5 Feb 2024 Kyle James GOATER · Prevention of Future Deaths report West Yorkshire (Western)
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Concerns raised 1
Failure to provide sufficient advance warning of the layby View source
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
Bradford City Council
Install a Hidden Dip warning sign to alert drivers to the prevailing hazard.
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AI-generated summary
Kyle James GOATER · 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
Kyle James GOATER, aged 25, died at the collision scene on 20 July 2021 after a road traffic collision in which his vehicle struck an RAC van and another vehicle became involved. He suffered chest injuries, developed breathing difficulties and then cardiac arrest; CPR was unsuccessful. The substantive concern was that the layby and vehicle turning into it were not signposted or visible sufficiently in advance of the crest of the hill, limiting the opportunity for an approaching driver to become aware of the hazard and reduce speed.
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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 provide sufficient advance warning of the layby
Wider context from the report “As the deceased was travelling in his motor vehicle approaching the brow of the hill on Moor Road controlled by a speed limit of 50mph, no sign was in place to provide a warning as to a layby situated at the bottom of a dip the road which was unforeseen by the deceased . At the bottom of the dip a vehicle was indicating to turn right into the layby, which the deceased travelling in the same traffic lane was not able to avoid, an inevitable collision occurred and as a result of such collision the deceased lost his life.
Had the layby been situated elsewhere or signposted well in advance of the crest of the hill it is likely that sufficient warning to an oncoming vehicle would have been provided in time to enable awareness of an oncoming vehicle and a reduction in speed from 50 mph.
” Source location Kyle James GOATER · Prevention of Future Deaths 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 a Hidden Dip warning sign to alert drivers to the prevailing hazard.
Verbatim wording from the response “Following careful consideration of the circumstances of this collision, the Council has installed a series of bollards on the edge of the carriageway (highway extent) to prevent access to the informal layby so that it can no longer be used by drivers. In addition, the intermittent white line associated with an access which spanned the informal layby has been removed by extending the edge of carriageway road marking across it, thus forming a continuous line and representative of a continuous section of highway. Furthermore, a Hidden Dip warning sign informing drivers of the prevailing hazard has been ordered and will be installed at the very earliest opportunity.” Source location Response from Bradford 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 The privately owned land and informal layby are outside the adopted highway network and not under the Council’s control.
Verbatim wording from the response “The land bordering the carriageway is privately owned, therefore not part of the adopted highway network maintainable at public expense or under the control of the Council in any capacity. The informal ‘layby’ which has been created and within which the broken-down vehicle was parked is wholly within this private land. The layby was not created by the Council.” Source location Response from Bradford Council
Open published response
Concerns raised 1
Failure to provide adequate speed control within the junction series 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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Kelly Nadine DUNNE · 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
Kelly Nadine DUNNE died at the Royal Victoria Infirmary in Newcastle on 4 July 2022 from fatal head injuries sustained in a road traffic collision on 2 July 2022. Concerns were raised about the adequacy and layout of the junction and other junctions on the A690, including traffic volume, traffic complexity, speed limits, and the timing and sufficiency of proposed safety improvements in light of planned development.
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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 provide adequate speed control within the junction series
Wider context from the report “During the course of the Inquest evidence was heard from the lead road traffic collision investigator in the case that there are significant concerns in relation to the adequacy and layout of this particular junction and the five other junctions on this stretch of road (A690). Evidence was given that since this fatality, there has been another fatal road traffic collision on the 22/12/22, at the junction directly opposite. Further that between 11/01/00 and 31/12/22 there have been 21 collisions at this junction (including this fatality and 3 other serious collisions) and that there have been 29 collisions at the other junctions on this stretch of road (including one further fatality and 6 other serious collisions).
