Recurring concern

Failure of the highway hazard reporting and response process

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First reported 14 Jan 2014•Latest report 6 Apr 2026

Definition

What this concern includes

Includes failures in the dedicated highway hazard and defect reporting-and-response process, from receipt of reports through logging, assessment, escalation, inspection, tracking and completion of remedial action, where the reports concern hazards or defects affecting highway safety.

Not included

  • Excludes generic failures in record-keeping, staffing, training or communication that are not explicitly tied to highway hazard or defect reporting and response.
  • Excludes highway design, layout, maintenance or inspection deficiencies that are not connected to the reporting-and-response process.
  • Excludes reporting processes for non-highway incidents, such as clinical, welfare or railway concerns.
  • Excludes the underlying physical hazard itself when no deficiency in reporting or response is identified.
Reports
10

Distinct published reports

Individual concerns
13

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
31

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department for Transport2
Dorset Council2
Anglian Water1
Bournemouth, Christchurch and Poole Council1
Cambridgeshire County Council1
Core Highways Group Limited1
Derbyshire County Council1
Dorset Police1
Kirklees Borough Council1
Monmouthshire County Council1
National Highways1
Norfolk County Council1
North Yorkshire Council1
Suffolk County Council1
Surrey County Council1

Concerns and responses across reports

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

  1. Suffolk

    AI-generated summary

    Allan STEVENSON · 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

    Allan Stevenson, a 73-year-old cyclist, died from injuries sustained in a road traffic collision involving an HGV at a roundabout with a temporary traffic management system. The inquest concluded that his death was contributed to by the temporary road layout. Concerns included the flipping of a complex traffic management plan without an enhanced safety review, inadequate or missing signage, limited escalation and inspection processes, delayed responses to reported defects, and the absence of spare signage for immediate changes.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to answer the temporary traffic management defect line promptly

    Wider context from the report

    “6. I am concerned that the ‘defect line’ operated by Anglian Water was not answered or responded to on the day of this incident, adding unnecessary delay to the changes required to the scheme signage. It is acknowledged that the signage defect identified on the 24th October 2022 would not have affected the tragic outcome of this case, however that may not be the case in future incidents ”

    Source location

    Allan STEVENSON · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Continue responding proportionately and promptly to defects reported to the business.

    Verbatim wording from the response

    “However, ████████ does and will continue to respond to any defects reported to it in a proportionate and timely manner.”

    Source location

    Response from Clyde & Co
    Page 7 · response
    Published 13 April 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement the SKEWB Permit Manager System to import defect data automatically and route failures or defects to appropriate teams.

    Verbatim wording from the response

    “17. Since early 2023, Anglian has tested and implemented the SKEWB Permit Manager System, which interfaces directly with the Street Manager platform and automatically imports incoming defect data into its database. Within the SKEWB system, Automated Working Groups are mapped to specific business cohorts, enabling the system to relay any identified failures or defects to the appropriate teams. While this represents a significant improvement over previous processes, the effectiveness of the system remains contingent upon the timely upload of defect information by the inspector to the Street Manager system. Consequently, the overall success of the system continues to depend on the SCC inspector’s ability to upload defects promptly to the Street Manager platform.”

    Source location

    Response from Anglian Water
    Page 3 · response
    Published 13 April 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Continue accepting urgent telephone defect notifications and manually enter them into SKEWB when digital permit updates are unavailable.

    Verbatim wording from the response

    “18. In order to ensure a rapid response to urgent issues and to prevent delays that could compromise safety, Anglian continues to accept direct telephone notifications from the Highway Authority. If a telephone notification is received before the corresponding digital permit update is available in Street”

    Source location

    Response from Anglian Water
    Page 3 · response
    Published 13 April 2026

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The respondent has no involvement in operating or using Anglian Water’s Defect Line.

    Verbatim wording from the response

    “████████ has no involvement in the operation or use of Anglian Water’s ‘Defect Line’ and is therefore unable to comment on its functionality or use at the material time.”

    Source location

    Response from Clyde & Co
    Page 7 · response
    Published 13 April 2026

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The defect line did not fail or cause delay; established procedures operated as intended for the identified risk level.

