Recurring concern

Failure to maintain roads, pavements and verges in a safe state of repair

First to latest report 16 Mar 2015 — 28 Aug 2024

Reports that mention this concern: 21
Times this concern has been raised: 25
Stated actions linked to this concern: 39

What this concern includes

Includes unsafe road surfaces, pavement or junction fabric and adjoining verge conditions caused by inadequate maintenance or repair.

What is not included

Road lighting, signs, markings, drainage or barriers unless the deficient control is physical repair of the road, pavement or verge
Unsafe original road design with no maintenance failure
Vehicle-maintenance failures

Trends

Reports over time

Reports mentioning this concern, over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department for Transport2

Dorset Council2

National Highways2

Avon and Somerset Constabulary1

Birmingham City Council1

Bradford City Council1

Bury Borough Council1

Cambridgeshire County Council1

Cumbria County Council1

Daughter of the deceased1

Denbighshire County Council1

Derbyshire County Council1

Dorset Highways Department1

Gloucestershire County Council1

Lancashire County Council1

Reports and published responses 21 reports

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

28 Aug2024
Milton Keynes
Concerns raised1
1. Failure to repair broken pavement
Linked response

Milton Keynes City Council
Respondent positions 2
1. Milton Keynes City Council
  Routine and responsive inspections found no actionable defect at the location requiring repair.
  Disputes the concern
1. Milton Keynes City Council
  The risk-based inspection code, routine inspections and responsive inspections are considered sufficient to manage highway safety at the location.
  Existing arrangements considered sufficient
AI-generated summary

Moira FARNELL · 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

Moira FARNELL fell on a broken pavement outside her home on 18 April 2024, hit her head, and was diagnosed with a traumatic subdural haematoma. Her condition deteriorated and she died in hospital on 6 May 2024; her family had contacted the council about the pavement hazard before her death, but it was not repaired.

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 repair broken pavement
Wider context from the report
“The deceased's family contacted the council prior to her death concerning the hazard posed by the broken pavement, but no action was taken to repair the pavement. ”
Source location
Moira FARNELL · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Routine and responsive inspections found no actionable defect at the location requiring repair.

Verbatim wording from the response
“• Utilising our ‘code of practice’ and our qualified and trained inspectors, it was determined that in line with national guidance, during both routine inspections and the ad-hoc responsive inspections following the incident, that there is no actionable defect in this location.”

Source location
Response from Milton Keynes Council
Page 5 · response
Published 30 August 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The risk-based inspection code, routine inspections and responsive inspections are considered sufficient to manage highway safety at the location.

Verbatim wording from the response
“• The core of our local code of practice, as the national guidance, is that intervention criteria must be applied to justify actions. Routine and reactive inspections did not reveal any actionable defect(s) at Mentieth Close.”

Source location
Response from Milton Keynes Council
Page 4 · response
Published 30 August 2024
Open published response
26 Jul2024
Cambridgeshire and Peterborough
Concerns raised1
1. Delays in repairing highway degradation
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses

Cambridgeshire County Council
Department for Transport
Stated actions 4
1. Cambridgeshire County Council
  Maintain enhanced maintenance checks on Puddock Road to identify and address highway degradation, including rutting.
2. Cambridgeshire County Council
  Take and analyse soil core samples to inform long-term remedial solutions for soil-affected sections of Puddock Road.
3. Cambridgeshire County Council
  Consult engineers on measures to address rutting caused by heavy agricultural machinery overrunning the paved road.
1. Cambridgeshire County Council
  Conduct verge reinstatement trials to identify effective treatments for rutting, soil erosion and verge collapse.
Respondent positions 2
1. Cambridgeshire County Council
  A weight restriction was not progressed because farm vehicles require access to the road.
  Unable to act
1. Department for Transport
  Cluster-site analysis enforcement and any central fund are matters for the relevant local highway authority, so no Department action is intended.
  Redirects responsibility
AI-generated summary

Jennifer BUNYAN and Marion BUNYAN · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

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

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Delays in repairing highway degradation
Wider context from the report
“This has been an issue and I have a concern about prompt repairs being effected to the road and also the weight of vehicles which is a factor in damage to the verge adjacent to the road itself. ”
Source location
Jennifer BUNYAN and Marion BUNYAN · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

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

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

Source location
Response from Cambridgeshire County Council
Page 3 · response
Published 1 August 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Take and analyse soil core samples to inform long-term remedial solutions for soil-affected sections of Puddock Road.

