16 Apr 2025 Freddie SLATER · Prevention of Future Deaths report North West Kent
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Concerns raised 1
Lack of physical barriers on the grass verge between the M20 and M25/M20 slip road View source
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
National Highways
Assess the barrier provision against current road restraint requirements using the Road Restraint Risk Assessment Process.
View source
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AI-generated summary
Freddie SLATER · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 16 October 2024, Freddie Slater died at the scene after his Smart car collided with two other vehicles on the M20 and an adjoining slip road in Kent. The report raised concerns that the grass verge separating the roads had no physical barriers, allowing an uncontrolled vehicle to cross into traffic travelling in the opposite carriageway and creating a risk of high-speed collisions and fatalities.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of physical barriers on the grass verge between the M20 and M25/M20 slip road
Wider context from the report “(1) The grass verge which separates the M20 and M25/ M20 slip road does not have erected upon it any physical barriers to prevent traffic crossing the verge from either of the 2 roads referred to and entering a parallel lane the opposite side of the verge.
(2) The evidence received from National Highways confirmed that under the present policy guidance, barriers would not normally be required as there are no features such as an incline on the slip road, bridge supports or trees requiring physical protection between the two merging roads of traffic travelling at similar speeds in the same direction.
(3) The facts of the present case illustrate that in the event of a loss of control of a vehicle travelling on either the M20 or in the slip road there is the potential for that vehicle, without any warning to drivers travelling at or about the same area in the coastbound direction, cross the grass verge to their side and enter their lane of travel. As both the material roads are subject to the same national speed limit of 70MPH, the risk of a high speed collision and fatality arises.
” Source location Freddie SLATER · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assess the barrier provision against current road restraint requirements using the Road Restraint Risk Assessment Process.
Verbatim wording from the response “A review of the current barrier provision at this locality with reference to current requirements” Source location Response from National Highways
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The merge arrangements do not constitute a barrier-requiring hazard because traffic travels in the same direction.
Verbatim wording from the response “As identified in paragraph 5(2) of the Regulation 28 report, current design requirements would not require a barrier to be erected within the grassed medium between the M25 link and the M20 link.” Source location Response from National Highways
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No further action or direct CD 377 amendment is intended because similar incidents are uncommon and changes must address safety and value for money.
Verbatim wording from the response “A review of fatal incidents on the whole of the SRN in England has been undertaken to identify any other incidents where a vehicle has crossed over a strip at the end of the nosing at an on-slip road and impacted a vehicle on the adjacent slip road. This search has been limited to fatal incidents as there is typically insufficient detail available for serious, slight and damage-only incidents in order to make a detailed assessment of the circumstances of the incident.” Source location Response from National Highways
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23 Aug 2024 Amal Mohamed AHMED · Prevention of Future Deaths report Milton Keynes
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Concerns raised 5
Inadequate positioning and visibility of No Entry signage for wrong-way slip-road entry View source Frequent wrong-way driving down the slip road into oncoming traffic View source Slip-road geometry allowing wrong-way vehicles to enter and build up considerable speed View source
Failure to maintain adequate visibility of road-surface No Entry markings at the slip-road junction View source Failure of commonly used satnav applications to provide unambiguous verbal directions at the junction View source See 2 more concerns
Linked responses
Apple (UK) Limited Google UK Limited Milton Keynes City Council National Highways TomTom International B.V.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 11
National Highways
Install temporary large No Entry signs on A-frames at both sides of the A5 off-slip exit.
View source
National Highways
Complete a full safety review of the junction against the current Wrong Way Driving: Mitigation Toolkit.
View source
National Highways
Continue developing enhanced A5 off-slip mitigation options and establish which measures will be progressed, including improved signage and road markings.
View source
National Highways
Undertake further work to assess junction capacity and whether the A5 off-slip bell-mouth width can be reduced with hatched markings.
View source
Milton Keynes City Council
Inspect the junction and assess signage and road markings for safety defects.
View source
Milton Keynes City Council
Review the junction situation later as part of the planned work programme.