The concerns in relation to this junction, and the other junctions relate to:-
1. The volume of traffic that the junctions must manage.
2. The complexity of traffic movement at the junctions.
3. The speed limit in the vicinity of the junctions.
Concerns were also raised in relation to the planned extensive expansion/development of the area in the vicinity of the junction, including increased housing development, a proposed retail park, football site, as well as developments occurring more widely in the area which will lead to increased traffic, and that any proposed improvements to the junction are not required until prior to the occupation of the 39th dwelling on the site. The concern is that the proposals to improve the safety of the junction are not sufficient nor timely, and that consideration does not appear to have been given to reducing the speed limit within the junction series. A further concern was raised that the proposed improvements to the junction considered this junction in isolation, and did not consider the series of junctions on this stretch of road.
” Source location Kelly Nadine DUNNE · 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 lower speed limit would not be credible or appropriate and could increase danger because a significant proportion of motorists might ignore it.
Verbatim wording from the response “A speed limit is an absolute maximum, and it is the driver’s responsibility to drive at a speed suitable to the environment and conditions. It is an intention of the Department for Transport guidance to ensure that speed limits are credible with the aim that they become self-evident and self-enforcing, by virtue of their surroundings. A limit lower than the current posted limit would not be credible or appropriate and would likely result in a significant proportion of motorists ignoring the limit. In addition, the imposition of non-credible lower limits can raise expectations that the speeds of vehicles will be reduced but seldom realised in practice, resulting in greater danger with drivers making decisions based on incorrect assumptions, and also unfair criticism of the police who have to enforce the speed limits.” Source location Response from Durham County Council
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24 Oct 2022 Matthew James Rouch · Prevention of Future Deaths report South Wales Central
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Concerns raised 1
Failure to ensure drivers slow down when approaching the A48 ‘Forage roundabout junction’ from every direction 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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Matthew James Rouch · 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
Matthew Rouch, aged 41, was fatally injured in a motorbike collision with a roundabout on the A48 near Cowbridge on 29 September 2021. The report raised concerns that the A48 Forage roundabout junction was dangerous and that, without changes to improve awareness and reduce vehicle speeds, further deaths might occur.
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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 ensure drivers slow down when approaching the A48 ‘Forage roundabout junction’ from every direction
Wider context from the report “(1) The A48 ‘Forage roundabout junction’ seems to be dangerous.
(2) Unless changes are made to make all road users more aware of this junction and to slow down drivers approaching it from every direction , more deaths may occur.
” Source location Matthew James Rouch · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Replace undersized chevron warning signs with enlarged signs featuring yellow borders.
Verbatim wording from the response “The Stage 3 RSA’s dated 10th January 2020 identified a number of minor issues in relation to surface water, carriageway surfacing, vehicle and pedestrian restraint barriers, drop kerb crossings and lack of signage associated with the shared cycleway / footway and drainage lagoon, which have subsequently been the subject of remedial works. The Stage 3 RSA also raised more specific concern in relation to the roundabout as identified below:” Source location Response from the Vale of Glamorgan Council
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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 50mph speed-limit signs before removing temporary traffic management.
Verbatim wording from the response “The Stage 3 RSA’s dated 10th January 2020 identified a number of minor issues in relation to surface water, carriageway surfacing, vehicle and pedestrian restraint barriers, drop kerb crossings and lack of signage associated with the shared cycleway / footway and drainage lagoon, which have subsequently been the subject of remedial works. The Stage 3 RSA also raised more specific concern in relation to the roundabout as identified below:” Source location Response from the Vale of Glamorgan Council
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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 Publish a Traffic Regulation Order proposing reduced speed limits on the A48 Cowbridge bypass and approaches to the roundabout.
Verbatim wording from the response “Notwithstanding the information above, the Council recognises the need to consider appropriate ways to enhance road safety on its existing local highway network and, where possible, measures should be employed to best avoid any deaths or collisions involving serious personal injury. Therefore, subsequent to the fatality on the 29th September, the Council took steps to publish a Legal Order (TRO) with the intention of reducing the speed limit on the A48 Cowbridge bypass from National speed limit to 50mph, and the immediate approaches to the ‘Forage roundabout junction’ to 30mph. Whilst the Order has completed the appropriate legal process, the necessary new signage in accordance with TSRGD and Traffic Signs Manual is estimated to cost over £100k to implement the new speed restriction along the A48, and this work is therefore subject to identifying available budget.” Source location Response from the Vale of Glamorgan 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 The Council disputes that the junction is dangerous or that deaths may occur without changes to reduce approach speeds.