    Verbatim wording from the response

    “12. Following additional internal investigation, we were able to confirm in the witness evidence that no phone call was made or expected, as the issues were not classified as high risk. Our Compliance Team received and acted upon the notifications as required, in accordance with Anglian’s established assignment and reporting procedures and SCC’s assessment of the risk profile.”

    Source location

    Response from Anglian Water
    Page 3 · response
    Published 13 April 2026

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Statutory undertakers and their appointed contractors are responsible for designing, implementing and safely operating temporary traffic management.

    Verbatim wording from the response

    “Under Section 48 of NRSWA, “street works” include not only the placement and maintenance of apparatus but also works required for or incidental to those activities, which includes the provision and management of temporary traffic management necessary to undertake the works safely.”

    Source location

    Response from Suffolk County Council
    Page 2 · response
    Published 13 April 2026

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Anglian Water is responsible for its internal defect-reporting arrangements, which Suffolk County Council cannot comment on.

    Verbatim wording from the response

    “6. Concern 6: ‘I am concerned that the ‘defect line’ operated by Anglian Water was not answered or responded to on the day of this incident, adding unnecessary delay to the changes required to the scheme signage. It is acknowledged that the signage defect identified on the 24 October 2022 would not have affected the tragic outcome of this case, however that may not be the case in future incidents’.”

    Source location

    Response from Suffolk County Council
    Page 6 · response
    Published 13 April 2026

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Works promoters and highway authorities are responsible for designing, approving, monitoring and implementing temporary traffic management arrangements.

    Verbatim wording from the response

    “The Department’s role is to set the overarching legal and policy framework for road safety and to provide guidance. Responsibility for the design, approval and monitoring of temporary traffic management arrangements sits with those undertaking the works and the relevant highway authority. These parties are responsible for ensuring that arrangements are appropriate for the specific circumstances on site.”

    Source location

    Response from Department for Transport
    Page 1 · response
    Published 13 April 2026

    Open published response
  2. Norfolk

    AI-generated summary

    Barry John HOWARD · 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

    Barry John Howard entered flood water at an unbridged ford on 13 December 2023, after warning signs were not visible, and his car was swept into the river. He was found deceased in the almost completely submerged car on 14 December 2023. Concerns included inadequate and poorly positioned warning signs, delayed or insufficient road-closure measures, and other risks associated with the ford and road surface.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to take appropriate action in response to reported incidents involving unawareness of the unbridged Ford risk

    Wider context from the report

    “i. While the evidence I heard was that the Council consider that the current signage is adequate & has been inspected, there was a history of incidents reported to them, and sadly the very tragic death of Barry. That suggests that, while they consider it adequate, it was not sufficiently so to prevent those incidents & Barry’s death. I have heard nothing to reassure me that appropriate action has been taken to prevent others continuing to fail to be aware of the risk of the unbridged Ford, especially after heavy periods of rain. ”

    Source location

    Barry John HOWARD · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Inspect all 47 county fords for safe conditions after the incident.

    Verbatim wording from the response

    “As the local highway authority for Norfolk, the Council is responsible for 47 fords across 6,200 miles of highway network. Within days of the incident on 13 December 2023, all these fords had been inspected by the local Highways teams to ensure vehicle users would encounter safe conditions. This initial review identified other locations where roads were closed due to higher than usual water levels, and replacements for any missing and damaged warning signs were also arranged. As a result of these actions, two further fords on the Norfolk network (at West Acre and Caste Acre) were closed and remain closed to ensure public safety.”

    Source location

    Response from Norfolk County Council
    Page 1 · response
    Published 31 July 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Arrange replacement warning signs at locations with missing or damaged signs.

    Verbatim wording from the response

    “As the local highway authority for Norfolk, the Council is responsible for 47 fords across 6,200 miles of highway network. Within days of the incident on 13 December 2023, all these fords had been inspected by the local Highways teams to ensure vehicle users would encounter safe conditions. This initial review identified other locations where roads were closed due to higher than usual water levels, and replacements for any missing and damaged warning signs were also arranged. As a result of these actions, two further fords on the Norfolk network (at West Acre and Caste Acre) were closed and remain closed to ensure public safety.”