View source
TomTom International B.V.
Review navigation instructions near the junction by simulating driver-speed scenarios and assessing instruction timing.
View source
TomTom International B.V.
Implement safeguards that time verbal navigation commands closer to the exit and after drivers pass the off-slip road.
View source
Google UK Limited
Investigate and develop improvements to the timing of Google Maps audio guidance.
View source
Apple (UK) Limited
Add special voice guidance directing westbound drivers to continue straight at the overpass and turn right onto the A5 toward Milton Keynes and Bletchley.
View source
Milton Keynes City Council
Reinspect the site after the incident and investigate whether an immediate safety hazard exists.
View source See 8 more actions
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AI-generated summary
Amal Mohamed AHMED · 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
Amal Mohamed Ahmed died at the scene after entering the A5 southbound off slip road in the wrong direction and colliding head-on with another vehicle. The other vehicle’s driver later died in hospital, and a passenger suffered life-threatening injuries. The principal concern was that inadequate, poorly positioned and poorly visible signage and the unlit, wide junction allowed drivers to enter the slip road incorrectly; other drivers were observed making the same manoeuvre.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inadequate positioning and visibility of No Entry signage for wrong-way slip-road entry
Wider context from the report “The exit point of the A5 "off" slip road at the Little Brickhill junction is wide. The signage indicating No Entry appears to be inadequate as there are two No Entry signs which are widely spaced at the junction. One is positioned to appear to forbid entry to the road over the bridge leading over the A5 and does not obviously relate to the slip road. The second is positioned such that it obliquely faces the road over the bridge and would not be visible to a driver turning right onto the slip road until they had completed the manoeuvre placing them at risk. There is a No Right Turn sign as the junction is approached. There is also No Entry in large white letters at the mouth of the slip road junction, however, this may be (1) obscured by vehicles leaving the slip road and (2) the junction is unlit and was said by a witness as being "pitch black". After the collision attention police officers saw three further vehicles perform exactly the same manoeuvre as Ms Ahmed and attempt to travel down the slip road in the wrong direction. Local residents have contacted police and claimed that it is a very common occurrence for drivers to mistakenly travel down the slip road in the wrong direction. The slip road is long and allows for the build up of considerable speed in turn facilitating what the police describe as a high energy impact. Following the collision, large temporary No Entry signs were positioned at the slip road junction. They were quickly removed apparently because the original signs were deemed to comply with necessary regulations. That seems wholly irrelevant to me because drivers are clearly commonly not seeing the signs because of the large numbers who mistakenly drive the wrong way onto the slip road. In my opinion, consideration should be given to alternative arrangements to prevent vehicles entering and travelling along the slip road in the wrong direction.
” Source location Amal Mohamed AHMED · 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 Frequent wrong-way driving down the slip road into oncoming traffic
Wider context from the report “I have made observations regarding the slip road at this junction in my initial pre-Inquest Report To Prevent Future Deaths dated the 21st December 2023.
National Highways undertook a number of immediate remedial measures to try to prevent drivers turning and travelling the wrong way down this slip road, including narrowing the "mouth" of the slip road to one lane, placement of very large temporary "No Entry" signs and placement of signs indicating "Do Not Use Satnav" at the site. CCTV monitoring of driver behaviour was commenced. Police activity and monitoring by National Highways showed that despite these measures, drivers were still turning early and attempting to drive the wrong way down the slip road . Further enquiries by the police and information volunteered by members of the public who made the same incorrect manoeuvre led to the finding that while the visual map display on commonly used satnav applications at this junction displayed the correct information, the verbal commands gave information likely to confuse and direct drivers down the wrong slip road into the path of oncoming traffic . This was observed to happen frequently.