Verbatim wording from the response “Therefore, given the evidence presented above, the Council would dispute that the ‘Forage roundabout junction’ is either dangerous, or unless changes are made to make users aware of the junction and to slow down drivers, more deaths may occur. Furthermore, the Council considers the advanced warning signage to be good and that the junction is safe for all traffic if drivers exercise responsible driving practices and take due care and attention of the provided signs and road markings, as well as comply with their legal obligations and follow the ‘General rules, techniques and advice for all drivers and riders’ (Rule 103 to 158) of the Highway Code.” Source location Response from the Vale of Glamorgan 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 Existing design, signage and road-safety audit measures are considered sufficient to make the junction safe for its intended purpose.
Verbatim wording from the response “Based on the above information, the Vale Council considers that a robust and appropriate process has been followed regarding the design and construction of the new A48 ‘Forage roundabout junction’, in accordance with all appropriate guidelines and legislation, and that the junction is safe for its intended purpose. Any initial road safety issues have been” Source location Response from the Vale of Glamorgan 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 Implementation of new speed-restriction signage is subject to identifying available budget because estimated costs exceed £100,000.
Verbatim wording from the response “Notwithstanding the information above, the Council recognises the need to consider appropriate ways to enhance road safety on its existing local highway network and, where possible, measures should be employed to best avoid any deaths or collisions involving serious personal injury. Therefore, subsequent to the fatality on the 29th September, the Council took steps to publish a Legal Order (TRO) with the intention of reducing the speed limit on the A48 Cowbridge bypass from National speed limit to 50mph, and the immediate approaches to the ‘Forage roundabout junction’ to 30mph. Whilst the Order has completed the appropriate legal process, the necessary new signage in accordance with TSRGD and Traffic Signs Manual is estimated to cost over £100k to implement the new speed restriction along the A48, and this work is therefore subject to identifying available budget.” Source location Response from the Vale of Glamorgan Council
Open published response
25 Jul 2022 Stephen John COOMBES · Prevention of Future Deaths report Suffolk
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Concerns raised 2
Inadequate provision of temporary reduced-speed signage View source Failure to obscure higher speed-limit signage when imposing temporary reductions View source
Linked response
Kier Integrated Services Limited
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
Kier Integrated Services Limited
Maintain a traffic management design standard requiring checks and maintenance after installation throughout each scheme.
View source
Kier Integrated Services Limited
Review traffic management procedures and require opaque covering or removal of existing higher-speed signs and road-surface roundels when temporary speed limits are imposed.
View source
Kier Integrated Services Limited
Undertake daily checks of temporary traffic management, including weekends and bank holidays, and install additional or replacement measures when issues are identified.
View source
Kier Integrated Services Limited
Update WMS and implement an enhanced, audited procedure for scheduling, allocating and completing traffic management checks and maintenance from installation.
View source
Kier Integrated Services Limited
Develop guidance for works gangs to check and photograph temporary traffic management measures and record that they remain in place.
View source
Kier Integrated Services Limited
Deliver toolbox talks to contract work gangs on undertaking traffic management checks.
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AI-generated summary
Stephen John COOMBES · 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
Stephen ‘John’ Coombes died at Addenbrookes Hospital on 3 September 2021 after a single-vehicle collision in which the Porsche he was driving left the road and overturned. The report identifies concern that inadequate signage failed to communicate a temporary 30 mph speed limit, leaving road users unaware of the reduced limit and potentially resulting in further fatalities if similar road defects occur.
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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 Inadequate provision of temporary reduced-speed signage
Wider context from the report “The court heard that the depression was known to be present by the Highways
Authority, and a temporary 30 mph speed limit (instead of the usual 50mph) had been
put in place.