    Source location

    Response from Norfolk County Council
    Page 1 · response
    Published 31 July 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Conduct detailed, site-specific safety reviews of all 47 county fords.

    Verbatim wording from the response

    “Alongside this initial inspection work, more detailed safety reviews of all 47 fords in the Norfolk network were commissioned. The characteristics of each ford across the Norfolk highway network are different and therefore each ford requires a detailed, individual assessment. As part of this review, Engineers are considering the points you have raised in the Regulation 28 Report and are investigating other opportunities to further improve safety at each ford location.”

    Source location

    Response from Norfolk County Council
    Page 2 · response
    Published 31 July 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Evaluate permanent closure and other longer-term treatment options for Shotesham Ford through a feasibility assessment.

    Verbatim wording from the response

    “A specific safety review has also been undertaken by the Council at Shotesham Ford. This has involved an initial scoping of options for addressing the specific issues identified at Shotesham, which has developed into a full feasibility assessment of alternative treatments at this location.”

    Source location

    Response from Norfolk County Council
    Page 2 · response
    Published 31 July 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Install improved warning signage at multiple ford locations following site-specific safety reviews.

    Verbatim wording from the response

    “vi) As outlined earlier in this response, there have been lessons learned from this tragic incident. Safety inspections of all fords in Norfolk were undertaken immediately after the event. Subsequently, more detailed site by site safety reviews have also been undertaken, with measures such as improved signage installed at a number of locations, and even some further road closures where water levels were observed to be high.”

    Source location

    Response from Norfolk County Council
    Page 3 · response
    Published 31 July 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Make the ford safe with temporary signs and order replacement permanent signs after theft of warning signs.

    Verbatim wording from the response

    “Regrettably, I report that since these more robust measures were installed in July 2024, the warning signs have been stolen on one side of the ford (identified on 1 August 2024) and the local Highway team have made safe with temporary signs and ordered replacement more permanent signs.”

    Source location

    Response from Norfolk County Council
    Page 3 · response
    Published 31 July 2024

    Open published response
  3. Derby and Derbyshire

    AI-generated summary

    Matthew SCOTT · Prevention of Future Deaths report

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

    Report summary

    Matthew James Scott died on 11 March 2023 after losing control of his vehicle on Station Road, Melbourne, when it hit a lengthy defective and subsided section of road filled with ice. The report identifies concerns that the road defect had not been surveyed or addressed by the date of the inquest, despite concerns raised by police and the highways authority.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to survey and act on reported road defects

    Wider context from the report

    “At 6 weeks post Mr Scott's death - on the 28th of April 2023 - a discussion took place between collision investigator officers, a traffic management officer (all of Derbyshire police) with the Project Engineer of the Highways Authority of Derbyshire County Council. The officers raised their concerns that at the place where Mr Scott lost control of his vehicle (Station Road, Melbourne Derbyshire) there was a lengthy, defective and subsided stretch of road. Further that at the time of Mr Scott's death the subsided section of road was some 4 metres in width, 37 metres in length and 5 cms in depth. Further, that it was deep enough to have had standing water in it which at the time of Mr Scott's death had turned to ice. Ice in the said defect would likely cause a vehicle to lose grip on the road surface. At that section of road, the road starts to bend to the right such that losing control on the ice could cause a vehicle to veer to the offside of the road, either into the path of an oncoming vehicle, into the opposite field or as in Mr Scott’s case, a tree. The Project Engineer of the Highways Authority discussed his concerns and the concerns that had been raised by the police, with the highway maintenance department in early May 2023. As at the date of the inquest into Mr Scott' death (22 April 2024) this stretch of road had not been surveyed, no consideration had been given to the concerns of the police and no decisions taken to repair the defect so as to prevent any further accidents. ”

    Source location

    Matthew SCOTT · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Conducted a laser survey of Station Road to assess whether an actionable safety defect existed.

    Verbatim wording from the response

    “Due to the inconsistency between the site report carried out by ████████ and the concerns raised by the Coroner Derbyshire County Council have undertaken a laser survey dated 26/04/2024. The results of the survey also clearly shows there was not an actionable safety defect that measured 4m wide by 37 meters in length, as that was the ice formation.”

