7 May 2024 Matthew SCOTT · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 1
Failure to survey and act on reported road defects View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Matthew SCOTT · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Matthew James Scott died on 11 March 2023 after losing control of his vehicle on Station Road, Melbourne, when it hit a lengthy defective and subsided section of road filled with ice. The report identifies concerns that the road defect had not been surveyed or addressed by the date of the inquest, despite concerns raised by police and the highways authority.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to survey and act on reported road defects
Wider context from the report “At 6 weeks post Mr Scott's death - on the 28th of April 2023 - a discussion took place between collision investigator officers, a traffic management officer (all of Derbyshire police) with the Project Engineer of the Highways Authority of Derbyshire County Council. The officers raised their concerns that at the place where Mr Scott lost control of his vehicle (Station Road, Melbourne Derbyshire) there was a lengthy, defective and subsided stretch of road. Further that at the time of Mr Scott's death the subsided section of road was some 4 metres in width, 37 metres in length and 5 cms in depth. Further, that it was deep enough to have had standing water in it which at the time of Mr Scott's death had turned to ice.
Ice in the said defect would likely cause a vehicle to lose grip on the road surface. At that section of road, the road starts to bend to the right such that losing control on the ice could cause a vehicle to veer to the offside of the road, either into the path of an oncoming vehicle, into the opposite field or as in Mr Scott’s case, a tree.
The Project Engineer of the Highways Authority discussed his concerns and the concerns that had been raised by the police, with the highway maintenance department in early May 2023. As at the date of the inquest into Mr Scott' death (22 April 2024) this stretch of road had not been surveyed , no consideration had been given to the concerns of the police and no decisions taken to repair the defect so as to prevent any further accidents.
” Source location Matthew SCOTT · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conducted a laser survey of Station Road to assess whether an actionable safety defect existed.
Verbatim wording from the response “Due to the inconsistency between the site report carried out by ████████ and the concerns raised by the Coroner Derbyshire County Council have undertaken a laser survey dated 26/04/2024. The results of the survey also clearly shows there was not an actionable safety defect that measured 4m wide by 37 meters in length, as that was the ice formation.” Source location Response from Derbyshire County Council
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undertake full-width resurfacing from Melbourne View Hotel approximately 200 metres eastward to level road-surface deviations.
Verbatim wording from the response “Nonetheless Derbyshire County Council take road safety very seriously and the area from Melbourne View Hotel to a point approximately 200 metres in an easterly direction has been put in for full width road surfacing work to be undertaken. This will be completed by 31 October 2024 and will level some of the deviations in the road surface caused by various pot hole repairs.” Source location Response from Derbyshire County Council
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The reported 37-metre-wide road defect was ice formation, not an actionable safety defect; pooled water was limited and typical.
Verbatim wording from the response “The site report states as follows “Large patch of ice on the road surface measuring 4 metres in diameter and 37 meters in length. Commencing in the centre of the carriageway, 4 meters prior to the entrance of the Melbourne Hotel, and terminating in the south-east bound lane. The area predominantly covered the south-east bound lane. It must be noted that this had reduced in size during my attendance due to weather conditions”. This does not say that there was a defect in the road but ice formation. There were some minor differences in level within the carriageway which allowed water to stand, such minor differences in level would be typical of an evolved road network in similar settings such as this and other areas of road across the county.” Source location Response from Derbyshire County Council
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Quarterly inspections by competent inspectors were sufficient to identify and repair significant road defects.
