9 Jun 2020 Mitica Mihaita Ladunca · Prevention of Future Deaths report Surrey
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Concerns raised 1
Absence of signage warning drivers on the A322 of the pedestrian crossing point linking to Swift Lane across both carriageways View source
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Mitica Mihaita Ladunca · 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
Mitica Mihaita Ladunca died at St. George’s Hospital on 8 November 2019 after unintentionally stepping into the path of a large vehicle while attempting to cross the A322 in Surrey. The report raised concern that the absence of signage warning drivers about the uncontrolled pedestrian crossing could give rise to a risk of future deaths.
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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 Absence of signage warning drivers on the A322 of the pedestrian crossing point linking to Swift Lane across both carriageways
Wider context from the report “- There is an absence of signage warning drivers on the A322 that there is a crossing point for pedestrians which links to Swift Lane across both carriageways.
- Consideration should be given to introducing such signage.
” Source location Mitica Mihaita Ladunca · 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 Install advance signage at the uncontrolled crossing to warn drivers that pedestrians may cross.
Verbatim wording from the response “In light of your report the Area Highway Manager has reviewed the location and while it is clear that your findings are that lack of signage did not contribute to this fatality he will install advance signage at this location. He is pleased to confirm that this work will go ahead on 29/30 September. This will be coordinated with the County’s high speed Traffic Management programme.” Source location Response from Surrey County Council
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15 Apr 2020 Millie TAYLOR-NOONAN · Prevention of Future Deaths report Lincolnshire
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Concerns raised 6
Lack of pedestrian railings at the school crossing area View source Lack of indication of an imminent school crossing area View source Lack of a school crossing patrol officer View source
Lack of street lighting at the school crossing area View source Vulnerability of pedestrians near the school access and exit during school traffic periods View source Lack of a pedestrian crossing giving pedestrians priority View source See 3 more concerns
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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Millie TAYLOR-NOONAN · Prevention of Future Deaths report
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Report summary
Millie TAYLOR-NOONAN, aged 18, was struck by a car while crossing the A607 near The Sir William Robertson School on 4 December 2018. She suffered an unsurvivable head injury and died following the collision; concerns included inadequate pedestrian protections, lighting and crossing arrangements near the school.
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PFD Monitor interpretation Lack of pedestrian railings at the school crossing area
Wider context from the report “1. The location of the collision is in the immediate vicinity to the access and exit entrances to a large secondary school;
2. Whilst motorists have the benefit of advanced warning triangles indicating to road users that there is a school 100 ahead along with a speed limit repeater the location of the incident took place near a dropped kerb with a section of tactile pavement on the footpaths either side of the road, there is no indication to road users as to the imminence of what, was in reality a school crossing area and the area is also unlit;
3. The evidence demonstrated that the deceased may have been distracted by other road traffic users and in particular a school bus emerging from the school premises in the immediacy of the collision that serves to demonstrate the vulnerability of pedestrians in this location at such a time;
4. There are no other measures that exist to protect pedestrians such as:
a. Railings;
b. Street lighting;
c. An automated zebra or other form of crossing to allow a priority to be given to pedestrians;
d. A school crossing patrol officer;
e. A temporary reduction in the speed limit to 20 miles per hour at the beginning and end of the school day;
” Source location Millie TAYLOR-NOONAN · 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 Lack of indication of an imminent school crossing area
Wider context from the report “1. The location of the collision is in the immediate vicinity to the access and exit entrances to a large secondary school;
2. Whilst motorists have the benefit of advanced warning triangles indicating to road users that there is a school 100 ahead along with a speed limit repeater the location of the incident took place near a dropped kerb with a section of tactile pavement on the footpaths either side of the road, there is no indication to road users as to the imminence of what, was in reality a school crossing area and the area is also unlit;
3. The evidence demonstrated that the deceased may have been distracted by other road traffic users and in particular a school bus emerging from the school premises in the immediacy of the collision that serves to demonstrate the vulnerability of pedestrians in this location at such a time;
4. There are no other measures that exist to protect pedestrians such as:
a. Railings;
b. Street lighting;
c. An automated zebra or other form of crossing to allow a priority to be given to pedestrians;
d. A school crossing patrol officer;
e. A temporary reduction in the speed limit to 20 miles per hour at the beginning and end of the school day;
” Source location Millie TAYLOR-NOONAN · 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 Lack of a school crossing patrol officer
Wider context from the report “1. The location of the collision is in the immediate vicinity to the access and exit entrances to a large secondary school;
2. Whilst motorists have the benefit of advanced warning triangles indicating to road users that there is a school 100 ahead along with a speed limit repeater the location of the incident took place near a dropped kerb with a section of tactile pavement on the footpaths either side of the road, there is no indication to road users as to the imminence of what, was in reality a school crossing area and the area is also unlit;
3. The evidence demonstrated that the deceased may have been distracted by other road traffic users and in particular a school bus emerging from the school premises in the immediacy of the collision that serves to demonstrate the vulnerability of pedestrians in this location at such a time;