    Source location

    Response from Derbyshire County Council
    Page 1 · response
    Published 4 July 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Undertake full-width resurfacing from Melbourne View Hotel approximately 200 metres eastward to level road-surface deviations.

    Verbatim wording from the response

    “Nonetheless Derbyshire County Council take road safety very seriously and the area from Melbourne View Hotel to a point approximately 200 metres in an easterly direction has been put in for full width road surfacing work to be undertaken. This will be completed by 31 October 2024 and will level some of the deviations in the road surface caused by various pot hole repairs.”

    Source location

    Response from Derbyshire County Council
    Page 2 · response
    Published 4 July 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The reported 37-metre-wide road defect was ice formation, not an actionable safety defect; pooled water was limited and typical.

    Verbatim wording from the response

    “The site report states as follows “Large patch of ice on the road surface measuring 4 metres in diameter and 37 meters in length. Commencing in the centre of the carriageway, 4 meters prior to the entrance of the Melbourne Hotel, and terminating in the south-east bound lane. The area predominantly covered the south-east bound lane. It must be noted that this had reduced in size during my attendance due to weather conditions”. This does not say that there was a defect in the road but ice formation. There were some minor differences in level within the carriageway which allowed water to stand, such minor differences in level would be typical of an evolved road network in similar settings such as this and other areas of road across the county.”

    Source location

    Response from Derbyshire County Council
    Page 1 · response
    Published 4 July 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Quarterly inspections by competent inspectors were sufficient to identify and repair significant road defects.

    Verbatim wording from the response

    “As referenced above the road in question, Station Road, Melbourne is subject to quarterly inspections. We have noted the following from records; 13 January 2023 – 2 customer reports of pot hole received on the same day – area put in for ad hoc inspection 17 January 2023 - ad hoc inspection – a number of separate pot holes put in for repair ref. 50186345 works completed 1 March 2023 17 February 2023 routine inspection – defect noted – 28 day repair requested ref. 50189695 - completed 20 February 2023 9 May 2023 – routine inspection – jobs raised outside Melbourne view repair requested ref 50197481– completed 30 May 2023 17 August 2023 – routine inspection – potholes repairs requested ref. 50204692 and 50204693 completed 04 September 2023. 22 November 2023 – routine inspection – potholes repairs requested ref. 50210507 completed on 21 December 2023.”

    Source location

    Response from Derbyshire County Council
    Page 2 · response
    Published 4 July 2024

    Open published response
  4. Dorset

    AI-generated summary

    Natalie Christina Mountford · 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

    Natalie Christina Mountford was struck by a vehicle while assisting at an earlier collision on an icy road and died at the scene from her injuries. The report raised concerns about repeated collisions at the location, the failure to investigate flowing water during highway inspections, and the absence of a robust process for logging and acting on reports of water leaks onto the highway.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to robustly log and action direct reports of water leaks onto highways

    Wider context from the report

    “iii. There would appear to be no process in place at Wessex Water to log and action reports made directly to staff of water leaks onto a highway, or if a process is existent it would appear not to be robust. The risk is that such reports may be “lost”, with the necessary work not undertaken, leaving water flowing from a leak on the highway, with the subsequent risk outlined above. ”

    Source location

    Natalie Christina Mountford · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Log highway water reports on the customer services system to acknowledge receipt, track investigations, and communicate findings and actions.

    Verbatim wording from the response

    “We have reviewed our processes and have made the following changes:”

    Source location

    Response from Wessex Water YTL Group
    Page 1 · response
    Published 21 February 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Engage Local Authority Highways teams to identify actual or potential risks to highway users.

    Verbatim wording from the response

    “• We are engaging with Local Authority Highways teams to identify actual or potential risks to users of the highway. Reports identified as high risk will be treated as a priority and all reports will be inspected as soon as possible.”

    Source location

    Response from Wessex Water YTL Group
    Page 1 · response
    Published 21 February 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Prioritise high-risk reports and inspect all reports as soon as possible.

    Verbatim wording from the response

    “• We are engaging with Local Authority Highways teams to identify actual or potential risks to users of the highway. Reports identified as high risk will be treated as a priority and all reports will be inspected as soon as possible.”

