Recurring concern

Unreliable highway inspection and asset-recording processes

First to latest report 17 Jul 2014 — 1 Dec 2025

Reports that mention this concern
13
Times this concern has been raised
24
Stated actions linked to this concern
24

What this concern includes

Includes failures in the dedicated highway inspection process and its supporting asset records, including incomplete highway-asset databases, inconsistent inspection coverage or methods, unclear inspection responsibilities and inadequate controls needed to ensure inspections identify and assess road-user hazards consistently.

What is not included
  • Excludes highway repairs, defect-response, public-complaint and remedial-action failures where the inspection or asset-recording process is not itself deficient.
  • Excludes generic database, information-management, training or staffing deficiencies not explicitly tied to highway inspection or highway-asset records.
  • Excludes landowner tree management and professional review where the concern is management of privately owned trees rather than the highway authority's inspection and asset-recording process.
  • Excludes specific road hazards, signage, markings, lighting or road-layout deficiencies when no failure of the highway inspection or asset-recording process is identified.

Reports and published responses 13 reports

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

  1. Milton Keynes

    AI-generated summary

    John Charles HICKMOTT · 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

    John Charles Hickmott died at the scene after stepping from a pedestrian island into the path of a moving car on V11 Tongwell Street, Milton Keynes, on 19 February 2025. The incident occurred in darkness, with several nearby streetlights not working, making pedestrians difficult to see. The principal concerns were the timeliness and monitoring of streetlight repairs and the extent of proactive inspections for faulty lights.

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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

    Insufficient proactive inspection for unreported faulty streetlights

    Wider context from the report

    “I am concerned at: 1) The timeliness of repairs being undertaken when streetlights are reported as not being lit; 2) The extent of monitoring of scheduled repairs to ensure timely repair; 3) The extent to which proactive inspections are undertaken by the Council to identify faulty streetlights, or blocks of lights, that may not have been reported to the Council. ”

    Source location

    John Charles HICKMOTT · Prevention of Future Deaths report
    Page 2 · concerns

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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 remote monitoring across most highway streetlighting assets, including all grid-road and high-priority lighting, to identify outages proactively.

    Verbatim wording from the response

    “By April 2026, most of the highways street lighting assets and all grid road and high priority lighting are now all have had a remote monitoring system installed. This enables proactive inspection and early identification of any streetlights out. This will replace most manual scouting. There will remain a minimal level manual ‘fault scouting’ and identification to check any significant or unclear fault reports from the system.”

    Source location

    Response from Highways and Transportation, Milton Keynes Council
    Page 2 · response
    Published 3 December 2025

    Open published response

  2. Cambridgeshire and Peterborough

    AI-generated summary

    Jennifer BUNYAN and Marion BUNYAN · 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

    Jennifer Bunyan and Marion Bunyan died by drowning on 7 June 2020 after their motor car left the carriageway, rolled onto its roof and became partially submerged in Crease Drain. Jennifer was pregnant, and her unborn daughter, later named Erin Marion Chatten, also died in utero. The report raised concerns about the speed limit, road inspections, highway degradation, delays in remedial action and the absence of an effective barrier preventing vehicles entering the waterway.

    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

    Insufficiently rigorous road inspections

    Wider context from the report

    “I have a concern that inspections of the road have not been sufficiently rigorous given a recurring issue of highway degradation from ‘rutting’ at the carriageway edge which can be a contributory factor causing loss of control of a vehicle. It is unclear if the council have carried out audits to review the quality of inspections and whether there have been examples of substandard inspections. ”

    Source location

    Jennifer BUNYAN and Marion BUNYAN · Prevention of Future Deaths report
    Page 2 · concerns

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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 audit the quality of road inspections

    Wider context from the report

    “I have a concern that inspections of the road have not been sufficiently rigorous given a recurring issue of highway degradation from ‘rutting’ at the carriageway edge which can be a contributory factor causing loss of control of a vehicle. It is unclear if the council have carried out audits to review the quality of inspections and whether there have been examples of substandard inspections. ”

    Source location

    Jennifer BUNYAN and Marion BUNYAN · 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

    Maintain enhanced maintenance checks on Puddock Road to identify and address highway degradation, including rutting.

