6 Nov 2024 Sarah McGreevy · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to undertake remedial works to guttering and drainpipes 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
Sarah McGreevy · 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
Sarah McGreevy, aged 37, sustained fatal injuries after falling from her sixth-floor balcony on 16 June 2024. It was found more likely than not that she had climbed onto a wooden box to clear a drainpipe and accidentally fallen. The principal concerns were residents’ practice of climbing onto balconies to clear blocked drainpipes, the associated risk of falls, and the absence of remedial works that could allow the practice to continue.
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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 Failure to undertake remedial works to guttering and drainpipes
Wider context from the report “(1) Several ████████ residents reported a practice of climbing onto their balconies in order to clear blocked drainpipes. This practice carries a clear risk of falls.
(2) The leaseholder of ████████ informed me that he was not aware of any work being undertaken to the guttering or drainpipes to the block following Ms McGreevy’s death.
(3) In the absence of remedial works , the practice of residents unblocking pipes themselves is likely to continue.
” Source location Sarah McGreevy · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Survey balcony surfaces and surface-water drainage across Macbeth House to identify defects and safety risks.
Verbatim wording from the response “A condition survey was undertaken from ground level on Monday, 25 November 2024 by the Borough’s Area Surveying Manager, and the TMO Manager. The survey was to examine the external elements and elevations with particular attention being given to the condition of surface water drainage serving the balconies to the rear of the block.” Source location Response from London Borough of Hackney
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish balcony safety guidance in the January Love Hackney edition, including instructions to avoid steps, stools and ladders and report guttering or pipework repairs.
Verbatim wording from the response “The Borough produces a publication called ‘Love Hackney’ which is printed 10 times a year and 120,000 copies delivered to homes and businesses in each publication cycle. The magazines are also available at pick up service points across the Borough and is available on the Borough’s website. The publication provides information including articles under the title ‘Housing Info’ which is for council tenants and leaseholders. The January edition will provide a general message regarding keeping residents, families and neighbours safe in their homes and to remind occupiers that if you have a balcony not to use steps, stools or ladders on the balcony and if any repairs need to be carried out, including issues with guttering or pipe works to contact the repairs contact centre.” Source location Response from London Borough of Hackney
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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 reports or defects were identified indicating that balcony drainage required remedial works.
Verbatim wording from the response “Following receipt of the Prevention of Future Deaths Report a search was conducted on the housing repairs system to identify any reports of blockages or defects in relation to the balcony surface water drainage stack. A search was conducted in respect of the block as a whole and individual flats. No reports had been received for any Works Orders. Enquiries were further undertaken with the TMO and they have confirmed no reports of any defects or request for repairs were made. At no point are tenants / leaseholders expected to undertake repairs to, or unblocking of gutters / fall pipes.” Source location Response from London Borough of Hackney
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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 Reactive repairs, established reporting routes and guidance mean residents are not expected to unblock gutters or fall pipes themselves.
Verbatim wording from the response “Following receipt of the Prevention of Future Deaths Report a search was conducted on the housing repairs system to identify any reports of blockages or defects in relation to the balcony surface water drainage stack. A search was conducted in respect of the block as a whole and individual flats. No reports had been received for any Works Orders. Enquiries were further undertaken with the TMO and they have confirmed no reports of any defects or request for repairs were made. At no point are tenants / leaseholders expected to undertake repairs to, or unblocking of gutters / fall pipes.” Source location Response from London Borough of Hackney
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24 Jan 2024 Christopher Kapessa · Prevention of Future Deaths report South Wales Central
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Concerns raised 1
Failure to ensure completion of remedial works identified during safety inspections View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
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Christopher Kapessa · 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
Christopher Kapessa, aged 13, was intentionally pushed into the River Cynon at the Red Bridge on 1 July 2019, became submerged and could not be saved after resuscitation attempts. The report identified concerns about inadequate water-safety policies, unclear inspections and guidance, a lack of warning signage and rescue equipment, and remedial works that were not completed.
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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 Failure to ensure completion of remedial works identified during safety inspections
Wider context from the report “(5) Remedial work was identified to remedy aspects of the site which rendered it unsafe, but were not carried out . No system appeared to be in place to ensure that such works were carried out following inspection .
” Source location Christopher Kapessa · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate the Public Safety Risk Assessment process to classify sites, prioritise visits proportionately and track timely recommendations.
