23 Nov 2017 Jonathan Philip Armstrong SHAW · Prevention of Future Deaths report Avon
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Concerns raised 1
Failure to implement slow painted markings on both approaches to the bend View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Jonathan Philip Armstrong 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
Jonathan Philip Armstrong Shaw died at the scene from injuries after his Mini crossed into the opposite carriageway and collided with another vehicle on a bend. The report raised concerns about previous incidents at the same location and noted that proposed speed-reduction signs and road markings had not been implemented by the day before the inquest.
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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 implement slow painted markings on both approaches to the bend
Wider context from the report “At the inquest ████████ from the Collision Investigation Unit gave evidence. He said that he had been made aware of a couple of incidents at the same location previously. I was also made aware by the family at the inquest of at least 3 or 4 incidents at this same location.
████████ confirmed that he spoke with the Highways Department at Bath and North East Somerset regarding the location of the incident and his findings. He indicated that it was your intention to highlight the need to reduce speed for the bend by adding road signs with a suggestion of a maximum speed for the bend. In addition that you were going to add “slow” painted markings on both approaches to the location of this tragic incident.
████████ confirmed that the day before the inquest he had travelled the road in question and that the changes had not been carried out .
” Source location Jonathan Philip Armstrong SHAW · Prevention of Future Deaths report
Open source report
21 Aug 2017 Mr Roger Hamer · Prevention of Future Deaths report Manchester (North)
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Concerns raised 1
Unmarked potholes lacking paint markings View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
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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.
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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 Unmarked potholes lacking paint markings
Wider context from the report “(2) The jury recorded its concern as to the lack of paint markings around the potholes which may have highlighted their presence to Mr Hamer thereby enabling him to avoid them.
” Source location Mr Roger Hamer · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Highway Authority does not paint carriageway potholes because doing so would expose highway inspectors to danger from traffic.
Verbatim wording from the response “2) The Highway Authority does not paint markings around potholes especially in the carriageway. As identified above this is for reasons of safety of the highway inspector who would otherwise place himself in a position of danger caused by traffic.” Source location 2017-0259-Response-by-Bury-Council
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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 Paint markings are unnecessary because handheld GPS identifies defects precisely and risk-based repair timescales ensure responsive repair.
Verbatim wording from the response “Paint markings are not used to highlight defects to users of the highway. If they were historically used then this would have been to allow a pothole raised for repair to be identified by the repair team. The need to mark defects is no longer” Source location 2017-0259-Response-by-Bury-Council
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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 Given traffic speeds, paint markings alone would not have sufficiently highlighted the pothole to road users.
Verbatim wording from the response “Given the speed at which vehicular traffic uses Bury New Road, Ramsbottom, the Highway Authority contend that markings alone would not have been sufficient to highlight the presence of the pothole to Mr Hamer.” Source location 2017-0259-Response-by-Bury-Council
Open published response
28 Feb 2017 Paul Michael BRIGGS · Prevention of Future Deaths report Liverpool and the Wirral
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Concerns raised 1
Lack of rumble strips alongside double white lines separating opposing traffic in the tunnel approach View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Paul Michael BRIGGS · 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 3 July 2015, Paul Michael Briggs was riding his motorcycle to work when an oncoming Nissan Micra crossed onto his side of the road and collided with him. He suffered multiple fractures and a traumatic brain injury, remained in a minimally conscious state, and died on 21 January 2017 after artificial nutrition and hydration was withdrawn. The report raised concern that adding rumble strips to the double white lines might reduce the risk of vehicles straying into the oncoming lane, and noted that risk assessments and remedial action were still outstanding some 20 months after the incident.
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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 rumble strips alongside double white lines separating opposing traffic in the tunnel approach
Wider context from the report “Though there is appropriate signage, a two way sign as the carriageways merge and though there are double white lines dividing the tunnel bound carriageway from the Liverpool bound carriageway; this incident occurred resulting in a tragic death. It is unclear as to why the Nissan Micra strayed onto the wrong side of the road but had the double white lines also included rumble strips – (as in the tunnel itself and similar to the lines next to motorway hard shoulders)- this would minimise the risk of inadvertently straying into the oncoming lane especially at quiet times when the side barriers and the bend inhibit visibility of oncoming traffic .
