Recurring concern

Inadequate road drainage allowing hazardous surface water to remain on carriageways

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First reported 17 Sep 2013•Latest report 30 Dec 2022

Definition

What this concern includes

Includes deficiencies in road drainage, gullies, cambers, slopes, roadway profiles or related permanent engineering controls where they allow rainwater, runoff or other surface water to accumulate, cross or remain on a carriageway, including the anchor's regular water spillage onto the B5302 and comparable failures on other roads.

Not included

  • Excludes generic road-surface defects, slippery surfaces or flooding hazards where no inadequate drainage or related water-removal control is identified.
  • Excludes temporary weather conditions where the recurring unsafe condition is not a deficient road-drainage or roadway-engineering control.
  • Excludes failures limited to warning signage, inspection, reporting or repair processes unless they directly concern the drainage or engineering control that allows hazardous surface water to remain.
  • Excludes non-road drainage or water hazards, including premises, rail, pedestrian and waterway settings.
Reports
10

Distinct published reports

Individual concerns
12

A report can raise multiple concerns

Date range
2013–2022

First to latest report issue date

Stated actions
37

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.

Cornwall Council2
National Highways2
Connect Plus (M25) Limited1
Department for Transport1
Devon County Council1
Devon Highways1
Dorset Council1
Gloucestershire County Council1
North Lincolnshire Council1
North Yorkshire 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. Surrey

    AI-generated summary

    Jordan Kevin Pry · 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

    Jordan Kevin Pry died after his car aquaplaned on surface water while travelling on the M25 on 2 April 2018, left the carriageway and collided with a tree. The principal concern was an ongoing risk of further deaths at the location, where aquaplaning incidents had continued and a flat spot remained while investigations and decisions about risk management were ongoing.

    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

    Persistent road-surface flat spot and associated aquaplaning hazard

    Wider context from the report

    “As stated in my Conclusion (above), Jordan Pry died on the M25 motorway at marker post B4348, when he drove his vehicle through an area of surface water and the car began to aquaplane and rotate, causing it to leave the carriageway and collide with a tree. There is a long and significant history of aquaplaning incidents at the location, including a previous similar fatality following which, in 2010, a Prevention of Future Deaths Report was issued by the then Senior Coroner for Surrey. That report drew attention to the presence of surface water from rain and the effects of a blocked drain, and the presence of a flat spot on the road. Subsequently, changes were made to the drainage system at the location, first in 2011 by means of a small scale improvement scheme and secondly, as part of works completed in 2015, by means of the introduction of a slot drain. However, the flat spot still remains and aquaplaning incidents have continued. I was told in evidence that there are ongoing investigations concerning the risk arising at the location, that a decision as to whether or not the flat spot should be addressed is still to be taken, and that a comprehensive plan for the management of the risk at the location cannot be made until that decision is taken. The concern arising, therefore, is that there is an ongoing risk of further death at this location pending the implementation of an informed and comprehensive plan for risk management. ”

    Source location

    Jordan Kevin Pry · 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

    Commission an independent review of the existing fixed warning sign’s effectiveness and possible visibility improvements.

    Verbatim wording from the response

    “Warning Messages for Drivers”

    Source location

    Response from National Highways
    Page 2 · response
    Published 9 January 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

    Install temporary surface-water warning signs at Marker Posts 36/7 and 36/4.

    Verbatim wording from the response

    “With CP, NH have commissioned CPS to review the effectiveness of the existing fixed warning sign to identify whether any measures are possible, within the legislative provisions that govern signage, to enhance the visibility of the sign.”

    Source location

    Response from National Highways
    Page 2 · response
    Published 9 January 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

    Implement a wet-weather monitoring protocol and activate “Surface Water – Slow” variable-message signs when appropriate.

    Verbatim wording from the response

    “NH has implemented a specific protocol to monitor the Clacket Lane area in times of wet weather and set warning messages of the form “Surface Water – Slow” on the variable message signs in the location when appropriate.”

    Source location

    Response from National Highways
    Page 2 · response
    Published 9 January 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

    Commission an independent review of the drainage system to identify improvements likely to reduce carriageway flooding.