” Source location Amal Mohamed AHMED · 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 Slip-road geometry allowing wrong-way vehicles to enter and build up considerable speed
Wider context from the report “The exit point of the A5 "off" slip road at the Little Brickhill junction is wide. The signage indicating No Entry appears to be inadequate as there are two No Entry signs which are widely spaced at the junction. One is positioned to appear to forbid entry to the road over the bridge leading over the A5 and does not obviously relate to the slip road. The second is positioned such that it obliquely faces the road over the bridge and would not be visible to a driver turning right onto the slip road until they had completed the manoeuvre placing them at risk. There is a No Right Turn sign as the junction is approached. There is also No Entry in large white letters at the mouth of the slip road junction, however, this may be (1) obscured by vehicles leaving the slip road and (2) the junction is unlit and was said by a witness as being "pitch black". After the collision attention police officers saw three further vehicles perform exactly the same manoeuvre as Ms Ahmed and attempt to travel down the slip road in the wrong direction. Local residents have contacted police and claimed that it is a very common occurrence for drivers to mistakenly travel down the slip road in the wrong direction. The slip road is long and allows for the build up of considerable speed in turn facilitating what the police describe as a high energy impact. Following the collision, large temporary No Entry signs were positioned at the slip road junction. They were quickly removed apparently because the original signs were deemed to comply with necessary regulations. That seems wholly irrelevant to me because drivers are clearly commonly not seeing the signs because of the large numbers who mistakenly drive the wrong way onto the slip road. In my opinion, consideration should be given to alternative arrangements to prevent vehicles entering and travelling along the slip road in the wrong direction.
” Source location Amal Mohamed AHMED · 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 maintain adequate visibility of road-surface No Entry markings at the slip-road junction
Wider context from the report “The exit point of the A5 "off" slip road at the Little Brickhill junction is wide. The signage indicating No Entry appears to be inadequate as there are two No Entry signs which are widely spaced at the junction. One is positioned to appear to forbid entry to the road over the bridge leading over the A5 and does not obviously relate to the slip road. The second is positioned such that it obliquely faces the road over the bridge and would not be visible to a driver turning right onto the slip road until they had completed the manoeuvre placing them at risk. There is a No Right Turn sign as the junction is approached. There is also No Entry in large white letters at the mouth of the slip road junction, however, this may be (1) obscured by vehicles leaving the slip road and (2) the junction is unlit and was said by a witness as being "pitch black". After the collision attention police officers saw three further vehicles perform exactly the same manoeuvre as Ms Ahmed and attempt to travel down the slip road in the wrong direction. Local residents have contacted police and claimed that it is a very common occurrence for drivers to mistakenly travel down the slip road in the wrong direction. The slip road is long and allows for the build up of considerable speed in turn facilitating what the police describe as a high energy impact. Following the collision, large temporary No Entry signs were positioned at the slip road junction. They were quickly removed apparently because the original signs were deemed to comply with necessary regulations. That seems wholly irrelevant to me because drivers are clearly commonly not seeing the signs because of the large numbers who mistakenly drive the wrong way onto the slip road. In my opinion, consideration should be given to alternative arrangements to prevent vehicles entering and travelling along the slip road in the wrong direction.
” Source location Amal Mohamed AHMED · 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 commonly used satnav applications to provide unambiguous verbal directions at the junction
Wider context from the report “I have made observations regarding the slip road at this junction in my initial pre-Inquest Report To Prevent Future Deaths dated the 21st December 2023.
National Highways undertook a number of immediate remedial measures to try to prevent drivers turning and travelling the wrong way down this slip road, including narrowing the "mouth" of the slip road to one lane, placement of very large temporary "No Entry" signs and placement of signs indicating "Do Not Use Satnav" at the site. CCTV monitoring of driver behaviour was commenced. Police activity and monitoring by National Highways showed that despite these measures, drivers were still turning early and attempting to drive the wrong way down the slip road. Further enquiries by the police and information volunteered by members of the public who made the same incorrect manoeuvre led to the finding that while the visual map display on commonly used satnav applications at this junction displayed the correct information, the verbal commands gave information likely to confuse and direct drivers down the wrong slip road into the path of oncoming traffic . This was observed to happen frequently.