It is now some 20 months after this tragic incident which proved fatal and risk assessments as to the risk of this eventuality, with appropriate remedial action should be nearing completion.
” Source location Paul Michael BRIGGS · Prevention of Future Deaths report
Open source report
22 Feb 2017 Mrs. Margaret Joyce Jones · Prevention of Future Deaths report Avon
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Concerns raised 1
Inadequate or unrepaired carriageway markings warning drivers of the junction risk View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
National Highways
Implement visibility and signing measures at the Branch Road junction, including warning signs, road markings, red surfacing, direction signs and vegetation clearance.
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AI-generated summary
Mrs. Margaret Joyce Jones · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs. Margaret Joyce Jones died at the scene after her car collided with a northbound articulated lorry while she was turning onto the A36 from Branch Road on 5 September 2016. The report identified repeated collisions at the junction and raised concerns about the speed limit, road signs, carriageway markings, and the condition of the high-friction surface.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inadequate or unrepaired carriageway markings warning drivers of the junction risk
Wider context from the report “(3) The road signs including carriageway markings should be reviewed and improved so as to provide greater warning to drivers as to the risk from this junction .
(4) Whilst not factors in this collision appropriate repairs should be made to the high friction surface and road markings in the vicinity of the junction .
” Source location Mrs. Margaret Joyce Jones · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement visibility and signing measures at the Branch Road junction, including warning signs, road markings, red surfacing, direction signs and vegetation clearance.
Verbatim wording from the response “A scheme was completed on 24th November 2015 at Branch Road, with the aim of raising the visibility of the Branch Road junction. It comprised the following elements:” Source location Response from Highways England
Open published response
20 Feb 2017 Esther HartSilver · Prevention of Future Deaths report Inner South London
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Concerns raised 2
Lack of road-surface warning of turning-traffic conflict View source Ambiguous road-surface indication of the bus-lane termination View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
London Borough of Southwark
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
London Borough of Southwark
Install left-turn and through-lane arrows between bus stop Q and the existing pelican-crossing zig-zag lines.
View source
London Borough of Southwark
Install durable left-turn and through-lane arrows between the relocated bus stop Q and the pelican-crossing zig-zag lines.
View source
London Borough of Southwark
Remove the southbound bus-lane line between bus stop Q and the existing pelican-crossing zig-zag lines.
View source
London Borough of Southwark
Install an advisory sign specifying left-turn-only movement except buses in the nearside lane and through movement only in the offside lane.
View source See 1 more action
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AI-generated summary
Esther HartSilver · 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
Esther HartSilver died after being seriously injured when an HGV lorry turning left at the junction of Denmark Hill and Orpheus Street collided with her bicycle as she cycled to work. The report raises concerns about the junction’s design, including the risk created by traffic turning across the bus lane, inadequate warning of potential conflicts, and a history of reported collisions and near misses involving vulnerable road users.
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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 road-surface warning of turning-traffic conflict
Wider context from the report “It may not be unusual for a lorry turning into a side road to have to cross a bus lane. The junction can be distinguished from this, however. This is a more major junction than it appears. It is a major because it feeds all the traffic that would have wanted to turn right as well as left, from a very busy road into what is effectively a side road. Further, it has a pedestrian crossing just before it. This means that although there is an early sign warning traffic of the banned right turn and to turn left instead, there are mandatory zig-zag lines on the road leading up to the junction and therefore there is no signage on the road surface warning any user of the potential for conflict.
” Source location Esther HartSilver · 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 Ambiguous road-surface indication of the bus-lane termination
Wider context from the report “The red coloured road surface that is present in the bus lane goes across this junction and will make vehicles think it is still a bus lane. Officially, the bus lane stops because the zig-zags take over as there is a pedestrian crossing present immediately before the turning on the left.