Verbatim wording from the response
“Puddock Road is subject to a formal inspection every three months and regular visits from a Local Highway Officer. Where identified, necessary repairs are undertaken and where possible, rutting is back filled. This is an interim solution to a complex issue around soil erosion and climate factors. In July 2024 soil core samples were taken from random sections of Puddock Road to assist engineers in understanding what lies beneath the road and identify possible long term remedial solutions. The core samples have revealed a peat layer between 300 and 500mm deep, on top of which is a layer of silty clay.”

Source location
Response from Cambridgeshire County Council
Page 2 · response
Published 1 August 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Consult engineers on measures to address rutting caused by heavy agricultural machinery overrunning the paved road.

Verbatim wording from the response
“As with other Fenland roads, Puddock Road is identified as one of the roads that has been impacted by the behaviour of the soils on which the road has been built. Engineers are now consulting on how best to deal with the rutting caused by the use of heavy”

Source location
Response from Cambridgeshire County Council
Page 2 · response
Published 1 August 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Conduct verge reinstatement trials to identify effective treatments for rutting, soil erosion and verge collapse.

Verbatim wording from the response
“agricultural machinery that overruns the paved road. Verge reinstatement trials will begin in early 2025 where different sections of rutting will receive treatment to see which performs best under varying conditions, and when it is anticipated the verges will be at their softest and most susceptible to collapse or wash out. As part of a wide-ranging change programme within our Place and Sustainability directorate, the County Council is revising and tightening its assurance arrangements.”

Source location
Response from Cambridgeshire County Council
Page 3 · response
Published 1 August 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
A weight restriction was not progressed because farm vehicles require access to the road.

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

Source location
Response from Cambridgeshire County Council
Page 3 · response
Published 1 August 2024
Open published response
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
Cluster-site analysis enforcement and any central fund are matters for the relevant local highway authority, so no Department action is intended.

Verbatim wording from the response
“The Department allocates highways maintenance capital funding to local highways authorities so they can most effectively invest in maintaining and improving their respective network, based upon their local knowledge, circumstances, and priorities.”

Source location
Response from Department of Transport
Page 2 · response
Published 1 August 2024
Open published response
7 May2024
Derby and Derbyshire
Concerns raised1
1. Defective and subsided road surface capable of accumulating ice
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response

Derbyshire County Council
Stated actions 2
1. Derbyshire County Council
  Conducted a laser survey of Station Road to assess whether an actionable safety defect existed.
2. Derbyshire County Council
  Undertake full-width resurfacing from Melbourne View Hotel approximately 200 metres eastward to level road-surface deviations.
Respondent positions 2
1. Derbyshire County Council
  The reported 37-metre-wide road defect was ice formation, not an actionable safety defect; pooled water was limited and typical.
  Disputes the concern
1. Derbyshire County Council
  Quarterly inspections by competent inspectors were sufficient to identify and repair significant road defects.
  Existing arrangements considered sufficient
AI-generated summary

Matthew SCOTT · 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 James Scott died on 11 March 2023 after losing control of his vehicle on Station Road, Melbourne, when it hit a lengthy defective and subsided section of road filled with ice. The report identifies concerns that the road defect had not been surveyed or addressed by the date of the inquest, despite concerns raised by police and the highways authority.