    Verbatim wording from the response

    “The composition of Puddock Road presents the County Council with many challenges, not least of which is the sub soil that the road is built on. Repairs that have been completed do not last, and with the continued movement of the sub soil it is proving difficult to find a long-lasting solution. This is why the Council instigated the enhanced maintenance checks on Puddock Road. A weight restriction on the road was considered but is not being progressed at this time due to the access requirements for farm vehicles. The trial sections to treat rutting in the verge will be commencing in early 2025 will hopefully give us some longer-term solutions to the soil erosion issues.”

    Source location

    Response from Cambridgeshire County Council
    Page 3 · response
    Published 1 August 2024

    Open published response

  3. Surrey

    AI-generated summary

    John William BASS · 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

    John William Bass, aged 80, died from head and chest injuries after falling from his bicycle into an approaching vehicle on A217 Brighton Road, Tadworth, on 6 December 2022. Concerns were raised that vegetation narrowing the pavement was not identified as a safety concern and that yearly inspections may be insufficient for a route frequently used by cyclists beside a busy road.

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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

    Lack of clear guidance for inspectors identifying vegetation encroachment on footpaths

    Wider context from the report

    “When the footpath was inspected in November 2022, just weeks before the accident, the highway inspector did not consider the narrowing of pathway as a safety concern and or met an intervention level which required action. It is noted in the policy that there is reference to trees and vegetation, but no clear guidance in terms of vegetation which encroaches on pavements. I am concerned that there is a risk to future pavement users if clear guidance is not provided to inspectors to identify safety concerns regarding vegetation on growth footpaths. The Highways current inspection of the pavement is only yearly albeit in evidence given at inquest by the family, this road is used frequently by cyclists next to a busy road. I am therefore concerned that the frequency of the inspections need to be reviewed. ”

    Source location

    John William BASS · Prevention of Future Deaths report
    Page 2 · concerns

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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

    Insufficient frequency of pavement inspections

    Wider context from the report

    “When the footpath was inspected in November 2022, just weeks before the accident, the highway inspector did not consider the narrowing of pathway as a safety concern and or met an intervention level which required action. It is noted in the policy that there is reference to trees and vegetation, but no clear guidance in terms of vegetation which encroaches on pavements. I am concerned that there is a risk to future pavement users if clear guidance is not provided to inspectors to identify safety concerns regarding vegetation on growth footpaths. The Highways current inspection of the pavement is only yearly albeit in evidence given at inquest by the family, this road is used frequently by cyclists next to a busy road. I am therefore concerned that the frequency of the inspections need to be reviewed. ”

    Source location

    John William BASS · 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

    Remind inspectors to assess pavement narrowing or obstruction risks to vulnerable users and request maintenance or urgent responses where necessary.

    Verbatim wording from the response

    “SCC believes that our current inspection processes are in line with the legal requirements and with the risk-based approach encouraged by national guidance. Following the receipt of the Prevention of Future Deaths report however, we have reminded our inspectors to consider the risk that narrowing/obstruction situations may pose, particularly to vulnerable users of pavements, such as wheelchair users or those with push chairs etc and to request maintenance work where needed, or to raise as an immediate risk for a quicker response where they consider such a risk to be very serious or life threatening.”

    Source location

    Response from Surrey County Council
    Page 3 · response
    Published 14 May 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Current inspection processes and public-reporting mechanisms sufficiently address pavement debris and vegetation risks without changing the inspection guidance.

    Verbatim wording from the response

    “Instances such as the situation on the pavements of the A217 in November/December 2022 where there has been a narrowing of the footway due to seasonal vegetation growth/detritus, are considered as street cleansing or general maintenance issues rather than as “safety defects” which require an immediate response. These situations are generally identified through reports from the public.”