” Source location Amal Mohamed AHMED · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Install temporary large No Entry signs on A-frames at both sides of the A5 off-slip exit.
Verbatim wording from the response “Further temporary signing has been put in place at the exit point of the A5 off slip at the Little Brickhill junction in the form of two large 1200mm ‘No Entry’ signs on A-frames on each side of the carriageway (Traffic Signs Regulations and General Directions (TSRGD), Diagram 616 No entry for vehicular traffic). These signs are intended to provide mitigation against further wrong way driving incidents while a full safety review of the junction has been undertaken.” Source location Response from Highways
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete a full safety review of the junction against the current Wrong Way Driving: Mitigation Toolkit.
Verbatim wording from the response “The site visit has informed a full safety review of the junction, including an assessment of the junction against the latest version of National Highways’ Wrong Way Driving: Mitigation Toolkit (v1.2 January 2021). The junction had previously been assessed against the previous version of the toolkit (first issued in 2017).” Source location Response from Highways
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue developing enhanced A5 off-slip mitigation options and establish which measures will be progressed, including improved signage and road markings.
Verbatim wording from the response “• The site assessment has established that, when measured against the Wrong Way Driving Toolkit, the junction has all the required ‘standard’ mitigation measures in place. However, potential improvements to road markings and signage on both National Highways and Milton Keynes City Council’s network have been identified.” Source location Response from Highways
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undertake further work to assess junction capacity and whether the A5 off-slip bell-mouth width can be reduced with hatched markings.
Verbatim wording from the response “○ Width of the junction bell mouth at the end of the A5 off slip – the A5 off slip and junction bell mouth is two lanes wide. The bell mouth is effectively widened by the concrete overrun area along the eastern edge of the bell mouth. Reducing the width of the junction with hatched road markings may increase the conspicuity of the ‘No Entry’ measures. Further work will be undertaken to understand the capacity of the junction and whether the junction width can be reduced.” Source location Response from Highways
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Inspect the junction and assess signage and road markings for safety defects.
Verbatim wording from the response “We received a ‘Report-It’ made on 28 May 2023. The records show that in this case a highways inspector visited the location on 2 June 2023 and made the following note ‘Inspection on 02/06/23 enough signage and road marking on road saying no entry. No safety defects found all below investigatory levels’. This reflects his remit to consider the condition of those assets in respect of safety. A standardised response was sent to the customer.” Source location Response from Milton Keynes City Council
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the junction situation later as part of the planned work programme.
Verbatim wording from the response “We have another ‘Report-It’ made on 21 November 2023 which was made following the incident. The same inspector visited the site again and again found no immediate safety hazard based on condition (of the asset) and highlighted to the resident on 13 January 2024 that we have investigated and intend to review the situation at a later date as part of our planned work programme. A standardised response was sent to the customer.” Source location Response from Milton Keynes City Council
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review navigation instructions near the junction by simulating driver-speed scenarios and assessing instruction timing.
Verbatim wording from the response “Following the report, we reviewed our navigation systems’ verbal instructions provided near the junction at hand. We have simulated different scenarios, including speed variations of 60mph and 30mph, to better understand how our navigation systems presented instructions based on driver speed. The scenarios assumed that the driver would either (i) maintain maximum speed until the junction; or (ii) slow down when approaching it. The outcome of the review revealed that instructions were given either (i) right when passing by the off-slip road; or (ii) after passing by the off-slip road, when on the overpass towards the exit.” Source location Response from TomTom
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement safeguards that time verbal navigation commands closer to the exit and after drivers pass the off-slip road.
Verbatim wording from the response “As part of our ongoing efforts to enhance road safety, we recently implemented additional safeguards, to limit drivers’ confusion where possible, regardless of their speed behavior on the road, by timing the verbal commands closer to the actual exit, and in any event after passing the off-slip road. However, please note that in order for these changes to be effective and visible by end users, they need to use the latest map and therefore in certain circumstances need to update their systems/devices.” Source location Response from TomTom
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Investigate and develop improvements to the timing of Google Maps audio guidance.