4. There are no other measures that exist to protect pedestrians such as:
a. Railings;
b. Street lighting;
c. An automated zebra or other form of crossing to allow a priority to be given to pedestrians;
d. A school crossing patrol officer;
e. A temporary reduction in the speed limit to 20 miles per hour at the beginning and end of the school day;
” Source location Millie TAYLOR-NOONAN · 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 Lack of street lighting at the school crossing area
Wider context from the report “1. The location of the collision is in the immediate vicinity to the access and exit entrances to a large secondary school;
2. Whilst motorists have the benefit of advanced warning triangles indicating to road users that there is a school 100 ahead along with a speed limit repeater the location of the incident took place near a dropped kerb with a section of tactile pavement on the footpaths either side of the road, there is no indication to road users as to the imminence of what, was in reality a school crossing area and the area is also unlit ;
3. The evidence demonstrated that the deceased may have been distracted by other road traffic users and in particular a school bus emerging from the school premises in the immediacy of the collision that serves to demonstrate the vulnerability of pedestrians in this location at such a time;
4. There are no other measures that exist to protect pedestrians such as:
a. Railings;
b. Street lighting;
c. An automated zebra or other form of crossing to allow a priority to be given to pedestrians;
d. A school crossing patrol officer;
e. A temporary reduction in the speed limit to 20 miles per hour at the beginning and end of the school day;
” Source location Millie TAYLOR-NOONAN · 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 Vulnerability of pedestrians near the school access and exit during school traffic periods
Wider context from the report “1. The location of the collision is in the immediate vicinity to the access and exit entrances to a large secondary school;
2. Whilst motorists have the benefit of advanced warning triangles indicating to road users that there is a school 100 ahead along with a speed limit repeater the location of the incident took place near a dropped kerb with a section of tactile pavement on the footpaths either side of the road, there is no indication to road users as to the imminence of what, was in reality a school crossing area and the area is also unlit;
3. The evidence demonstrated that the deceased may have been distracted by other road traffic users and in particular a school bus emerging from the school premises in the immediacy of the collision that serves to demonstrate the vulnerability of pedestrians in this location at such a time ;
4. There are no other measures that exist to protect pedestrians such as:
a. Railings;
b. Street lighting;
c. An automated zebra or other form of crossing to allow a priority to be given to pedestrians;
d. A school crossing patrol officer;
e. A temporary reduction in the speed limit to 20 miles per hour at the beginning and end of the school day;
” Source location Millie TAYLOR-NOONAN · 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 Lack of a pedestrian crossing giving pedestrians priority
Wider context from the report “1. The location of the collision is in the immediate vicinity to the access and exit entrances to a large secondary school;
2. Whilst motorists have the benefit of advanced warning triangles indicating to road users that there is a school 100 ahead along with a speed limit repeater the location of the incident took place near a dropped kerb with a section of tactile pavement on the footpaths either side of the road, there is no indication to road users as to the imminence of what, was in reality a school crossing area and the area is also unlit;
3. The evidence demonstrated that the deceased may have been distracted by other road traffic users and in particular a school bus emerging from the school premises in the immediacy of the collision that serves to demonstrate the vulnerability of pedestrians in this location at such a time;
4. There are no other measures that exist to protect pedestrians such as:
a. Railings;
b. Street lighting;
c. An automated zebra or other form of crossing to allow a priority to be given to pedestrians;
d. A school crossing patrol officer;
e. A temporary reduction in the speed limit to 20 miles per hour at the beginning and end of the school day;
” Source location Millie TAYLOR-NOONAN · 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 Improve school-entrance conspicuity by installing road markings, additional warning signs and amber flashing lights for school start and finish times.
Verbatim wording from the response “However, it is agreed that the conspicuity of the school entrance could be enhanced and I shall outline our proposed measures below.” Source location 2020-0097-Response-from-Lincolnshire-County-Council_Redacted
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How this respondent action was interpreted
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PFD Monitor interpretation Provide school staff to marshal pupils at the gate and hold them until it is safe to cross.
Verbatim wording from the response “With regard to your third point, a joint examination with the Academy of the school's vehicular access arrangements, which currently operate as a one-way system utilising the northern access and southern exit, was carried out at school exit times. For the internal operation within the school premises, of children boarding and exiting buses, this is the safest option. An option to reverse this arrangement was considered but it was agreed this would create queuing vehicles on the highway which would obscure pedestrian and vehicle visibility and, at worst, actually prevent crossing of the road.” Source location 2020-0097-Response-from-Lincolnshire-County-Council_Redacted
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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 Install streetlighting at the school entrance as an authorised exceptional measure.
Verbatim wording from the response “b. The provision of Streetlighting at this location does not meet the requirements of the County Council's Streetlighting Policy. However, the school feel that this request would have the most significant benefit and the Executive Councillor has authorised its installation as an exceptional case.” Source location 2020-0097-Response-from-Lincolnshire-County-Council_Redacted
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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 Examine the Academy’s vehicular access arrangements jointly with the school at exit times.