Verbatim wording from the response “As outlined in ████████ letter of the 17th January, a new Public Safety Risk Assessment (PSRA) process was introduced during July 2020. The PSRA, its associated guidance and the e-learning package, was developed by the Authority’s Safety, Health & Environment (SHE) team in collaboration with the Environment Agency and with good practice adapted to meet the specific needs of the Authority.” Source location Response from Browne Jacobson
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain a single system for recording, tracking, reporting and reviewing remedial works arising from public-safety inspections.
Verbatim wording from the response “This concern has been addressed through the reviewed Public Safety Risk Assessment process as mentioned above and in Paul Frammingham’s letter of the 17 January 2024 where in addition to a description of the new Public Safety Risk Assessment process, he states,” Source location Response from Browne Jacobson
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Give Project Managers authority to arrange immediate site repairs costing up to £25,000 without awaiting the budget process.
Verbatim wording from the response “There is now a system in place and a process to be followed which ensures that identified works are recorded, notified, remedied and reviewed, with Project Managers (who inspect sites) now having the authority to organise immediate repairs up to the value of £25,000 on their own initiative. The latter reduces the possibility that lower cost repairs, which would include additional fencing for example, can be undertaken more swiftly than if it had to go through the budget process and would remain in the immediate oversight of the inspector.” Source location Response from Browne Jacobson
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Concerns raised 1
Failure to record completion and specification of highway remedial works View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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Joanne Constable · 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
Joanne Constable was a passenger on a motorbike that collided with a tractor-trailer on the A141 Isle of Ely Way on 2 August 2020. Vegetation on the highway verge obstructed the tractor driver's view, and Mrs Constable sustained multiple injuries and was pronounced deceased. The report raised concerns about inadequate systems for recording, tracking and addressing highway hazards and defects, creating a risk of further fatal collisions.
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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 Failure to record completion and specification of highway remedial works
Wider context from the report “• In the course of evidence from the local authority's highway maintenance manager, I heard concerning testimony as to the apparent lack of systems and processes in place to record complaints or reports of hazards or defects with the highway. Consequently, there seemed to be no way of identifying which reports had been actioned or inspected and even when the system indicated that an inspection had taken place and led to a recommendation for work to be carried out within a statutory timeframe, there was no information available on the system to show if or when any work was carried out, much less to what specification .
• On the evidence I heard, the circumstances prevailing at the entrance to Bypass Field onto the A141 Isle of Ely Way are replicated at many points across the county and therefore, should those with a statutory responsibility to maintain the highways, including verges, at public cost be unaware of the status of reported hazards or defects, there is a clear risk of future deaths occurring due to those with the responsibility not taking steps to remedy the problem and more fatal road traffic collisions occurring.
” Source location Joanne Constable · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a new integrated Highways Asset Management and public reporting system linking reports, works, completion records and customer feedback.
Verbatim wording from the response “The County Council is implementing a new Highways Asset Management System which will replace and improve on the current IT system. The new system has been specified to deliver a range of enhancements, alongside a new public reporting system. This report system will function as an integral part of the wider” Source location Response from Cambridgeshire County Council
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Concerns raised 1
Failure to undertake advised remedial works to trees aligning Sailors Creek View source
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AI-generated summary
Paul John Welch · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Paul John Welch was struck by an overhanging tree while walking with his daughter at Sailors Creek on 2 January 2021, suffered a serious head injury and died at the scene. Trees in the area had been omitted from previous surveys, and recommended remedial works had not been carried out, leaving an identified risk to people accessing the foreshore.
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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 Failure to undertake advised remedial works to trees aligning Sailors Creek
Wider context from the report “As set out above, the remedial works that it has been advised be carried out to the trees aligning Sailors Creek have not been undertaken notwithstanding the obvious risks to individuals present there, as evidenced by the tragic death of Mr Welch.
” Source location Paul John Welch · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Obtain the exception notice for felling Ash tree T807.
Verbatim wording from the response “1. Following confirmation of the TPO area, an exception notice is only required for the felling of the Ash tree T807. SCCIC to progress this without further delay. Submitted by Sailors Creek CIC 08/08/22 and granted 09/08/22. The dead elms outside TPO to be safely removed, all before the end of September 2022.” Source location Response from Sailors Creek CIC
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a long-term mooring access solution to move boats away from trees overhanging the creek.
Verbatim wording from the response “5. It was agreed that Sailors Creek CIC should find a method of positioning moored boats further into the creek away from the area overhung by trees. A temporary system using the mussel frames has been implemented as of 08/08/22. A long term mooring access solution is being developed for implementation in 2023.” Source location Response from Sailors Creek CIC
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and publish an online tree management plan incorporating professional surveys and periodic inspections.