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
Defective and subsided road surface capable of accumulating ice
Wider context from the report
“At 6 weeks post Mr Scott's death - on the 28th of April 2023 - a discussion took place between collision investigator officers, a traffic management officer (all of Derbyshire police) with the Project Engineer of the Highways Authority of Derbyshire County Council. The officers raised their concerns that at the place where Mr Scott lost control of his vehicle (Station Road, Melbourne Derbyshire) there was a lengthy, defective and subsided stretch of road. Further that at the time of Mr Scott's death the subsided section of road was some 4 metres in width, 37 metres in length and 5 cms in depth. Further, that it was deep enough to have had standing water in it which at the time of Mr Scott's death had turned to ice. Ice in the said defect would likely cause a vehicle to lose grip on the road surface. At that section of road, the road starts to bend to the right such that losing control on the ice could cause a vehicle to veer to the offside of the road, either into the path of an oncoming vehicle, into the opposite field or as in Mr Scott’s case, a tree. The Project Engineer of the Highways Authority discussed his concerns and the concerns that had been raised by the police, with the highway maintenance department in early May 2023. As at the date of the inquest into Mr Scott' death (22 April 2024) this stretch of road had not been surveyed, no consideration had been given to the concerns of the police and no decisions taken to repair the defect so as to prevent any further accidents. ”
Source location
Matthew SCOTT · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Conducted a laser survey of Station Road to assess whether an actionable safety defect existed.

Verbatim wording from the response
“Due to the inconsistency between the site report carried out by ████████ and the concerns raised by the Coroner Derbyshire County Council have undertaken a laser survey dated 26/04/2024. The results of the survey also clearly shows there was not an actionable safety defect that measured 4m wide by 37 meters in length, as that was the ice formation.”

Source location
Response from Derbyshire County Council
Page 1 · response
Published 4 July 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Undertake full-width resurfacing from Melbourne View Hotel approximately 200 metres eastward to level road-surface deviations.

Verbatim wording from the response
“Nonetheless Derbyshire County Council take road safety very seriously and the area from Melbourne View Hotel to a point approximately 200 metres in an easterly direction has been put in for full width road surfacing work to be undertaken. This will be completed by 31 October 2024 and will level some of the deviations in the road surface caused by various pot hole repairs.”

Source location
Response from Derbyshire County Council
Page 2 · response
Published 4 July 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The reported 37-metre-wide road defect was ice formation, not an actionable safety defect; pooled water was limited and typical.

Verbatim wording from the response
“The site report states as follows “Large patch of ice on the road surface measuring 4 metres in diameter and 37 meters in length. Commencing in the centre of the carriageway, 4 meters prior to the entrance of the Melbourne Hotel, and terminating in the south-east bound lane. The area predominantly covered the south-east bound lane. It must be noted that this had reduced in size during my attendance due to weather conditions”. This does not say that there was a defect in the road but ice formation. There were some minor differences in level within the carriageway which allowed water to stand, such minor differences in level would be typical of an evolved road network in similar settings such as this and other areas of road across the county.”

Source location
Response from Derbyshire County Council
Page 1 · response
Published 4 July 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Quarterly inspections by competent inspectors were sufficient to identify and repair significant road defects.

Verbatim wording from the response
“As referenced above the road in question, Station Road, Melbourne is subject to quarterly inspections. We have noted the following from records; 13 January 2023 – 2 customer reports of pot hole received on the same day – area put in for ad hoc inspection 17 January 2023 - ad hoc inspection – a number of separate pot holes put in for repair ref. 50186345 works completed 1 March 2023 17 February 2023 routine inspection – defect noted – 28 day repair requested ref. 50189695 - completed 20 February 2023 9 May 2023 – routine inspection – jobs raised outside Melbourne view repair requested ref 50197481– completed 30 May 2023 17 August 2023 – routine inspection – potholes repairs requested ref. 50204692 and 50204693 completed 04 September 2023. 22 November 2023 – routine inspection – potholes repairs requested ref. 50210507 completed on 21 December 2023.”

