Recurring concern

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

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First reported 16 Mar 2015•Latest report 28 Aug 2024

Definition

What this concern includes

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

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
Reports
21

Distinct published reports

Individual concerns
25

A report can raise multiple concerns

Date range
2015–2024

First to latest report issue date

Stated actions
39

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

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

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Inner South London

    AI-generated summary

    Paul Fairey · 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

    Paul Fairey was a pedestrian who was struck by a northbound car on Mayow Rd at about 00.40 on 23 September 2017 and later died from a severe head injury. Concerns included poor visibility caused by tree foliage, a faded road marking, and a speed cushion that could be straddled and was beginning to break up; the evidence also indicated that the car was travelling above the 20mph speed limit.

    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

    Deterioration of speed-cushion surface

    Wider context from the report

    “(3) There is a speed cushion close to the pedestrian crossing point. The evidence was that a car can straddle this speed cushion without needing to slow down. Also the speed cushion is beginning to break up. ”

    Source location

    Paul Fairey · 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

    Reconstruct speed cushions near the two pedestrian refuge crossing points adjacent to Mayow Park.

    Verbatim wording from the response

    “Response - The speed cushions in Mayow Road have been in place for a number of years and may be less effective due to long term wear. Financial constraints generally mean that widespread renewal of worn traffic calming features is not feasible. However it is proposed to reconstruct the speed cushions in close proximity of the two pedestrian refuge crossing points adjacent to Mayow Park to ensure that they are as effective as possible. This work is programmed to be completed by the end of April 2019.”

    Source location

    Response from Lewisham
    Page 1 · response
    Published 21 December 2018

    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

    Financial constraints mean widespread renewal of worn traffic-calming features is not feasible; only cushions near the crossings will be reconstructed.

    Verbatim wording from the response

    “Response - The speed cushions in Mayow Road have been in place for a number of years and may be less effective due to long term wear. Financial constraints generally mean that widespread renewal of worn traffic calming features is not feasible. However it is proposed to reconstruct the speed cushions in close proximity of the two pedestrian refuge crossing points adjacent to Mayow Park to ensure that they are as effective as possible. This work is programmed to be completed by the end of April 2019.”

    Source location

    Response from Lewisham
    Page 1 · response
    Published 21 December 2018

    Open published response
  2. Worcestershire

    AI-generated summary

    Gareth James Jones · Prevention of Future Deaths report

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

    Report summary

    Gareth James Jones died on the A422 at Inkberrow after losing control of the car he was driving and colliding with another vehicle. Concerns included previous road traffic deaths at the location, a road surface below the specified standard for three years, and the likelihood that the road surface contributed to the 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

    Failure to maintain the road surface to the specified highways-agency standard

    Wider context from the report

    “(1) This is not the first road traffic 1st death at this location (2) The traffic collision investigator's report (attached) indicates that the standard of the road surface has for 3 years been below that specified by the highways agency. (3) The condition of the road surface is likely to have played a part in this death ”

    Source location

    Gareth James Jones · 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

    Surface dress the road section to restore skid resistance.

    Verbatim wording from the response

    “The section of road in question was surface dressed as soon as possible following the accident thus restoring the skid resistance. We can therefore confirm that following the accident, a remedial measure to improve skid resistance was carried out. The exact timing of the works was governed by the DFT guidance over the time of year when this could be done.”

    Source location

    Response from Highways
    Page 3 · response
    Published 18 March 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

    Surface dressing is not necessary or reasonable for every carriageway section below the investigatory level; relevant circumstances determine whether it would be beneficial.

    Verbatim wording from the response

    “It is neither necessary nor reasonable to surface dress all sections of highway in which the CSC level falls below investigatory level, whether with or without previous skidding accidents. Rather it is necessary to consider all relevant circumstances to identify whether surface dressing would be beneficial in any event.”

    Source location

    Response from Highways
    Page 2 · response
    Published 18 March 2019

    Open published response
  3. Inner West London

    AI-generated summary

    Lucia CICCIOLI · 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

    Lucia CICCIOLI was cycling westbound through the junction of Latchmere Road and Elspeth Road towards Lavender Hill when she lost her balance after travelling over a dip in the road and collided with a MAN lorry. She sustained fatal injuries and died at the scene. The principal concerns were inadequate cycle-lane provision and protection, the junction layout and yellow box, the narrow road, and a dangerous dip in the road requiring urgent repair.