Verbatim wording from the response “With regard to your third point, a joint examination with the Academy of the school's vehicular access arrangements, which currently operate as a one-way system utilising the northern access and southern exit, was carried out at school exit times. For the internal operation within the school premises, of children boarding and exiting buses, this is the safest option. An option to reverse this arrangement was considered but it was agreed this would create queuing vehicles on the highway which would obscure pedestrian and vehicle visibility and, at worst, actually prevent crossing of the road.” Source location 2020-0097-Response-from-Lincolnshire-County-Council_Redacted
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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 Guardrails are not reasonably practicable because widening, utility conflicts, reduced visibility and pedestrian risks would create safety problems.
Verbatim wording from the response “a. At this location the width of the footway is such that the installation of guardrail would require significant widening works and affect underground utility services. Safety concerns would also be created due to reduced highway visibility for properties opposite the school; and also the risk that pedestrians may be tempted to walk outside the barrier if the footpath was occupied by other waiting pedestrians. It is not considered to be reasonably practicable to provide guardrail taking into account the above issues.” Source location 2020-0097-Response-from-Lincolnshire-County-Council_Redacted
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PFD Monitor interpretation A School Safety Zone is unsuitable because this secondary-school location lacks primary-school characteristics and has no recent pedestrian collision history.
Verbatim wording from the response “With regard to your second point, the school entrance benefits from both advance warning triangles and a 30mph speed limit. There is no School Safety Zone present in the vicinity as these are largely designed for primary schools where pupils will generally have less road safety awareness and where parking around school entrances may be an issue. These factors do not apply to this location. Further, we confirm that we have no record of any other incident involving a pedestrian at this location within the last 20 years.” Source location 2020-0097-Response-from-Lincolnshire-County-Council_Redacted
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A temporary 20 mph limit will not be implemented because evidence of speed reduction is debated and the County Council has no such policy.
Verbatim wording from the response “e. The benefits of a temporary speed limit are a matter of debate nationally as evidence suggests such a measure may not have the effect of reducing average speeds. The County Council does not therefore have a policy of implementing temporary speed limits of 20 mph in place. However, as mentioned above it is agreed that the conspicuity of the school entrance can be enhanced. Therefore, we will carry out works this year to place improved roadmarkings including SLOW and yellow SCHOOL zig-zag markings adjacent to the entrance. We will also install additional school warning signs and finally we will provide school amber flashing lights to raise awareness at start and finish times.” Source location 2020-0097-Response-from-Lincolnshire-County-Council_Redacted
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PFD Monitor interpretation School staff at the pedestrian exit provide a suitable alternative because pupil numbers do not justify a School Crossing Patrol.
Verbatim wording from the response “d. Similarly, whilst a School Crossing Patrol does not meet the necessary criteria in terms of numbers of pupils who would use that patrol, as the school have volunteered the services of their staff at the pedestrian exit this provides a suitable alternative that ameliorates the risk.” Source location 2020-0097-Response-from-Lincolnshire-County-Council_Redacted
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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 The existing one-way school access system is considered safest because reversing it would obstruct visibility and prevent road crossing.
Verbatim wording from the response “With regard to your third point, a joint examination with the Academy of the school's vehicular access arrangements, which currently operate as a one-way system utilising the northern access and southern exit, was carried out at school exit times. For the internal operation within the school premises, of children boarding and exiting buses, this is the safest option. An option to reverse this arrangement was considered but it was agreed this would create queuing vehicles on the highway which would obscure pedestrian and vehicle visibility and, at worst, actually prevent crossing of the road.” Source location 2020-0097-Response-from-Lincolnshire-County-Council_Redacted
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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 A teacher marshals pupils at the school gate, providing a safe alternative to a light-controlled crossing despite unmet eligibility criteria.
Verbatim wording from the response “c. Unusually for a large academy the vast majority of pupils access this school by coach/bus. The school roll shows that only 15 children live in Leadenham and 16 children live in Welbourn and physical counts at exit time showed less than 50 pupils cross the road. As such this location does not meet the minimum criteria to provide a light controlled crossing. However, the school has now provided a teacher to effectively marshal and hold students at the school gate until it is safe to cross the road; effectively providing a safe method of crossing.” Source location 2020-0097-Response-from-Lincolnshire-County-Council_Redacted
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17 Feb 2020 Liam Floyd SEAGER · Prevention of Future Deaths report Inner North London
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Concerns raised 2
Delays in implementing a traffic management order prohibiting pedestrian crossing on the A12 View source Unavailability of a pedestrian crossing on the A12 at Wick Lane View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Liam Floyd SEAGER · 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
Liam Floyd Seager was knocked over and killed by a transit van at approximately 3am on New Year’s Day 2019 while crossing the A12 southbound underpass. The concerns were the absence of a pedestrian crossing near the collision site, the delay before a traffic management order would prohibit pedestrians crossing there, and the need for preparatory work and a pedestrian crossing at Wick Lane.
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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 Delays in implementing a traffic management order prohibiting pedestrian crossing on the A12
Wider context from the report “I heard at inquest that there is no pedestrian crossing on the A12 near the location of the collision.
1. Transport for London has indicated that it hopes to have a traffic management order in place by June 2020, which will prohibit pedestrians from crossing at this point. I am concerned that we are still four months away from this.
