns relate to visibility at the junction and absent or inadequate filter lanes, exacerbated by heavy traffic and the contour of the road at this junction. It is also known to be on a major cycle route into the city. ”

    Source location

    Anais Chantal Thouvenot · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    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 junction design, signalling and gradient comply with applicable design requirements and provide adequate safety controls.

    Verbatim wording from the response

    “The junction design and signalling arrangements have taken account of the Design Manual for Roads and Bridges (Volume 6, Section 2, Part 3 - TD 50/04, The Geometric Layout of Signal Controlled Junction and Signalised Roundabouts). As such, constraints such as existing road geometry, buildings and availability of land have been considered in accordance with TD50/04 and junction inter-visibility has been maximised.”

    Source location

    2015-0110-Response-by-Leicester-City-Council
    Page 2 · response
    Published 18 March 2015

    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 road geometry makes providing both cycle and all-vehicle lanes difficult, while removing the right-turn lane could harm traffic flow and cyclist safety.

    Verbatim wording from the response

    “The existing road geometry at the junction renders the provision of both cycle and all-vehicle lanes difficult. In addition, loss of the right turn lane into King Street may not be of any benefit to cyclists, but could cause problems with traffic flow through the junction, adding to congestion. It may also result in inappropriate driver behaviour which could have a detrimental effect on the safety of cyclists through the junction.”

    Source location

    2015-0110-Response-by-Leicester-City-Council
    Page 2 · response
    Published 18 March 2015

    Open published response

  7. Hartlepool

    AI-generated summary

    Keri Victoria Holdsworth · 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

    Keri Victoria Holdsworth died after sustaining fatal injuries in a road traffic crash at the junction of the A19 and the road from Dalton Piercy village on 13 June 2014. The report raised concern that this was the latest in several serious incidents at the junction, including three fatal incidents within the previous five years.

    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

    Serious and fatal collision hazard at the junction involving right-turning vehicles

    Wider context from the report

    “(1) This is the latest in several serious incidents at this junction, three of which have been fatal within the last five years. All of the fatal incidents have involved vehicles either turning right at this junction to join the northbound A19, or turning right from the northbound into the Dalton Piercy junction. ”

    Source location

    Keri Victoria Holdsworth · 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

    Complete the Route Safety Action Plan identifying A19 junctions with poor accident records.

    Verbatim wording from the response

    “Prior to the above accident the Highways Agency undertook a Route Safety Action Plan to identify locations on the A19 that display a poor accident record. This highlighted the junctions at Elwick, a short distance north of the Dalton Piercy junction. Study work was initiated to look at what improvements could be made to the junction including the provision of a bridge and the closure of the central reserve gaps. Following the above accident the scope of this study was extended to consider whether the provision of a bridge at Elwick could facilitate the closure of some or all of the central reserve gaps, including the Dalton Piercy junction, along the section of the A19 between the A689 and A179 junctions. Hartlepool Borough Council are a partner in this study.”

    Source location

    2015-0060-Response-by-Highways-Agency
    Page 1 · response
    Published 18 February 2015

    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

    Conduct and report the extended study of A19 junction improvements, including whether bridge provision could enable closure of central reserve gaps.

    Verbatim wording from the response

    “Prior to the above accident the Highways Agency undertook a Route Safety Action Plan to identify locations on the A19 that display a poor accident record. This highlighted the junctions at Elwick, a short distance north of the Dalton Piercy junction. Study work was initiated to look at what improvements could be made to the junction including the provision of a bridge and the closure of the central reserve gaps. Following the above accident the scope of this study was extended to consider whether the provision of a bridge at Elwick could facilitate the closure of some or all of the central reserve gaps, including the Dalton Piercy junction, along the section of the A19 between the A689 and A179 junctions. Hartlepool Borough Council are a partner in this study.”

    Source location

    2015-0060-Response-by-Highways-Agency
    Page 1 · response
    Published 18 February 2015

    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

    Speed restrictions, road layout design and potential improvement schemes are outside the council’s jurisdiction and responsibility.

    Verbatim wording from the response

    “The position is that this stretch of road network falls under the jurisdiction of Highways England (formerly known as The Highways Agency).”

    Source location

    2015-0060-Response-by-Hartlepool-Borough-Council
    Page 1 · response
    Published 18 February 2015

    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

    Highways England is responsible for funding, sponsoring and initiating improvements to the A19 network.

    Verbatim wording from the response

    “I contacted Highways England (Highways Agency) upon receipt of your last 11th correspondence and asked them as lead body to respond on behalf of both ourselves and the Highways Agency, explaining the position in respect of potential studies being carried out to improve the safety of the network. All funding responsibility for improvements to the A19 network lie with Highways England and therefore deems them to be the project sponsor and instigator of any improvement scheme(s).”

    Source location

    2015-0060-Response-by-Hartlepool-Borough-Council
    Page 1 · response
    Published 18 February 2015

    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

    Closing the Dalton Piercy junction depends on study findings about alternative routes and whether a strong business case exists.