Verbatim wording from the response “As referenced above the road in question, Station Road, Melbourne is subject to quarterly inspections. We have noted the following from records;
13 January 2023 – 2 customer reports of pot hole received on the same day – area put in for ad hoc inspection
17 January 2023 - ad hoc inspection – a number of separate pot holes put in for repair ref. 50186345 works completed 1 March 2023
17 February 2023 routine inspection – defect noted – 28 day repair requested ref. 50189695 - completed 20 February 2023
9 May 2023 – routine inspection – jobs raised outside Melbourne view repair requested ref 50197481– completed 30 May 2023
17 August 2023 – routine inspection – potholes repairs requested ref. 50204692 and 50204693 completed 04 September 2023.
22 November 2023 – routine inspection – potholes repairs requested ref. 50210507 completed on 21 December 2023.” Source location Response from Derbyshire County Council
Open published response
10 Oct 2022 Charles Michael Stringer · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 2
Failure to conduct detailed holistic risk assessments for road defects View source Failure of inspector guidance and training to prevent overly mechanistic road-defect assessments View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Charles Michael Stringer · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Charles Michael Stringer, a cyclist, died after hitting a pothole on Church Lane, causing a punctured front tyre and loss of control that resulted in a fatal chest injury. The report raises concerns about Surrey County Council’s lack of documented reflection, changes to pothole-management systems, communication, risk assessment, defect categorisation and timely repairs following his death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to conduct detailed holistic risk assessments for road defects
Wider context from the report “2. A lack of action and/or change to the management of potholes by SCC following Mr Stringer’s death
SCC has indicated in written submissions that a number of discussions have taken place following Mr Stringer’s death but there has been no documented changes in systems or practice in particular:
1. What steps have been taken to ensure inspectors of defects are fully informed of recent complaints including those from members of the public regarding damage to bicycles by the state of the road.
2. What steps have been taken in the provision of a detailed and robust risk assessment by inspectors with all the available information available such as past complaints, the nature of the road and who uses the road to ensure a ‘holistic’ approach to decision making with regard to the necessity and the speed of road repairs.
3. What, if any, changes have been made to the pictorial guide and the matrix given to inspectors to ensure training there is not an ‘overly mechanistic’ assessment of a road defect.
4. What steps have been taken to ensure there is appropriate and timely communication between the SCC contact centre and the highways department such as a standard operating procedure in place when complaints must be forwarded on and responded to?
5. What steps have been taken to ensure repairs are completed in a timely fashion after serious injuries and deaths have occurred, as a result of a road defect?
” Source location Charles Michael Stringer · Prevention of Future Deaths report
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 of inspector guidance and training to prevent overly mechanistic road-defect assessments
Wider context from the report “2. A lack of action and/or change to the management of potholes by SCC following Mr Stringer’s death
SCC has indicated in written submissions that a number of discussions have taken place following Mr Stringer’s death but there has been no documented changes in systems or practice in particular:
1. What steps have been taken to ensure inspectors of defects are fully informed of recent complaints including those from members of the public regarding damage to bicycles by the state of the road.
2. What steps have been taken in the provision of a detailed and robust risk assessment by inspectors with all the available information available such as past complaints, the nature of the road and who uses the road to ensure a ‘holistic’ approach to decision making with regard to the necessity and the speed of road repairs.
3. What, if any, changes have been made to the pictorial guide and the matrix given to inspectors to ensure training there is not an ‘overly mechanistic’ assessment of a road defect.
4. What steps have been taken to ensure there is appropriate and timely communication between the SCC contact centre and the highways department such as a standard operating procedure in place when complaints must be forwarded on and responded to?
5. What steps have been taken to ensure repairs are completed in a timely fashion after serious injuries and deaths have occurred, as a result of a road defect?
” Source location Charles Michael Stringer · Prevention of Future Deaths report
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 Implement LTP4 measures to collect and use cycle-route data in network management and future maintenance decisions.
Verbatim wording from the response “3. The Local Transport Plan 4 (LTP4) is currently being implemented. This has prompted broad consideration of ways to improve the services we deliver. In particular, the LTP4 places greater emphasis on cyclist-use of roads within the network and steps are being taken to collect data on cycle-routes in order to inform future decisions about how best to incorporate this knowledge into the policy and systems and, if appropriate, to facilitate access to this data for highways-inspectors.” Source location Response from Surrey County Council
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 Build a new data system and assess whether historical complaint data should be made available to highway inspectors.
