Recurring concern

Inadequate control of vehicle loss-of-control risks on hazardous road sections

First to latest report 28 Apr 2014 — 26 Jul 2024

Reports that mention this concern
8
Times this concern has been raised
9
Stated actions linked to this concern
10

What this concern includes

Includes recurring failures or hazards on public road sections where geometry, surface features, roadside features or dedicated traffic controls create a material risk of vehicle loss of control, including the anchor's Hartley Bends and comparable crest, undulation or road-stud hazards.

What is not included
  • Excludes generic road collisions or road-safety concerns where no recurring loss-of-control hazard or dedicated control deficiency is identified.
  • Excludes hazards confined solely to pedestrian safety, road drainage, lighting, signage, junction visibility or traffic separation unless they directly create or control a vehicle loss-of-control risk.
  • Excludes driver misconduct or excessive speed where no hazardous road-section condition or related control failure is identified.
  • Excludes the specific condition of slippery roads, which is covered only where slippery conditions are the shared material qualifier.

Reports and published responses 8 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Cambridgeshire and Peterborough

    AI-generated summary

    Jennifer BUNYAN and Marion BUNYAN · 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

    Jennifer Bunyan and Marion Bunyan died by drowning on 7 June 2020 after their motor car left the carriageway, rolled onto its roof and became partially submerged in Crease Drain. Jennifer was pregnant, and her unborn daughter, later named Erin Marion Chatten, also died in utero. The report raised concerns about the speed limit, road inspections, highway degradation, delays in remedial action and the absence of an effective barrier preventing vehicles entering the waterway.

    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

    Unsafe speed limit for the road design and condition

    Wider context from the report

    “The designated speed for this section of road was 60 mph. The charity BRAKE have stated that the default speed limit on rural roads is 60 mph, a speed at which it is rarely safe to travel. They stated the approach should be based on the design of roads. This road has an uneven road surface and it was within local knowledge that the designated speed limit was dangerous and could lead to a loss of control whilst driving in the upper speed range. The need for a reduction in the limit as a safety measure does not appear to have been raised during inspections/debriefs following a series of fatalities that have led to a number of drowning incidents along this section of road. It raises a concern that the speed limit should be reduced significantly as a risk reduction measure – some areas have adopted 20 mph on some sections of road. ”

    Source location

    Jennifer BUNYAN and Marion BUNYAN · 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

    Implement a 30mph speed limit on the single-track section of Puddock Road with 40mph buffer zones.

    Verbatim wording from the response

    “The speed limit on the single-track section of Puddock Road will be reduced to 30mph, with 40mph buffer entry sections, from November 2024. A formal traffic regulation order (TRO) has been approved for implementation of the new speed limit. The order will be formally made following installation of the signage.”

    Source location

    Response from Cambridgeshire County Council
    Page 2 · response
    Published 1 August 2024

    Open published response

  2. Hampshire, Portsmouth and Southampton

    AI-generated summary

    George Robert DILLON · 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

    George Robert DILLON, aged 19, lost control of a VW Golf while driving over a crest on Lee Lane at night on 18 May 2023 and collided with a tree. He suffered catastrophic injuries and died in hospital on 20 May 2023. The report raises concern that the hazard posed by the crest is not readily apparent at night, even to vehicles travelling within the speed limit, and that warning signs are absent.

    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

    Road crest permitting loss of vehicle control at the national speed limit

    Wider context from the report

    “B. The maximum speed at which a person can travel over the crest whilst remaining in full control of the vehicle is 45mph. A driver negotiating the crest around the speed limit of 60 mph will run the risk of the vehicle leaving the ground, or at the very least a momentary loss of effective steering control, followed by the underside ‘bottoming out’ on the road surface. Numerous historical gouge marks on the road surface either side of the junction demonstrate that “numerous vehicles have previously ‘bottomed out.” ”

    Source location

    George Robert DILLON · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Recommend providing crossroads warning signs, reduce-speed-now signs and SLOW road markings on both approaches to the Spaniard’s Lane crossroads.

    Verbatim wording from the response

    “In summary, after careful consideration, we have recommended that crossroad warning signs and reduce speed now signs together with SLOW road markings are provided along Lee Lane on both approaches to the Spaniard’s Lane crossroads.”

    Source location

    Response from Hampshire County Council
    Page 1 · response
    Published 13 September 2024

    Open published response

  3. Suffolk

    AI-generated summary

    Stephen John COOMBES · 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

    Stephen ‘John’ Coombes died at Addenbrookes Hospital on 3 September 2021 after a single-vehicle collision in which the Porsche he was driving left the road and overturned. The report identifies concern that inadequate signage failed to communicate a temporary 30 mph speed limit, leaving road users unaware of the reduced limit and potentially resulting in further fatalities if similar road defects occur.