    Source location

    Response from Wessex Water YTL Group
    Page 1 · response
    Published 21 February 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Hold briefing events for Highways teams on the revised reporting system as the process rolls out.

    Verbatim wording from the response

    “• We shall hold briefing events for all Highways teams in our area on the changes to our reporting system as the process rolls out.”

    Source location

    Response from Wessex Water YTL Group
    Page 1 · response
    Published 21 February 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Keep the reporting process’s operation and effectiveness under review and amend it if further improvements are identified.

    Verbatim wording from the response

    “The operation and effectiveness of this process will be kept under review and may be amended if further improvements are identified.”

    Source location

    Response from Wessex Water YTL Group
    Page 1 · response
    Published 21 February 2024

    Open published response
  5. Cambridgeshire and Peterborough

    AI-generated summary

    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.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to record and track highway hazard and defect reports

    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
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to remedy reported highway hazards and defects

    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
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to 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
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Operate a risk-based highway inspection regime and record identified defects in the highways asset management system.

    Verbatim wording from the response

    “• A clear process is in place for the inspection of the highway network. The inspection regime used by the Council is risk based and operates in accordance with UK Roads Liaison Group (UKRLG) Code of Practice ‘Well-managed highway infrastructure. The County Council’s Highway Operational Standards¹ document sets out our operational policies and identifies the types of defects to be inspected also details the required intervention and repair timescales for these defects. These standards are reviewed on a regular basis.”

    Source location

    Response from Cambridgeshire County Council
    Page 2 · response
    Published 28 December 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement a 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
    Page 2 · response
    Published 28 December 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Proactively identify vegetation risks and arrange cyclic and reactive cutting, including cutting vegetation on major roads requiring maintenance.

    Verbatim wording from the response

    “• The Green Infrastructure Team is resourced so that it can proactively manage areas of known risk and identify similar locations, raising works orders to attend to overgrowing vegetation on a cyclic and reactive basis. This will include proactively cutting back vegetation on major stretches of road that require maintenance.”

    Source location

    Response from Cambridgeshire County Council
    Page 3 · response
    Published 28 December 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The Council disputes that it lacks systems and processes to record highway hazard and defect reports.

    Verbatim wording from the response

    “The County Council has considered with care the issues that you have raised. The Council does have systems and processes in place to record reports of hazards or defects, which I will refer to later in this letter. However, the Council also continuously develops its systems and approaches to improve the management of the highway and to ensure that we meet our statutory duty to maintain them safely.”

    Source location

    Response from Cambridgeshire County Council
    Page 1 · response
    Published 28 December 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Existing highway management systems are considered appropriate to manage risk and minimise future deaths as far as practicable.

    Verbatim wording from the response

    “Summary The County Council’s Highways Service has appropriate systems in place to manage risk on the highway and is taking action to further improve these to ensure the risk of future deaths from similar circumstances and situations is minimised as far as practicable.”

    Source location

    Response from Cambridgeshire County Council
    Page 3 · response
    Published 28 December 2023

    Open published response
  6. Gwent

    AI-generated summary

    Andrew Mark STILL · 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

    Andrew Mark Still died at the scene after his motorcycle collided with a VW campervan on the A466 near Tintern on 3 June 2022. The concerns included an overgrown chevron sign, missing chevron markers and a lack of evidence that remedial action had been taken after the relevant authority was alerted.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to take remedial action on a reported road-signage problem

    Wider context from the report

    “There was a warning sign which alerted motorists to the forthcoming series of bends and the extended white road marking indicated a pending hazard. There was also a chevron marker closer to the bend. At the inquest I found that Andrew had overtaken vehicles prior to the bends and would have seen the warning sign and the road markings. However, I found that the chevron sign near to the bend was overgrown. Moreover there was evidence that there had previously been 3 markers but two had been removed and not replaced. I was informed that the relevant authority had been made aware of this problem by Gwent Police after Andrew’s death but there was no evidence at the inquest that any remedial action had been taken ”

    Source location

    Andrew Mark STILL · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Replace the chevron signs to improve visibility for motorists.

    Verbatim wording from the response

    ““Confirm that plans are in place for the chevron markers to be replaced and foliage removed from the remaining chevron marker to ensure it is visible to motorists.””