Verbatim wording from the response “There are risks and benefits to providing historical data and not providing it. These have been carefully considered, and SCC is still giving specific consideration to whether providing historical complaint data to Inspectors would be beneficial.” Source location Response from Surrey County Council
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 Update the pictorial defect guide and matrix to reflect new contract arrangements and reinforce their use within dynamic risk assessments.
Verbatim wording from the response “The pictorial guide is periodically reviewed and following this inquest SCC has reviewed it in detail and a new draft has been produced with a number of pictures updated along with updates to reflect the changes introduced as part of the new contact arrangements. SCC maintains that the pictures provide suitable supplementary assistance for classification of defects in accordance with the policy. The most recent review aligns the guide with the changes made as part of the new contract arrangements in terms of repairing the area” Source location Response from Surrey County Council
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 regular refresher training emphasising situational and wider characteristics in dynamic defect risk assessments.
Verbatim wording from the response “In addition to the pictorial guide and matrix, the training that Inspectors receive continues to emphasise that the situational and wider characteristics of a defect are important – as described in point 2 above. Refresher training happens regularly for SCC Inspectors which covers the risk assessment process and how a dynamic risk assessment is to be conducted without placing over-reliance on the dimensions of a defect in an overly mechanistic way.” Source location Response from Surrey County Council
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 Operate dedicated internal audits and continuous performance monitoring of defect assessment and repair quality.
Verbatim wording from the response “SCC also has a team dedicated to carrying out internal audits of the quality of repairs and of the assessment of defects to ensure that an ‘overly mechanistic’ approach is not adopted. All stages of the safety defect process from identification and categorisation through to the repair are monitored and scrutinised continuously. Issues are reviewed and, where necessary, discussed with relevant officers. Trends and performance are reported through a monthly performance board and as a result processes are continuously evolving across the teams involved.” Source location Response from Surrey County Council
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 pictorial guide and matrix remain suitable supplementary tools within inspectors’ broader dynamic risk assessments, training and audit arrangements.
Verbatim wording from the response “All highway authorities have their own guidance and processes to provide guidance to staff in carrying out their role. The pictures are helpful to give an indication of the types of defect that may fall into each category and as an aide-mémoire. The document clearly states that it is there to “assist” with identification and classification and that it should be used in conjunction with other information. Comparing the visual characteristics of a defect against the pictures in the guide provides a good starting point for Inspectors when assessing the risk posed by a defect.” Source location Response from Surrey County Council
Open published response
14 Oct 2019 Dev Dilesh Naran · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1
Failure to treat the M6 junctions 5 and 6 risk as an acute problem requiring specific work View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Dev Dilesh Naran · 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
Dev Dilesh Naran, aged 8, sustained an unsurvivable head injury as a rear-seat passenger when the Toyota Yaris in which he was travelling stopped in a live motorway lane and was struck from behind by a large goods vehicle. Concerns included the risks posed by stopped vehicles in live lanes, the lack of automatic alerts for lone stationary vehicles, and specific safety risks associated with the dynamic hard shoulder on this section of the M6.
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 treat the M6 junctions 5 and 6 risk as an acute problem requiring specific work
Wider context from the report “6. The effect of this evidence is to cause me concern that the particular nature of the risk on this section of the M6 arising from the matters set out at para 3 above is not regard as an acute problem by the Highways Agency when it should be and that I was not given evidence of specific work being undertaken to address this particular risk .
” Source location Dev Dilesh Naran · Prevention of Future Deaths report
Open source report
28 Dec 2017 Mark Nicholas Welsh · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1
Failure to include overall collision incidence and reported near misses in traffic-control assessments View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mark Nicholas Welsh · 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
Mark Nicholas Welsh died after being knocked over by a lorry while crossing Duke’s Road at its junction with Euston Road in London on 6 July 2017. The report raised concerns about the prolonged delay in improving pedestrian safety at the crossroads, the decision not to install crossings, and the traffic-control statistics used by Transport for London, which did not account for all collisions or reported near misses.