2. Once the traffic management order is in place, a pedestrian crossing is needed to make it easier for pedestrians to cross the top of the A12 at Wick Lane. Even before this, Tower Hamlets could undertake useful preparatory work to enable the build to proceed quickly following the TMO.
” Source location Liam Floyd SEAGER · 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 Unavailability of a pedestrian crossing on the A12 at Wick Lane
Wider context from the report “I heard at inquest that there is no pedestrian crossing on the A12 near the location of the collision .
1. Transport for London has indicated that it hopes to have a traffic management order in place by June 2020, which will prohibit pedestrians from crossing at this point. I am concerned that we are still four months away from this.
2. Once the traffic management order is in place, a pedestrian crossing is needed to make it easier for pedestrians to cross the top of the A12 at Wick Lane . Even before this, Tower Hamlets could undertake useful preparatory work to enable the build to proceed quickly following the TMO.
” Source location Liam Floyd SEAGER · 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 Implement a Traffic Regulation Order and install signage and supplementary measures prohibiting pedestrian access to the A12.
Verbatim wording from the response “Prohibiting pedestrian access to the A12” Source location Response from Transport for London
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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 Produce detailed plans for new pedestrian phases, protected crossing infrastructure, railings and additional pedestrian restriction signage at the A12/Wick Lane junction.
Verbatim wording from the response “Tower Hamlets Council has produced detailed plans for new pedestrian phases to be incorporated into the signalled junction of the A12 / Wick Lane to provide protected pedestrian crossing. These have been discussed with the Police and TfL and it is recognised that the railings around the crossing landing points at the top of the slip roads provide an additional deterrent to pedestrians seeking to cross the A12. The railings will also provide space for additional signage indicating that pedestrians are not permitted to walk along the A12.” Source location Response from Tower Hamlets Council
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How this respondent action was interpreted
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PFD Monitor interpretation Seek TfL approval to close the A12 slip roads for four days to enable necessary footway widening works.
Verbatim wording from the response “These works will commence once approval is secured from TfL to close the A12 slip roads for 4 days to facilitate the necessary footway widening work. Those approvals are being sought as a matter of urgency.” Source location Response from Tower Hamlets Council
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PFD Monitor interpretation Continue working with relevant London boroughs to identify and establish new or improved pedestrian crossings across the A12.
Verbatim wording from the response “As part of our longer-term strategic plans, we will continue working with the relevant London boroughs to identify and establish new and improved pedestrian crossing opportunities across the A12. These plans may include long term development proposals and are dependent on both the private and public sectors, as well as the use of land outside the highway boundary.” Source location Response from Transport for London
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PFD Monitor interpretation COVID-19 restrictions may prevent completion of the TRO’s remaining works until it is safe and government guidance permits them.
Verbatim wording from the response “However, due to the current health crisis caused by COVID-19 pandemic, we are following Government guidance in respect of the operations we can continue whilst following social distancing. As such and considering the pandemic, we may be unable to carry out the remaining activities to put in place the TRO. When it is safe to undertake the necessary works in respect of the TRO (and in accordance with guidance from the Department of Transport), this work will be a priority.” Source location Response from Transport for London
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PFD Monitor interpretation LBTH is responsible for designing and constructing the new pedestrian crossing and providing wayfinding signs.
Verbatim wording from the response “Joint work between TfL and LBTH” Source location Response from Transport for London
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17 Feb 2020 Lorraine Anne Molyneaux and James Anthony Lewis · Prevention of Future Deaths report Dorset
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Concerns raised 1
Lack of a suitable pedestrian crossing near the bus stops and entrance to Turbary Retail Park View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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Lorraine Anne Molyneaux and James Anthony Lewis · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 16 October 2019, Lorraine Molyneaux was struck by a motorcycle while crossing Ringwood Road near Turbary Retail Park and died at the scene. The motorcyclist, James Anthony Lewis, had consumed alcohol, suffered significant traumatic head injuries and died on 22 October 2019. Concerns related to repeated pedestrian collisions at the location, the distance of crossings from nearby bus stops and the adequacy and operation of street lighting.
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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 a suitable pedestrian crossing near the bus stops and entrance to Turbary Retail Park
Wider context from the report “i. The deaths of Lorraine and James now bring the total fatalities to 3 in the same location and in similar circumstances since September 2018. I have concerns that there could be future deaths at this location if action is not taken.
ii. I therefore request that a review is undertaken of the pedestrian crossings and the layout of Ringwood Road outside of Turbary Retail Park . I request that consideration is given to the placing of a pedestrian crossing closer to the bus stops and the entrance to Turbary Retail Park as soon as possible to avoid future deaths.
” Source location Lorraine Anne Molyneaux and James Anthony Lewis · 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 Complete a joint fatal-collision investigation and site visit with the Dorset Police Road Casualty Reduction Officer.
Verbatim wording from the response “BCP Council carries out joint investigations into fatal road traffic collisions in conjunction with the Dorset Police Road Casualty Reduction Officer. With regards to the incident on Ringwood Rd, the site was visited by three officers at 10.00hrs on Tuesday 26th Nov 2019 (see Appendix A).” Source location 2020-0033-Response-from-BCP-Council-Redacted
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PFD Monitor interpretation Identify the crossing location as a funding priority and submit a Transforming Cities Fund bid for treatment there.