Verbatim wording from the response “• We have liaised with National Highways and reviewed their helpful dashcam footage of the relevant junction. This has assisted our product and engineering teams in carefully investigating the audio guidance provided by Google Maps. Our teams are working on improvements to the timing of the audio guidance.” Source location Response from Google
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add special voice guidance directing westbound drivers to continue straight at the overpass and turn right onto the A5 toward Milton Keynes and Bletchley.
Verbatim wording from the response “However, to ensure we were following the very best approach we are taking an additional measure to add the following special voice guidance for drivers heading past the A5 offramp toward the A5 onramp, which we intend will be live by the start of next week.
- Drivers heading past the A5 offramp toward the A5 onramp would be instructed to “Continue straight at the overpass” (that will happen as they are traveling westward from the offramp).
- While on the overpass, drivers would be instructed to “Turn right onto A5 toward Milton Keynes, Bletchley.”” Source location Response from Apple
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reinspect the site after the incident and investigate whether an immediate safety hazard exists.
Verbatim wording from the response “City highways officials visited the site on 20 November after the fatal incident with Thames Valley Police (TVP). TVP then conveyed a video call with MKCC and National Highways on 21 November and National Highways took subsequent actions on their junction. We would” Source location Response from Milton Keynes City Council
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The junction already has all standard wrong-way-driving mitigation measures required by the current toolkit.
Verbatim wording from the response “• The site assessment has established that, when measured against the Wrong Way Driving Toolkit, the junction has all the required ‘standard’ mitigation measures in place. However, potential improvements to road markings and signage on both National Highways and Milton Keynes City Council’s network have been identified.” Source location Response from Highways
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing signage and road markings appeared adequate under applicable regulations, although illumination might improve the no-entry signage.
Verbatim wording from the response “agree with National Highways that the signage appeared adequate to regulations, although we would suggest that the National Highways no-entry signage at the slip road junction may benefit from illumination (although the Traffic Signs Regulations and General Directions guidance does not require this).” Source location Response from Milton Keynes City Council
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The council has no powers to improve the junction mouth, signage or road markings because these are outside its highway authority functions.
Verbatim wording from the response “The slip road, its junction with the local road, and the signage and road markings at the end of the slip road are part of the National Highways asset and they are therefore the responsible highway authority.” Source location Response from Milton Keynes City Council
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation National Highways is responsible for the slip road junction, its signage and road markings, so it must undertake related improvements.
Verbatim wording from the response “The slip road, its junction with the local road, and the signage and road markings at the end of the slip road are part of the National Highways asset and they are therefore the responsible highway authority.” Source location Response from Milton Keynes City Council
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maps had no data or routing error that contributed to the deaths.
Verbatim wording from the response “We immediately investigated the concerns raised and found no data or routing error on Maps which would have contributed to these tragic events.” Source location Response from Apple
Open published response
22 Aug 2024 Tracey Julie HAYBITTLE · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 1
Frequent wrong-way driving on the slip road View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
Apple (UK) Limited Google UK Limited National Highways TomTom International B.V.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 14
TomTom International B.V.
Implement safeguards that time verbal commands closer to the exit and after the off-slip road.
View source
National Highways
Install additional temporary No-Entry signs at the A5 off-slip exit to mitigate wrong-way driving.
View source
National Highways
Restore and maintain the temporary and fixed No-Entry signing, including correcting sign orientation, removing graffiti and repairing sign-related defects.
View source
National Highways
Close the offside slip-road lane and reposition the temporary No-Entry signs closer together to reduce apparent two-way-road movements.
View source
National Highways
Operate daily inspections of the temporary signing and cones to monitor their condition and alignment.
View source
National Highways
Deploy temporary ‘Do not follow Sat Nav’ and customer-information signs at the junction.
View source
National Highways
Investigate Sat Nav routing and liaise with Google Maps, Apple Maps and WAZE regarding potentially confusing audible instructions.