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 include overall collision incidence and reported near misses in traffic-control assessments
Wider context from the report “I heard at inquest that:
• Transport for London (TfL) made a decision in 2007 that it would not undertake any consideration of pedestrian crossings at that crossroads until after the completion of HS1;
• £50,000 was paid to TfL in 2009 by UNISON as part of planning permission to allow building on the opposite corner, £20,000 of which was used on a feasibility study in 2013, but TfL decided that traffic flow would be impeded by four pedestrian crossings, so none was installed and use was not made of the remaining £30,000;
• UNISON has made several complaints to Camden Council/TfL about the dangers of this particular crossroads, but TfL’s best expectation of delivery of any improvement is for the year 2020.
I appreciate that every decision about traffic control at one junction must be taken in the context of the whole network, but 13 years after the issue was first raised seems an inordinately long time to wait for some improvement at such a busy crossroads (about which there had been several complaints prior to this fatality).
Consideration of the junction was described to me as being based on four new crossings or none, which I did not quite understand.
The statistics upon which TfL decisions about traffic control are based, were described to me by TfL’s lead sponsor as only taking account of the proportion of collisions/accidents that result in serious injury or death , not taking into account the overall incidence of collisions/accidents (or even taking into account reported near misses) . This seems an omission .
” Source location Mark Nicholas Welsh · Prevention of Future Deaths report
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 TfL relies on police-reported collision data and existing prioritisation methods because damage-only collisions and near misses cannot be recorded consistently.
Verbatim wording from the response “There is no consistent way of recording damage-only collisions, as the police don’t routinely attend site or require those involved to report the incident. A damage-only collision may be relatively trivial (i.e. scraping a wing mirror), and may not even be taken into account by insurance companies (who would be the other potential source of data). There is also no reasonable way of recording near misses, and it would be impossible to ensure consistency throughout the reporting.” Source location 2017-0456-Response-by-Transport-for-Lonodn
Open published response
Concerns raised 1
Failure of location risk assessment to recognise risk and prioritise major works funding View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Sean Craig Salvin · 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
Sean Craig Salvin died on 30 December 2015 from severe injuries sustained when his car left a heavily flooded road at Woolley Wood Bottom, Sheffield. The report identified concerns about failures by authorities to collect, share and collate information about incidents and flooding, as well as concerns about risk assessment and the identification of the location's increasing 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 location risk assessment to recognise risk and prioritise major works funding
Wider context from the report “e) The risk assessment of this location was also of concern to the inquest, both in respect of prioritisation of funding for major work and in terms of the recognition of the degree of risk . This was a location where traffic might be expected to be travelling comparatively quickly with the low hazard of trees immediately adjoining the carriageway. The emergence of a propensity to flood was a most important addition to the risk calculation .
” Source location Mr Sean Craig Salvin · Prevention of Future Deaths report
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 Introduce the new Highway Flooding Priority Rating System, making it operational by 30 June 2017.
Verbatim wording from the response “The Highway Flooding Priority Rating System (please see appendix C) is entirely new and will be operational by 30th June 2017.” Source location Sean-Salvin-Response
Open published response
23 Mar 2017 Ralph Ian Brazier · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 2
Failure to specifically consider cyclist numbers and risks in highway repair assessments View source Failure to account for highway use by cyclists in highway-defect priority categorisations View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ralph Ian Brazier · 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
Ralph Ian Brazier, a 52-year-old man, died after his bicycle struck a pothole next to a drainage gully cover on the A317 on 1 March 2016, throwing him onto the road. The concern was that Surrey County Council’s defect categorisation and repair priorities did not sufficiently account for cyclists using highways, particularly the nearside section of the road.
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 specifically consider cyclist numbers and risks in highway repair assessments
Wider context from the report “Having heard evidence from a number of members of Surrey County Council, I am concerned that insufficient consideration is taken by the Council of the increasing number of cyclists on their highways, particular in relation to the categorisation of defects on the highway. I am particularly concerned that designated cycle lanes are given higher priority relating to a defect than a highway, despite the high number of cyclists using the highway rather than cycle lanes with closer proximity to traffic including heavy goods vehicles.