Verbatim wording from the response “As you have clearly indicated in your report, BCP Council has identified this location as a priority for the funding of a crossing facility following a previous incident in September 2018 which involved the death of a pedestrian crossing the road at this location. The Fatal Accident report that followed the site visit recommended the following remedial action:” Source location 2020-0033-Response-from-BCP-Council-Redacted
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PFD Monitor interpretation Prioritise crossing design work within the Transforming Cities Fund requirements to support the anticipated road-layout adjustment.
Verbatim wording from the response ““To consider the installation of a controlled crossing at this location. Transforming Cities Fund (TCF) bid submitted to DfT on 28 November (2019). Ringwood Road is on a TCF route where treatment may be considered. This may be in the form of a controlled crossing or the installation of a new signalised junction with pedestrian facilities. Any works at this location to be discussed with TCF programme manager”.” Source location 2020-0033-Response-from-BCP-Council-Redacted
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23 Dec 2019 Adam Wilcox · Prevention of Future Deaths report Hampshire (Central)
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Concerns raised 2
Failure to warn motorists of pedestrian and cyclist crossings on the A27 Mansbridge Road View source Lack of a safe pedestrian and cycle crossing on the A27 Mansbridge Road View source
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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Adam Wilcox · 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 Wilcox was struck by a motorcycle while crossing the A27 Mansbridge Road on 7 March 2019 and died in hospital from his injuries. The report raised concerns that this stretch of road had no safe pedestrian or cycle crossing, no warnings to motorists, and that pedestrians and cyclists were likely to cross where the footpath ended and barriers began. It also identified the road as busy and noted previous collisions, including incidents involving pedestrians.
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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 warn motorists of pedestrian and cyclist crossings on the A27 Mansbridge Road
Wider context from the report “(1) The A27 Mansbridge Road at the stretch of carriageway from well before the White Swan pub to beyond the scene of this incident (as far as Gaters Hill) does not provide any form of (safe) pedestrian or cycle crossing or any warnings to motorists that pedestrians or cyclist are crossing along its length .
(2) For pedestrians walking (or cyclists not on the carriageway heading) east on the southern side, the only option to travel beyond the scene of this incident is on the northern side of the A27 carriageway. As such, anyone who has not sought to cross the carriageway at a much earlier juncture is either forced to retrace their steps to find another point to cross or (as is more likely) to attempt to cross the carriageway once the path way runs out, where it tapers and stops at the metal barriers and at its junction with the Itchen Navigation. In either event, neither pedestrians nor cyclists have a defined or safe means by which to cross the carriageway and no warnings are given to motorists that they may do so .
(3) The A27 Mansbridge Road is a busy, popular and major thoroughfare, running east-west and south of and parallel to the M27. As such it presents an increased risk to pedestrians and cyclists alike.
(4) I am advised by the Roads Policing Unit that during their visit to the scene (in the conduct of the forensic examination for this inquest) they themselves saw several pedestrians and cyclists crossing the road, at either end, often climbing the metal barrier where the pavement ended.
(5) I am advised that in the past 5 years there have been 15 collisions on the A27 between Itchen Side Close and Allington Lane, of which 5 were classed as serious collisions and 10 classed as slight, with 11 occurring within daylight hours. 2 specific incidents (excluding this fatality) involved pedestrians being struck by vehicles.
” Source location Adam Wilcox · 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 Lack of a safe pedestrian and cycle crossing on the A27 Mansbridge Road
Wider context from the report “(1) The A27 Mansbridge Road at the stretch of carriageway from well before the White Swan pub to beyond the scene of this incident (as far as Gaters Hill) does not provide any form of (safe) pedestrian or cycle crossing or any warnings to motorists that pedestrians or cyclist are crossing along its length.
(2) For pedestrians walking (or cyclists not on the carriageway heading) east on the southern side, the only option to travel beyond the scene of this incident is on the northern side of the A27 carriageway. As such, anyone who has not sought to cross the carriageway at a much earlier juncture is either forced to retrace their steps to find another point to cross or (as is more likely) to attempt to cross the carriageway once the path way runs out, where it tapers and stops at the metal barriers and at its junction with the Itchen Navigation. In either event, neither pedestrians nor cyclists have a defined or safe means by which to cross the carriageway and no warnings are given to motorists that they may do so.
(3) The A27 Mansbridge Road is a busy, popular and major thoroughfare, running east-west and south of and parallel to the M27. As such it presents an increased risk to pedestrians and cyclists alike.
(4) I am advised by the Roads Policing Unit that during their visit to the scene (in the conduct of the forensic examination for this inquest) they themselves saw several pedestrians and cyclists crossing the road, at either end, often climbing the metal barrier where the pavement ended.
(5) I am advised that in the past 5 years there have been 15 collisions on the A27 between Itchen Side Close and Allington Lane, of which 5 were classed as serious collisions and 10 classed as slight, with 11 occurring within daylight hours. 2 specific incidents (excluding this fatality) involved pedestrians being struck by vehicles.