Source location
Response from Derbyshire County Council
Page 2 · response
Published 4 July 2024
Open published response
15 Dec2023
North Wales (East and Central)
Concerns raised1
1. Failure to maintain the general condition of the highway near the Sun Trevor Public House
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

John Michael Thomas · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

John Michael Thomas died on 2 December 2023 after losing control of the motorcycle he was riding and colliding with an oncoming vehicle, sustaining fatal injuries. Witness evidence indicated that the motorcycle may have slipped on the road, and concerns were raised about flooding and the general condition of parts of the A539, including issues previously brought to the Local Authority’s attention.

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 maintain the general condition of the highway near the Sun Trevor Public House
Wider context from the report
“Initial indications by way of witness evidence suggest that the loss of control occurred as a result of Mr Thomas’ motorcycle “slipping on the road”. My understanding is that this has occurred near to the Sun Trevor Public House, and I have been made aware that some issues regarding flooding and the general condition of this part of the highway had been made known to the Local Authority prior to the accident. Furthermore my understanding is that concerns have also been raised with the Local Authority in relation to surface water/flooding on another part of the A539 near to Llangollen, namely near to the Wenfrwd Pocket Park entrance. I am therefore concerned that if action is not taken to remedy these issues, there is a risk that future deaths may occur. ”
Source location
John Michael Thomas · Prevention of Future Deaths report
Page 1 · concerns
Open source report
16 Nov2023
Lancashire and Blackburn with Darwen
Concerns raised1
1. Inadequate maintenance of road surfacing affected by natural movement and local geography
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Lancashire County Council
Stated actions 2
1. Lancashire County Council
  Continue researching techniques and products to increase the longevity of moss roads, including geosynthetic materials.
2. Lancashire County Council
  Review the Moss Road Strategy, republish it with updates, and review it annually from 2024.
AI-generated summary

Harry College · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

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

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
Inadequate maintenance of road surfacing affected by natural movement and local geography
Wider context from the report
“2. Evidence from a Highways Expert, ████████, explained that Island Lane is part of peat/moss road which is the subject of natural movement when it rains. The water is absorbed by the peat/moss and swells caused the tarmac to move then it compacts when it dries and the road surface lowers, causing cracks. ████████’s evidence was that there is natural movement but these defects rarely get better, only worse. I am concerned that the road surfacing on Island Lane, Winmarleigh will continue to be the subject of natural movement and the present surfacing is hampered by the geography of the location including camber of the road. I consider there is a risk of future deaths to road users if the surfacing of this road is not adequately maintained. Whilst the inspection schedule timescales enacted by the Council are considered to be appropriate, I consider there is a risk of future deaths due to the present surfacing and underlying geological features of this road if inspections are unable to reasonably identify hazardous defects. ”
Source location
Harry College · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Continue researching techniques and products to increase the longevity of moss roads, including geosynthetic materials.

Verbatim wording from the response
“5. Moss Road Strategy”

Source location
Response from Lancashire County Council
Page 5 · response
Published 23 February 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review the Moss Road Strategy, republish it with updates, and review it annually from 2024.

Verbatim wording from the response
“Awareness of common defects on peat moss roads has been raised through the post-incident debrief, which is set out above.”

Source location
Response from Lancashire County Council
Page 5 · response
Published 23 February 2024
Open published response
14 Apr2023
Northamptonshire
Concerns raised1
1. Poor road condition with potholes
Linked response

National Highways
Stated actions 4
1. National Highways
  Increase safety inspections on the affected A5 stretch to twice weekly until resurfacing is complete.
2. National Highways
  Make defects identified during inspections safe and complete temporary repairs within risk-based timescales until resurfacing is complete.
3. National Highways
  Complete localized patch repairs over approximately two miles of the A5 between Pottersbury and Towcester.
1. National Highways
  Carry out the seven-phase resurfacing programme to renew targeted A5 running-surface sections between south Northamptonshire and Attherstone.
AI-generated summary

Benjamin James TEAGUE · 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

Benjamin James Teague died at the scene after his BMW crossed onto the incorrect side of the A5 and collided head-on with an approaching car on 2 August 2021. Evidence at the inquest raised concern about the poor condition of the road, including potholes, which had reportedly deteriorated after repairs.