- Surrey County Council has failed to take into sufficient account the fact that cyclists use the highways as well as the cycle lanes in their priority categorisations.
- That the great number of cyclists, and the risks to them using the highways, particularly the nearside section, are not specifically considered when Surrey County Council are assessing the highways for repair.
Re-consideration should be given to whether any steps, including changes to the categorisation of highway defects in light of the greater use of public highways by cyclists, can be taken to address the above concerns.
” Source location Ralph Ian Brazier · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to account for highway use by cyclists in highway-defect priority categorisations
Wider context from the report “Having heard evidence from a number of members of Surrey County Council, I am concerned that insufficient consideration is taken by the Council of the increasing number of cyclists on their highways, particular in relation to the categorisation of defects on the highway. I am particularly concerned that designated cycle lanes are given higher priority relating to a defect than a highway, despite the high number of cyclists using the highway rather than cycle lanes with closer proximity to traffic including heavy goods vehicles.
- Surrey County Council has failed to take into sufficient account the fact that cyclists use the highways as well as the cycle lanes in their priority categorisations.
- That the great number of cyclists, and the risks to them using the highways, particularly the nearside section, are not specifically considered when Surrey County Council are assessing the highways for repair.
Re-consideration should be given to whether any steps, including changes to the categorisation of highway defects in light of the greater use of public highways by cyclists, can be taken to address the above concerns.
” Source location Ralph Ian Brazier · Prevention of Future Deaths report
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 Review the highway policy, analyse cyclists’ use of the network, and consider whether inspection, defect assessment, or categorisation should be amended.
Verbatim wording from the response “The latest revision of the Code of Practice was published in October 2016 and in accordance with the revision of this national document SCC has begun a review of its highway policy. As part of this review SCC will also consider the Coroner’s concerns and if and to what extent the inspection regime, including defect assessment and categorisation, should be amended. This will include further analysis of the number of cyclists and differing use of the highway network by cyclists in Surrey. To allow for sufficient consideration of the revised national Code of Practice the authority has two years to make any amendments to their policies following its publication. On this basis the latest timeframe for implementation of any changes to our Highway Policy will be September 2018.” Source location 2017-0090-Response-by-Surrey-County-Council_Redacted
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 Prepare additional highway-inspector training on risk assessment for vulnerable road users, including cyclists.
Verbatim wording from the response “Inspector training requirements are set out in the Code of Practice and SCC is satisfied that it is compliant in this regard. To enhance the existing training regime SCC are preparing additional training for the highway inspectors in relation to the risk assessment for vulnerable users, which includes for cyclists. This additional training will be completed by the end of August 2017. Ongoing training requirements will be further reviewed following the completion of the review of the highway policy.” Source location 2017-0090-Response-by-Surrey-County-Council_Redacted
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 Highway inspectors already consider risks to cyclists when assessing defects, and the relevant assessment complied with the highway policy.