    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 obscure higher speed-limit signage when imposing temporary reductions

    Wider context from the report

    “The court heard that the depression was known to be present by the Highways Authority, and a temporary 30 mph speed limit (instead of the usual 50mph) had been put in place. Evidence was heard from the Forensic Crash Investigation Officer from Suffolk Constabulary, who conducted an investigation into the road traffic collision which caused John’s death. This officer told the court, how he and a colleague drove a police vehicle over the depression in the road at various speeds to observe the reaction the vehicle had to damaged road surface. At 30 mph the police vehicle negotiated the depression in the road with relative ease. At 50 mph, the police vehicle reacted significantly when negotiating the depression. At the time of Johns collision, he had just overtaken another vehicle and therefore crossed the depression a slight angle as he returned to his own side of the carriage way. When the police officers replicated this vehicle movement at 50 mph, the police vehicle reacted violently, with one of the wheels leaving the surface of the road. The officer driving that vehicle was not prepared to attempt the same manoeuvre at any higher speed due to the risk involved. The police officer then told the court that the attending officers themselves were unaware of 30 mph speed limit on this stretch of road. The officer told the court that the main 50 mph signs, the smaller repeater 50 mph signs and the 50 mph roundels painted on the road surface were all clearly visible on this stretch of road. Prior to the depression the officer saw one temporary 30mph partially obscured in the verge, but assumed it was left over from previous works, as all of the 50mph signs remained in view. Evidence was heard that in the normal course of events, when a temporary reduction in a speed limit is imposed on a stretch of road, any signage indicating a higher speed limit should be covered by either securing a dark bag or sack over each sign, or spray painting it out. On the basis of the police officers’ evidence, that clearly did not occur in this case, and this, coupled to there being only one 30mph temporary sign in place prior to the depression in the road, left road users (and attending police officers) unaware of the reduced speed limit in place. I am therefore concerned that should further identified road defects require a reduction in the speed limit, that any repeat of the provision of inadequate signage and/or a failure obscure higher speed limits may result in further fatalities. ”

    Source location

    Stephen John COOMBES · 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

    Review traffic management procedures and require opaque covering or removal of existing higher-speed signs and road-surface roundels when temporary speed limits are imposed.

    Verbatim wording from the response

    “Since the incident Kier has reviewed its procedures relating to checks and maintenance of traffic management measures at unattended sites in Suffolk. In the event that Kier receives an instruction from Suffolk County Council that includes the imposition of a temporary reduced speed limit the existing speed limit signs are fully covered with an opaque material. In the event that there are roundels displaying the existing speed limit on the road surface these will also be appropriately obscured and/or removed.”

    Source location

    Response from Kier Integrated Services
    Page 2 · response
    Published 28 September 2022

    Open published response

  4. Newcastle upon Tyne

    AI-generated summary

    Graeme Stafford Flatman · 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

    Graeme Stafford Flatman, an experienced pedal cyclist, suffered fatal injuries when he collided with a Nissan Qashqai while riding on the A593 at Oxen Fell, Skelwith, Ambleside. The concerns identified were the absence of warning signs about the severe gradient and limited visibility, and whether the 60-mile-per-hour speed limit was appropriate for the road.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Inappropriateness of a 60 mile per hour speed limit on a single carriageway road

    Wider context from the report

    “The A593 is a scenic cross country road with a speed limit of 60 miles per hour. No signage is present within the area in which the collision occurred, warning road users of the severity of the road gradient or the limitations upon visibility. Coroners concerns are: 1. The absence of appropriate signage to warn road users approaching severe incline/decline on the road ahead 2. The absence of appropriate signage warning of visibility limitations on the road ahead 3. The appropriateness of a 60 mile per hour speed limit on a single carriageway road, with one lane in each direction containing numerous straight sections, bends and gradient changes ”

    Source location

    Graeme Stafford Flatman · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review the appropriateness of the 60 mph speed limit at the location.

    Verbatim wording from the response

    “The speed limit of 60 mph is typical for the rural roads in the County but this will also be looked at with regard its appropriateness. Any changes to this will require a consultation and legal process which will take at least 6 months to complete.”

    Source location

    Response from Cumbria County Council
    Page 1 · response
    Published 15 February 2018

    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

    Changes to the speed limit cannot be completed immediately because consultation and legal processes will take at least six months.

    Verbatim wording from the response

    “The speed limit of 60 mph is typical for the rural roads in the County but this will also be looked at with regard its appropriateness. Any changes to this will require a consultation and legal process which will take at least 6 months to complete.”