Evidence was heard from the Forensic Crash Investigation Officer from Suffolk
Constabulary, who conducted an investigation into the road traffic collision which
caused John’s death.
This officer told the court, how he and a colleague drove a police vehicle over the
depression in the road at various speeds to observe the reaction the vehicle had to
damaged road surface.
At 30 mph the police vehicle negotiated the depression in the road with relative ease.
At 50 mph, the police vehicle reacted significantly when negotiating the depression.
At the time of Johns collision, he had just overtaken another vehicle and therefore
crossed the depression a slight angle as he returned to his own side of the carriage
way.
When the police officers replicated this vehicle movement at 50 mph, the police
vehicle reacted violently, with one of the wheels leaving the surface of the road.
The officer driving that vehicle was not prepared to attempt the same manoeuvre at
any higher speed due to the risk involved.
The police officer then told the court that the attending officers themselves were
unaware of 30 mph speed limit on this stretch of road. The officer told the court that
the main 50 mph signs, the smaller repeater 50 mph signs and the 50 mph roundels
painted on the road surface were all clearly visible on this stretch of road.
Prior to the depression the officer saw one temporary 30mph partially obscured in the
verge, but assumed it was left over from previous works, as all of the 50mph signs
remained in view.
Evidence was heard that in the normal course of events, when a temporary reduction
in a speed limit is imposed on a stretch of road, any signage indicating a higher speed
limit should be covered by either securing a dark bag or sack over each sign, or spray
painting it out.
On the basis of the police officers’ evidence, that clearly did not occur in this case,
and this, coupled to there being only one 30mph temporary sign in place prior to the
depression in the road, left road users (and attending police officers) unaware of the
reduced speed limit in place.
I am therefore concerned that should further identified road defects require a
reduction in the speed limit, that any repeat of the provision of inadequate signage
and/or a failure obscure higher speed limits may result in further fatalities.
” Source location Stephen John COOMBES · 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 Failure to obscure higher speed-limit signage when imposing temporary reductions
Wider context from the report “The court heard that the depression was known to be present by the Highways
Authority, and a temporary 30 mph speed limit (instead of the usual 50mph) had been
put in place.
Evidence was heard from the Forensic Crash Investigation Officer from Suffolk
Constabulary, who conducted an investigation into the road traffic collision which
caused John’s death.
This officer told the court, how he and a colleague drove a police vehicle over the
depression in the road at various speeds to observe the reaction the vehicle had to
damaged road surface.
At 30 mph the police vehicle negotiated the depression in the road with relative ease.
At 50 mph, the police vehicle reacted significantly when negotiating the depression.
At the time of Johns collision, he had just overtaken another vehicle and therefore
crossed the depression a slight angle as he returned to his own side of the carriage
way.
When the police officers replicated this vehicle movement at 50 mph, the police
vehicle reacted violently, with one of the wheels leaving the surface of the road.
The officer driving that vehicle was not prepared to attempt the same manoeuvre at
any higher speed due to the risk involved.
The police officer then told the court that the attending officers themselves were
unaware of 30 mph speed limit on this stretch of road. The officer told the court that
the main 50 mph signs, the smaller repeater 50 mph signs and the 50 mph roundels
painted on the road surface were all clearly visible on this stretch of road.
Prior to the depression the officer saw one temporary 30mph partially obscured in the
verge, but assumed it was left over from previous works, as all of the 50mph signs
remained in view.
Evidence was heard that in the normal course of events, when a temporary reduction
in a speed limit is imposed on a stretch of road, any signage indicating a higher speed
limit should be covered by either securing a dark bag or sack over each sign, or spray
painting it out.
On the basis of the police officers’ evidence, that clearly did not occur in this case ,
and this, coupled to there being only one 30mph temporary sign in place prior to the
depression in the road, left road users (and attending police officers) unaware of the
reduced speed limit in place.
I am therefore concerned that should further identified road defects require a
reduction in the speed limit, that any repeat of the provision of inadequate signage
and/or a failure obscure higher speed limits may result in further fatalities.