Verbatim wording from the response “In relation to the matter of assessment, highway inspectors, when assessing any defect in the highway, are required not only to apply the defect criteria set out in the policy but also to consider the particular circumstances of the locus including the potential danger created by the defect to all road users, cyclists as well as vehicle drivers. Cyclists are entitled to, and do, use all parts of Surrey’s road network. Highway Inspectors take this into account when assessing potential defects. ████████ the Highway Inspector who identified the defect scrutinised at the inquest, gave evidence that he took into account the potential dangers to cyclists when he categorised the defect. SCC is satisfied that ████████ assessment fully complied with its highway policy.” Source location 2017-0090-Response-by-Surrey-County-Council_Redacted
Open published response
28 Feb 2017 Paul Michael BRIGGS · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 1
Delays in completing risk assessments and appropriate remedial action for wrong-side-road risks View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Paul Michael BRIGGS · 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 3 July 2015, Paul Michael Briggs was riding his motorcycle to work when an oncoming Nissan Micra crossed onto his side of the road and collided with him. He suffered multiple fractures and a traumatic brain injury, remained in a minimally conscious state, and died on 21 January 2017 after artificial nutrition and hydration was withdrawn. The report raised concern that adding rumble strips to the double white lines might reduce the risk of vehicles straying into the oncoming lane, and noted that risk assessments and remedial action were still outstanding some 20 months after the incident.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in completing risk assessments and appropriate remedial action for wrong-side-road risks
Wider context from the report “Though there is appropriate signage, a two way sign as the carriageways merge and though there are double white lines dividing the tunnel bound carriageway from the Liverpool bound carriageway; this incident occurred resulting in a tragic death. It is unclear as to why the Nissan Micra strayed onto the wrong side of the road but had the double white lines also included rumble strips – (as in the tunnel itself and similar to the lines next to motorway hard shoulders)- this would minimise the risk of inadvertently straying into the oncoming lane especially at quiet times when the side barriers and the bend inhibit visibility of oncoming traffic.
It is now some 20 months after this tragic incident which proved fatal and risk assessments as to the risk of this eventuality, with appropriate remedial action should be nearing completion .
” Source location Paul Michael BRIGGS · Prevention of Future Deaths report
Open source report
27 May 2015 Nicholas Gary Stocks · Prevention of Future Deaths report West Yorkshire (West)
View report summary
Concerns raised 1
Failure to undertake risk assessments and determine urgency of remedial work after road traffic collisions View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Nicholas Gary Stocks · 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
Nicholas Gary Stocks was struck and fatally injured by a vehicle after a collision at the junction of Dry Hill Lane and the A635 Barnsley Road in Huddersfield on 27 September 2012. The report raised concerns about damaged and poorly maintained give-way signs and road markings, inadequate reporting and repair systems, highway inspection practices, risk assessment, and coordination between West Yorkshire Police and Kirklees Council.
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 undertake risk assessments and determine urgency of remedial work after road traffic collisions
Wider context from the report “West Yorkshire Police
(1) I am concerned with the system that was in place to ensure that matters of concern identified by Officers of West Yorkshire Police who attend the scene of Road Traffic Collision in November 2011 were not fully reported to Kirklees Council.
I would ask you to review the system presently in place to ensure that all future reports are made and fully reported
(2) On the afternoon of the 27th September 2012 following the earlier road traffic incident, a Police Officer identified the need for a repair to the Give Way sign which had been demolished. The Police Officer in attendance would have been able to also identify that the road markings at the scene were no longer visible and therefore any road user who was travelling along Dry Hill Lane would have had no visible signs or road markings on the approaching Give Way junction. In essence the Officer would have been able to undertake a risk assessment and identify the level of urgency for remedial repair works to be undertaken.
I would invite West Yorkshire Police to liaise with the relevant department of Kirklees Council and undertake a new review and consider whose responsibility it should be to undertake a risk assessment at the scene of a road traffic collision in order to determine the level of urgency of remedial work which is required to be carried out so as to ensure the safety of road users and to develop a system so as to ensure that risk assessment process is implemented and carried out.
(3) I would also ask you to liaise with the relevant departments of Kirklees Council in order to carry out investigations to determine which departments of Kirklees Council was contacted on the afternoon on 27th September 2012 to report the damage to the give way sign. I heard evidence that Kirklees Council Customer Services, the relevant department which should have been contacted, and who are contactable between the hours of 8.00 and 18 hours. Outside of these hours an answer machine message provides an emergency contact number. If the control room unit had contacted the customer service centre then this telephone line should have been manned and a response received rather than sending an email which was acknowledged by an automated response. I wish to ensure that firstly West Yorkshire Police have the relevant contact number which needs to be used in the future and secondly if the Customer Service centre at Kirklees Council was contacted it clearly was not manned at the appropriate time, I wish to ensure this is rectified.
