6 Jul 2015 John Paul Clarke · Prevention of Future Deaths report Inner West London
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Concerns raised 5
Failure of highway inspections to identify missing road signs View source Failure of highway inspections to identify defective sign lighting View source Insufficiently comprehensive highway asset database View source
Failure of the inspection system to facilitate remedial works for road-sign and lighting defects View source Failure to record highway signs in the inspection asset database View source See 2 more concerns
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John Paul Clarke · 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 Paul Clarke died on 5 March 2014 after his motorcycle contacted the raised kerb of a traffic island in London, causing him to fall and collide with a rigid metal Keep Left sign. The concerns included failures to identify a missing sign, defective lighting, and incomplete highway asset records, together with an inspection system that was not sufficiently effective to identify and remedy these defects.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of highway inspections to identify missing road signs
Wider context from the report “1. Westminster City Council in its capacity as the highways authority carried out monthly walked inspections of Northumberland Avenue (along with other inspections). These inspections did not register that a “Keep Left” sign located at the easterly end of the traffic island involved in the incident was missing and had been missing for at least three years.
” Source location John Paul Clarke · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of highway inspections to identify defective sign lighting
Wider context from the report “2. The various inspections carried out by Westminster City Council failed to register that the external lighting arrangement for the “Keep Left” sign that was located on the traffic island was defective and had probably not been working for three years.
” Source location John Paul Clarke · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficiently comprehensive highway asset database
Wider context from the report “5. The database of street signs and other highway assets used by Westminster City Council as a basis for its periodic inspections was not sufficiently comprehensive.
” Source location John Paul Clarke · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of the inspection system to facilitate remedial works for road-sign and lighting defects
Wider context from the report “4. The inspection system in force in the period 2011-2014 was not sufficiently effective to identify missing road signs and/or lighting defects which good practice required to be in place and to facilitate remedial works to rectify the situation.
” Source location John Paul Clarke · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to record highway signs in the inspection asset database
Wider context from the report “3. The missing “Keep Left” sign and the Keep Left sign which was in place at the western end of the traffic island, were not recorded on the database of assets used by Westminster City Council in the course of their inspections . This omission made it less likely that the defects referred to would be noticed and hindered any attempts to initiate remedial works.
” Source location John Paul Clarke · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Replace illuminated-sign attributes with a handheld Sign Number and Description attribute, with rollout to non-illuminated signs if successful.
Verbatim wording from the response “3.4 With the move to handheld technology, a new attribute of Sign Number and Description has been added to enable site staff, including highways inspectors, to easily select the sign type by description without having to know the TSRGD ref number (Figure 2). The drop down menu has the TSRGD number at the end of the description. This will replace the two existing Illuminated sign attributes listed in paragraph 3.3. This is a work in progress and if successful, it will be rolled out to Highways non-illuminated signs as well (Figure 1).” Source location Response
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PFD Monitor interpretation Agree the scope and method for updating legacy scheme areas, including whether to resurvey them and use Confirm Connect.
Verbatim wording from the response “4.5 There remain some schemes from our previous contract that have not been updated in the inventory. A scope of works and method are actively in discussion, including the need to resurvey these areas and whether the Confirm Connect could be used. The timeline to complete the physical inventory updates is by the end of the current financial year (31 March 2016).” Source location Response
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How this respondent action was interpreted
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PFD Monitor interpretation Complete physical inventory updates for outstanding legacy scheme areas by 31 March 2016.
Verbatim wording from the response “4.5 There remain some schemes from our previous contract that have not been updated in the inventory. A scope of works and method are actively in discussion, including the need to resurvey these areas and whether the Confirm Connect could be used. The timeline to complete the physical inventory updates is by the end of the current financial year (31 March 2016).” Source location Response
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PFD Monitor interpretation Train inspectors on updated missing-asset works-order and inventory-reporting protocols.