” Source location Esther HartSilver · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Install left-turn and through-lane arrows between bus stop Q and the existing pelican-crossing zig-zag lines.
Verbatim wording from the response “3. The installation of left turn lane arrows on the nearside lane, and through arrows on the offside lane between bus stop Q and the existing pelican crossing zig-zag lines, subject to available space.” Source location 2017-0052-Response-by-Southwark-Council
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Install durable left-turn and through-lane arrows between the relocated bus stop Q and the pelican-crossing zig-zag lines.
Verbatim wording from the response “The following long-term safety improvements were agreed to proceed and be implemented by Southwark as part of the Denmark Hill town centre upgrade project (during 2017-18), subject to design, feasibility and safety audit:” Source location 2017-0052-Response-by-Southwark-Council
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remove the southbound bus-lane line between bus stop Q and the existing pelican-crossing zig-zag lines.
Verbatim wording from the response “2. The removal of bus lane line on the southbound lane between bus stop Q and the existing pelican crossing zig-zag lines; and” Source location 2017-0052-Response-by-Southwark-Council
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Install an advisory sign specifying left-turn-only movement except buses in the nearside lane and through movement only in the offside lane.
Verbatim wording from the response “The following long-term safety improvements were agreed to proceed and be implemented by Southwark as part of the Denmark Hill town centre upgrade project (during 2017-18), subject to design, feasibility and safety audit:” Source location 2017-0052-Response-by-Southwark-Council
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Changes affecting the Strategic Route Network require TfL approval and cannot be implemented unilaterally.
Verbatim wording from the response “Denmark Hill is also part of the designated Strategic Route Network (SRN) in London. This means that although Southwark is the Highway and Traffic Authority for this area that it must notify TfL of any proposals which may have an impact on the Strategic Route Network. TfL must give approval to any such proposals before they can be implemented. As such, any changes to road design in this area cannot be made unilaterally if they may impact on the SRN, which anything altering the traffic flow along Denmark Hill may do.” Source location 2017-0052-Response-by-Southwark-Council
Open published response
13 Oct 2016 Philip David EVANSON · Prevention of Future Deaths report Cheshire
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Concerns raised 1
Failure to maintain legible road markings at the junction View source
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Philip David EVANSON · 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
Philip David Evanson died at the scene after sustaining multiple injuries when his motorcycle collided with a car on the A49 Tarporley Road on 27 May 2016. The report raised concerns that road markings at the junction with the ‘old’ Tarporley Road were significantly worn and partly indistinct, including markings for a ghost island, lane dividing lines and right-turn arrows.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to maintain legible road markings at the junction
Wider context from the report “The road markings on the A49 Tarporley Road, Tarporley Cheshire at its junction with what is known locally as the ‘old’ Tarporley Road are significantly worn and in parts indistinct.
The markings in question relate to:
1. A ‘ghost’ island;
2. The lane dividing lines on the approach to the island;
3. Right turn arrows.
████████ of Cheshire Police gave evidence to this effect at the inquest. Photographs of the scene were produced to me in evidence. The officer indicated that the police had raised concerns with the relevant authorities immediately following the incident on a Police Form 43 (F43).
” Source location Philip David EVANSON · Prevention of Future Deaths report
Open source report
11 Oct 2016 Vichai Tonpradit · Prevention of Future Deaths report Hertfordshire
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Concerns raised 1
Potential confusion from a visual marking from a previous road layout View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
National Highways
Obscure the redundant solid white line with bituminous material.
View source
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AI-generated summary
Vichai Tonpradit · 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
Vichai Tonpradit died after falling from his motorcycle on the A1(M) and being struck by a heavy goods vehicle and a small hatchback. The report identified a raised section of tarmac as potentially hazardous and a solid white line from a previous road layout as potentially confusing.
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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 Potential confusion from a visual marking from a previous road layout
Wider context from the report “(2) At the same location, the visual marking (solid white line) from the previous road layout is potentially confusing
” Source location Vichai Tonpradit · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Obscure the redundant solid white line with bituminous material.