Kirklees Council
(1) I have concerns with the regard to the wide variation of how road inspections are undertaken by your Safety Inspectors. During the course of the enquiries undertaken by West Yorkshire Police a number of interviews were conducted with a number of safety inspectors. I have reviewed those interviews and note that there was a wide variation on how Safety Inspectors undertook inspections of a highway.. One Inspector indicated that they would inspect one side of the road one month, and when inspecting the road the following month would inspect the other side of the carriageway. Another Inspector indicated that they would inspect the whole of the carriageway on each inspection. Another Safety Inspector stated that the driver also had a role to place in inspecting the road in addition to driving the vehicle which transported the Safety Inspector who would be seated in the front passenger seat.
(2) I have concerns with regard to how Safety Inspectors identify issues at the junction of two roads and which inspection has responsibility to consider matters at the actual junction. There appeared to have been vague and unclear responses from the Inspectors who gave evidence, as to whose responsibility it would be to actually inspect the junction of the two roads.
(3) I was concerned that neither of the two Safety Inspectors who gave evidence, considered that the lack of road markings at the junction of Barnsley Road and Dry Hill Lane, and upon Dry Hill Lane itself posed a safety risk to road users and applying appropriate risk assessment should have been repaired I heard evidence from a highly qualified independent expert who was fully familiar with the Kirklees inspection policy and who stated that the lack of road markings at the junction with Barnsley Road and upon Dry Hill Lane itself, were identifiable and reportable defects applying Kirklees Council Policy criteria and should have been reported by the Safety Inspectors and repaired. In addition the independent expert stated that the poor state of the road markings would have been present for a considerable and significant period of time. Certainly, when each of the roads had last been inspected by a Safety Inspector from Kirklees Council.
(4) I also have concern that there is no ongoing training and assessment of Safety Inspectors after initial training has been given so as to ensure consistency and appropriate standard levels of inspections are maintained.
I would invite Kirklees Council to undertake a comprehensive review of the training of all of their Safety Inspectors and consider what further retraining requirements are required now and in the future.
(5) I would refer you to the comments I have made in the West Yorkshire Police section of this report in respect of the operation of Kirklees Council’s Customer Service Centre. I would ask you to liaise directly with West Yorkshire Police and review and ensure the Customer Centre Service facility is fully operational at all relevant times
(6) I would also ask you to liaise with West Yorkshire Police in respect of the comments made in the West Yorkshire Police Section of this report concerning risk assessments when a road traffic collision occurs and West Yorkshire Police in attendance and identify the need for repair works to be undertaken, so as to ensure that an immediate risk assessment is undertaken to safeguard members of the public.
(7). From details provided in the course of this investigation, it appears that remedial work was required to be undertaken by Yorkshire Water at the junction with Barnsley Road and Dry Hill Lane. This work was to identified on 13th March 2010 and the 5th March 2012, but there was no record that such work had been undertaken, and no follow up was implemented by Kirklees Council, so as to ensure that this work was carried out. I would invite you to review your systems so as to ensure that work is undertaken by other agencies and checks made to ensure that all necessary works are completed.
(8) Evidence at the inquest also revealed that members of the public had reported the lack of road markings to Kirklees Council, some months prior to this incident occurring. Although Kirklees Council records show no further action required. I am concerned with regard to this finding in light of the evidence provided to me by the independent expert who confirmed that the lack of road markings was clearly a defect which fell within the Councils existing guidance as an identifiable defect which required rectification. I would invite you to review the present system that Kirklees Council has in place with addressing complaints made by members of the public in respect of the roads and highways which fall within your designated area.
9. I understand that major road works have been undertaken by Kirklees Council at the scene of this incident. However, at the inquest it was clear that the speed limit still remains to be 50 mph. I would invite you to review the speed limit not only on Dry Hill Lane, but also Barnsley Road and Lower Denby Lane.
I would request you to review the street lighting along Lower Denby Lane and Dry Hill Lane at their approach to the junction with Barnsley Road and whether any additional lighting is required.