    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 dangerous road dip in LAVENDER HILL

    Wider context from the report

    “6) The dip in the road in LAVENDER HILL (between position 4 and position 5 on the Reconstruction Plan) is dangerous and is in need of urgent repair. ”

    Source location

    Lucia CICCIOLI · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
  4. Warwickshire

    AI-generated summary

    Katherine Tracey Vanloo · 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

    Katherine Tracey Vanloo died on 3 January 2016 from catastrophic injuries after falling from her bicycle when it hit an unrepaired pothole and being struck by a car. The report identified delays in repairing the pothole and a lack of systems to track outstanding works and audit whether repairs had been completed and were of adequate quality.

    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 formal auditing of pothole repair completion and quality

    Wider context from the report

    “(1) The pothole was first identified on 23rd March 2015 as a category 2 defect with a target of 28 days within which such defects should be repaired. (2) The works order to carry out the repair was only raised by Warwickshire County Council 3 months later on 5th June 2015. This was sent to Balfour Beatty Living Places who had entered into a contract with Warwickshire County Council to repair road surfaces in Warwickshire. They in turn subcontracted the road repair work, which included pothole repair work, to CR MacDonald. The works order was received by CR MacDonald on 19th June 2015. (3) The work to repair the pothole was not undertaken by an employee of CR MacDonald until 2nd November 2015, albeit that the wrong pothole was repaired on that day. (4) There was a delay of over 7 months between the identification of the pothole and the time it was supposedly repaired on 2nd November 2015. (5) At the time of the incident Warwickshire County Council did not have a system in place to track with Balfour Beatty Living Places or CR MacDonald the progress of works orders, i.e. when outstanding works had been completed, nor any formal programme of auditing to check if the work has been done and to check the quality of the work. ”

    Source location

    Katherine Tracey Vanloo · Prevention of Future Deaths report
    Page 2 · concerns

    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

    Delays in raising and transmitting pothole repair works orders

    Wider context from the report

    “(1) The pothole was first identified on 23rd March 2015 as a category 2 defect with a target of 28 days within which such defects should be repaired. (2) The works order to carry out the repair was only raised by Warwickshire County Council 3 months later on 5th June 2015. This was sent to Balfour Beatty Living Places who had entered into a contract with Warwickshire County Council to repair road surfaces in Warwickshire. They in turn subcontracted the road repair work, which included pothole repair work, to CR MacDonald. The works order was received by CR MacDonald on 19th June 2015. (3) The work to repair the pothole was not undertaken by an employee of CR MacDonald until 2nd November 2015, albeit that the wrong pothole was repaired on that day. (4) There was a delay of over 7 months between the identification of the pothole and the time it was supposedly repaired on 2nd November 2015. (5) At the time of the incident Warwickshire County Council did not have a system in place to track with Balfour Beatty Living Places or CR MacDonald the progress of works orders, i.e. when outstanding works had been completed, nor any formal programme of auditing to check if the work has been done and to check the quality of the work. ”

    Source location

    Katherine Tracey Vanloo · Prevention of Future Deaths report
    Page 2 · concerns

    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

    Delays in completing pothole repairs

    Wider context from the report

    “(1) The pothole was first identified on 23rd March 2015 as a category 2 defect with a target of 28 days within which such defects should be repaired. (2) The works order to carry out the repair was only raised by Warwickshire County Council 3 months later on 5th June 2015. This was sent to Balfour Beatty Living Places who had entered into a contract with Warwickshire County Council to repair road surfaces in Warwickshire. They in turn subcontracted the road repair work, which included pothole repair work, to CR MacDonald. The works order was received by CR MacDonald on 19th June 2015. (3) The work to repair the pothole was not undertaken by an employee of CR MacDonald until 2nd November 2015, albeit that the wrong pothole was repaired on that day. (4) There was a delay of over 7 months between the identification of the pothole and the time it was supposedly repaired on 2nd November 2015. (5) At the time of the incident Warwickshire County Council did not have a system in place to track with Balfour Beatty Living Places or CR MacDonald the progress of works orders, i.e. when outstanding works had been completed, nor any formal programme of auditing to check if the work has been done and to check the quality of the work. ”

    Source location

    Katherine Tracey Vanloo · Prevention of Future Deaths report
    Page 2 · concerns