View source
National Highways
Undertake seven-day, 24-hour CCTV monitoring to measure the effectiveness of the temporary layout.
View source
National Highways
Commission and complete consultant feasibility assessments of permanent junction options, including safety risk, effectiveness, cost, engineering difficulty and lighting appraisal.
View source
National Highways
Review feasibility outcomes with consultants and develop the preferred permanent option through a workshop, outline design, cost estimate and Stage 1 road-safety-audit documents.
View source
National Highways
Carry out detailed design and programme implementation of permanent junction works for the 2025/26 financial year.
View source
Google UK Limited
Liaised with National Highways and reviewed dashcam footage of the junction to inform investigation of Google Maps audio guidance.
View source
Google UK Limited
Investigate and develop improvements to the timing of Google Maps audio guidance.
View source
Apple (UK) Limited
Add special voice guidance instructing drivers to continue straight at the overpass and turn right onto the A5 toward Milton Keynes, Bletchley.
View source See 11 more actions
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AI-generated summary
Tracey Julie HAYBITTLE · 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
Tracey Julie Haybittle died at the John Radcliffe Hospital after a head-on collision when another driver entered the wrong slip road at the Little Brickhill junction. The report raised concerns that verbal commands from commonly used satnav applications could confuse and direct drivers down the wrong slip road into oncoming traffic, and that this occurred frequently despite remedial measures.
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 Frequent wrong-way driving on the slip road
Wider context from the report “I have made observations regarding the slip road at this junction in my initial pre-Inquest Report To Prevent Future Deaths dated the 21st December 2023 in respect of the linked case of Amal Mohamed Ahmood.
National Highways undertook a number of immediate remedial measures to try to prevent drivers turning and travelling the wrong way down this slip road, including narrowing the "mouth" of the slip road to one lane, placement of very large temporary "No Entry" signs and placement of signs indicating "Do Not Use Satnav" at the site. CCTV monitoring of driver behaviour was commenced. Police activity and monitoring by National Highways showed that despite these measures, drivers were still turning early and attempting to drive the wrong way down the slip road . Further enquiries by the police and information volunteered by members of the public who made the same incorrect manoeuvre led to the finding that while the visual map display on commonly used satnav applications at this junction displayed the correct information, the verbal commands gave information likely to confuse and direct drivers down the wrong slip road into the path of oncoming traffic. This was observed to happen frequently .
” Source location Tracey Julie HAYBITTLE · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement safeguards that time verbal commands closer to the exit and after the off-slip road.
Verbatim wording from the response “As part of our ongoing efforts to enhance road safety, we recently implemented additional safeguards, to limit drivers’ confusion where possible, regardless of their speed behavior on the road, by timing the verbal commands closer to the actual exit, and in any event after passing the off-slip road. However, please note that in order for these changes to be effective and visible by end users, they need to use the latest map and therefore in certain circumstances need to update their systems/devices.” Source location Response from TomTom
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Install additional temporary No-Entry signs at the A5 off-slip exit to mitigate wrong-way driving.
Verbatim wording from the response “Additional temporary signing has been put in place at the exit point of the A5 off slip at the Little Brickhill junction in the form of two large 1200mm ‘No Entry’ signs on A-frames on each side of the carriageway (Traffic Signs Regulations and General Directions (TSRGD), Diagram 616 No entry for vehicular traffic). These signs are intended to provide mitigation against further wrong way driving incidents while a full safety review of the junction has been undertaken.” Source location Response from National Highways
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Restore and maintain the temporary and fixed No-Entry signing, including correcting sign orientation, removing graffiti and repairing sign-related defects.
Verbatim wording from the response “Following a site inspection on 24 April 2024, it was observed that the offside fixed (permanent) No-Entry sign had been rotated to face westwards (facing the Little Brickhill approach). This alteration had not been instructed or carried out by National Highways.” Source location Response from National Highways
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Close the offside slip-road lane and reposition the temporary No-Entry signs closer together to reduce apparent two-way-road movements.