    Source location

    Response from Surrey County Council
    Page 3 · response
    Published 14 May 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The footway's annual Category 4 inspection is considered appropriate because its hierarchy is correctly assessed and public reports are handled throughout the year.

    Verbatim wording from the response

    “Footways have four levels of hierarchy. The highest is a primary walking route (Category 1) which is inspected monthly, then a secondary walking route (Category 2) which is inspected every three months, link footways (Category 3) which are inspected every 6 months and finally local access footways (Category 4) which are inspected annually.”

    Source location

    Response from Surrey County Council
    Page 4 · response
    Published 14 May 2024

    Open published response

  4. Lancashire and Blackburn with Darwen

    AI-generated summary

    Harry College · 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

    Harry Colledge, an 84-year-old man, died after his bicycle entered a crack in the carriageway on Island Lane, throwing him from the bicycle and causing fatal injuries. Concerns included highway operatives’ ability to identify defects hazardous to cyclists and the adequacy of maintaining road surfacing affected by natural movement and underlying geological features.

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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 of inspections to reasonably identify hazardous defects on geologically unstable road surfacing

    Wider context from the report

    “2. Evidence from a Highways Expert, ████████, explained that Island Lane is part of peat/moss road which is the subject of natural movement when it rains. The water is absorbed by the peat/moss and swells caused the tarmac to move then it compacts when it dries and the road surface lowers, causing cracks. ████████’s evidence was that there is natural movement but these defects rarely get better, only worse. I am concerned that the road surfacing on Island Lane, Winmarleigh will continue to be the subject of natural movement and the present surfacing is hampered by the geography of the location including camber of the road. I consider there is a risk of future deaths to road users if the surfacing of this road is not adequately maintained. Whilst the inspection schedule timescales enacted by the Council are considered to be appropriate, I consider there is a risk of future deaths due to the present surfacing and underlying geological features of this road if inspections are unable to reasonably identify hazardous defects. ”

    Source location

    Harry College · Prevention of Future Deaths report
    Page 3 · concerns

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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 of highway operatives to identify defects hazardous to cyclists

    Wider context from the report

    “1. Highway operatives gave evidence that their inspections primarily consider the impact of defects upon cars using that road surface. All gave evidence of no specific training or experience with regards to identifying defects which present a hazard to bicycle users, when expert evidence indicated that the Council’s statutory duty required reasonable steps to protect all road users which includes cyclists. The evidence of Council witnesses was unanimous that since Mr Colledge’s death, there has been no additional training, updates, briefings or policy reviews to offer further knowledge of operatives in safely assessing defects which pose risks to cyclists or road users other than car drivers. I consider there is a risk of future deaths of all cyclists if Highways Operatives are not able to identify defects on a carriageway which present a risk to cyclists as opposed to simply car users. ”

    Source location

    Harry College · 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

    Deliver and disseminate an incident debrief covering lessons learned, operational instructions, defect reporting, surface cracking and hazards to all road users.

    Verbatim wording from the response

    “1. Inquest Debrief”

    Source location

    Response from Lancashire County Council
    Page 1 · response
    Published 23 February 2024

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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

    Deliver annual workshops for staff inspecting and assessing highway defects, covering policy compliance, national guidance and operational learning.

    Verbatim wording from the response

    “d) Awareness Training – front line highway teams”

    Source location

    Response from Lancashire County Council
    Page 4 · response
    Published 23 February 2024

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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 commissioned peer review of the Highway Safety Inspection Policy, prioritising learning from this case.

    Verbatim wording from the response

    “The Council has also identified that a peer review of the Highway Safety Inspection Policy could assist in identifying any changes or improvements to the current policy. The original policy was written in 2018 and was compared with other local authorities at that time. A peer authority has been commissioned and the review will start on 22.01.2024. It is anticipated that this review will take up to 8 months to complete.”