    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 ensure repair of the identified pothole

    Wider context from the report

    “(1) The pothole was first identified on 23rd March 2015 as a category 2 defect with a target of 28 days within which such defects should be repaired. (2) The works order to carry out the repair was only raised by Warwickshire County Council 3 months later on 5th June 2015. This was sent to Balfour Beatty Living Places who had entered into a contract with Warwickshire County Council to repair road surfaces in Warwickshire. They in turn subcontracted the road repair work, which included pothole repair work, to CR MacDonald. The works order was received by CR MacDonald on 19th June 2015. (3) The work to repair the pothole was not undertaken by an employee of CR MacDonald until 2nd November 2015, albeit that the wrong pothole was repaired on that day. (4) There was a delay of over 7 months between the identification of the pothole and the time it was supposedly repaired on 2nd November 2015. (5) At the time of the incident Warwickshire County Council did not have a system in place to track with Balfour Beatty Living Places or CR MacDonald the progress of works orders, i.e. when outstanding works had been completed, nor any formal programme of auditing to check if the work has been done and to check the quality of the work. ”

    Source location

    Katherine Tracey Vanloo · 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

    Issue works orders within five days of safety defects being uploaded to EXOR.

    Verbatim wording from the response

    “We have introduced a target to issue a works order within no more than five days from a safety defect being uploaded to EXOR. The letter prefix means that safety defects in the defects pool can be easily collected and organised for review within the database. Our Delivery Teams in Highways are now required to review the defects pool on a daily basis and the review includes the following objectives:”

    Source location

    2017-0493-Response-by-Warwickshire-County-Council
    Page 2 · response
    Published 28 September 2017

    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 defects pool daily to identify overdue safety defects and prioritise them for immediate works orders.

    Verbatim wording from the response

    “We have introduced a target to issue a works order within no more than five days from a safety defect being uploaded to EXOR. The letter prefix means that safety defects in the defects pool can be easily collected and organised for review within the database. Our Delivery Teams in Highways are now required to review the defects pool on a daily basis and the review includes the following objectives:”

    Source location

    2017-0493-Response-by-Warwickshire-County-Council
    Page 2 · response
    Published 28 September 2017

    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

    Arrange emergency temporary repairs where reasons prevent Category 2 defects being repaired within 28 days.

    Verbatim wording from the response

    “(i) to check whether there is any reason why a Category 2 defect cannot be repaired within 28 days and, if there is such a reason, to arrange for an emergency temporary repair;”

    Source location

    2017-0493-Response-by-Warwickshire-County-Council
    Page 2 · response
    Published 28 September 2017

    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

    Use Confirm dashboard alerts to identify overdue works orders and prioritise them for urgent completion.

    Verbatim wording from the response

    “Our ████████ team have direct access to Confirm as well as BBLP (at the moment only ████████ in Highways has access but access will be provided to all the relevant team leaders in January 2018). Confirm displays a “dashboard” which automatically displays details of any works orders which have gone “red”, meaning that they have not been carried out within 23 days of the date of the works order. Allowing up to five days for the works order to be issued after inspection, this effectively sounds an alert that the 28 day target is at risk of being missed. These works orders are then prioritised for urgent completion.”

    Source location

    2017-0493-Response-by-Warwickshire-County-Council
    Page 3 · response
    Published 28 September 2017

    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

    Work collaboratively with BBLP to target overdue works orders and monitor whether joint action achieves timely repairs.

    Verbatim wording from the response

    “At present, the County Council are working co-operatively with BBLP to target overdue works orders and will keep under review whether joint monitoring and action on a collaborative basis is proving sufficient to ensure that repairs are being effected on time or, in a small number of cases very shortly thereafter. However, inspection of the Confirm dashboard on 19 December 2017 showed that only 14 safety defects were at or beyond the 28 day target across the whole county.”

    Source location

    2017-0493-Response-by-Warwickshire-County-Council
    Page 3 · response
    Published 28 September 2017

    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

    Capture inspected pothole details directly into the EXOR defects pool using handheld devices.