    Verbatim wording from the response

    “Improvement to the Drainage System”

    Source location

    Response from National Highways
    Page 3 · response
    Published 9 January 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

    Commission investigations into carriageway reprofiling options, including outline designs and construction feasibility and cost.

    Verbatim wording from the response

    “Profile of the Carriageway”

    Source location

    Response from National Highways
    Page 3 · response
    Published 9 January 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 weekly visual inspections of slot drains and catchpit surfaces to identify debris accumulation.

    Verbatim wording from the response

    “1.1 Enhanced inspections”

    Source location

    Response from Connect Plus
    Page 2 · response
    Published 9 January 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

    Develop and operate a severe-weather surface-water response procedure covering patrol deployment, incident logging, secondary response and CCTV monitoring.

    Verbatim wording from the response

    “b) CPS and National Highways are discussing the implementation of the following procedure:”

    Source location

    Response from Connect Plus
    Page 2 · response
    Published 9 January 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

    Develop and issue an inspection guide defining acceptable debris levels for hardstrips, central reserves and slot drains.

    Verbatim wording from the response

    “c) CPS are developing an inspection guide/checklist to enable CPS ISU crews to have a clear understanding of the acceptable levels of surface debris on the hardstrip, central reserve and slot drains. This will be issued in March 2023 as an addendum to the ISU inspection check sheet.”

    Source location

    Response from Connect Plus
    Page 3 · response
    Published 9 January 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

    Trial catchpit sensors to monitor water levels and flow and inform intervention frequency.

    Verbatim wording from the response

    “d) CPS are carrying out a trial of catchpit sensors to monitor the level of water and flow at the Location. The data gathered will be used to monitor asset performance and inform any changes to intervention frequency. CPS have installed these sensors at two catchpits in February 2023.”

    Source location

    Response from Connect Plus
    Page 3 · response
    Published 9 January 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

    Maintain the newly installed temporary flooding warning signs and inspect them weekly for presence and function.

    Verbatim wording from the response

    “ii) Temporary ‘Road Liable to Flooding’ signs were installed in advance of the Location at MP436/7 & MP436/4 on the anti-clockwise B carriageway, and these are subject to a weekly driven visual inspection at prevailing traffic speeds to ensure presence and function.”

    Source location

    Response from Connect Plus
    Page 3 · response
    Published 9 January 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

    Undertake scheduled drainage inspections, cleansing of blocked or silted assets, and sweeping of the hardstrip and central reserve.

    Verbatim wording from the response

    “b) Drainage system inspection and cleanse”

    Source location

    Response from Connect Plus
    Page 3 · response
    Published 9 January 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 vegetation cutting and remove excess vegetation from the adjacent landscape plot to reduce leaf burden.

    Verbatim wording from the response

    “c) Vegetation management”

    Source location

    Response from Connect Plus
    Page 4 · response
    Published 9 January 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

    Review drainage maintenance and inspection requirements, assess best practice and determine whether enhanced requirements are justified.

    Verbatim wording from the response

    “a) Recommendation 1 – Review of, and if appropriate improvements to, the drainage maintenance and inspection regime”

    Source location

    Response from Connect Plus
    Page 4 · response
    Published 9 January 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

    Review and develop contingency plans for proactive management of heavy rain, surface water and associated warnings or restrictions.

    Verbatim wording from the response

    “b) Recommendation 2 – Development of surface water contingency plans”

    Source location

    Response from Connect Plus
    Page 4 · response
    Published 9 January 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

    Investigate flooding-hotspot anomalies and identify justified potential improvements to the drainage system.

    Verbatim wording from the response

    “c) Recommendation 3 – Improvement to drainage system”

    Source location

    Response from Connect Plus
    Page 5 · response
    Published 9 January 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

    Assess carriageway profile and develop sufficiently detailed remediation proposals for cost-benefit analysis where issues are identified.

    Verbatim wording from the response

    “d) Recommendation 4 – Cost benefit analysis of carriage reprofiling”

    Source location

    Response from Connect Plus
    Page 5 · response
    Published 9 January 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

    Review whether alternative carriageway surfacing could provide beneficial risk mitigation.