Verbatim wording from the response “6.1 The user guide produced for the inspectors on the use of Confirm Connect is attached as Appendix 1. This is used as part of the inspector training, including induction for new staff, and has been updated to include the protocol for raising works orders when the asset is missing (page 32 for highways assets, page 56 for lighting assets and page 61 for gully assets).” Source location Response
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PFD Monitor interpretation Provide additional regulatory-signage and TSRGD training to inspectors in January 2016.
Verbatim wording from the response “6.4 While the inventory holds the sign diagram number already and will be updated to give both the TSRGD diagram number and the description so the inspectors see this, given the latter will take some time to complete, additional training on regulatory signage and TSRGD is being provided to the inspectors in January 2016.” Source location Response
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PFD Monitor interpretation Implement Confirm Connect for lighting maintenance to provide real-time inventory updates.
Verbatim wording from the response “4.2 There are two methods of updating the inventory. The first is using handheld units and this method updates the inventory for reactive and routine maintenance works carried out using the same Confirm Connect software as the inspectors. This is already used by our drainage provider and shortly will be used by our lighting service provider for both reactive and routine maintenance. This brings much greater opportunity to keep the inventory updated in real time.” Source location Response
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How this respondent action was interpreted
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PFD Monitor interpretation Develop protocols enabling lighting crews to correct base inventory data during routine maintenance inspections.
Verbatim wording from the response “4.4 As a result of the implementation of Confirm Connect in the lighting service, we are currently developing protocols that will enable the lighting crews to not only update the inventory with maintenance works carried out, but also to make corrections to the base inventory asset data during routine maintenance inspections. This means that over the course of the next two full year’s maintenance inspection cycles (by 31 March 2018) when every illuminated asset will have been inspected using the new hand held units, the inventory will be updated. Taken together with the other update protocols, this provides a complete cycle of keeping the inventory updated.” Source location Response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete illuminated-asset inventory updates over two full maintenance inspection cycles by 31 March 2018.
Verbatim wording from the response “4.4 As a result of the implementation of Confirm Connect in the lighting service, we are currently developing protocols that will enable the lighting crews to not only update the inventory with maintenance works carried out, but also to make corrections to the base inventory asset data during routine maintenance inspections. This means that over the course of the next two full year’s maintenance inspection cycles (by 31 March 2018) when every illuminated asset will have been inspected using the new hand held units, the inventory will be updated. Taken together with the other update protocols, this provides a complete cycle of keeping the inventory updated.” Source location Response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor uncommitted works orders daily using a newly introduced Confirm report.
Verbatim wording from the response “2.9 Outstanding committed works orders issued to the service provider are monitored every day through a report generated from Confirm and at regular monitoring meetings. In certain circumstances works orders can become stuck and stay ‘uncommitted’ in the system. When this happens, the works order does not go through to the service provider. However, a new report has been introduced to allow staff and the provider to monitor these on a daily basis as well.” Source location Response
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing inspection, contingency and inventory systems ensure missing or incorrectly recorded assets generate remedial work and prompt database updates.
Verbatim wording from the response “The aim of the measures that the City Council already has in place, and those to be implemented, is that the City Council maintains an accurate inventory. The systems in place ensure that where an asset is missing or the record of it is incorrect, that the inventory database, contingency protocols and inspector knowledge and awareness ensure that the required remedial work is always ordered for our service provider to action and that the required update to the inventory database occurs promptly.” Source location Response
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27 May 2015 Nicholas Gary Stocks · Prevention of Future Deaths report West Yorkshire (West)
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Concerns raised 2
Inconsistent highway inspection practices View source Unclear allocation of responsibility for inspecting road junctions View source
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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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.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inconsistent highway inspection practices
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
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unclear allocation of responsibility for inspecting road junctions
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
Open source report
17 Jul 2014 Michael Arthur Warren · Prevention of Future Deaths report Berkshire
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Concerns raised 4
Lack of clear, detailed guidance for Local Authorities on highway inspection of trees View source Highway inspections conducted at speeds that reduce the likelihood of identifying tree hazards View source Absence of dedicated inspections of trees abutting the highway View source
Lack of adequate guidance for Highway Inspectors on identifying tree hazards View source See 1 more concern
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Michael Arthur Warren · 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
Michael Arthur Warren died from serious head injuries after a large branch from an oak tree fell onto the roof of the car he was driving on 5 October 2012. The concerns included limited training and guidance for highway inspectors assessing tree hazards, insufficiently targeted tree inspections, a lack of clear national guidance for local authorities, and the absence of professional management of the landowner’s trees near the highway.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of clear, detailed guidance for Local Authorities on highway inspection of trees
Wider context from the report “(1) The evidence at the Inquest revealed that Bracknell Forest Council employ Highways Inspectors to carry out driven and walked inspections in order to attempt to identify any potential hazards that might impact adversely on road users.