Verbatim wording from the response “b. Having reviewed the road markings at the location it would appear that since the incident on 10 November 2015 the road marking referred to was covered over by applying a bituminous material to obscure the redundant solid white line and this is no longer visible.” Source location 2016-0380-Response-by-Highways-England
Open published response
21 Apr 2016 Keith John Charles Harper · Prevention of Future Deaths report Essex
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Concerns raised 1
Obscured carriageway markings exiting the roundabout View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Essex County Council
Refresh the segregated cycle facility lining, replace missing give-way triangles, and refresh worn edge-of-carriageway markings.
View source
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AI-generated summary
Keith John Charles Harper · 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
Keith John Charles Harper was struck by a Renault Clio while exiting a footpath crossing the central reservation of the A132 Southmayne and died in hospital on 2 December 2015. Concerns related to limited warning and visibility of the pedestrian crossing for drivers, and obscured carriageway markings caused by resurfacing work and road debris.
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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 Obscured carriageway markings exiting the roundabout
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) A driver exiting the roundabout has no prior warning of the crossing. From the driver's position the aspect view of the pedestrian/cycle path is limited and the central reservation presents itself as a grassed area. A review should be carried out of features of the pedestrian crossing – warning signs/design/position etc etc
(2) The carriageway markings exiting the roundabout have been obscured by resurfacing work and road debris. This work needs to be carried out
” Source location Keith John Charles Harper · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Refresh the segregated cycle facility lining, replace missing give-way triangles, and refresh worn edge-of-carriageway markings.
Verbatim wording from the response ““Following our site investigations we have identified that the lining as part of the segregated cycle facility clearly needs refreshing, as the central segregation line has worn, and the give-way triangles are both missing (either side of the A132 Southmayne)” Source location 2016-0151-Response-by-Essex-County-Council
Open published response
9 Mar 2016 Robert Walker · Prevention of Future Deaths report South London
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Concerns raised 1
Lack of sufficient deviation markings at the bend View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Robert Walker · 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
Robert Walker, aged 62, died from multiple injuries following a road traffic collision after losing control of his motorcycle on a bend on Old Farleigh Road on 4 August 2015. Concerns included insufficient bend deviation markings, a tree trunk close to the carriageway, and a slippery path leading towards the 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 sufficient deviation markings at the bend
Wider context from the report “(1) The bend lacks sufficient deviation markings
(2) There is a tree trunk near the edge of the carriageway that presents a danger to road users particularly cyclists
(3) A path that approaches the road and is well used by walkers has a surface that could cause walkers to slip into the carriageway.
(The matters of concern are summarised in the report of ████████ from Catford Traffic Police. An extract from his report is attached.
” Source location Robert Walker · Prevention of Future Deaths report
Open source report
27 May 2015 Nicholas Gary Stocks · Prevention of Future Deaths report West Yorkshire (West)
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Concerns raised 2
Failure to identify and report defective road markings for repair View source Absence of visible signs or road markings at an approaching Give Way junction View source
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
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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.
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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 identify and report defective road markings for repair
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 × 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
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Circulate force-wide guidance reminding staff to submit timely defect reports after collisions and record the requirement in Force collision policy.
Verbatim wording from the response “I will ensure that a Force wide communication is circulated to ensure that staff are reminded of the importance of submitting this information in a timely manner and that it is mandatory after the attendance at a road traffic collision where defects are identified. This will also be entered into Force Policy on dealing with collisions.” Source location 2015-0200-Response-by-West-Yorkshire-Police
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require officers to risk-assess collision scenes, remain until safety is addressed, and prevent log closure until safety and defect-reporting questions are answered.
Verbatim wording from the response “All officers will be reminded of the need to conduct a thorough risk assessment of the location prior to leaving the scene and will not resume until either; i) it is deemed safe to do so, or, ii) the local authority has attended, or, iii) the local authority have assessed the risk against their protocols or, iv) remedial works have been implemented to remove any risk to the safety of other road users.
This will be endorsed on the log by the communications staff. The log will not be closed unless the following questions are answered” Source location 2015-0200-Response-by-West-Yorkshire-Police
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.