    Verbatim wording from the response

    “2.2 Complementary measures”

    Source location

    Response from Connect Plus
    Page 5 · response
    Published 9 January 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

    Undertake a standards-based review of signage requirements, including whether the fixed warning sign should be illuminated.

    Verbatim wording from the response

    “2) Investigate whether the existing fixed warning sign could be illuminated: National Highways, Connect Plus and CPS have decided to undertake a thorough review of the signage required at the Location against NH standards. CPS will discuss the findings of the CPS design team's review with Connect Plus and National Highways by 28 April 2023.”

    Source location

    Response from Connect Plus
    Page 5 · response
    Published 9 January 2023

    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

    National Highways retains control of safety-critical technology, including decisions on speed-limit signs and variable message warnings.

    Verbatim wording from the response

    “HM Senior Coroner will recall from evidence heard at the inquest that in May 2009 the Secretary of State for Transport signed a 30 year contract with Connect Plus (M25) Limited (Connect Plus) for the M25 Project Road Network. The Secretary of State's interest has since been transferred to National Highways Limited (National Highways). As is the case with privately financed projects, Connect Plus subcontracted a significant proportion of its core operations and maintenance obligations to CPS under a 30-year operations and maintenance agreement. National Highways retained control of most of the technology for the functioning of the M25 Project Road Network related to safety-critical assets, such as the setting of speed limit signs on overhead gantries.”

    Source location

    Response from Connect Plus
    Page 1 · response
    Published 9 January 2023

    Open published response
  2. Mid Kent and Medway

    AI-generated summary

    Josie Archer-Smith · 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

    Josie Archer-Smith died on 31 October 2020 from traumatic injuries sustained when the vehicle in which she was travelling as a front seat passenger lost control and collided with a stationary vehicle on the M20. The location had experienced previous collisions apparently associated with water or aquaplaning, and police identified concerns about water running across the carriageway and the need to investigate possible remedial works.

    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 of road drainage to prevent water running across the carriageway

    Wider context from the report

    “The M20, a dual lane motorway, at the location where the collision took place has had a number of collisions occur which appear to have been caused by water/aquaplaning. Investigating police from the Serious Collisions Investigation unit commented that they are aware that this location is a problem in heavy weather and have attended collisions at this location in the past. The crash location is at the bottom of an incline on the M20 motorway which normally would not cause an issue, however the road also has a camber which causes water to run across the carriageway rather than draining into either the central reservation of the drain on the hard shoulder. The police officer believes that it is when this heavy water is running across the carriageway that there is an issue which does require further investigation as to any remedial works that can be completed to prevent any further fatal/serious injury collisions. ”

    Source location

    Josie Archer-Smith · 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

    Jet and survey the London-bound drainage system to improve drainage efficiency and identify remedial requirements.

    Verbatim wording from the response

    “In the days immediately following the collision, and then over a period of approximately 18 months (as road space booking allowed for the lane closures) National Highways staff and our contractors carried out the following actions:”

    Source location

    Response from National Highways Limited
    Page 2 · response
    Published 19 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

    Complete drainage remedial works, including cleaning channels, drains, gullies and catchpits, repairing drainage pitches, installing a drainage pipe and adding an asphalt kerb.

    Verbatim wording from the response

    “• Remedial works carried out following a full CCTV drainage survey: ◦ Traffic management put in place to carry out the works:”

    Source location

    Response from National Highways Limited
    Page 2 · response
    Published 19 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

    Deliver the M20 Medway and Allington Deck Refurbishment scheme, including carriageway refurbishment and higher-grip, faster-draining Hot Rolled Asphalt surfacing.

    Verbatim wording from the response

    “The M20 Medway and Allington Deck Refurbishment scheme is due to be delivered between June and July 2023 at an estimated cost of £3 million.”

    Source location

    Response from National Highways Limited
    Page 3 · response
    Published 19 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

    Replace the distributor road’s vehicle restraint system and drainage as part of the refurbishment scheme.

    Verbatim wording from the response

    “The M20 Medway and Allington Deck Refurbishment scheme is due to be delivered between June and July 2023 at an estimated cost of £3 million.”