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
Poor road condition with potholes
Wider context from the report
“During the course of the inquest, evidence was given that the A5 between Pottersbury and Paulesbury (scene of the collision) is in a very poor state with potholes. I understand that a repair was carried out shortly after the road traffic collision but has since deteriorated. I believe that this matter should be looked at by National Highways, ”
Source location
Benjamin James TEAGUE · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Increase safety inspections on the affected A5 stretch to twice weekly until resurfacing is complete.

Verbatim wording from the response
“• Increased the safety inspection regime from once every week to twice weekly to identify any immediate safety concerns in December 2022. Defects identified were made safe and repaired within risk based timescales set out in National Highways defect prioritisation guidance notes. Repair timescale is typically within 24 hours for defects which could impact safety and within 28 days for those defects with a high potential of deteriorating to a condition that could impact on safety.”

Source location
Response from National Highways
Page 1 · response
Published 22 March 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Make defects identified during inspections safe and complete temporary repairs within risk-based timescales until resurfacing is complete.

Verbatim wording from the response
“• Increased the safety inspection regime from once every week to twice weekly to identify any immediate safety concerns in December 2022. Defects identified were made safe and repaired within risk based timescales set out in National Highways defect prioritisation guidance notes. Repair timescale is typically within 24 hours for defects which could impact safety and within 28 days for those defects with a high potential of deteriorating to a condition that could impact on safety.”

Source location
Response from National Highways
Page 1 · response
Published 22 March 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Complete localized patch repairs over approximately two miles of the A5 between Pottersbury and Towcester.

Verbatim wording from the response
“• Carried out localised repair work of patches of between 7m to 160m in length over a 2-mile section of carriageway between Pottersbury and Towcester between 9 and 10 January 2023.”

Source location
Response from National Highways
Page 1 · response
Published 22 March 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Carry out the seven-phase resurfacing programme to renew targeted A5 running-surface sections between south Northamptonshire and Attherstone.

Verbatim wording from the response
“• Commenced work on an extensive seven-phase road resurfacing scheme to renew targeted sections of the running surface along the A5 between south Northamptonshire and Attherstone. This work commenced on 20 February 2023. The link to the A5 press release can”

Source location
Response from National Highways
Page 1 · response
Published 22 March 2023
Open published response
8 Dec2022
Birmingham and Solihull
Concerns raised1
1. Failure to maintain the kerb at the junction to prevent it appearing to be an official crossing point
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response

Birmingham City Council
Stated actions 2
1. Birmingham City Council
  Amend the kerb height at the footpath outside 214 Alcester Road South at the Livingstone Road junction.
2. Birmingham City Council
  Review network kerb-defect information and intervention criteria to identify similar locations and incorporate necessary maintenance processes.
AI-generated summary

Mervyn Charles Gladstone Leonard HOLBROOK · 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 June 2022, Mervyn Charles Gladstone Leonard Holbrook was knocked from his mobility scooter and run over at a junction after entering the carriageway where a kerb had been worn down. He suffered catastrophic thoracic injuries and was pronounced deceased at the scene. The concern was that the worn and defective kerb could be mistaken for an official crossing point by vulnerable road users, particularly mobility scooter and bicycle users, creating a risk of entering the carriageway unsafely.