Verbatim wording from the response “8. It was agreed that Sailors Creek would develop a tree management plan including professional tree surveys and periodic inspection by Sailors Creek CIC. This tree management plan will be available online at sailorscreekcic.org by the end of September 2022.” Source location Response from Sailors Creek CIC
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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 could not determine the tree works application because the supporting information lacked sufficient detail and justification.
Verbatim wording from the response “The Council received an application from Sailors Creek CIC for works to various trees subject to Tree Preservation Order at Sailors Creek, Trevisome, Flushing on 14th January 2022. The application reference is PA22/00364. Such applications are required to provide sufficient detail for the Local Planning Authority to be clear on the extent of the works and the justification therein. In this instance, the supporting information provided with the application was not sufficiently detailed for the Local Planning Authority to determine the application. This was raised with the applicant on 9th March 2022 and further justification was requested to support the application. The Council's Tree Officer sought out the applicant's arboriculturist at that time but there was a reluctance to do so and on 23rd March 2022 the applicant asked for the application to be put on hold for the time being.” Source location Response from Planning and Housing Cornwall 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 applicant and its appointed arboriculturalist must finalise and submit proportionate, evidence-based tree management proposals, including replanting measures.
Verbatim wording from the response “4. These proposals, including any replanting measures, once finalised to the satisfaction of the applicant (SC CIC) and their appointed arboriculturalist/arborist, should be submitted to Cornwall Council planning service, care of the Case Officer.” Source location Response from Planning and Housing Cornwall 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 TreeWise must submit the final tree-work specification in accordance with the client's requirements and the Forestry Officer's guidance.
Verbatim wording from the response “2. TreeWise to submit final specification in line with the requirements of their client (Sailors Creek CIC) and, where acceptable, in line with the advice and guidance provided by CC Forestry Officer. Treewise to confirm timeframe for this. An updated specification was received from Treewise on Monday 8th August.” Source location Response from Planning and Housing Cornwall Council
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28 Sep 2017 Katherine Tracey Vanloo · Prevention of Future Deaths report Warwickshire
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Concerns raised 3
Delays in raising and transmitting pothole repair works orders View source Failure to ensure repair of the identified pothole View source Lack of tracking of outstanding pothole repair works orders View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
County Council
Issue works orders within five days of safety defects being uploaded to EXOR.
View source
County Council
Review the defects pool daily to identify overdue safety defects and prioritise them for immediate works orders.
View source
County Council
Capture inspected pothole details directly into the EXOR defects pool using handheld devices.
View source
County Council
Use Confirm dashboard alerts to identify overdue works orders and prioritise them for urgent completion.
View source
County Council
Work collaboratively with BBLP to target overdue works orders and monitor whether joint action achieves timely repairs.
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AI-generated summary
Katherine Tracey Vanloo · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Katherine Tracey Vanloo died on 3 January 2016 from catastrophic injuries after falling from her bicycle when it hit an unrepaired pothole and being struck by a car. The report identified delays in repairing the pothole and a lack of systems to track outstanding works and audit whether repairs had been completed and were of adequate quality.
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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 Delays in raising and transmitting pothole repair works orders
Wider context from the report “(1) The pothole was first identified on 23rd March 2015 as a category 2 defect with a target of 28 days within which such defects should be repaired.
(2) The works order to carry out the repair was only raised by Warwickshire County Council 3 months later on 5th June 2015. This was sent to Balfour Beatty Living Places who had entered into a contract with Warwickshire County Council to repair road surfaces in Warwickshire. They in turn subcontracted the road repair work, which included pothole repair work, to CR MacDonald. The works order was received by CR MacDonald on 19th June 2015.
(3) The work to repair the pothole was not undertaken by an employee of CR MacDonald until 2nd November 2015, albeit that the wrong pothole was repaired on that day.
(4) There was a delay of over 7 months between the identification of the pothole and the time it was supposedly repaired on 2nd November 2015.
(5) At the time of the incident Warwickshire County Council did not have a system in place to track with Balfour Beatty Living Places or CR MacDonald the progress of works orders, i.e. when outstanding works had been completed, nor any formal programme of auditing to check if the work has been done and to check the quality of the work.
” Source location Katherine Tracey Vanloo · Prevention of Future Deaths report
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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 Failure to ensure repair of the identified pothole
Wider context from the report “(1) The pothole was first identified on 23rd March 2015 as a category 2 defect with a target of 28 days within which such defects should be repaired.