    Source location

    Response from National Highways Limited
    Page 3 · response
    Published 19 December 2022

    Open published response
  3. North Lincolnshire and Grimsby

    AI-generated summary

    Adam David Simms · Prevention of Future Deaths report

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

    Report summary

    Adam David Simms was the sole occupant and driver of a car that lost control after striking standing water on the A18 during heavy rain and collided with an oncoming lorry, causing fatal injuries. Concerns were raised about blocked drainage gullies, extensive standing water on the carriageway, and the absence of an explanation and remedial action to prevent recurrence.

    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 identify and remedy blocked drainage gullies

    Wider context from the report

    “(1) I received evidence regarding the system of inspection utilised to identify and remedy any blocked drainage gullies. Two blocked gullies were found at the site of the accumulation of water upon the carriageway notwithstanding that an inspection undertaken only four days previously on 17 May 2021 had not identified those defects. They had not been included in cleansing works undertaken on 8 April 2022. (2) The evidence suggested that at around the point at which Mr Simms lost control of his motor car there were two separate patches of standing water upon the carriageway. They were said to be 62m in length and 36m in length respectively. They occupied the majority of the width of the Eastbound carriageway. Water was noted to a depth of between 10 and 15mm. There was plainly a significant quantity of standing water which posed a serious hazard to road users. (3) Whilst the evidence I received did not establish on balance of probabilities that those blocked gullies were the cause of the patches of water described above, no alternative explanation for such a significant accumulation of water was provided by the evidence. It had plainly rained heavily, although there was no evidence to suggest an exceptional downpour had occurred. (4) The absence of any explanation for this accumulation, and the consequential absence of any remedial action undertaken to prevent a repetition of these events gives rise to a concern that the highway at that location remains at risk of water ingress (from whatever source) unless and until the cause can be established and appropriate remedial action taken. ”

    Source location

    Adam David Simms · Prevention of Future Deaths report
    Page 2 · 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

    No further action is considered necessary beyond monitoring the highway under the Council’s existing inspection system.

    Verbatim wording from the response

    “In the circumstances, we do not intend to take any further action at this location, other than ensuring monitoring of the highway in accordance with the Council’s system of inspection as set out above.”

    Source location

    Response from North Lincolnshire Council
    Page 3 · response
    Published 20 October 2022

    Open published response
  4. North Yorkshire and York including North Yorkshire Western District

    AI-generated summary

    Sasha Raven Marie Brown · 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

    Sasha Raven Marie Brown was the unaccompanied driver of a car that lost control on a very wet section of the A6068 and collided with an oncoming vehicle on 19 January 2021. The principal concerns were inadequate drainage and road design, the absence of flood-risk signage, and the reported ongoing high risk to motorists from surface water at that location.

    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 of roadway drainage and engineering to safely clear and channel storm and rainwater

    Wider context from the report

    “It is acknowledged that officers of the Highway Authority were not called to give evidence at the Inquest Hearing nor was the Authority designated as an Interested Person for the purposes of disclosure and participation at the Hearing. There had been a written Report Collision ref 01-21 however from the Authority received at the Hearing relating to the roadway being the “A6068 Colne Road between Carr Head Lane and New Hall Farm near Cowling/Crosshills, Craven District” However the evidence revealed: a) The particular stretch of the A6068 was known to local, and other motorists familiar with it, as being frequently incapable of adequately and safely clearing surface storm and rainwater off the carriageway surface, thereby to make the road as reasonably safe as possible for the passage of motor vehicles, especially those travelling down the incline (as was the deceased). b) That water flowed and flows rapidly down the incline. It was (and is) not adequately regulated by drains and did not (and does not) get away. Instead water which came off (and comes off) adjacent land as well as the road itself accumulated (and accumulates) in volume. The want of appropriate cambers and slopes across the carriageway allowed (and allows) and indeed encouraged (and encourages) the water flow across the whole of the carriageway, rather than be conducted along drainage channels to the sides of the carriageway. c) The profile of the roadway meant (and means) that the water was (and is likely to be) thrown back (and forth) across the carriageway. The evidence showed a heavy water flow spread right across the carriageway into the deceased’s path from the deceased’s offside to nearside. That had been from an accumulation of water after there was a flow nearside to offside a short distance back from the incident scene. d) The process of simply cleaning out drains was not (and has not been) adequate to minimise the risk to road users. The evidence pointed to the need to make significant permanent road engineering alterations to the camber, layout, profile and slopes of the road surface and drains. The evidence indicated that the high levels of traversing water were not rare occurrences, creating what was found to be a ‘notoriety’. Climate change will increase the likelihood of adverse incidents such as was evidenced happening in the future, causing increased risk of death. The roadway here will remain a high risk, as it was for the deceased, for fatal accidents. e) There were (and are) no signs/signage indicating the risk of the road ‘flooding’, whether temporary or permanent at this location. Those familiar with it, including the Police expert, knew it for the past and present risk of loss of control. That should not mean the risk can be acceptable. f) The Authority must consider promptly permanent road engineering solutions and implement those appropriate to make this road as safe as reasonably possible. ”