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 maintain the kerb at the junction to prevent it appearing to be an official crossing point
Wider context from the report
“1. I heard and considered evidence from West Midlands Police's Forensic Collision Unit which confirmed that where the footpath outside 214 Alcester Road South reaches the junction of Livingstone Road, it appears that there is a dropped kerb at the apex. On the opposite side of the junction, the kerbs are raised. West Midlands Police advise that this indicates that the dropped kerbs at this side of the junction are a result of vehicles mounting the kerb as they turn left from Livingstone Road to Alcester Road and therefore causing them to be eroded to be level with the road surface. There is also no tactile paving next to these kerbs, which indicate that this dropped kerb is not an "official" pedestrian crossing point - the same being situated approximately 9m from the end of Livingstone Road. 2. Mr Holbrook was able to leave the carriageway on his mobility scooter at apex/mouth of the junction due to the kerb being worn down to the road surface, and was struck in the carriageway. 3. On 12 September 2022, PC ████████ of West Midlands Police submitted a notification via Birmingham City Council's Highway Department's online portal of the defect, with the Highways responding via email on 20 September 2022 stating that it did not meet the intervention levels that require repair. 4. I am concerned that vulnerable road users - particularly users of mobility scooters or bicycles - may inadvertently consider the worn down and defective kerb to be an "official" crossing point and enter the carriageway when it is unsafe to do so. 5. Furthermore, if a mobility scooter or similar were to enter the carriageway at the mouth of the junction (as Mr Holbrook did), they would then be unable to mount the curb at the opposite side - they would have to travel West down the carriageway of Livingstone road to the official crossing point, or alternatively (and more dangerously) navigate South on the carriageway into oncoming traffic onto Alcester Road. ”
Source location
Mervyn Charles Gladstone Leonard HOLBROOK · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Amend the kerb height at the footpath outside 214 Alcester Road South at the Livingstone Road junction.

Verbatim wording from the response
“1. I confirm the height of the kerb where the footpath outside 214 Alcester Road South reaches the junction of Livingstone Road was amended by the City Council in early January 2023 as per your recommendations.”

Source location
Response from Birmingham City Council
Page 1 · response
Published 9 December 2022
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review network kerb-defect information and intervention criteria to identify similar locations and incorporate necessary maintenance processes.

Verbatim wording from the response
“2. We have also commissioned to undertake a review of the available kerb defect information to identify locations similar to the incident site on the network so that the necessary processes are incorporated and similar sites are addressed as part of the Council’s maintenance activities. The scope of the study also includes a review of the intervention criteria and whether these need to be revised in the light of this incident. This study is well underway and is expected to be completed by March 2023. A copy of the report will be shared with you as soon as it is available along with details of further proposed actions.”

Source location
Response from Birmingham City Council
Page 2 · response
Published 9 December 2022
Open published response
10 Oct2022
Surrey
Concerns raised1
1. Delays in completing road-defect repairs after serious injuries or deaths
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Surrey County Council
Stated actions 2
1. Surrey County Council
  Increase capacity for larger-scale pothole repairs where conditions warrant.
2. Surrey County Council
  Reinforce immediate notification requirements with Surrey Police and the Surrey Contact Centre after serious road incidents.
Respondent positions 1
1. Surrey County Council
  The existing pothole-management system was not determined to be inadequate; defects were correctly classified and assigned appropriate repair periods.
  Disputes the concern
AI-generated summary

Charles Michael Stringer · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

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

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

How this respondent action was interpreted

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

PFD Monitor interpretation
Increase capacity for larger-scale pothole repairs where conditions warrant.

Verbatim wording from the response
“The Inquest did not therefore determine that the current system was inadequate. However, given the tragic circumstances of Mr Stringer’s death, SCC has undertaken reviews of each of the issues raised by the Family (set out at paragraphs 1-5 in Section 5 of the PFD Report) and several changes have been made since the Inquest (albeit not all directly as a result of this Inquest). Most pertinently the main changes since Mr Stringer’s passing are:”

Source location
Response from Surrey County Council
Page 2 · response
Published 14 October 2022
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Reinforce immediate notification requirements with Surrey Police and the Surrey Contact Centre after serious road incidents.

Verbatim wording from the response
“5. What steps have been taken to ensure repairs are completed in a timely fashion after serious injuries and deaths have occurred, as a result of a road defect?”

Source location
Response from Surrey County Council
Page 5 · response
Published 14 October 2022
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The existing pothole-management system was not determined to be inadequate; defects were correctly classified and assigned appropriate repair periods.