    Source location

    Response from Lancashire County Council
    Page 5 · response
    Published 23 February 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Deliver approved toolbox-talk awareness training to all Highway Operatives, including defect impacts and procedures for reporting defects for assessment.

    Verbatim wording from the response

    “As outlined above, there is an instruction in place that Highway Operatives are not to be used for defect identification through the "find and fix" method of working, their capacity being limited to repairing additional defects to those directed where they can be seen within existing traffic management arrangements.”

    Source location

    Response from Lancashire County Council
    Page 4 · response
    Published 23 February 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Highway Operatives are not responsible for identifying defects; Highway Safety Inspectors and Technicians carry out the inspection regime.

    Verbatim wording from the response

    “Highway Operatives are not required to identify or assess any defect as set out in the Highway Safety Inspection Policy, however they are given the scope to repair additional defects they may see within the area of highway contained in any traffic management already in place.”

    Source location

    Response from Lancashire County Council
    Page 3 · response
    Published 23 February 2024

    Open published response

  5. North Lincolnshire and Grimsby

    AI-generated summary

    Adam David Simms · 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

    Adam David Simms was the sole occupant and driver of a car that lost control after striking standing water on the A18 during heavy rain and collided with an oncoming lorry, causing fatal injuries. Concerns were raised about blocked drainage gullies, extensive standing water on the carriageway, and the absence of an explanation and remedial action to prevent recurrence.

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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 identify and remedy blocked drainage gullies

    Wider context from the report

    “(1) I received evidence regarding the system of inspection utilised to identify and remedy any blocked drainage gullies. Two blocked gullies were found at the site of the accumulation of water upon the carriageway notwithstanding that an inspection undertaken only four days previously on 17 May 2021 had not identified those defects. They had not been included in cleansing works undertaken on 8 April 2022. (2) The evidence suggested that at around the point at which Mr Simms lost control of his motor car there were two separate patches of standing water upon the carriageway. They were said to be 62m in length and 36m in length respectively. They occupied the majority of the width of the Eastbound carriageway. Water was noted to a depth of between 10 and 15mm. There was plainly a significant quantity of standing water which posed a serious hazard to road users. (3) Whilst the evidence I received did not establish on balance of probabilities that those blocked gullies were the cause of the patches of water described above, no alternative explanation for such a significant accumulation of water was provided by the evidence. It had plainly rained heavily, although there was no evidence to suggest an exceptional downpour had occurred. (4) The absence of any explanation for this accumulation, and the consequential absence of any remedial action undertaken to prevent a repetition of these events gives rise to a concern that the highway at that location remains at risk of water ingress (from whatever source) unless and until the cause can be established and appropriate remedial action taken. ”

    Source location

    Adam David Simms · 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

    No further action is considered necessary beyond monitoring the highway under the Council’s existing inspection system.

    Verbatim wording from the response

    “In the circumstances, we do not intend to take any further action at this location, other than ensuring monitoring of the highway in accordance with the Council’s system of inspection as set out above.”

    Source location

    Response from North Lincolnshire Council
    Page 3 · response
    Published 20 October 2022

    Open published response

  6. Surrey

    AI-generated summary

    Charles Michael Stringer · 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

    Charles Michael Stringer, a cyclist, died after hitting a pothole on Church Lane, causing a punctured front tyre and loss of control that resulted in a fatal chest injury. The report raises concerns about Surrey County Council’s lack of documented reflection, changes to pothole-management systems, communication, risk assessment, defect categorisation and timely repairs following his death.