    Source location

    Sasha Raven Marie Brown · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  5. Cornwall and Isles of Scilly

    AI-generated summary

    Ryan Gareth TAYLOR · 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

    Ryan Gareth TAYLOR died after his vehicle lost control and collided with another vehicle while aquaplaning on converging surface water during heavy rain. The principal concerns were that road drainage allowed surface water from Coliza Hill to converge with water on the A390, a similar aquaplaning incident had occurred previously, and feasible drainage improvements had not yet been implemented.

    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 implement feasible road drainage improvements

    Wider context from the report

    “(1) During periods of heavy rainfall surface water from the adjoining road known as Coliza Hill is likely to converge with surface water on the A390 in the vicinity of where Ryan initially lost control of his car. (2) A rear wheel drive car had been involved in an aquaplaning incident at the same location in similar conditions, four years before this collision. (3) Improvements to road drainage are feasible in this particular location but have not yet been implemented. These improvements may diminish the risks of vehicles aquaplaning due to converging surface water. ”

    Source location

    Ryan Gareth TAYLOR · Prevention of Future Deaths report
    Page 3 · 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

    Converging surface water on the A390 during heavy rainfall

    Wider context from the report

    “(1) During periods of heavy rainfall surface water from the adjoining road known as Coliza Hill is likely to converge with surface water on the A390 in the vicinity of where Ryan initially lost control of his car. (2) A rear wheel drive car had been involved in an aquaplaning incident at the same location in similar conditions, four years before this collision. (3) Improvements to road drainage are feasible in this particular location but have not yet been implemented. These improvements may diminish the risks of vehicles aquaplaning due to converging surface water. ”

    Source location

    Ryan Gareth TAYLOR · 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

    Improve drainage by installing combined kerb drainage, additional surface-water gullies, and increased carrier-drain capacity.

    Verbatim wording from the response

    “Significant improvements have now been made to the drainage in the area of Mr Taylor’s accident, at a cost of approximately £370,000. Nearly 500m of combined kerb drainage has been installed, along with additional surface water gullies. The capacity of over 400m of the underlying carrier drains has been increased accordingly to take the additional water flow.”

    Source location

    Response from Cormac and Cornwall Council
    Page 1 · response
    Published 4 January 2023

    Open published response
  6. Cornwall and Isles of Scilly

    AI-generated summary

    Ryan Gareth TAYLOR · 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

    Ryan Gareth TAYLOR died after losing control of his Jaguar XF when surface water converged on the A390 during heavy rain, causing aquaplaning and a collision. The principal concerns were inadequate road drainage, a previous similar aquaplaning incident at the same location, and feasible drainage improvements that had not yet been implemented.

    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 implement feasible road drainage improvements

    Wider context from the report

    “(1) During periods of heavy rainfall surface water from the adjoining road known as Coliza Hill is likely to converge with surface water on the A390 in the vicinity of where Ryan initially lost control of his car. (2) A rear wheel drive car had been involved in an aquaplaning incident at the same location in similar conditions, four years before this collision. (3) Improvements to road drainage are feasible in this particular location but have not yet been implemented. These improvements may diminish the risks of vehicles aquaplaning due to converging surface water. ”

    Source location

    Ryan Gareth TAYLOR · 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

    Replace existing Coliza Hill slip-road gully grids with larger-capacity gratings.