Verbatim wording from the response
“The Coroner has indicated that the written submissions provided (it is assumed by ████████ refer to ‘a number of discussions…but there has been no documented changes in systems of practice’. SCC notes that the conclusion of the Inquest was Accident and that the Coroner determined that at every relevant inspection where the index defect was identified, it was classified correctly, and an appropriate repair completion date was imposed. Tragically, Mr Stringer’s accident occurred whilst the pothole was scheduled for repair (and was within the appropriate repair time window).”

Source location
Response from Surrey County Council
Page 2 · response
Published 14 October 2022
Open published response
24 May2019
Gloucestershire
Concerns raised1
1. Failure to maintain the cycle lane in a safe condition
Linked response

Gloucestershire County Council
Stated actions 2
1. Gloucestershire County Council
  Resurface Cole Avenue, including planing and replacing the tarmac surface and cycle-lane surfacing, through the 2020/21 programme.
2. Gloucestershire County Council
  Inspect Cole Avenue monthly and apply footpath-defect criteria to cycle lanes, with qualifying defects attended to.
Respondent positions 2
1. Gloucestershire County Council
  The site currently has no actionable safety defects under the applicable safety defect criteria.
  Disputes the concern
1. Gloucestershire County Council
  Monthly key-route inspections and attendance to qualifying defects are considered sufficient until planned resurfacing.
  Existing arrangements considered sufficient
AI-generated summary

Ahmed Hassam Motala · 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

Ahmed Motala was cycling to work on the A38 in Gloucester on 29 November 2018 when he collided with a lorry; the injuries he sustained resulted in his death. The report raised concern that the cycle lane was in very poor condition, requiring cyclists to swerve or cycle close to the traffic lane, and that cyclists’ lives could be put at risk if it remained unrepaired.

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 maintain the cycle lane in a safe condition
Wider context from the report
“The evidence of the Police Collision Investigator and the evidence of witnesses who were motorists on the day (one who regularly used the cycle lane himself) describe the state of the cycle lane as being in very poor condition and cyclists have to swerve in the cycle lane to avoid the defects. Moreover I heard that to avoid the defects they cycle very close to the white line separating the lane with the traffic. This is obviously very dangerous. At the time of the impact, Mr Motala was not in a cycle lane, what is more the weather on that day was described as “diabolical”. Therefore I do not consider that the state of the cycle lane itself contributed to his death. However, I am concerned that lives of cyclists in the future may be put at risk if the cycle lane stays in the current state of repair. ”
Source location
Ahmed Hassam Motala · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Resurface Cole Avenue, including planing and replacing the tarmac surface and cycle-lane surfacing, through the 2020/21 programme.

Verbatim wording from the response
“Our Safety Inspection Team have been out and assessed the site using our Safety Defect Criteria. At present there are no actionable safety defects, however the red surfacing that is sometimes used in cycle lanes to highlight their presence is starting to strip away. There is no quick fix for this issue and the lanes have to be planned out and fully resurfaced.”

Source location
2019-0168-Response-by-Gloucestershire-County-Council
Page 1 · response
Published 29 July 2019
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Inspect Cole Avenue monthly and apply footpath-defect criteria to cycle lanes, with qualifying defects attended to.

Verbatim wording from the response
“Cole Avenue is currently in our resurfacing programme for the next financial year 20/21, this will involve the tarmac surface and cycle lanes being planed out and new tarmac put in its place. Until this time, Cole Avenue will continue to be inspected as part of our key route inspections once a month and any defects that are present will be attended to. I have stressed the importance of picking any issues up in this location and the inspectors will now pick up any defects that meet the criteria for a footpath defect within the cycle lanes. This criteria is different to that of a carriageway and will highlight smaller defects.”

Source location
2019-0168-Response-by-Gloucestershire-County-Council
Page 1 · response
Published 29 July 2019
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The site currently has no actionable safety defects under the applicable safety defect criteria.