    Source location

    Response from Monmouthshire County Council
    Page 1 · response
    Published 27 February 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Remove foliage obstructing the remaining chevron marker.

    Verbatim wording from the response

    ““Confirm that plans are in place for the chevron markers to be replaced and foliage removed from the remaining chevron marker to ensure it is visible to motorists.””

    Source location

    Response from Monmouthshire County Council
    Page 1 · response
    Published 27 February 2023

    Open published response
  7. Dorset

    AI-generated summary

    Stephen Robert Wood · 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 30 May 2021, Stephen Robert Wood was riding his motorcycle when it entered a 60-metre stretch of grass covering the carriageway, causing him to fall into the path of an oncoming car. He sustained numerous significant and unsurvivable injuries and died. The principal concern was a lack of knowledge about when road obstructions should be reported, meaning hazards may not be removed or warnings provided to other road users.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of knowledge and/or understanding of when to report road obstructions

    Wider context from the report

    “2. I have concerns with regard to the following: i. That there is a lack of knowledge and/or understanding as to when people should report an obstruction in the road. I would request that consideration is given to making all road users aware of the dangers of obstructions in the road and to encourage them to report any hazards to the local Police force or Local Authority so that it can be removed as soon as possible, or at least other road users be warned of the hazard to prevent a future death. ”

    Source location

    Stephen Robert Wood · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Update The Highway Code with guidance on responding to road obstructions and using eCall to contact emergency services.

    Verbatim wording from the response

    “Finally, the Department regularly updates and promotes The Highway Code. Under Rule 280 of The Highway Code, if anything falls from a vehicle on to a motorway or other high-speed road, road users are advised to stop in a place of relative safety and call the emergency services on 999. On other roads, road users are advised to only remove obstructions if it is safe to do so. The Highway Code was last updated in September 2021, and under The Highway Code rules 277, 279, and 283 now advises the use of ‘eCall’ to contact the police and to provide a specific location directly to a 999 operator.”

    Source location

    Response from Department for Transport
    Page 2 · response
    Published 24 February 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Regularly promote The Highway Code’s safety guidance to road users.

    Verbatim wording from the response

    “Finally, the Department regularly updates and promotes The Highway Code. Under Rule 280 of The Highway Code, if anything falls from a vehicle on to a motorway or other high-speed road, road users are advised to stop in a place of relative safety and call the emergency services on 999. On other roads, road users are advised to only remove obstructions if it is safe to do so. The Highway Code was last updated in September 2021, and under The Highway Code rules 277, 279, and 283 now advises the use of ‘eCall’ to contact the police and to provide a specific location directly to a 999 operator.”

    Source location

    Response from Department for Transport
    Page 2 · response
    Published 24 February 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review partner websites and contact details, then establish clear, cross-referenced public reporting links and urgent and non-urgent obstruction-reporting guidance.

    Verbatim wording from the response

    “• Commitment 1 Websites for Dorset Police, the respective Local Authority for Dorset and BCP, along with National Highways, will all review and ensure there is a clear link to enable reporting of obstructions and debris on the road by the public.”

    Source location

    Response from Dorset Council
    Page 1 · response
    Published 24 February 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Introduce a Dorset Road Safe website link identifying whom to contact about road obstructions and debris, with information highlighting associated dangers.

    Verbatim wording from the response

    “• Commitment 2 Dorset Road Safe’s Partnership website will introduce a clear link around who to contact in respect of an obstruction/debris on the road. There will also be a section devoted to highlighting the associated dangers to road users.”

    Source location

    Response from Dorset Council
    Page 2 · response
    Published 24 February 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review partner websites and ensure clear, cross-referenced reporting links, emergency instructions, and guidance for reporting non-urgent road obstructions or debris.

    Verbatim wording from the response

    “• Commitment 1 Websites for Dorset Police, the respective Local Authority for Dorset and BCP, along with National Highways, will all review and ensure there is a clear link to enable reporting of obstructions and debris on the road by the public.”

    Source location

    Response from Dorset Police
    Page 2 · response
    Published 24 February 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Introduce a Dorset Road Safe website link identifying who to contact about road obstructions or debris and highlighting associated dangers.