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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 ensure defect inspectors receive recent road-condition complaints

    Wider context from the report

    “2. A lack of action and/or change to the management of potholes by SCC following Mr Stringer’s death SCC has indicated in written submissions that a number of discussions have taken place following Mr Stringer’s death but there has been no documented changes in systems or practice in particular: 1. What steps have been taken to ensure inspectors of defects are fully informed of recent complaints including those from members of the public regarding damage to bicycles by the state of the road. 2. What steps have been taken in the provision of a detailed and robust risk assessment by inspectors with all the available information available such as past complaints, the nature of the road and who uses the road to ensure a ‘holistic’ approach to decision making with regard to the necessity and the speed of road repairs. 3. What, if any, changes have been made to the pictorial guide and the matrix given to inspectors to ensure training there is not an ‘overly mechanistic’ assessment of a road defect. 4. What steps have been taken to ensure there is appropriate and timely communication between the SCC contact centre and the highways department such as a standard operating procedure in place when complaints must be forwarded on and responded to? 5. What steps have been taken to ensure repairs are completed in a timely fashion after serious injuries and deaths have occurred, as a result of a road defect? ”

    Source location

    Charles Michael Stringer · Prevention of Future Deaths report
    Page 3 · 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

    Build a new data system and assess whether historical complaint data should be made available to highway inspectors.

    Verbatim wording from the response

    “There are risks and benefits to providing historical data and not providing it. These have been carefully considered, and SCC is still giving specific consideration to whether providing historical complaint data to Inspectors would be beneficial.”

    Source location

    Response from Surrey County Council
    Page 3 · response
    Published 14 October 2022

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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

    Limited resources and inconsistent public reporting mean inspections cannot be redirected or biased solely by the number of complaints received.

    Verbatim wording from the response

    “Inspections are based on what the Inspector sees at the point in time that the inspection takes place. SCC often gets multiple reports of what might be the same defect and there can be a variety of reasons why certain defects may be the subject of multiple reports (it is not always the case that a higher number of reports means that a defect poses a greater risk than a defect which has received only one report). For this reason, while we assess all reports from the public regarding potential safety defects, we need to ensure that limited resources are not diverted or biased based on what can be inconsistent reporting by the public. It is important that inspections that are prompted by a customer complaint are carried out to review what is reported at that point in time as an independent one-off inspection carried out by a trained Inspector.”

    Source location

    Response from Surrey County Council
    Page 3 · response
    Published 14 October 2022

    Open published response

  7. East Sussex

    AI-generated summary

    Jennifer Ann DYER · 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

    Jennifer Ann DYER, aged 36, died after her bicycle collided with a van following contact with a defective pothole on the B2188. The pothole had a history of failed repairs and previous concerns about the danger it posed to road users. The report raises concern that its categorisation as a low-risk defect requires significant review, stating that the death was avoidable.

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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 appropriately categorise pothole risks

    Wider context from the report

    “Under the East Sussex Highway Asset Inspection Manual, this pothole fell within the definition of Cat 3 - LOW for risk and remedial works. The definition is “Greater than 40mm and less than 59mm deep and at least 300mm in all directions”. Clearly, this pothole was the proximate cause of the death of a young woman, and the categorisation of potholes in East Sussex requires significant review, to prevent future avoidable deaths within the County. ”

    Source location

    Jennifer Ann DYER · 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

    Introduce an enhanced risk-based inspection process allowing defect categories and response times to reflect location, usage and assessed risk.

    Verbatim wording from the response

    “In May 2021 a revised Highway Inspection Manual introduced an enhanced risk assessment process where the highway inspector can consider other factors, such as the location of a defect and usage, as well as the defect category in determining whether a response is required or a different response time required. This means that, following the risk assessment, they are able to change the category of a defect such as changing a non-intervention defect to an intervention defect or reduce or increase the category response time if deemed appropriate. For example, if a category 3 pothole is located on the part of the carriageway cyclists are likely to use such as the nearside edge, this could be increased to a category 2 or 1 depending on risk assessment.”

    Source location

    Response from East Sussex County Council
    Page 2 · response
    Published 16 September 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Continue reviewing the effectiveness of the enhanced risk-based approach, including how it would have affected the incident.