” Source location Adam Wilcox · Prevention of Future Deaths report
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Concerns raised 2
Failure to set a vehicle speed limit compatible with pedestrian detection and stopping distances View source Lack of lighting at a pedestrian crossing point View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
David Stewart MOORE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David Stewart Moore died after being struck by a motor car while crossing an unlit section of the A693 at around 1830hrs on 28 January 2019. The principal concerns were that the location was a natural pedestrian crossing point without street lighting, was in complete darkness, and had a 60mph speed limit, leaving drivers insufficient distance to detect and stop for pedestrians.
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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 set a vehicle speed limit compatible with pedestrian detection and stopping distances
Wider context from the report “The section of the A693 where the collision occurred is:
• a de facto pedestrian crossing point connecting footpaths intersecting that road ;
• an area to which the national speed limit applies (60mph for cars);
• very dark at night, being unaffected by ambient illumination;
• without street lighting
The material section of road is a natural crossing point for pedestrians travelling between two footpaths leading between the collision site: and (i) the village of No Place, to the south of the A693 and (ii) the village of Kip Hill, to the north of the A693.
I accepted the following evidence about the material section of road (given by a police Collision Investigator): (i) the road is approximately 12m wide, and after nightfall is “in complete darkness”, being bordered by dense trees and unaffected by discernible ambient light; (ii) drivers are entirely reliant on headlamp illumination to detect pedestrians; (iii) in reliance on his own dipped headlamps, a driver could gain first sight of a static pedestrian in the carriageway at a distance of no more than 40m from that pedestrian; and (iv) a motor car travelling at 60mph would require significantly more than 40m (around 80m) to come to a halt (taking into account driver reaction time and mechanical stopping distance).
In this case, the driver first saw the deceased “just prior to the collision” when the latter was running “with large strides” towards the southern side of the A693. Despite emergency braking, he failed to avoid the collision. It was impossible to stop in the available distance.
” Source location David Stewart MOORE · 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 Lack of lighting at a pedestrian crossing point
Wider context from the report “The section of the A693 where the collision occurred is:
• a de facto pedestrian crossing point connecting footpaths intersecting that road ;
• an area to which the national speed limit applies (60mph for cars);
• very dark at night, being unaffected by ambient illumination ;
• without street lighting
The material section of road is a natural crossing point for pedestrians travelling between two footpaths leading between the collision site: and (i) the village of No Place, to the south of the A693 and (ii) the village of Kip Hill, to the north of the A693.
I accepted the following evidence about the material section of road (given by a police Collision Investigator): (i) the road is approximately 12m wide, and after nightfall is “in complete darkness” , being bordered by dense trees and unaffected by discernible ambient light; (ii) drivers are entirely reliant on headlamp illumination to detect pedestrians ; (iii) in reliance on his own dipped headlamps, a driver could gain first sight of a static pedestrian in the carriageway at a distance of no more than 40m from that pedestrian; and (iv) a motor car travelling at 60mph would require significantly more than 40m (around 80m) to come to a halt (taking into account driver reaction time and mechanical stopping distance).
In this case, the driver first saw the deceased “just prior to the collision” when the latter was running “with large strides” towards the southern side of the A693. Despite emergency braking, he failed to avoid the collision. It was impossible to stop in the available distance.
” Source location David Stewart MOORE · Prevention of Future Deaths report
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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 Additional street lighting or engineering measures were not considered appropriate because risk assessment, accident history, visibility and warning signage indicated existing controls were sufficient.
Verbatim wording from the response “The A693 is a principal road through the County which is primarily rural in nature and follows the topography of the land through which it passes. The road bisects many Public Footpaths, Bridleways and footways linking communities. Along the route there are sections of the road which have systems of street lighting where there are areas of conflict such as at junctions and roundabouts. However, the street lighting does not cover all pedestrian or bridleway crossing points. The non-provision of street lighting along the route was considered and examined through a robust Risk Assessment process between 2013 and 2015, with this location being assessed in 2013.” Source location Response from Durham County Council
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9 Aug 2019 Pauline Howell · Prevention of Future Deaths report Newcastle upon Tyne
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Concerns raised 1
Junction and crossing design allowing no margin for pedestrian or driver error View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Pauline Howell · 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 5 February 2018, Pauline Howell was struck by a bus while crossing Newbridge Street West at the junction with John Dobson Street in Newcastle upon Tyne, sustaining injuries that resulted in her death. The principal concerns were the crossing’s proximity to the junction, its location on a busy bus route, the tight junction design, and the lack of margin for error, with a similar previous pedestrian death reported at the junction.
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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 Junction and crossing design allowing no margin for pedestrian or driver error
Wider context from the report “(1) The risk of pedestrian error at the John Dobson Street crossing is foreseeable.
(2) The crossing is situated close to the junction.
(3) The crossing is situated on a busy bus route.
(4) The Junction is “tight” and challenging for public service vehicle drivers to negotiate.
(5) The design/layout of the junction/crossing allow no margin for error by either or both pedestrian and driver.