    Verbatim wording from the response

    “Ensuring Prompt Issue of a Works Order The Highways Safety Inspectors now use one of six handheld devices to create details of potholes that they find (co-ordinates, photographs, categorisation, etc.) and upload them directly into the County Council’s database in the EXOR computer system. The database is known as the “defects pool”. The defects pool contains records of all kinds of defects and so we have introduced measures to enable safety defects found by Inspectors to be readily distinguished from other defects that do not present an immediate safety concern. This is done by assigning a letter to each of the handheld devices (A, B, C, D, E or F) which prefixes the reference number of any safety defect when it is uploaded to EXOR (e.g. B9678).”

    Source location

    2017-0493-Response-by-Warwickshire-County-Council
    Page 1 · response
    Published 28 September 2017

    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

    Existing pothole repair target times were not changed because they were not criticised at the inquest.

    Verbatim wording from the response

    “Our actions relate, firstly, to the period between a pothole being identified by a Safety Inspector and a works order being issued to BBLP and, secondly, to the period after a works order has been issued. We have not changed the target times for repairing potholes (and no criticism was made of them during the inquest) but have aimed our actions at ensuring that works orders are issued promptly and that any slippage by Balfour Beatty is quickly detected and pursued.”

    Source location

    2017-0493-Response-by-Warwickshire-County-Council
    Page 1 · response
    Published 28 September 2017

    Open published response
  5. Manchester (North)

    AI-generated summary

    Mr Roger Hamer · Prevention of Future Deaths report

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

    Report summary

    Mr Roger Hamer fell from his bicycle on Bury New Road, suffering a traumatic brain injury and multiple fractures, and died in hospital from those injuries on 2 April 2016. The inquest jury found that a pothole probably caused his fall. Concerns included inadequate recording and monitoring of carriageway deterioration, a lack of paint markings around potholes, the absence of a duty-of-candour procedure for investigating significant incidents, and proposed highway-management thresholds that might increase risks to cyclists.

    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 carriageway defects at or above the 40mm threshold

    Wider context from the report

    “(4) The Highway Authority is in the process of adopting a new procedure for highway management (“the New Procedure”), apparently based upon Well-Managed Highway Infrastructure: a Code of Practice published by the Department for Transport in October 2016. With regards to defects in the carriageway, the Highway Authority’s current procedure for highway management has an intervention level of 40mm so that any defect which is found to be 40mm or greater is repaired. Under the New Procedure 40mm will be redefined as the “investigation level”, so that once a carriageway defect is greater than 40mm a highway inspector will investigate it and consider whether a repair is needed. If 40mm is specified in the New Procedure as the minimum threshold for investigation then defects which measure less than 40mm may not be investigated and defects of 40mm or above may not be repaired. Whilst I was informed that highway inspectors have a discretion under both the current and new procedures to repair defects which do not meet the intervention or investigation criteria the jury noted inconsistencies in the application of the current procedure and I consider that the New Procedure will increase the risk of future deaths, in particular to cyclists. ”

    Source location

    Mr Roger Hamer · 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

    Agree an overarching framework with Greater Manchester highway authorities for consistent risk-based inspection, repair and investigation approaches.

    Verbatim wording from the response

    “Bury Council in collaboration with the other 9 Greater Manchester Highway Authorities, are seeking to agree an “Overarching Framework of Agreed Principles” which would provide consistency of approach across the boundaries on the following matters: frequency and classification of highways, the risk based approach to safety inspections, the risk based approach to repair timescales, the investigative levels which would trigger the Highway inspector to apply the risk based matrix for assessing the risk.”

    Source location

    2017-0259-Response-by-Bury-Council
    Page 4 · response
    Published 7 November 2017

    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

    Provide nearly £6 billion to local highway authorities in England outside London to improve local road condition.

    Verbatim wording from the response

    “I was very saddened to hear of the circumstances leading to Mr Hamer’s death. The Department for Transport considers the safety of all road users, including cyclists, a priority. The Government is providing just under £6 billion from 2015 to 2021 to allow local highway authorities in England, outside of London, to improve the condition of local roads across they are responsible for. In addition, we have topped this funding up with an extra £250 million specifically to tackle the blight of potholes.”

    Source location

    2017-0259-Response-by-Department-for-Transport
    Page 1 · response
    Published 7 November 2017

    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

    Provide an additional £250 million specifically to address potholes on local roads.