(2) The works order to carry out the repair was only raised by Warwickshire County Council 3 months later on 5th June 2015. This was sent to Balfour Beatty Living Places who had entered into a contract with Warwickshire County Council to repair road surfaces in Warwickshire. They in turn subcontracted the road repair work, which included pothole repair work, to CR MacDonald. The works order was received by CR MacDonald on 19th June 2015.
(3) The work to repair the pothole was not undertaken by an employee of CR MacDonald until 2nd November 2015, albeit that the wrong pothole was repaired on that day.
(4) There was a delay of over 7 months between the identification of the pothole and the time it was supposedly repaired on 2nd November 2015.
(5) At the time of the incident Warwickshire County Council did not have a system in place to track with Balfour Beatty Living Places or CR MacDonald the progress of works orders, i.e. when outstanding works had been completed, nor any formal programme of auditing to check if the work has been done and to check the quality of the work.
” Source location Katherine Tracey Vanloo · Prevention of Future Deaths report
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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 tracking of outstanding pothole repair works orders
Wider context from the report “(1) The pothole was first identified on 23rd March 2015 as a category 2 defect with a target of 28 days within which such defects should be repaired.
(2) The works order to carry out the repair was only raised by Warwickshire County Council 3 months later on 5th June 2015. This was sent to Balfour Beatty Living Places who had entered into a contract with Warwickshire County Council to repair road surfaces in Warwickshire. They in turn subcontracted the road repair work, which included pothole repair work, to CR MacDonald. The works order was received by CR MacDonald on 19th June 2015.
(3) The work to repair the pothole was not undertaken by an employee of CR MacDonald until 2nd November 2015, albeit that the wrong pothole was repaired on that day.
(4) There was a delay of over 7 months between the identification of the pothole and the time it was supposedly repaired on 2nd November 2015.
(5) At the time of the incident Warwickshire County Council did not have a system in place to track with Balfour Beatty Living Places or CR MacDonald the progress of works orders, i.e. when outstanding works had been completed , nor any formal programme of auditing to check if the work has been done and to check the quality of the work.
” Source location Katherine Tracey Vanloo · Prevention of Future Deaths report
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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 Issue works orders within five days of safety defects being uploaded to EXOR.
Verbatim wording from the response “We have introduced a target to issue a works order within no more than five days from a safety defect being uploaded to EXOR. The letter prefix means that safety defects in the defects pool can be easily collected and organised for review within the database. Our Delivery Teams in Highways are now required to review the defects pool on a daily basis and the review includes the following objectives:” Source location 2017-0493-Response-by-Warwickshire-County-Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the defects pool daily to identify overdue safety defects and prioritise them for immediate works orders.
Verbatim wording from the response “We have introduced a target to issue a works order within no more than five days from a safety defect being uploaded to EXOR. The letter prefix means that safety defects in the defects pool can be easily collected and organised for review within the database. Our Delivery Teams in Highways are now required to review the defects pool on a daily basis and the review includes the following objectives:” Source location 2017-0493-Response-by-Warwickshire-County-Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Capture inspected pothole details directly into the EXOR defects pool using handheld devices.
Verbatim wording from the response “Ensuring Prompt Issue of a Works Order
The Highways Safety Inspectors now use one of six handheld devices to create details of potholes that they find (co-ordinates, photographs, categorisation, etc.) and upload them directly into the County Council’s database in the EXOR computer system. The database is known as the “defects pool”. The defects pool contains records of all kinds of defects and so we have introduced measures to enable safety defects found by Inspectors to be readily distinguished from other defects that do not present an immediate safety concern. This is done by assigning a letter to each of the handheld devices (A, B, C, D, E or F) which prefixes the reference number of any safety defect when it is uploaded to EXOR (e.g. B9678).” Source location 2017-0493-Response-by-Warwickshire-County-Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use Confirm dashboard alerts to identify overdue works orders and prioritise them for urgent completion.
Verbatim wording from the response “Our ████████ team have direct access to Confirm as well as BBLP (at the moment only ████████ in Highways has access but access will be provided to all the relevant team leaders in January 2018). Confirm displays a “dashboard” which automatically displays details of any works orders which have gone “red”, meaning that they have not been carried out within 23 days of the date of the works order. Allowing up to five days for the works order to be issued after inspection, this effectively sounds an alert that the 28 day target is at risk of being missed. These works orders are then prioritised for urgent completion.” Source location 2017-0493-Response-by-Warwickshire-County-Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work collaboratively with BBLP to target overdue works orders and monitor whether joint action achieves timely repairs.