    Verbatim wording from the response

    “The study is due to report in August 2015. Closure of any of the gaps, including the Dalton Piercy junction will be dependent on the outcome of the study which will consider whether there are viable alternative routes for right turning traffic and whether there is a strong business case for doing so. Construction of any subsequent scheme would be subject to the availability of funds.”

    Source location

    2015-0060-Response-by-Highways-Agency
    Page 1 · response
    Published 18 February 2015

    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

    Constructing any resulting scheme depends on the availability of funding.

    Verbatim wording from the response

    “The study is due to report in August 2015. Closure of any of the gaps, including the Dalton Piercy junction will be dependent on the outcome of the study which will consider whether there are viable alternative routes for right turning traffic and whether there is a strong business case for doing so. Construction of any subsequent scheme would be subject to the availability of funds.”

    Source location

    2015-0060-Response-by-Highways-Agency
    Page 1 · response
    Published 18 February 2015

    Open published response

  8. Sunderland

    AI-generated summary

    Dolores Mary Hubbert · 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

    Dolores Mary Hubbert suffered fatal injuries in a vehicle collision at a crossroads on the A690 at East Rainton and was pronounced dead at hospital on 29 August 2014. Her family raised concerns about the safety of the junction, including speed restrictions and the frequency of grass cutting, which might obscure drivers’ views.

    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

    Insufficient grass-cutting frequency allowing longer grass to obscure drivers' views

    Wider context from the report

    “The family of Mrs Hubbert expressed concerns to me about the overall safety of the junction and in particular the speed restrictions before and after the junction as well as the policy with regard to the frequency of grass cutting as longer grass may have the potential to obscure the views of drivers. ”

    Source location

    Dolores Mary Hubbert · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    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 established spring and autumn maintenance closure programme was considered appropriate for the A690 location.

    Verbatim wording from the response

    “With regards to maintenance activity on the A690, the Council's approach over the years for all principal high speed roads has been to implement a programme of Spring and Autumn closures to facilitate work such as servicing of road gullies, grass cutting, street cleansing, safety barrier and lighting repairs . This year the lane closures on this section of the A690 took place on 27th/28th March and 22nd/23rd September. This schedule was in line with the Council’s intended programme set at the start of the year and is considered to be appropriate to the location in question.”

    Source location

    Response from Sunderland City Council
    Page 2 · response
    Published 14 November 2014

    Open published response

  9. South London

    AI-generated summary

    Roger William Maurice De Klerk · 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 12 November 2013, Roger William Maurice De Klerk was cycling along Addiscombe Road when his bicycle wheels contacted tramlines, causing him to fall into the path of a bus. The bus collided with him and his bicycle. Concerns included the danger posed by tramlines to cyclists, confusing cycle-lane design and signage, and the intended route across tactile paving and pedestrian areas.

    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

    Cycle-path geometry forcing cyclists to parallel tramlines at the junction

    Wider context from the report

    “(2) The design and appearance of the bicycle lane at the junction of Addiscombe Road and Cherry Orchard Road may cause confusion for cyclists who are apparently required to go on to the pavement before the junction in order to cross it safely. The cycle path continues into the junction so that cyclists turning left will be forced to parallel with the lines, rather than crossing at 90 degrees, which is safer. ”

    Source location

    Roger William Maurice De Klerk · 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

    Conduct the junction safety review with TfL designers and obtain short- and long-term improvement options.

    Verbatim wording from the response

    “Following the findings of your Coroner’s inquest, the council has agreed to carry out a detailed review of the junction of Addiscombe Road / Cherry Orchard Road with the aim of finding any improvements that will assist cyclist and improve road safety at this site. To this end, the council is requesting TfL’s design team (with expertise employed on TfL’s cycling better junction review and central London cycle Superhighway design) to carry out this review and provide the council with a range of workable options. These will include both short term options that can be implemented quickly, and more extensive improvement. We are entering into discussions with TfL regarding cycling Quietway funding with a view to making such more extensive improvement by 2016.”

    Source location

    2014-0448-Response-De-Klerk
    Page 1 · response
    Published 16 October 2014

    Open published response

  10. Teesside

    AI-generated summary

    Jerome Antoine Marie GONNET · 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 2 May 2012, Jerome Antoine Marie GONNET was a passenger in a car involved in a head-on collision after a female driver travelled the wrong way along the A66 eastbound carriageway. Concerns included unclear advance signage for the no-entry slip road and temporary no-entry signs that could be knocked over and become unnoticeable; two further drivers reportedly later used the exit slip road in the same way.

    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

    Lack of advance road-sign information identifying the slip road as no entry

    Wider context from the report

    “(1) It is unclear in advance of approaching the junction that the slip road upon which the female drove is ‘no entry’ slip road. There is no information in this regard on the road signs surrounding the junction. ”

    Source location

    Jerome Antoine Marie GONNET · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    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

    Responsibility for advance signs on local roads and roundabouts rests with Stockton-on-Tees Borough Council, not the Highways Agency or A-one+.

    Verbatim wording from the response

    “Local highway authorities are responsible for the management of maintenance of local roads, which are outside of the Highways Agency’s remit.”

    Source location

    2014-0415-Response-by-A-one.pdf
    Page 2 · response
    Published 22 September 2014

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026