    Verbatim wording from the response

    “I was very saddened to hear of the circumstances leading to Mr Hamer’s death. The Department for Transport considers the safety of all road users, including cyclists, a priority. The Government is providing just under £6 billion from 2015 to 2021 to allow local highway authorities in England, outside of London, to improve the condition of local roads across they are responsible for. In addition, we have topped this funding up with an extra £250 million specifically to tackle the blight of potholes.”

    Source location

    2017-0259-Response-by-Department-for-Transport
    Page 1 · response
    Published 7 November 2017

    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

    Central Government cannot override local highway authorities’ decisions about highway maintenance, repair priorities or applicable standards.

    Verbatim wording from the response

    “However, as you will be aware, local highway authorities, in this case Bury Council, have a duty under Section 41 of the Highways Act 1980 to maintain the highways network in their area. The Act does not set out specific standards of maintenance, as it is for each individual local highway authority to assess which parts of their network are in need of repair and what standards should be applied, based upon their local knowledge and circumstances. Central Government has no powers to override local decisions in these matters.”

    Source location

    2017-0259-Response-by-Department-for-Transport
    Page 1 · response
    Published 7 November 2017

    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

    Local highway authorities are responsible for deciding highway repairs, maintenance standards and pothole dimensions based on local circumstances.

    Verbatim wording from the response

    “However, as you will be aware, local highway authorities, in this case Bury Council, have a duty under Section 41 of the Highways Act 1980 to maintain the highways network in their area. The Act does not set out specific standards of maintenance, as it is for each individual local highway authority to assess which parts of their network are in need of repair and what standards should be applied, based upon their local knowledge and circumstances. Central Government has no powers to override local decisions in these matters.”

    Source location

    2017-0259-Response-by-Department-for-Transport
    Page 1 · response
    Published 7 November 2017

    Open published response
  6. Manchester West

    AI-generated summary

    Cameron Chadwick · 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

    Cameron Chadwick was riding a motorcycle on Helvellyn Road, Wigan, on 7 February 2017 when he lost control, fell, and sustained injuries that led to his death. Evidence at the inquest concerned a pothole near the accident site, reportedly measured at 45mm deep, although the exactness of the measurement could not be fully guaranteed.

    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 a carriageway pothole meeting the stated repair threshold

    Wider context from the report

    “1. During the Inquest evidence was heard that:- i. Evidence was given at the Inquest that there was a pothole in the carriageway near to where the accident that caused Cameron Chadwick’s death occurred. An officer of Wigan Council informed the Court that a pothole that was 40mm or more deep should be repaired. A Police Officer gave evidence that whilst he could not fully guarantee the exactness of his measurement the pothole was 45mm deep at the time of this accident. ”

    Source location

    Cameron Chadwick · 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

    Repair the carriageway pothole through temporary and subsequent permanent repairs.

    Verbatim wording from the response

    “However, in line with best practice and from the Regulation 28 - Coroner’s Report advising us this incident, the highway asset management service has exercised their discretion to carry out a repair, although it did not actually meet the Council’s highway intervention level for a safety defect. For recording purposes I can advise that a temporary repair to the carriageway pothole was actioned 6th July 2017. This temporary repair was followed up with a permanent one on 17th July 2017. I have attached a photograph referenced H2 as evidence of this repair.”

    Source location

    Response from Wigan Council
    Page 2 · response
    Published 6 July 2017

    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 pothole was 36mm deep, not the 45mm depth reported in police evidence.

    Verbatim wording from the response

    “I can confirm that a Technical Officer (Highways and Streetworks) and a Technical Design Officer (Highways) from the Highway Asset Management Team, who are experienced in carrying out highway safety inspections, attended the location of the incident at Hevvellyn Road, Norley Hall, Wigan on 6th July 2017. The purpose of this site visit was to establish the depth of the carriageway pothole. In the police report (exhibit DJH 2- point 19) the police officer gave evidence that the pothole was 4.5cm (45mm) deep at its lowest point at the time of the accident.”

    Source location

    Response from Wigan Council
    Page 1 · response
    Published 6 July 2017

    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

    Regular inspections and repairs under the Highway Safety Inspection Policy address highway safety defects according to the existing danger-based intervention thresholds.

    Verbatim wording from the response

    “I can confirm that Wigan Council has in place a Highway Safety Inspection Policy for its highway network. All highways are subject to regular safety inspections by competent highway inspectors. Any safety defects found during those inspections giving rise to a real source of dangers to reasonable users would have been subject to repair within certain timescales dependent on the degree of the danger.”