Verbatim wording from the response “At present, the County Council are working co-operatively with BBLP to target overdue works orders and will keep under review whether joint monitoring and action on a collaborative basis is proving sufficient to ensure that repairs are being effected on time or, in a small number of cases very shortly thereafter. However, inspection of the Confirm dashboard on 19 December 2017 showed that only 14 safety defects were at or beyond the 28 day target across the whole county.” Source location 2017-0493-Response-by-Warwickshire-County-Council
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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 Existing pothole repair target times were not changed because they were not criticised at the inquest.
Verbatim wording from the response “Our actions relate, firstly, to the period between a pothole being identified by a Safety Inspector and a works order being issued to BBLP and, secondly, to the period after a works order has been issued. We have not changed the target times for repairing potholes (and no criticism was made of them during the inquest) but have aimed our actions at ensuring that works orders are issued promptly and that any slippage by Balfour Beatty is quickly detected and pursued.” Source location 2017-0493-Response-by-Warwickshire-County-Council
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13 May 2016 Harold James Davies · Prevention of Future Deaths report Nottinghamshire
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Concerns raised 1
Delays in approval and commencement of remedial junction safety work View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Harold James Davies · 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
Harold James Davies, aged 91, died in a road traffic collision on the evening of 8 November 2015 after his Volvo collided with a Jaguar at the junction of Station Road and the A.46 in Nottinghamshire. The principal concern was that this was the third fatality at the junction since 2010, with concerns about the absence of a date for funding or commencing proposed remedial safety work and the potential need for additional warning signs and a lower speed limit.
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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 Delays in approval and commencement of remedial junction safety work
Wider context from the report “2. Highways England and their maintenance contractor A-One+ have undertaken an extensive risk assessment of the junction and there is a proposal to undertake the following remedial safety work:
(a) vehicle activated signs on both carriageways of the A.46 to alert oncoming traffic of the presence of vehicles at the junction waiting to join or cross the carriageways
(b) the installation of slim line bollards at the Station Road junction
(c) appropriate demarcation of the central reservation/turning area.
3. Evidence was given at the inquest that there is no date for the approval of funding or the commencement of the remedial safety work .
” Source location Harold James Davies · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Convene highway partners to discuss the Regulation 28 report and proposed junction safety measures.
Verbatim wording from the response “I called together representatives of Highway England and Nottinghamshire County Council to attend a meeting at Nottinghamshire Police Lakeside Court building on the 2nd June 2016.” Source location Response from Highways England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Clear vegetation around the Station Road junction to improve visibility in all directions.
Verbatim wording from the response “We sent a crew out on the 4th June to clear the vegetation around the Station Road junction to improve the visibility in all directions.” Source location Response from Highways England
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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 Implementation of the accident remedial scheme was assigned to Highways England as the responsible highway authority.
Verbatim wording from the response “A meeting has taken place with all highway representatives pertinent to this case and the report has been fully discussed. All parties agree that the best way forward to prevent further deaths which was the purpose of the Regulation 28 report issued by HM Coroner, would be for the accident remedial scheme designed by AOne + to be implemented by the Highways Agency.” Source location Response from Highways England
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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 Delivery of the junction improvement scheme was constrained by the lack of available funding and the need for investment approval.
Verbatim wording from the response “Each partner had previously received a copy of the report from HD and the report was then discussed at length. RK reported that as stated at the inquest an accident remedial scheme had been designed by AOne + and RK was now trying to obtain the necessary funding from Highways England to get it put into the work programme. The scheme did not meet the criteria for funding from the ‘Minor Safety Improvement Fund’ so RK had escalated the funding request to senior manager level.” Source location Response from Highways England
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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 Further junction improvements cannot be progressed because A-one+ lacks authority to undertake additional work.
Verbatim wording from the response “Unfortunately, A-one+ has taken this matter as far as it can and it is now the responsibility of Highways England to secure funding for the improvements.” Source location Response from A One
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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 Highways England is responsible for securing funding for the recommended junction safety improvements.
Verbatim wording from the response “Unfortunately, A-one+ has taken this matter as far as it can and it is now the responsibility of Highways England to secure funding for the improvements.” Source location Response from A One
Open published response
27 May 2015 Nicholas Gary Stocks · Prevention of Future Deaths report West Yorkshire (West)
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Concerns raised 1
Failure to follow up remedial work assigned to other agencies View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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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.
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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 Failure to follow up remedial work assigned to other agencies
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
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.