    Verbatim wording from the response

    “- Continue to review the effectiveness of the implemented enhanced risk based approach and in particular review how it would have affected this case”

    Source location

    Response from East Sussex County Council
    Page 3 · response
    Published 16 September 2022

    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 enhanced risk-based inspection process makes a specific review of pothole categories unnecessary.

    Verbatim wording from the response

    “risk based approach to its safety inspection regimes which allows for a more flexible approach to determining risk for all road users and defect response times. This enables the inspector to change the categorisation of a pothole to include potholes for repair that do not meet the lowest category if required or to change the category of a pothole to a medium or high risk following an onsite risk assessment that now also considers location and road usage in addition to size and depth.”

    Source location

    Response from East Sussex County Council
    Page 3 · response
    Published 16 September 2022

    Open published response

  8. Derby and Derbyshire

    AI-generated summary

    Heike MOJAY-SINCLARE · 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

    Heike Mojay-Sinclare drowned after her car became stuck in high and rising flood water at a ford on Doles Lane, Derbyshire, in late December 2018. The report raised concerns about the lack of mandatory standards, inspection and maintenance requirements for ford depth gauges, and insufficient sharing of information about previous serious incidents.

    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 include river fords and depth gauges in mandatory highways inspection requirements

    Wider context from the report

    “2. The inquest heard that river fords and depth gauges do not currently lie within mandatory highways inspection requirements and therefore there is no guarantee of their maintenance and review, and therefore no guarantee that they continue to provide on-going usability and safety. ”

    Source location

    Heike MOJAY-SINCLARE · 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

    The Government has no power to override local highway maintenance decisions or intervene in local inspection arrangements.

    Verbatim wording from the response

    “3. With regards to highways inspection requirements, local highway authorities have a duty, under section 41 of the Highways Act 1980, to maintain the highway network in their area. The Act does not set out specific standards of maintenance, as it is for each individual local highway authority to assess which parts of its network are in need of repair and what standards should be applied, based upon their local knowledge and circumstances. The Government has no powers to override local decisions in these matters or intervene in these kinds of local issues.”

    Source location

    Response from Department for Transport
    Page 2 · response
    Published 23 September 2021

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    No Departmental action is considered necessary because the relevant decisions rest with local authorities and tools are already available.

    Verbatim wording from the response

    “I hope this response has explained my thinking on why I do not believe there are any actions necessary from the Department. I am afraid the concerns that you have raised are issues where the decision to act rests with the local authority, and there are tools available to them already to enable them to do so.”

    Source location

    Response from Department for Transport
    Page 2 · response
    Published 23 September 2021

    Open published response

  9. Milton Keynes

    AI-generated summary

    Susan Barbara HENDERSON and Margaret Louise SHAW · 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

    Susan Barbara Henderson and Margaret Louise Shaw died at the scene from injuries after one car aquaplaned across the A5, Milton Keynes, into the path of an oncoming vehicle. Evidence indicated that standing water had accumulated because blocked roadside gullies had not been identified during routine inspections, prompting concern that the inspection process should be reviewed.

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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 of road inspections to identify drain problems

    Wider context from the report

    “During the course of the evidence I heard how the roads are examined and monitored on a regular basis but that such inspections are conducted at speed and that the process failed to identify the problem with this particular drain on the A5. I believe that the process for inspection should be reviewed. ”

    Source location

    Susan Barbara HENDERSON and Margaret Louise SHAW · 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 a review of inspection requirements and processes across the Strategic Road Network, including the speed of driven inspections.

    Verbatim wording from the response

    ““During the course of the evidence I heard how the roads are examined and monitored on a regular basis but that such inspections are conducted at speed and that the process failed to identify the problem with this particular drain on the A5. I believe that the process for inspection should be reviewed.””

    Source location

    Response from Highways England
    Page 2 · response
    Published 14 August 2019

    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

    Issue a memorandum to all Areas highlighting recessed-gully locations, defect-recording methods, possible renewal of non-standard gullies, and communication of defects to Local Authorities.