    Verbatim wording from the response

    “• The existing gully grids on the Coliza Hill slip road will be replaced with larger capacity gratings. This is scheduled to take place in October, in combination with maintenance work programmed after the summer road works embargo period.”

    Source location

    2021-0176-Response-from-CORMAC_Published
    Page 1 · response
    Published 27 May 2021

    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 detailed drainage and topographical surveys of the main road alignment.

    Verbatim wording from the response

    “• Detailed drainage and topographical surveys will be undertaken on the main road alignment, again in combination with the scheduled maintenance work in October.”

    Source location

    2021-0176-Response-from-CORMAC_Published
    Page 1 · response
    Published 27 May 2021

    Open published response
  7. Gloucestershire

    AI-generated summary

    Ray Ronald Westlake and Barry Malcolm Clow · 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 9 December 2018, Barry Malcolm Clow lost control of his car on the A424 near Upper Rissington and collided with another vehicle; Ray Ronald Westlake, a passenger in the other vehicle, and Mr Clow died at the scene from their injuries. The concern was that standing and running water regularly overwhelmed roadside drainage on this stretch of road, with no warning signs for the potential for flooding, putting future motorists' lives at risk.

    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 of roadside drainage to prevent standing and running water on the A424

    Wider context from the report

    “The evidence that I heard was that it had been raining on that day and there were large areas of standing water and running water throughout this stretch of the A424. I am told that there are features in the side of the road (grips) which are dug out to encourage the water to run away but these are regularly overwhelmed. The evidence from other motorists and local residents is that this is a significant problem for motorists, especially those who do not know this stretch of road. Whilst it may not be possible to ensure that the water runs away I was surprised as was the Police Collision Investigator that there were no signs warning motorists for the potential for this area to flood. I am concerned that if this situation continues, future lives will be put at risk in the same way. ”

    Source location

    Ray Ronald Westlake and Barry Malcolm Clow · 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

    The site was not considered to have an established flooding or drainage problem, based on only one slight prior incident and no subsequent reports.

    Verbatim wording from the response

    “Prior to receipt of your report, Gloucestershire County Council was not aware that flooding was as an issue at that location which was already furnished with roadside ‘grips’ to aid drainage. We had not been informed of any incidents of flooding at that location by motorists or residents and have not received any reports of flooding since. In the 10 years prior to 9/12/18, Gloucestershire County Council had received only one report of a “slight” road traffic accident on 28 July 2018 that involved some surface water in the general vicinity of where the 9/12/18 incident took place. This incident followed what was described as a “dramatic rain storm” that led to temporary presence of surface water on the highway.”

    Source location

    2019-0170-Response-from-Gloucestershire-Highways_Redacted
    Page 1 · response
    Published 2 August 2019

    Open published response
  8. Dorset

    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 of surface-water drainage on the road stretch

    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

    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 resurfacing improvements are considered sufficient, so no further work is planned at this location for the time being.

    Verbatim wording from the response

    “The highway in question is affected by run off from neighbouring properties and springs. As a result of these issues there will always be some surface water on the carriageway but the improvements we have made will reduce it as much as is reasonably possible.”

    Source location

    2019-0165-Response-by-Dorset-Council
    Page 1 · response
    Published 29 July 2019

    Open published response
  9. Exeter and Greater Devon

    AI-generated summary

    Darren Richard Trewin · 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 31 January 2017, Darren Richard Trewin was fatally injured when the car he was driving left the A30 after encountering water flowing across the carriageway from a partially blocked drain and collided with a roadside barrier. Concerns related to the drain’s ability to capture heavy rainfall and the possible need to extend the nearside barrier to reduce the risk of vehicles leaving the carriageway.