    Verbatim wording from the response

    “• Commitment 2 Dorset Road Safe’s Partnership website will introduce a clear link around who to contact in respect of an obstruction/debris on the road. There will also be a section devoted to highlighting the associated dangers to road users.”

    Source location

    Response from Dorset Police
    Page 2 · response
    Published 24 February 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Construct and deliver a multi-platform communications campaign alerting road users to road obstructions or debris, with messaging continuing at an agreed frequency.

    Verbatim wording from the response

    “• Commitment 3 Corporate communications colleagues from Police, Councils, and National Highways, we will be constructing a communications campaign, ready for this Spring/Summer’s increased road activity, to alert all road users around obstructions/debris on Dorset’s roads.”

    Source location

    Response from Dorset Police
    Page 2 · response
    Published 24 February 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Responsibility for local roads, including Coombe Road, lies outside National Highways’ remit.

    Verbatim wording from the response

    “I note that the collision occurred on Coombe Road, Winterbourne Steepleton, Dorchester, Dorset. For clarity, National Highways is the Government-owned company, sponsored by the Department for Transport (DfT), charged with operating, maintaining and improving England's motorways and major A-roads. Responsibility for local roads, including Coombe Road, rests with local highway authorities (not National Highways), and the road network in other parts of the UK rests with the devolved administrations.”

    Source location

    Response from National Highways Agency
    Page 1 · response
    Published 24 February 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Local highway authorities are responsible for local roads, including addressing hazards and obstructions on Coombe Road.

    Verbatim wording from the response

    “I note that the collision occurred on Coombe Road, Winterbourne Steepleton, Dorchester, Dorset. For clarity, National Highways is the Government-owned company, sponsored by the Department for Transport (DfT), charged with operating, maintaining and improving England's motorways and major A-roads. Responsibility for local roads, including Coombe Road, rests with local highway authorities (not National Highways), and the road network in other parts of the UK rests with the devolved administrations.”

    Source location

    Response from National Highways Agency
    Page 1 · response
    Published 24 February 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    No further action by the Department is considered appropriate at this stage.

    Verbatim wording from the response

    “Based on this, we have concluded that there is no further action that would be appropriate for the Department to take at this stage.”

    Source location

    Response from Department for Transport
    Page 2 · response
    Published 24 February 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Dorset Council, BCP Council and National Highways have good existing arrangements for the public to report road obstructions and debris.

    Verbatim wording from the response

    “Partnership colleagues in both Councils and National Highways have good existing arrangements for the Public to report issues on the road.”

    Source location

    Response from Dorset Council
    Page 2 · response
    Published 24 February 2023

    Open published response
  8. Surrey

    AI-generated summary

    Charles Michael Stringer · Prevention of Future Deaths report

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

    Report summary

    Charles Michael Stringer, a cyclist, died after hitting a pothole on Church Lane, causing a punctured front tyre and loss of control that resulted in a fatal chest injury. The report raises concerns about Surrey County Council’s lack of documented reflection, changes to pothole-management systems, communication, risk assessment, defect categorisation and timely repairs following his death.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to ensure defect inspectors receive recent road-condition complaints

    Wider context from the report

    “2. A lack of action and/or change to the management of potholes by SCC following Mr Stringer’s death SCC has indicated in written submissions that a number of discussions have taken place following Mr Stringer’s death but there has been no documented changes in systems or practice in particular: 1. What steps have been taken to ensure inspectors of defects are fully informed of recent complaints including those from members of the public regarding damage to bicycles by the state of the road. 2. What steps have been taken in the provision of a detailed and robust risk assessment by inspectors with all the available information available such as past complaints, the nature of the road and who uses the road to ensure a ‘holistic’ approach to decision making with regard to the necessity and the speed of road repairs. 3. What, if any, changes have been made to the pictorial guide and the matrix given to inspectors to ensure training there is not an ‘overly mechanistic’ assessment of a road defect. 4. What steps have been taken to ensure there is appropriate and timely communication between the SCC contact centre and the highways department such as a standard operating procedure in place when complaints must be forwarded on and responded to? 5. What steps have been taken to ensure repairs are completed in a timely fashion after serious injuries and deaths have occurred, as a result of a road defect? ”

    Source location

    Charles Michael Stringer · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Build a new data system and assess whether historical complaint data should be made available to highway inspectors.