    Source location

    Response from Cumbria County Council
    Page 1 · response
    Published 15 February 2018

    Open published response

  5. Worcestershire

    AI-generated summary

    James Gerard McGEOWN · 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

    James Gerard McGEOWN died following a road traffic collision after overtaking at well over the 70mph speed limit while under the influence of alcohol and not wearing a seat belt. A road-surface undulation was identified as a potential concern because, at higher speeds, it could cause loss of control and may have contributed to the collision.

    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

    Road-surface undulation causing loss of control at higher speeds

    Wider context from the report

    “(1) I enclose a copy of the Collision Investigator's Report, prepared by ████████, I draw your attention to paragraphs 6.13 and 8.6. ████████ has identified an "undulation" in the road surface. It is likely that this caused the "wobble" seen by the witness immediately prior to Mr McGeown losing control of his vehicle. In his evidence to the Court, ████████ said that he had driven this stretch of road on several occasions as a consequence of this incident. While travelling within the speed limit the undulation causes drivers no concern. At higher speeds (95mph), ████████ described the undulation as causing a loss of control that may have caused an unsuspecting driver to have a collision. ”

    Source location

    James Gerard McGEOWN · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  6. Powys, Bridgend and Glamorgan Valleys

    AI-generated summary

    Brendan Owain Ryan · 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

    Brendan Owain Ryan, aged 21, was the front-seat passenger in a Peugeot 205 that left the A488 between Pen-Y-Bont and Knighton on 31 July 2013 and collided with a fence before entering a field. He was declared deceased at the scene; the inquest concluded the death was due to a road traffic collision, with neck injuries recorded as the medical cause. The principal concern was an unusually high number of collisions at or near the location, with evidence indicating that excessive speed was likely, and consideration of a restricted speed area was raised.

    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

    Excessive vehicle speeds on bends at the road location

    Wider context from the report

    “2. Evidence from the Collision Investigator in this case showed that the maximum speed at which the bends in this road at this location could be travelled at were 50 and 53 mph depending on the direction of approach. Whilst it is acknowledged that the County Council have installed new signage and double white lines in the area in light of the unusually high number of incidents in which vehicles appear to have left the road, most likely as a direct result of excessive speed, it is felt that consideration ought to be given to a restricted speed area at this location. ”

    Source location

    Brendan Owain Ryan · 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

    Erect additional series-of-bends warning signs on both approaches.

    Verbatim wording from the response

    “Surveys into the signing and lining resulted in sections of double solid white centre line being introduced through the bends and additional series of bends warning signs being erected on both approaches. The solid centre lines were considered appropriate not just because of the reduced forward visibility but also from concerns raised by the Community Council of poor overtaking manoeuvres. Verge marker posts have also been added adjacent to the bridge parapet to highlight its presence and assist in denoting the road alignment.”

    Source location

    2014-0541-Response-by-Powys-County-Council
    Page 1 · response
    Published 18 December 2014

    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 engineering measures are considered sufficient to meet the authority’s duty, and guidance makes a lower speed limit inappropriate for this individual hazard.

    Verbatim wording from the response

    “These engineering measures are considered appropriate measures to meet the duty of this Authority under Section 122 of the Road Traffic Regulation Act 1984 as amended. Given this and the Welsh Government guidance not recommending speed limits for individual hazards it is not considered appropriate to impose a lower speed limit at this location.”

    Source location

    2014-0541-Response-by-Powys-County-Council
    Page 2 · response
    Published 18 December 2014

    Open published response

  7. Powys, Bridgend and Glamorgan Valleys

    AI-generated summary

    Alan Derek Evans · 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

    Alan Derek Evans died at the scene after losing control of his motorcycle while overtaking on the A489, colliding with an oncoming vehicle and being run over by another vehicle. Concerns included the road’s single broken white line and whether a protruding old-style cat’s eye may have contributed to the loss of control.

    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

    Protruding road studs creating a motorcycle loss-of-control hazard

    Wider context from the report

    “(2) The evidence suggested that one of the most likely causes of the deceased losing control of his motorcycle was contact with a protruding cats eye. This was agreed by the senior investigation officer and the collision investigation officer who both held the view that this may have contributed to the accident. Consideration in my view ought to be given to replacing the “old style cats eyes” with the newer “slim line” version to minimise this risk in the future should it not be considered appropriate to make the area subject to double white lines to prohibit overtaking. ”

    Source location

    Alan Derek Evans · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  8. Avon

    AI-generated summary

    Miss Yasmin Mary Richards · 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

    Miss Yasmin Mary Richards died at the scene after her Ford Ka crossed into the opposing carriageway and collided with a Range Rover on the A46 on 2 November 2013. The inquest heard that worn and under-inflated tyres contributed to the collision, alongside the vehicle’s speed and the driver’s inexperience. Concerns were raised about repeated collisions on the same section of road and the adequacy of the speed limit, signs, carriageway markings and other measures at the bends.