(6) The deaths of two pedestrians resulted from injuries sustained whilst crossing this junction in similar circumstances and the risk of future deaths continues.
” Source location Pauline Howell · 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 Commissioned and completed two independent Stage 4 road safety audits of the junction layout and signal phasing.
Verbatim wording from the response “In order to give full consideration to the issues you raised, we commissioned two independent Stage 4 Road Safety Audits by different experienced Civil Engineers to review the current junction layout and signal phasing. Should you wish to see copies of the independent road safety audits we will make them available to you.” Source location 2019-0498-Response-from-Newcastle-City-Council-Redacted-1
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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 Install “Look both ways” text on kerb edges at pedestrian crossing points.
Verbatim wording from the response “Potential confusion over road layout as the segregated cycle lane could be mistaken as southbound carriageway – there had been an original suggestion to install text on the kerb edge at pedestrian crossing points to state ‘Look both ways’ which was discounted at the time as not permitted under the regulations. This is now permitted by the Traffic Signs Regulations and General Directions and will be installed.” Source location 2019-0498-Response-from-Newcastle-City-Council-Redacted-1
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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 Revise light phasing, install detection sensors, relocate the primary traffic signal head, and raise pedestrian repeater signals.
Verbatim wording from the response “Other minor scheme improvements will include:” Source location 2019-0498-Response-from-Newcastle-City-Council-Redacted-1
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12 Jul 2019 Jason Robert Imi and John Carl Shackley · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 1
Lack of street lighting at the hotel entrance View source
This report raised 3 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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AI-generated summary
Jason Robert Imi and John Carl Shackley · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 2 August 2018, Jason Imi and John Shackley were struck by a motor car while crossing the A329 to return to the Royal Berkshire Hotel, sustaining fatal injuries and dying at the scene. The principal concern was the continuing risk to pedestrians because there was no footpath or street lighting by the hotel, alongside reduced visibility caused by tree canopy and a dip in the road.
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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 street lighting at the hotel entrance
Wider context from the report “I am concerned that there is no footpath on the A329 on the side of the road where the Royal Berkshire Hotel is located, meaning that any pedestrians walking into or out of the hotel entrance have to cross the A329 to get from or to a footpath, and that there is no street lighting in the vicinity of the hotel . Street lights end 100 metres west of the hotel entrance. This means that pedestrians entering or leaving the hotel during the hours of darkness have to cross the road in a place where there is no illumination , and so they are
not easily visible to motorists driving along the A329 . There is also a tree canopy in the summer, further shading the road, and a dip in the road surface on the eastbound approach to the hotel which adversely affects forward visibility towards the hotel for motorists.
I consider that unless some action is taken there is a continuing risk of pedestrians entering or leaving the Royal Berkshire Hotel being run over as they cross the A329 at night.
” Source location Jason Robert Imi and John Carl Shackley · Prevention of Future Deaths report
Open source report
Concerns raised 1
Lack of a safe pedestrian route and crossing facility near the bus stop View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Christopher Thomas INNES · 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
Christopher Innes died on 25 May 2018 after being struck by a van while crossing the A28 Ashford Road in Chartham, having alighted from a bus. The concerns included the unmarked bus stop, the lack of a footway or nearby pedestrian crossing on a 50 mph road, and vegetation restricting the space available for pedestrians. There was also no clear responsibility for managing the vegetation or land adjoining the bus stop.
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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 a safe pedestrian route and crossing facility near the bus stop
Wider context from the report “(1) The presence and position of the unmarked bus stop on the carriageway, where Mr Innes alighted from the bus may be considered a hazard. The bus stop is known locally but is absent any signage or warning to approaching vehicles. The evidence revealed at the Inquest was that this may have led to him being in a position of vulnerability at the side of the carriageway, where there is no footway available for use but only a small grass verge . In order to reach a footway to progress in either direction of the A28 at this point, Mr Innes was required to cross the carriageway to which a 50mph speed limit applies and which has no pedestrian crossing facility in the vicinity .
(2) Although it is lawful for buses to stop at this location and the stop is recognised as a “hail and ride stop”, there is not at present signage indicating that this is a designated bus stop, and this is of concern given that the carriageway has a 50mph speed limit.
(3) The vegetation close to the area where buses stop includes substantial trees and hedgerows alongside the carriageway and the close proximity of this to the carriageway causes restriction for any pedestrian alighting from the bus to negotiate an appropriate place to stand on a busy rural road prior to attempting to cross a 50mph road. Although the Highways Department at Kent County Council have completed work in respect of cutting back vegetation as part of a site review on the 31st October 2018, there is no clear responsibility for the management of the cutting away of the vegetation and no clear indication of ownership of the land close to the bus stop as the Highway Authority did not concede any responsibility for the land adjoining the hard carriageway.
” Source location Christopher Thomas INNES · Prevention of Future Deaths report
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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 A controlled pedestrian crossing is not considered appropriate because pedestrian crossing numbers and general footway use are minimal.