    Source location

    Response from Wigan Council
    Page 2 · response
    Published 6 July 2017

    Open published response
  7. Dorset

    AI-generated summary

    Reverend Colin Hodge · 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 January 2016, Reverend Colin Hodge stumbled on an uneven pavement at a junction in Wareham and fell against a turning vehicle, then struck his head. He was taken to hospital and died on 25 January from an inoperable head injury. Concerns included the poor state of repair and lack of a clear boundary between the pavement and roadway, with vehicles sometimes cutting the corner.

    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 pavement and roadway at the junction in a safe state of repair

    Wider context from the report

    “(1) The evidence from the witnesses who were all from the Wareham area, was that the pavement and road way at the junction of the High Street and Howards Lane was in a poor state of repair. ”

    Source location

    Reverend Colin Hodge · 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

    Install kerb stones and renew a small section of footway surface to define the footway edge and improve its condition.

    Verbatim wording from the response

    “Prior to this investigation the County Councillor for the area had raised local concerns with this location. The concerns centred on there being no kerb line defining the ‘end’ of the footway. In recognition of these concerns kerb stones were installed on 19 August 2016 to define the edge of the footway. As part of these works, a small section of new surface was laid in order to address the concerns with the footway surface. Whilst the surface was not in any way defective a pragmatic decision was taken to improve the footway surface as part of the kerbing work. The images attached show the site in question before and after the work had been completed.”

    Source location

    2017-0042-Response-by-Dorset-County-Council
    Page 1 · response
    Published 5 March 2017

    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 fatal site investigation found no highway-related factors contributed to the fatality.

    Verbatim wording from the response

    “The fatal site investigation was completed by colleagues at Dorset Police and Highway Officers on 23 May 2016. This investigation did not reveal any highway related factors that contributed to the fatality.”

    Source location

    2017-0042-Response-by-Dorset-County-Council
    Page 1 · response
    Published 5 March 2017

    Open published response
  8. Avon

    AI-generated summary

    Mrs. Margaret Joyce Jones · Prevention of Future Deaths report

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

    Report summary

    Mrs. Margaret Joyce Jones died at the scene after her car collided with a northbound articulated lorry while she was turning onto the A36 from Branch Road on 5 September 2016. The report identified repeated collisions at the junction and raised concerns about the speed limit, road signs, carriageway markings, and the condition of the high-friction surface.

    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 high-friction road surface in the vicinity of the junction

    Wider context from the report

    “(3) The road signs including carriageway markings should be reviewed and improved so as to provide greater warning to drivers as to the risk from this junction. (4) Whilst not factors in this collision appropriate repairs should be made to the high friction surface and road markings in the vicinity of the junction. ”

    Source location

    Mrs. Margaret Joyce Jones · Prevention of Future Deaths report
    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

    Complete a localized temporary repair to the high-friction surfacing at the junction.

    Verbatim wording from the response

    “Our maintenance interventions are made on the basis of priority and safety. We have had our pavement specialists inspect the junction recently. The wear of the HFS is immediately opposite the junction, caused by tyre friction associated with vehicles turning off of the A36 and not in the braking zone for approaching vehicles.”

    Source location

    Response from Highways England
    Page 3 · response
    Published 5 March 2017

    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

    Progress a permanent replacement scheme for part of the high-friction surfacing through the prioritized value-management process.

    Verbatim wording from the response

    “Our maintenance interventions are made on the basis of priority and safety. We have had our pavement specialists inspect the junction recently. The wear of the HFS is immediately opposite the junction, caused by tyre friction associated with vehicles turning off of the A36 and not in the braking zone for approaching vehicles.”

    Source location

    Response from Highways England
    Page 3 · response
    Published 5 March 2017

    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

    Continue monitoring the locality for changes requiring appropriate safety action.

    Verbatim wording from the response

    “The road surface, specifically the HFS, while showing signs of wear is still fit for purpose and what wear there is can be considered normal and adjacent to the junction rather than in the braking zone. It will of course be monitored and overtime be replaced during our normal cycle of renewals. On that basis I consider we have implemented appropriate repairs and management regimes.”

    Source location

    Response from Highways England
    Page 3 · response
    Published 5 March 2017

    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 high-friction surfacing remains fit for purpose, with wear outside the braking zone managed through monitoring and normal renewal arrangements.