    Verbatim wording from the response

    “Following the review of inspection requirements and processes Highways England has decided to issue a memorandum to all our Areas to highlight the importance of:”

    Source location

    Response from Highways England
    Page 3 · response
    Published 14 August 2019

    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

    Move Area 8 from Asset Support Contract arrangements to the Asset Delivery approach, with inspections undertaken in-house by Highways England staff.

    Verbatim wording from the response

    “From the 1st October 2019 Area 8 will be moving from the current Asset Support Contract arrangements to the new Asset Delivery approach. Asset Delivery inspections will be undertaken in-house by Highways England staff.”

    Source location

    Response from Highways England
    Page 3 · response
    Published 14 August 2019

    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 risk-based inspection requirements and processes are considered consistent and sufficient, so no changes are proposed beyond the Asset Delivery transition.

    Verbatim wording from the response

    “Highways England’s review of the inspection requirements and processes used by Highways England’s Areas and Regions, and our supply chain, concluded they had a common risk based approach, and were understood by inspectors and applied consistently. Therefore, there are no proposals to change the requirements and processes.”

    Source location

    Response from Highways England
    Page 4 · response
    Published 14 August 2019

    Open published response

  10. Manchester (North)

    AI-generated summary

    Mr Roger Hamer · 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

    Mr Roger Hamer fell from his bicycle on Bury New Road, suffering a traumatic brain injury and multiple fractures, and died in hospital from those injuries on 2 April 2016. The inquest jury found that a pothole probably caused his fall. Concerns included inadequate recording and monitoring of carriageway deterioration, a lack of paint markings around potholes, the absence of a duty-of-candour procedure for investigating significant incidents, and proposed highway-management thresholds that might increase risks to 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

    Failure to document carriageway defect condition during inspections

    Wider context from the report

    “(1) When he inspected the carriageway in January 2016 and February 2016 the highway inspector did not photograph, measure and/or record any details as to the condition of the carriageway where the Pothole developed despite it having started to deteriorate, wear and crack by October 2015. This prevented the Highway Authority from effectively assessing the rate of deterioration of this part of the carriageway which may have helped to inform it as to the need for earlier repair. Also, the lack of images and/or measurements of the Pothole as at the date of the inspections restricted the Highway Authority’s ability to effectively supervise and monitor the highway inspector and it hindered the jury’s ability to make more detailed findings as to the circumstances of Mr Hamer’s death. ”

    Source location

    Mr Roger Hamer · 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

    Maintain highway inspection procedures and systems in accordance with best-practice guidance.

    Verbatim wording from the response

    “1) Bury Council, as Highway Authority, ensured that their procedures and systems of inspection were in accordance with best practice guidance as set out within the Well Maintained Highways – A Code of Practice for Highway Maintenance Management 2009.”

    Source location

    2017-0259-Response-by-Bury-Council
    Page 1 · response
    Published 7 November 2017

    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

    Take routine photographs of dangerous defects before repair and of repairs afterward.

    Verbatim wording from the response

    “Due to investment in the highway maintenance procedures and IT systems, highway inspectors now routinely take photographs of defects giving rise to a real source of danger. Repair crews also take photographs prior to and post repair.”

    Source location

    2017-0259-Response-by-Bury-Council
    Page 2 · response
    Published 7 November 2017

    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 lack of pothole images or measurements did not restrict effective supervision or compliance with the statutory highway safety duty.

    Verbatim wording from the response

    “It is not accepted that the lack of images or measurements of the pothole restricted the Highway Authority’s ability to effectively supervise and monitor the highway inspector or did not allow it to comply with its statutory duty under the Highways Act 1980 to ensure that they had taken such care as in all the circumstances was reasonably required to secure that part of the highway was not dangerous for traffic.”

    Source location

    2017-0259-Response-by-Bury-Council
    Page 2 · response
    Published 7 November 2017

    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