” Source location Stephen John COOMBES · 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 Maintain a traffic management design standard requiring checks and maintenance after installation throughout each scheme.
Verbatim wording from the response “Kier is committed to protecting road users and the workforce in relation to the installation of traffic management by or on behalf of Kier. To this end, Kier has in place a specific traffic management design standard setting out the necessary process, which includes the planning of traffic management checks and maintenance following installation on site the purpose of which is to maintain the safety and integrity of the traffic management measures for the duration of the scheme.” Source location Response from Kier Integrated Services
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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 Review traffic management procedures and require opaque covering or removal of existing higher-speed signs and road-surface roundels when temporary speed limits are imposed.
Verbatim wording from the response “Since the incident Kier has reviewed its procedures relating to checks and maintenance of traffic management measures at unattended sites in Suffolk. In the event that Kier receives an instruction from Suffolk County Council that includes the imposition of a temporary reduced speed limit the existing speed limit signs are fully covered with an opaque material. In the event that there are roundels displaying the existing speed limit on the road surface these will also be appropriately obscured and/or removed.” Source location Response from Kier Integrated Services
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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 Undertake daily checks of temporary traffic management, including weekends and bank holidays, and install additional or replacement measures when issues are identified.
Verbatim wording from the response “Checks of installed temporary traffic management measures, to include temporary speed limit signs, are undertaken on a daily basis, to include weekends and bank holidays, at all sites. In the event that an issue is identified with the traffic management measures on site requiring additional or replacement measures these are duly installed.” Source location Response from Kier Integrated Services
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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 Update WMS and implement an enhanced, audited procedure for scheduling, allocating and completing traffic management checks and maintenance from installation.
Verbatim wording from the response “WMS has been updated to continue to ensure that traffic management checks are scheduled from the point of installation. This update of WMS has been underpinned by the implementation of an enhanced procedure, with an associated audit programme, to help ensure that traffic management checks and maintenance, to include signs showing temporary speed limits, are planned, scheduled, allocated and undertaken. All staff responsible for the planning, scheduling and allocation of traffic management works have been trained on and are working to this enhanced procedure. In addition, enhanced guidance has been developed for works gangs carrying out checks of traffic management measures on site, this includes the taking and recording of photographs to show that the measures remain in place.” Source location Response from Kier Integrated Services
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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 Develop guidance for works gangs to check and photograph temporary traffic management measures and record that they remain in place.
Verbatim wording from the response “WMS has been updated to continue to ensure that traffic management checks are scheduled from the point of installation. This update of WMS has been underpinned by the implementation of an enhanced procedure, with an associated audit programme, to help ensure that traffic management checks and maintenance, to include signs showing temporary speed limits, are planned, scheduled, allocated and undertaken. All staff responsible for the planning, scheduling and allocation of traffic management works have been trained on and are working to this enhanced procedure. In addition, enhanced guidance has been developed for works gangs carrying out checks of traffic management measures on site, this includes the taking and recording of photographs to show that the measures remain in place.” Source location Response from Kier Integrated Services
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver toolbox talks to contract work gangs on undertaking traffic management checks.
Verbatim wording from the response “In conjunction with this guidance, toolbox talks on undertaking traffic management checks have been delivered to the work gangs engaged by Kier on the contract with Suffolk County Council.” Source location Response from Kier Integrated Services
Open published response
Concerns raised 1
Potentially inappropriate speed limit 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.
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
Complete a speed-limit review using speed surveys and injury-collision records to assess whether the A483 location requires a speed-limit change.
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AI-generated summary
Daniel Mark HUGHES · 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
Daniel Mark HUGHES died at the scene after his motorcycle collided with a motorcar on the A483 at Sweeney near Oswestry on 4 June 2017. The report raised concerns about visibility from a driveway near a blind bend, the appropriateness of the speed limit, and whether a warning of the concealed driveway should be displayed.
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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 Potentially inappropriate speed limit at the bend
Wider context from the report “The motorist concerned was turning right from the driveway of a property approximately 90 meters south of a blind bend. There was little or no margin of error in crossing the southbound carriageway to travel north. There are specific areas of concern:
1) Whether and how visibility to the right may be improved or turning deterred.