Verbatim wording from the response
“Our Safety Inspection Team have been out and assessed the site using our Safety Defect Criteria. At present there are no actionable safety defects, however the red surfacing that is sometimes used in cycle lanes to highlight their presence is starting to strip away. There is no quick fix for this issue and the lanes have to be planned out and fully resurfaced.”

Source location
2019-0168-Response-by-Gloucestershire-County-Council
Page 1 · response
Published 29 July 2019
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Monthly key-route inspections and attendance to qualifying defects are considered sufficient until planned resurfacing.

Verbatim wording from the response
“Cole Avenue is currently in our resurfacing programme for the next financial year 20/21, this will involve the tarmac surface and cycle lanes being planed out and new tarmac put in its place. Until this time, Cole Avenue will continue to be inspected as part of our key route inspections once a month and any defects that are present will be attended to. I have stressed the importance of picking any issues up in this location and the inspectors will now pick up any defects that meet the criteria for a footpath defect within the cycle lanes. This criteria is different to that of a carriageway and will highlight smaller defects.”

Source location
2019-0168-Response-by-Gloucestershire-County-Council
Page 1 · response
Published 29 July 2019
Open published response
20 May2019
Dorset
Concerns raised1
1. Failure to maintain the road and its verges
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response

Dorset Council
Stated actions 2
1. Dorset Council
  Resurface the B3091, adjusting the road camber to improve drainage and reduce surface water.
2. Dorset Council
  Clean the drainage system serving the affected highway section.
AI-generated summary

Richard Geoffrey Phillips · 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

Richard Geoffrey Phillips died at the scene after a car lost control on ice while he was riding his motorcycle on the B3091 on 19 December 2017. The concerns identified included poor drainage of surface water, ice forming on the carriageway, and the maintenance and condition of the road and its verges.

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 maintain the road and its verges
Wider context from the report
“2. I have concerns with regard to the following: a) The collision investigation officer from Dorset Police expressed concern in relation to the poor drainage of surface water on this particular stretch of road. My attention was drawn to four draining gullies within 150 metres of the scene, two on each side of the road. As the water flows down the southbound side of the road it does not flow into the gulley but due to the camber of the road the water crosses over the centre of the road and flows down the centre of the road before flowing on to the opposite carriageway. On the nearside of the opposite carriageway is another drainage gulley which contains a gridded metal drain which was (at the time) largely obscured and overgrown by grass. The water once again bypasses this gulley. It is this surface water which has frozen at the time of the accident. At least 2 of the gullies which could drain the water away from the carriageway appear redundant. The positioning of these gullies are questionable. b) Maintenance of the road and its verges. ”
Source location
Richard Geoffrey Phillips · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Resurface the B3091, adjusting the road camber to improve drainage and reduce surface water.

Verbatim wording from the response
“The accident took place on the section of the B3091 that has subsequently been resurfaced.”

Source location
2019-0165-Response-by-Dorset-Council
Page 1 · response
Published 29 July 2019
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Clean the drainage system serving the affected highway section.

Verbatim wording from the response
“The drainage system has been cleaned recently but we will react to any blockages that are reported to us by the public or staff locally.”

Source location
2019-0165-Response-by-Dorset-Council
Page 1 · response
Published 29 July 2019
Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Data last updated 7 September 2026

What this concern includes

Trends

Reports mentioning this concern, over time

Concerns raised1

Failure to repair broken pavement

Linked response

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Delays in repairing highway degradation

Linked responses

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Defective and subsided road surface capable of accumulating ice

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Failure to maintain the general condition of the highway near the Sun Trevor Public House

Concerns raised1

Inadequate maintenance of road surfacing affected by natural movement and local geography

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised1

Poor road condition with potholes

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Concerns raised1

Failure to maintain the kerb at the junction to prevent it appearing to be an official crossing point

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Respondent positions 2

Stated actions 4

Respondent positions 2

Stated actions 2

Respondent positions 2

Stated actions 2

Stated actions 4

Stated actions 2