    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 carriageway drainage capacity for heavy rain

    Wider context from the report

    “(1) The drain in the central reservation was partially blocked with detritus washed from the road. The drain therefore could not take all the water from the heavy rain showers resulting in the water cascading across the carriageway contributing to the collision. Highways engineers who attended the Inquest were of the view that the grating on the drain should be changed to capture more water and the drains inspected more frequently and an additional drain, located above the drain that blocked should be created to assist with the capture of excess water from heavy rain. ”

    Source location

    Darren Richard Trewin · 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 keep central reservation drainage clear

    Wider context from the report

    “(1) The drain in the central reservation was partially blocked with detritus washed from the road. The drain therefore could not take all the water from the heavy rain showers resulting in the water cascading across the carriageway contributing to the collision. Highways engineers who attended the Inquest were of the view that the grating on the drain should be changed to capture more water and the drains inspected more frequently and an additional drain, located above the drain that blocked should be created to assist with the capture of excess water from heavy rain. ”

    Source location

    Darren Richard Trewin · 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

    Provide temporary sandbag mitigation to direct excess rainwater into the gully and away from the carriageway.

    Verbatim wording from the response

    “Immediately after the collision we provided temporary mitigation by placing sand bags on the downhill side of the gully grating to ensure that any excess flow of rainwater was directed into the gully and away from the carriageway.”

    Source location

    2018-0138-Response-by-Highway-England
    Page 1 · response
    Published 1 July 2018

    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

    Install an additional gully adjacent to the existing gully to increase rainwater interception and prevent water reaching the carriageway.

    Verbatim wording from the response

    “An additional gully has been installed adjacent to the existing gully at the end of the drainage channel to increase the efficiency of rainwater interception and prevent water from reaching the carriageway. This work was completed on 16 June 2018. This gully will be subject to the same maintenance regime as described above.”

    Source location

    2018-0138-Response-by-Highway-England
    Page 1 · response
    Published 1 July 2018

    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

    Design and construct a further gully approximately 100 metres uphill to increase drainage capacity and reduce water reaching the lower gully.

    Verbatim wording from the response

    “A further gully will be installed approximately 100 metres uphill of the end of the drainage channel referred to in point 3a. above. This will further increase surface water drainage capacity and reduce the amount of water reaching the existing lower gully. This piece of work is currently in the design process and will be constructed by the end of September 2018.”

    Source location

    2018-0138-Response-by-Highway-England
    Page 2 · response
    Published 1 July 2018

    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 a wider drainage study with detailed modelling to identify further work mitigating the risk of a similar collision.

    Verbatim wording from the response

    “A wider drainage study at the location (from the top to the bottom of the hill) has commenced and is due for completion this financial year (2018/19). The study will require detailed modelling to determine if there is any other work that can be undertaken to further mitigate the risk of a similar collision.”

    Source location

    2018-0138-Response-by-Highway-England
    Page 2 · response
    Published 1 July 2018

    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

    Flag the location as a flooding hotspot and conduct weekly inspections with material removal or service-provider intervention when required.

    Verbatim wording from the response

    “The location was flagged and recorded as a flooding ‘hotspot’ immediately after the incident. This ensures that the location is subjected to a weekly inspection by Highways England (HE) inspectors. If the inspector sees any material that may have the potential to compromise the gully operation it is removed at the time if possible. If the matter cannot be dealt with by HE inspectors at the time, our service provider (Ringway Infrastructure Services Limited) is called in to undertake more substantial operations to ensure the gully operates as designed. The time period for response from the service provider is dependent upon a combination of the nature of the problem, weather conditions at the time and the immediate weather forecast.”

    Source location

    2018-0138-Response-by-Highway-England
    Page 1 · response
    Published 1 July 2018

    Open published response
  10. Exeter & Greater Devon

    AI-generated summary

    Luke James LYONS · 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

    Luke James Lyons died at the scene of a road accident on 25 January 2013 after his vehicle hit overnight black ice on the A396. The area was affected by water flowing across the road, which washed away salt, and information indicated that a subsequently installed drain may have been inadequate.