2) Whether the speed limit at the bend is appropriate.
3) Whether a warning of a concealed driveway could be displayed.
” Source location Daniel Mark HUGHES · 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 speed-limit review using speed surveys and injury-collision records to assess whether the A483 location requires a speed-limit change.
Verbatim wording from the response “We completed a speed limit review for the A483 Trunk Road in 2016 when speed surveys took place both north and south of the incident site. The speed limit review showed that 85% of vehicle speeds recorded were found to be below the posted national speed limit of 60mph. When considering this speed survey result and the record of injury collisions on this section of the A483, this location was not identified as requiring consideration for a potential change in the speed limit.” Source location 2020-0295-Response-from-Highways-England-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 60mph speed limit is considered appropriate because surveys found most drivers complied and injury collisions did not indicate change was needed.
Verbatim wording from the response “We completed a speed limit review for the A483 Trunk Road in 2016 when speed surveys took place both north and south of the incident site. The speed limit review showed that 85% of vehicle speeds recorded were found to be below the posted national speed limit of 60mph. When considering this speed survey result and the record of injury collisions on this section of the A483, this location was not identified as requiring consideration for a potential change in the speed limit.” Source location 2020-0295-Response-from-Highways-England-Redacted
Open published response
Concerns raised 1
Lack of warning signs at a reduced-visibility bend 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
Durham County Council
Erect bend warning signs on both approaches to the bend.
View source
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AI-generated summary
Frazer GOLDEN · 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
Frazer Golden, aged 30, died on 9 April 2017 after his motorcycle collided with another motorcycle on the A689 road near Whit’s Hill, County Durham. Concerns included potentially confusing “SLOW” road markings alongside a change from a 30 mph to a 60 mph limit, and the absence of warning signs or double white hazard lines at a bend where forward visibility was reduced.
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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 warning signs at a reduced-visibility bend
Wider context from the report “I heard evidence from 2 police collision experts who could not explain in their examination of the A689 road between Ireshopeburn & St Johns Chapel why SLOW road markings were displayed on the carriageway when immediately leaving these 2 villages and the 30mph limit and entering a 60mph limit.
The evidence heard was that it would appear to be confusing that a warning to SLOW was displayed when the immediately adjacent signs were confirming a change in speed limit from 30 to 60 mph.
Evidence was also heard that at the collision location near Whit’s Hill on the A689 road between the 2 villages there is a bend where forward visibility is reduced . This is accepted in a Durham County Council Highways report read as evidence at the inquest. There are no warning signs or double white hazard warning lines approaching the bend or at the bend in either direction.
The police experts further opined that a speed travelled by one of the motorcyclists into the bend of 51mph was not supported when considering the reduced view created by the bend. The speed limit in this area of the A689 is 60 mph.
” Source location Frazer GOLDEN · Prevention of Future Deaths 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 Erect bend warning signs on both approaches to the bend.
Verbatim wording from the response “• Bend warning signs: a bend warning sign will be erected on both approaches to the bend;” Source location 2020-0197-Response-from-Durham-County-Council_Redacted.pdf
Open published response
4 Sep 2020 Ellie Jessalyn Isaacs · Prevention of Future Deaths report East London
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Concerns raised 1
Hazardous crossing approach following a bend with a higher preceding speed limit 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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AI-generated summary
Ellie Jessalyn Isaacs · 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 19 June 2019, 22-year-old Ellie Isaacs was struck by a motor vehicle while crossing the A12 at a Pelican crossing in Romford before the pedestrian light turned green; she sustained fatal injuries and died in hospital on 21 June 2019. The concerns included obstructed driver views, the crossing’s location and changing speed limits, and high levels of vehicles failing to stop during the amber traffic-light phase, which together raised 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 Hazardous crossing approach following a bend with a higher preceding speed limit
Wider context from the report “2. The Pelicon crossing is sited shortly following a bend in the road and the immediate speed limit approaching the crossing is 30 miles per hour. Very shortly before the Pelicon crossing, the speed limit is 50mph .