(2) The Highway Inspectors were expected to identify a range of potential problems including potholes in the road, damaged or obscured signage and potential hazards from trees abutting the highway which were often of considerable height. There was little by way of guidance given to Highways Inspectors who had developed their own system of drive-by investigations conducted at a speed rarely less than thirty miles per hour.
(3) The evidence highlighted the limited nature of training provided to Highway Inspectors in identifying potential hazards from trees. The two Inspectors who conducted a drive-by survey two days before the branch fell and killed Mr Warren and who had noted nothing of concern, had not completed any form of tree training since a two day course some seven years earlier. Another Highway Inspector who gave evidence at the Inquest, had never attended a formal training course with regard to tree hazards.
(4) There is therefore a need for appropriate guidelines to be provided by Bracknell Forest Council to Highway Inspectors to ensure that they are properly trained in tree issues; that they have an appropriate system of work that ensures that they drive at a speed appropriate to maximise the chances of identifying tree hazards and that there should be a series of inspections which are limited to only the inspection of trees.
(5) The evidence also revealed that there was very little by way of clear, detailed guidance available to Local Authorities as regards the appropriate systems of highway inspection of trees abutting the highway . There is a potential need for clear direction from a suitably qualified source to assist Local Authorities in this crucial role .
(6) The owner of the land on which the relevant oak tree stood lived abroad and had no arrangements for professional review of the trees on his property, in particular those that were close to the highway and therefore a potential hazard to road users. It was of concern that the lack of active management of the owner’s land continued some two and a half years after Mr Warren’s death.
” Source location Michael Arthur Warren · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Highway inspections conducted at speeds that reduce the likelihood of identifying tree hazards
Wider context from the report “(1) The evidence at the Inquest revealed that Bracknell Forest Council employ Highways Inspectors to carry out driven and walked inspections in order to attempt to identify any potential hazards that might impact adversely on road users.
(2) The Highway Inspectors were expected to identify a range of potential problems including potholes in the road, damaged or obscured signage and potential hazards from trees abutting the highway which were often of considerable height. There was little by way of guidance given to Highways Inspectors who had developed their own system of drive-by investigations conducted at a speed rarely less than thirty miles per hour .
(3) The evidence highlighted the limited nature of training provided to Highway Inspectors in identifying potential hazards from trees. The two Inspectors who conducted a drive-by survey two days before the branch fell and killed Mr Warren and who had noted nothing of concern, had not completed any form of tree training since a two day course some seven years earlier. Another Highway Inspector who gave evidence at the Inquest, had never attended a formal training course with regard to tree hazards.
(4) There is therefore a need for appropriate guidelines to be provided by Bracknell Forest Council to Highway Inspectors to ensure that they are properly trained in tree issues; that they have an appropriate system of work that ensures that they drive at a speed appropriate to maximise the chances of identifying tree hazards and that there should be a series of inspections which are limited to only the inspection of trees.
(5) The evidence also revealed that there was very little by way of clear, detailed guidance available to Local Authorities as regards the appropriate systems of highway inspection of trees abutting the highway. There is a potential need for clear direction from a suitably qualified source to assist Local Authorities in this crucial role.