    Verbatim wording from the response

    “Our maintenance interventions are made on the basis of priority and safety. We have had our pavement specialists inspect the junction recently. The wear of the HFS is immediately opposite the junction, caused by tyre friction associated with vehicles turning off of the A36 and not in the braking zone for approaching vehicles.”

    Source location

    Response from Highways England
    Page 3 · response
    Published 5 March 2017

    Open published response
  9. Cumbria

    AI-generated summary

    Kevin David RITSON · 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 4 August 2015, Kevin David RITSON lost control of his motorcycle on a bend on the A595 in Cumbria and died at Preston Hospital from unsurvivable injuries. The report raised concerns about the road surface, including poor adhesion, patched holes and the absence of a chevron warning sign removed after an earlier accident.

    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 surface in a safe condition

    Wider context from the report

    “(1) The deceased was riding his motor bike through Stangrah Farm near Whitbeck. This had been the scene of an earlier accident damage from which had removed a chevron warning sign. It was clear from photographs that the road surface was not in good condition and holes had been patched. Evidence also showed the road surface adhesion to be below standard. ”

    Source location

    Kevin David RITSON · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  10. West Yorkshire (Western)

    AI-generated summary

    Lee James Nauman · 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

    Lee James Nauman died after losing control of his motorcycle on Lee Lane and colliding with an oncoming vehicle, sustaining fatal head injuries. Evidence at the inquest identified a crumbling road edge, a pothole and leaf and soil debris across the road; although these were not shown to have caused the loss of control, a contributory effect could not be discounted. The concern was to review the road conditions and consider whether remedial action was appropriate.

    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 keep the road surface clear of leaf and soil debris

    Wider context from the report

    “During the course of the inquest I heard evidence from ████████ (Collision Investigator), who conducted an examination of the road surface approximately 32.4 metres to the Cottingley side of the collision scene and found that the extreme nearside edge of the road surface was broken and crumbling away, leaving a pothole approximately 4 metres long and 5cm deep encroaching onto the road surface approximately 0.6 metres from the extreme nearside edge. He also found an area of leaf and soil debris upon the road surface 14 metres in length across the whole width of the road encompassing the pothole. Although there was no evidence to suggest that this caused or contributed to the loss of control of the motorcycle, ████████ was unable to discount the possibility that it may have had a contributory effect. ”

    Source location

    Lee James Nauman · Prevention of Future Deaths report
    Page 2 · concerns

    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 maintain the road surface free from potholes

    Wider context from the report

    “During the course of the inquest I heard evidence from ████████ (Collision Investigator), who conducted an examination of the road surface approximately 32.4 metres to the Cottingley side of the collision scene and found that the extreme nearside edge of the road surface was broken and crumbling away, leaving a pothole approximately 4 metres long and 5cm deep encroaching onto the road surface approximately 0.6 metres from the extreme nearside edge. He also found an area of leaf and soil debris upon the road surface 14 metres in length across the whole width of the road encompassing the pothole. Although there was no evidence to suggest that this caused or contributed to the loss of control of the motorcycle, ████████ was unable to discount the possibility that it may have had a contributory effect. ”

    Source location

    Lee James Nauman · 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

    Inspect Lee Lane and identify carriageway defects requiring remedial work.

    Verbatim wording from the response

    “Following an inspection of Lee Lane, some work was ordered on w/c 16 May to address issued identified during a site inspection of the issues highlighted in the Regulation 28 notification. These works consist of pothole filling and patching, primarily along the edge of carriageway at various locations between Cottingley Moor Road and Bank Top.”

    Source location

    Response from Bradford Metropolitan District Council
    Page 1 · response
    Published 6 May 2016

    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

    Order pothole filling and edge-of-carriageway patching at locations between Cottingley Moor Road and Bank Top.

    Verbatim wording from the response

    “Following an inspection of Lee Lane, some work was ordered on w/c 16 May to address issued identified during a site inspection of the issues highlighted in the Regulation 28 notification. These works consist of pothole filling and patching, primarily along the edge of carriageway at various locations between Cottingley Moor Road and Bank Top.”

    Source location

    Response from Bradford Metropolitan District Council
    Page 1 · response
    Published 6 May 2016

    Open published response
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Data last updated 7 September 2026