    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 drainage to prevent water crossing the road and washing away road gritting

    Wider context from the report

    “I received evidence that the area in question was subject to water egress from the land at the side of the road which flowed from the higher ground across the road, thereby washing away any salt gritting put down by the Highway Department in anticipation of bad weather. It was clear that procedures were followed, gritting undertaken which it was anticipated would have satisfied the need for gritting in the area in question in the absence of the localised water problem. I received evidence that a number of vehicles going through this area also lost control despite the gritting but had managed to counteract the loss of control. I understand that the Highways Department have since placed a drain at the location in order to combat the problem but it appears that it is inadequate (from information received from ████████ of Devon and Cornwall Constabulary). Clearly a repetition of Luke’s death in the forthcoming winter would be a disaster if it could be avoided by further action. ”

    Source location

    Luke James LYONS · 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

    Undertake further weather-response treatments on the A396 in support of precautionary winter gritting routes.

    Verbatim wording from the response

    “In tandem with the special treatments taken on the A396 last winter and in support of the treatments undertaken throughout our precautionary gritting routes, Devon County Council will undertake further treatments in support of the response to the weather conditions.”

    Source location

    2013-0203-Response-by-Devon-County-Council
    Page 1 · response
    Published 17 September 2013

    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 drainage features and best-practice measures within the 2013/14 winter maintenance approach.

    Verbatim wording from the response

    “Our plans for the 2013/14 winter period therefore include the use of the drainage features and best practice and we will continue to use our inspection process and intelligence gathering to inform our approach. We will also use the media to communicate this information to travellers.”

    Source location

    2013-0203-Response-by-Devon-County-Council
    Page 2 · response
    Published 17 September 2013

    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 inspections, intelligence gathering and risk assessment to inform responses to severe weather and drainage conditions.

    Verbatim wording from the response

    “As you noted within the letter, the flooding on the A396, with water practically spilling onto the road, was a result of the conditions and would be difficult to predict. Our staff seeing this road and were thought to be proportionate to the predicted conditions. Our configuration of the road, together with the conditions at the time, meant that, for the most part, water was not going over the centre of the carriageway. The issues on sight lines, public, and our inspections have not noted recurring drainage issues. This further suggests that any water on the carriageway will be picked up and removed from the carriageway, before the saturated water flows above the carriageway. We accept the types of weather events to repeat in future and our inspections and risk assessment will continue to respond to this.”

    Source location

    2013-0203-Response-by-Devon-County-Council
    Page 1 · response
    Published 17 September 2013

    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 works at the A396 junction and review drainage management at that location.

    Verbatim wording from the response

    “Since the incident involving Mr Lyons, we have undertaken work at the junction of the A396 and have reviewed the way in which drainage is managed at this location. We have also reviewed the winter service arrangements over the winter period, and these support measures will continue throughout the coming winter.”

    Source location

    2013-0203-Response-by-Devon-County-Council
    Page 2 · response
    Published 17 September 2013

    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

    Communicate the commitment to fit-for-purpose winter maintenance work and improve communication and management of drainage features among relevant staff.

    Verbatim wording from the response

    “The commitment to ensuring that the work has been fit for purpose and helps to prepare us for a level of inspection for this location, following our winter maintenance routes and procedures, has been communicated to all relevant staff. This will include improved communication and management of the drainage features.”

    Source location

    2013-0203-Response-by-Devon-County-Council
    Page 2 · response
    Published 17 September 2013

    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

    Flooding at the A396 was difficult to predict, and inspections had not identified recurring drainage issues at the location.

    Verbatim wording from the response

    “As you noted within the letter, the flooding on the A396, with water practically spilling onto the road, was a result of the conditions and would be difficult to predict. Our staff seeing this road and were thought to be proportionate to the predicted conditions. Our configuration of the road, together with the conditions at the time, meant that, for the most part, water was not going over the centre of the carriageway. The issues on sight lines, public, and our inspections have not noted recurring drainage issues. This further suggests that any water on the carriageway will be picked up and removed from the carriageway, before the saturated water flows above the carriageway. We accept the types of weather events to repeat in future and our inspections and risk assessment will continue to respond to this.”

    Source location

    2013-0203-Response-by-Devon-County-Council
    Page 1 · response
    Published 17 September 2013

    Open published response
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Data last updated 7 September 2026