Verbatim wording from the response “These further changes involved closing the offside lane of the slip road to remove the potential ‘appearance’ of a two-way road. This also enabled the two large diameter No-Entry signs to be positioned closer together, see images below:” Source location Response from National Highways
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate daily inspections of the temporary signing and cones to monitor their condition and alignment.
Verbatim wording from the response “These works were undertaken on the night of the 24 April 2024. A daily inspection regime was put in place to monitor the signs and cones, and this is ongoing.” Source location Response from National Highways
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deploy temporary ‘Do not follow Sat Nav’ and customer-information signs at the junction.
Verbatim wording from the response “Again, on the 29 April 2024, the location was visited by National Highways and Thames Valley Police (Traffic Management Officer). During the site visit, a vehicle was observed to attempt to turn right into the slip road against the No-Entry signing. The driver was flagged down and aborted the turn. On speaking to the driver, they said that the Sat Nav app said to turn right. This raised concerns that Sat Nav instructions may have been leading to driver confusion.” Source location Response from National Highways
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Investigate Sat Nav routing and liaise with Google Maps, Apple Maps and WAZE regarding potentially confusing audible instructions.
Verbatim wording from the response “Investigations have been undertaken to understand the potential influence Sat Nav instructions are having on driver behaviour. Route drives were undertaken using various Sat Nav apps (Google Maps, Apple Maps and WAZE) to review route guidance given to drivers.” Source location Response from National Highways
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undertake seven-day, 24-hour CCTV monitoring to measure the effectiveness of the temporary layout.
Verbatim wording from the response “As part of continued monitoring of the junction, we are planning to undertake CCTV monitoring, initially for 24hours a day for a period of 7 days, to measure the effectiveness of the temporary layout.” Source location Response from National Highways
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission and complete consultant feasibility assessments of permanent junction options, including safety risk, effectiveness, cost, engineering difficulty and lighting appraisal.
Verbatim wording from the response “Following receipt of the Regulation 28 Report to Prevent future Deaths, we commissioned our external design consultant (WSP) to carry out feasibility work to determine and recommend appropriate permanent changes at the junction, including the following key activities:” Source location Response from National Highways
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review feasibility outcomes with consultants and develop the preferred permanent option through a workshop, outline design, cost estimate and Stage 1 road-safety-audit documents.
Verbatim wording from the response “Details of the external design consultants’ initial assessment and options were submitted to National Highways on 14 June 2024, and we are currently reviewing the outcomes and planning the next steps, which include:” Source location Response from National Highways
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Carry out detailed design and programme implementation of permanent junction works for the 2025/26 financial year.
Verbatim wording from the response “Following completion of above actions, detailed design will be carried out and implementation programmed for the 2025/26 financial year.” Source location Response from National Highways
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Liaised with National Highways and reviewed dashcam footage of the junction to inform investigation of Google Maps audio guidance.
Verbatim wording from the response “• We have liaised with National Highways and reviewed their helpful dashcam footage of the relevant junction. This has assisted our product and engineering teams in carefully investigating the audio guidance provided by Google Maps. Our teams are working on improvements to the timing of the audio guidance.” Source location Response from Google
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Investigate and develop improvements to the timing of Google Maps audio guidance.
Verbatim wording from the response “• We have liaised with National Highways and reviewed their helpful dashcam footage of the relevant junction. This has assisted our product and engineering teams in carefully investigating the audio guidance provided by Google Maps. Our teams are working on improvements to the timing of the audio guidance.” Source location Response from Google
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add special voice guidance instructing drivers to continue straight at the overpass and turn right onto the A5 toward Milton Keynes, Bletchley.
Verbatim wording from the response “However, to ensure we were following the very best approach we are taking an additional measure to add the following special voice guidance for drivers heading past the A5 offramp toward the A5 onramp, which we intend will be live by the start of next week.
- Drivers heading past the A5 offramp toward the A5 onramp would be instructed to “Continue straight at the overpass” (that will happen as they are travelling west toward the offramp).