” Source location Nicholas Gary Stocks · Prevention of Future Deaths report
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 Require officers to risk-assess collision scenes, remain until safety is addressed, and prevent log closure until safety and defect-reporting questions are answered.
Verbatim wording from the response “All officers will be reminded of the need to conduct a thorough risk assessment of the location prior to leaving the scene and will not resume until either; i) it is deemed safe to do so, or, ii) the local authority has attended, or, iii) the local authority have assessed the risk against their protocols or, iv) remedial works have been implemented to remove any risk to the safety of other road users.
This will be endorsed on the log by the communications staff. The log will not be closed unless the following questions are answered” Source location 2015-0200-Response-by-West-Yorkshire-Police
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 Agree shared responsibility with Kirklees Council for collision-scene risk assessment and urgency decisions, transferring responsibility after council staff assess the defect.
Verbatim wording from the response “I have liaised with Kirklees Council and have agreed that responsibility for this risk assessment is shared as follows: For incidents that the Police attend it will be for the attending officer to carry out the risk assessment and decide the urgency of any remedial action required. If the officer decides that the defect is so dangerous as to require immediate action then they should communicate this to the council via their control room and remain with the defect until the council attend. Once the council staff do attend the officer should explain their concerns. It will” Source location 2015-0200-Response-by-West-Yorkshire-Police
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 After council staff attend, Kirklees Council assumes responsibility for assessing and determining action on the road defect.
Verbatim wording from the response “I have liaised with Kirklees Council and have agreed that responsibility for this risk assessment is shared as follows: For incidents that the Police attend it will be for the attending officer to carry out the risk assessment and decide the urgency of any remedial action required. If the officer decides that the defect is so dangerous as to require immediate action then they should communicate this to the council via their control room and remain with the defect until the council attend. Once the council staff do attend the officer should explain their concerns. It will” Source location 2015-0200-Response-by-West-Yorkshire-Police
Open published response
6 Aug 2014 Lee Michael FRIEND · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1
Failure to carry out effective risk assessments for road works View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Lee Michael FRIEND · 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 Michael Friend died on 21 February 2013 after his motorcycle collided with stationary traffic near temporary road works on a blind bend. The report raised concerns about the positioning and visibility of temporary traffic lights, the adequacy of risk assessments and training for road works, the response to public safety concerns, and Surrey Police’s procedures for identifying and reporting risks created by road 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 to carry out effective risk assessments for road works
Wider context from the report “4. Action is required by Sutton and East Surrey Water to take steps to ensure all members of staff are fully and properly trained in the safe setting up of road works and the carrying out of effective risk assessments .
” Source location Lee Michael FRIEND · Prevention of Future Deaths report
Open source report
19 Jun 2014 Names not published · Prevention of Future Deaths report West Somerset
View report summary
Concerns raised 1
Failure of road-safety-equipment deployment criteria to provide special consideration below six personal injury collisions in three years View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Names not published · 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
Seven people died when 34 vehicles collided in thick fog on the M5 motorway near Taunton on 4 November 2011; 51 others were injured. The concerns related to preventing vehicles entering areas of severely reduced visibility, detecting and warning of fog, and managing risks from firework displays that may increase fog or smoke near highways.
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-safety-equipment deployment criteria to provide special consideration below six personal injury collisions in three years
Wider context from the report ““A”
I am concerned that the Highway Agency's proposals whilst possibly preventing further vehicles entering an accident scene or a large area of reduced visibility would not prevent the initial incident and that this can only be achieved by the erection of fog detection devises and greater use of overhead gantries displaying signs warning of events that may cause reduced visibility.
AND as the criterion for deploying road safety equipment is six personal injury collisions in three years the present incident would not qualify for special consideration .
” Source location Names not published · Prevention of Future Deaths report
Open source report
Pin
Get email alerts
Request correction
Includes failures of highway or road-works risk-assessment processes that assess material road-user hazards, determine their urgency and inform prioritisation, funding or completion of remedial works, including location assessments, post-collision assessments and risk assessments before road works.