    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

    Recurring loss of vehicle control on the same section of the A46

    Wider context from the report

    “(1) Notwithstanding the contribution made to this collision by the condition of the tyres of Ford Ka this is the second Inquest I have conducted within the past 12 months into the death of a driver who lost control of their vehicle on the same section of the A46. (2)The speed limit in the section of the A46 known as the 'Hartley Bends' should be reviewed and reduced so as to improve the safety of drivers as they approach these bends. (3) The road signs including carriageway markings should be reviewed and improved so as to provide greater warning to drivers as to the severity of the approaching bends. (4) Consideration be given to the provision of ‘rumble strips’ in advance of the bends so as to further encourage the reduction in the speed of vehicles as they approach the bends. ”

    Source location

    Miss Yasmin Mary Richards · 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 of the speed limit to adequately protect drivers approaching the Hartley Bends

    Wider context from the report

    “(1) Notwithstanding the contribution made to this collision by the condition of the tyres of Ford Ka this is the second Inquest I have conducted within the past 12 months into the death of a driver who lost control of their vehicle on the same section of the A46. (2)The speed limit in the section of the A46 known as the 'Hartley Bends' should be reviewed and reduced so as to improve the safety of drivers as they approach these bends. (3) The road signs including carriageway markings should be reviewed and improved so as to provide greater warning to drivers as to the severity of the approaching bends. (4) Consideration be given to the provision of ‘rumble strips’ in advance of the bends so as to further encourage the reduction in the speed of vehicles as they approach the bends. ”

    Source location

    Miss Yasmin Mary Richards · 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

    Complete road resurfacing and most planned Hartley Bends safety-scheme works.

    Verbatim wording from the response

    “This recommendation was accepted and, following development of a business case, this safety scheme was included in our forward programme for implementation in early 2014. The salient proposals in the Hartley Bends locality were as follows:”

    Source location

    2014-0193-Response-by-Highway-Agency
    Page 1 · response
    Published 28 April 2014

    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 vehicle-activated signs on both approaches to Hartley Bends.

    Verbatim wording from the response

    “• Interactive vehicle activated signs (VAS) to be installed on the north and southbound approaches to Hartley Bends. These signs visually are activated by high speed and advise drivers to slow down and of the geometric hazards ahead;”

    Source location

    2014-0193-Response-by-Highway-Agency
    Page 2 · response
    Published 28 April 2014

    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 temporary advisory 30 mph signing while accelerating consideration of road-surface renewal.

    Verbatim wording from the response

    “As previously stated, these works were programmed for early 2014 and therefore after November 2013. However, following 2 November, we took the additional precaution of providing temporary advisory 30 mph signing while we looked into accelerating future road surface renewal works, over and above the planned safety scheme.”

    Source location

    2014-0193-Response-by-Highway-Agency
    Page 2 · response
    Published 28 April 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Commission an independent peer review of the Hartley Bends safety work.

    Verbatim wording from the response

    “In reviewing the 2011 report I still consider that the now implemented local measures to highlight the nature of the road are logical and proactive steps, which may positively affect speeds without the need for a revised posted limit. As regards your recommendation 2 of Section 5 we proposed the following future actions:”

    Source location

    2014-0193-Response-by-Highway-Agency
    Page 2 · response
    Published 28 April 2014

    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

    Gather speed data and monitor accidents for a reasonable period to assess the implemented safety scheme.

    Verbatim wording from the response

    “2. The gathering of speed data to ascertain the effectiveness of the now implemented safety scheme together with a reasonable period of accident monitoring to gauge impact, and if required, further intervention development. In this case one year would seem appropriate.”

    Source location

    2014-0193-Response-by-Highway-Agency
    Page 3 · response
    Published 28 April 2014

    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

    Implemented local measures are considered sufficient to influence speeds without revising the posted speed limit, subject to continued monitoring.

    Verbatim wording from the response

    “In reviewing the 2011 report I still consider that the now implemented local measures to highlight the nature of the road are logical and proactive steps, which may positively affect speeds without the need for a revised posted limit. As regards your recommendation 2 of Section 5 we proposed the following future actions:”

    Source location

    2014-0193-Response-by-Highway-Agency
    Page 2 · response
    Published 28 April 2014

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026