- While on the overpass, drivers would be instructed to “Turn right onto A5 toward Milton Keynes, Bletchley.”” Source location Response from Apple
Open published response
22 Sep 2014 Jerome Antoine Marie GONNET · Prevention of Future Deaths report Teesside
View report summary
Concerns raised 2
Continuing hazard of drivers entering the exit slip road View source Lack of advance road-sign information identifying the slip road as no entry View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Jerome Antoine Marie GONNET · 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 2 May 2012, Jerome Antoine Marie GONNET was a passenger in a car involved in a head-on collision after a female driver travelled the wrong way along the A66 eastbound carriageway. Concerns included unclear advance signage for the no-entry slip road and temporary no-entry signs that could be knocked over and become unnoticeable; two further drivers reportedly later used the exit slip road in the same way.
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 Continuing hazard of drivers entering the exit slip road
Wider context from the report “(3) It has been brought to the Coroners attention that since Mr Gonnet’s passing a further two drivers have driven down the exit slip road , in the same manner as the female driver who caused Mr Gonnet’s passing.
” Source location Jerome Antoine Marie GONNET · 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 Lack of advance road-sign information identifying the slip road as no entry
Wider context from the report “(1) It is unclear in advance of approaching the junction that the slip road upon which the female drove is ‘no entry’ slip road. There is no information in this regard on the road signs surrounding the junction.
” Source location Jerome Antoine Marie GONNET · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain supplementary illuminated “No entry” signs through regular inspection and prompt damage rectification.
Verbatim wording from the response “In response to the road traffic collision of 2 May 2012, and at Cleveland Police’s request, supplementary ‘No entry’ signs, which are in addition to those mandated under statutory requirements, have been installed. However, one of these signs has been placed in a block paved area of carriageway and this sign is at times knocked over by passing vehicles, as indicated by the Report.” Source location 2014-0415-Response-by-A-one.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Investigate options for safety improvements at the interchange following reported wrong-way driving incidents.
Verbatim wording from the response “3. Two other incidents have been reported involving drivers travelling in the wrong direction on this exit slip road.” Source location 2014-0415-Response-by-A-one.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Submit a proposal for interchange safety improvement works during the next improvement-scheme funding round.
Verbatim wording from the response “Both A-one+ and the Highways Agency have been made aware of one of these incidents by Cleveland Police. I can advise that an investigation has been undertaken to identify options for improvement at this interchange. The improvements which are being considered include installing demountable bollards or marker posts in the block paved area and installing additional road markings.” Source location 2014-0415-Response-by-A-one.pdf
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Permanent signs cannot be installed in the block-paved area because escorted abnormal loads must pass through it.
Verbatim wording from the response “The block paved area at this location was installed to address problems associated with the lower than normal bridge deck level at Elton Interchange when the interchange was originally constructed. When abnormally tall and wide or long loads are being moved along the A66 eastbound carriageway, these vehicles are required to divert from the main carriageway of the A66 over the extents of this interchange. Some of these vehicles, under escort, need to pass through the block paved area and travel in an anticlockwise direction around the roundabout’s circulatory carriageway, in order to rejoin the A66.” Source location 2014-0415-Response-by-A-one.pdf
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Proposed interchange improvements depend on securing funding through the Highways Agency's prioritised improvement-scheme bidding process.
Verbatim wording from the response “Both A-one+ and the Highways Agency have been made aware of one of these incidents by Cleveland Police. I can advise that an investigation has been undertaken to identify options for improvement at this interchange. The improvements which are being considered include installing demountable bollards or marker posts in the block paved area and installing additional road markings.” Source location 2014-0415-Response-by-A-one.pdf
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for advance signs on local roads and roundabouts rests with Stockton-on-Tees Borough Council, not the Highways Agency or A-one+.
Verbatim wording from the response “Local highway authorities are responsible for the management of maintenance of local roads, which are outside of the Highways Agency’s remit.” Source location 2014-0415-Response-by-A-one.pdf
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.