Verbatim wording from the response “33. Controlled pedestrians’ crossings in the form of a zebra, pelican or puffin crossing are only considered where there are high numbers of pedestrians crossing within a small area and where the volume of traffic provides very little opportunity for pedestrians to cross a road. In this instance the level of pedestrians crossing the road is very minimal and level of pedestrian traffic generally on the provided footways is very low. A controlled crossing at this location is therefore not considered appropriate.” Source location 2019-0124-Response-by-Kent-County-Council
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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 An uncontrolled crossing cannot be provided because there is no southern footway and insufficient verge width for an accessible facility.
Verbatim wording from the response “34. An uncontrolled crossing in the form of dropped kerbs on either side of the road, can only be provided where there is a continuous route of footways. In this instance there is no southern footway and the available verge width is insufficient to provide a facility suitable for all users.” Source location 2019-0124-Response-by-Kent-County-Council
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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 A hard-standing pedestrian refuge cannot be provided because the available verge is too narrow for required accessible infrastructure.
Verbatim wording from the response “25. KCC has concluded that providing a hard-standing pedestrian refuge area would involve design considerations which could not be provided at this location or within a reasonable proximity to Nickle Cottages. The main limitation to this is that permanent infrastructure must be designed for people with mobility impairments and should be to the highest standard. This can include people with physical, sensory or mental impairment but also includes people using the facility with small children, carrying heavy shopping and older people. This would place requirements to accommodate facility widths and access arrangements which cannot be constructed within the available space of the verge.” Source location 2019-0124-Response-by-Kent-County-Council
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4 Apr 2019 Julia Luxmore Peto · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 2
Lack of louvres preventing pedestrian see-through at two-stage pedestrian crossings View source Lack of road markings warning pedestrians of traffic direction at two-stage pedestrian crossings View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Julia Luxmore Peto · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 16 September 2018, Julia Luxmore Peto was struck by a bus while crossing Deptford Broadway and suffered a catastrophic head injury; she died in hospital the following day. The principal concern was that pedestrians might be distracted or confused by green pedestrian signals visible across the other carriageway at two-stage crossings, with wider concern about similar crossings lacking louvres and road markings to indicate traffic direction.
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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 louvres preventing pedestrian see-through at two-stage pedestrian crossings
Wider context from the report “TfL informed me, at the inquest, that they are putting in place “Look Left” and “Look Right” markings on the road to inform pedestrians on the direction of approaching traffic (A copy of the TfL report to me is appended for ease of reference. This contains a useful plan and photographs). From the evidence I heard I am satisfied that these particular changes would not have a wider impact on traffic flow but would improve the safety of pedestrians.
I was pleased to hear that TfL had taken proactive practical measures to reduce the risk at this particular junction but I remain concerned that there are likely be other “two stage” pedestrian crossings throughout England and Wales which also do not currently have louvres to prevent pedestrian ‘see-through’ and road markings to warn pedestrians of traffic direction.
I am therefore of the view that I am under a duty to report this wider concern to the Department of Transport to take appropriate action to reduce the risk of fatalities and serious injuries at two stage crossings throughout England and Wales.
” Source location Julia Luxmore Peto · 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 road markings warning pedestrians of traffic direction at two-stage pedestrian crossings
Wider context from the report “TfL informed me, at the inquest, that they are putting in place “Look Left” and “Look Right” markings on the road to inform pedestrians on the direction of approaching traffic (A copy of the TfL report to me is appended for ease of reference. This contains a useful plan and photographs). From the evidence I heard I am satisfied that these particular changes would not have a wider impact on traffic flow but would improve the safety of pedestrians.
I was pleased to hear that TfL had taken proactive practical measures to reduce the risk at this particular junction but I remain concerned that there are likely be other “two stage” pedestrian crossings throughout England and Wales which also do not currently have louvres to prevent pedestrian ‘see-through’ and road markings to warn pedestrians of traffic direction .
I am therefore of the view that I am under a duty to report this wider concern to the Department of Transport to take appropriate action to reduce the risk of fatalities and serious injuries at two stage crossings throughout England and Wales.
” Source location Julia Luxmore Peto · Prevention of Future Deaths report
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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 Local traffic management responsibility rests with Transport for London as the relevant highways authority, rather than the Department.
Verbatim wording from the response “The responsibility for traffic management on local roads rests with the relevant local highways authority; in this case Transport for London, as they are best placed to consider how to use a range of traffic management measures so that local needs can be effectively met. My Department’s role is to provide the overarching strategy and policy context, as well as guidance to help them in managing their roads.” Source location 2019-0119-Response-from-the-Department-for-Transport_Redacted
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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 pedestrian-crossing guidance, soon to be updated in Traffic Signs Manual Chapter 6, makes further action unnecessary.
Verbatim wording from the response “Guidance on pedestrian crossings is currently provided in two documents: Traffic Advisory Leaflet 5/05: Pedestrian Facilities at Signal-Controlled Junctions, and Local Transport Note 2/95: The Design of Pedestrian Crossings. These provide advice on the phasing and staging of pedestrian movements as well pedestrian crossing display sequencing.” Source location 2019-0119-Response-from-the-Department-for-Transport_Redacted
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Includes crossing provision, siting, visibility, signals, markings, refuge, warnings and speed controls when the source ties them directly to pedestrian crossing safety.