    Verbatim wording from the response

    “There are risks and benefits to providing historical data and not providing it. These have been carefully considered, and SCC is still giving specific consideration to whether providing historical complaint data to Inspectors would be beneficial.”

    Source location

    Response from Surrey County Council
    Page 3 · response
    Published 14 October 2022

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Limited resources and inconsistent public reporting mean inspections cannot be redirected or biased solely by the number of complaints received.

    Verbatim wording from the response

    “Inspections are based on what the Inspector sees at the point in time that the inspection takes place. SCC often gets multiple reports of what might be the same defect and there can be a variety of reasons why certain defects may be the subject of multiple reports (it is not always the case that a higher number of reports means that a defect poses a greater risk than a defect which has received only one report). For this reason, while we assess all reports from the public regarding potential safety defects, we need to ensure that limited resources are not diverted or biased based on what can be inconsistent reporting by the public. It is important that inspections that are prompted by a customer complaint are carried out to review what is reported at that point in time as an independent one-off inspection carried out by a trained Inspector.”

    Source location

    Response from Surrey County Council
    Page 3 · response
    Published 14 October 2022

    Open published response
  9. West Yorkshire (West)

    AI-generated summary

    Nicholas Gary Stocks · Prevention of Future Deaths report

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

    Report summary

    Nicholas Gary Stocks was struck and fatally injured by a vehicle after a collision at the junction of Dry Hill Lane and the A635 Barnsley Road in Huddersfield on 27 September 2012. The report raised concerns about damaged and poorly maintained give-way signs and road markings, inadequate reporting and repair systems, highway inspection practices, risk assessment, and coordination between West Yorkshire Police and Kirklees Council.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to appropriately assess and act on public reports of highway defects

    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
    Page 4 · concerns

    Open source report
  10. North Yorkshire (West)

    AI-generated summary

    William David McCourt · 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

    William David McCourt died at the scene after losing control of his motorcycle on running water across the A6108 road. The warning sign had fallen over, and the water hazard had reportedly remained unresolved for several months. Concerns included missing records of residents’ reports, inadequate investigation of land ownership, lack of written escalation, failure to address the hazard, and inspections not recording the water as a potential hazard.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to record reports of flooding

    Wider context from the report

    “1) No record was found of the reports made by local residents prior to June, 2012, of flooding at this location either via the Highways website or by telephone on two occasions and, therefore, no action taken. ”

    Source location

    William David McCourt · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to act on reported flooding

    Wider context from the report

    “1) No record was found of the reports made by local residents prior to June, 2012, of flooding at this location either via the Highways website or by telephone on two occasions and, therefore, no action taken. ”

    Source location

    William David McCourt · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review customer-contact recording systems to support robust logging and recording.

    Verbatim wording from the response

    “(1) It is acknowledged by North Yorkshire County Council that no records of the alleged customer contacts could be found. During the inquest, it was identified that the customers were unable to provide evidence of these contacts so any further investigation, by the County Council is not possible. North Yorkshire County Council systems have been reviewed in the past and found to be robust. In addition, training has been provided to minimise the potential for human error to occur, resulting in an enquiry not being logged and recorded correctly.”

    Source location

    2013-0383-Response-by-North-Yorkshire-County-Council
    Page 1 · response
    Published 12 December 2013

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide staff training to minimise human errors in logging and recording enquiries.

    Verbatim wording from the response

    “(1) It is acknowledged by North Yorkshire County Council that no records of the alleged customer contacts could be found. During the inquest, it was identified that the customers were unable to provide evidence of these contacts so any further investigation, by the County Council is not possible. North Yorkshire County Council systems have been reviewed in the past and found to be robust. In addition, training has been provided to minimise the potential for human error to occur, resulting in an enquiry not being logged and recorded correctly.”

    Source location

    2013-0383-Response-by-North-Yorkshire-County-Council
    Page 1 · response
    Published 12 December 2013

    Open published response
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Data last updated 7 September 2026