” Source location Ellie Jessalyn Isaacs · 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 Renew the 30mph signs so the central-reservation and farside signs match the nearside sign size.
Verbatim wording from the response “Work undertaken” Source location 2020-0169-Response-from-TFL_Redacted.pdf
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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 Resurface the Gallows Corner roundabout and A12 approaches, renewing white lines, markings, bus-stop cage lining and red surfacing.
Verbatim wording from the response “Work undertaken” Source location 2020-0169-Response-from-TFL_Redacted.pdf
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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 30 mph speed limit and its location relative to the pedestrian crossing comply with relevant highway regulations.
Verbatim wording from the response “Below is an aerial photo of the crossing. The speed limit for the Gallows Corner roundabout is 30mph and remains so through the pedestrian crossing location for traffic exiting the roundabout to travel north-east along the A12.” Source location 2020-0169-Response-from-TFL_Redacted.pdf
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 Highway safety actions at the location fall outside Havering Council’s authority because Transport for London is the highway authority.
Verbatim wording from the response “While Colchester Road is part of the adopted highway network, Havering Council are not the Highway Authority for this road, this responsibility falls to Transport for London (TfL). The plan shown below shows the boundary of TfL’s responsibility around Gallows Corner roundabout and also the section of Colchester Road where the crossing point is situated.” Source location 2020-0169-Response-from-Havering-Council-_Redacted.pdf
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 Transport for London must investigate and determine any action concerning the highway network at the location.
Verbatim wording from the response “A site inspection was undertaken on Thursday 17th September to look at the incident site so that Havering could give responses to the points raised in the coroner’s report. While these comments are made by a Senior Engineer at Havering it must be stressed that TfL would need to carry out their own investigation as they would be ultimately responsible for any action (or inaction) carried out to the highway network at this location.” Source location 2020-0169-Response-from-Havering-Council-_Redacted.pdf
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 No road bend causing driver sightline problems was apparent near the crossing during inspection.
Verbatim wording from the response “While on site there was no visible bend apparent in the carriageway along this length of the road that would cause any sight line issues for drivers what so ever.” Source location 2020-0169-Response-from-Havering-Council-_Redacted.pdf
Open published response
15 Apr 2020 Millie TAYLOR-NOONAN · Prevention of Future Deaths report Lincolnshire
View report summary
Concerns raised 1
Lack of a temporary 20-mile-per-hour speed limit during school start and finish periods View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Lincolnshire County Council
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AI-generated summary
Millie TAYLOR-NOONAN · 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
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.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of a temporary 20-mile-per-hour speed limit during school start and finish 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
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 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
Open published response
5 Dec 2019 Darren WILSON · Prevention of Future Deaths report Lincolnshire
View report summary
Concerns raised 1
Failure to provide an appropriate reduced speed limit at the hazardous location 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
Darren WILSON · 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
Darren WILSON died at the scene after his car collided with vehicles during an overtaking manoeuvre on 20 April 2019. The inquest heard concerns that the collision location was a known accident hotspot and lacked traffic-calming measures, including a reduced speed limit and double white lines to prevent overtaking.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide an appropriate reduced speed limit at the hazardous location
Wider context from the report “i. The Inquest heard from a Forensic Collision Investigator and a local resident who was also a former Highways Officer who both confirmed that the location of the collision was a notorious accident "hotspot", in that whilst there had been no previous fatalities, there had been innumerable "near misses" as well as non-fatal road traffic collisions;
ii. The inherent danger of the location arose because of a lack of traffic calming measures such as a reduction of the speed limit at this location as well as deployment of double white lines to inform drivers of the potential hazard and to prevent overtaking;
” Source location Darren WILSON · Prevention of Future Deaths report
Open source report
Concerns raised 1
Failure to set a vehicle speed limit compatible with pedestrian detection and stopping distances 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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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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× 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 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
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 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
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.