(6) The owner of the land on which the relevant oak tree stood lived abroad and had no arrangements for professional review of the trees on his property, in particular those that were close to the highway and therefore a potential hazard to road users. It was of concern that the lack of active management of the owner’s land continued some two and a half years after Mr Warren’s death.
” Source location Michael Arthur Warren · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Absence of dedicated inspections of trees abutting the highway
Wider context from the report “(1) The evidence at the Inquest revealed that Bracknell Forest Council employ Highways Inspectors to carry out driven and walked inspections in order to attempt to identify any potential hazards that might impact adversely on road users.
(2) The Highway Inspectors were expected to identify a range of potential problems including potholes in the road, damaged or obscured signage and potential hazards from trees abutting the highway which were often of considerable height. There was little by way of guidance given to Highways Inspectors who had developed their own system of drive-by investigations conducted at a speed rarely less than thirty miles per hour.
(3) The evidence highlighted the limited nature of training provided to Highway Inspectors in identifying potential hazards from trees. The two Inspectors who conducted a drive-by survey two days before the branch fell and killed Mr Warren and who had noted nothing of concern, had not completed any form of tree training since a two day course some seven years earlier. Another Highway Inspector who gave evidence at the Inquest, had never attended a formal training course with regard to tree hazards.
(4) There is therefore a need for appropriate guidelines to be provided by Bracknell Forest Council to Highway Inspectors to ensure that they are properly trained in tree issues; that they have an appropriate system of work that ensures that they drive at a speed appropriate to maximise the chances of identifying tree hazards and that there should be a series of inspections which are limited to only the inspection of trees .
(5) The evidence also revealed that there was very little by way of clear, detailed guidance available to Local Authorities as regards the appropriate systems of highway inspection of trees abutting the highway. There is a potential need for clear direction from a suitably qualified source to assist Local Authorities in this crucial role.
(6) The owner of the land on which the relevant oak tree stood lived abroad and had no arrangements for professional review of the trees on his property, in particular those that were close to the highway and therefore a potential hazard to road users. It was of concern that the lack of active management of the owner’s land continued some two and a half years after Mr Warren’s death.
” Source location Michael Arthur Warren · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of adequate guidance for Highway Inspectors on identifying tree hazards
Wider context from the report “(1) The evidence at the Inquest revealed that Bracknell Forest Council employ Highways Inspectors to carry out driven and walked inspections in order to attempt to identify any potential hazards that might impact adversely on road users.
(2) The Highway Inspectors were expected to identify a range of potential problems including potholes in the road, damaged or obscured signage and potential hazards from trees abutting the highway which were often of considerable height. There was little by way of guidance given to Highways Inspectors who had developed their own system of drive-by investigations conducted at a speed rarely less than thirty miles per hour.
(3) The evidence highlighted the limited nature of training provided to Highway Inspectors in identifying potential hazards from trees. The two Inspectors who conducted a drive-by survey two days before the branch fell and killed Mr Warren and who had noted nothing of concern, had not completed any form of tree training since a two day course some seven years earlier. Another Highway Inspector who gave evidence at the Inquest, had never attended a formal training course with regard to tree hazards.
(4) There is therefore a need for appropriate guidelines to be provided by Bracknell Forest Council to Highway Inspectors to ensure that they are properly trained in tree issues; that they have an appropriate system of work that ensures that they drive at a speed appropriate to maximise the chances of identifying tree hazards and that there should be a series of inspections which are limited to only the inspection of trees.
(5) The evidence also revealed that there was very little by way of clear, detailed guidance available to Local Authorities as regards the appropriate systems of highway inspection of trees abutting the highway. There is a potential need for clear direction from a suitably qualified source to assist Local Authorities in this crucial role.
(6) The owner of the land on which the relevant oak tree stood lived abroad and had no arrangements for professional review of the trees on his property, in particular those that were close to the highway and therefore a potential hazard to road users. It was of concern that the lack of active management of the owner’s land continued some two and a half years after Mr Warren’s death.
” Source location Michael Arthur Warren · Prevention of Future Deaths report
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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.
