Recurring concern

Inadequate controls preventing dangerous vehicle movements between slip roads and carriageways

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First reported 22 Sep 2014•Latest report 16 Apr 2025

Definition

What this concern includes

Includes recurring hazards or deficient physical, directional, separation, signage or other dedicated road controls at slip-road and carriageway interfaces where they permit or fail to prevent wrong-way entry, unintended crossing or other dangerous vehicle movement between traffic routes.

Not included

Excludes generic road collisions, junction hazards or driver error where no specific slip-road or carriageway-interface control failure is identified.
Excludes ordinary road-marking, signage, lighting or barrier deficiencies that are not materially connected to preventing dangerous vehicle movements between slip roads and carriageways.
Excludes road hazards confined to pedestrians, vehicle loss of control, road-surface conditions or unrelated highway maintenance.
Excludes routine vehicle approval, driver licensing or enforcement concerns unless they directly concern controlling dangerous movements at a slip-road or carriageway interface.

Reports: 4
Individual concerns: 9
Date range: 2014–2025
Stated actions: 29

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

National Highways3

Apple (UK) Limited2

Google UK Limited2

Office of the Chief Coroner2

TomTom2

A-One+1

Cleveland Police1

Kent Police1

Milton Keynes City Council1

Recipient name withheld1

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.

16 Apr2025
North West Kent
Concerns raised1
1. Lack of physical barriers on the grass verge between the M20 and M25/M20 slip road
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Assess the barrier provision against current road restraint requirements using the Road Restraint Risk Assessment Process.
  Stated by National HighwaysStated completed
Respondent positions 2
1. Position
  The merge arrangements do not constitute a barrier-requiring hazard because traffic travels in the same direction.
  Stated by National HighwaysDisputes the concern
1. Position
  No further action or direct CD 377 amendment is intended because similar incidents are uncommon and changes must address safety and value for money.
  Stated by National HighwaysNo action considered necessary
AI-generated summary

Freddie SLATER · Prevention of Future Deaths report

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

Report summary

On 16 October 2024, Freddie Slater died at the scene after his Smart car collided with two other vehicles on the M20 and an adjoining slip road in Kent. The report raised concerns that the grass verge separating the roads had no physical barriers, allowing an uncontrolled vehicle to cross into traffic travelling in the opposite carriageway and creating a risk of high-speed collisions and fatalities.

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 physical barriers on the grass verge between the M20 and M25/M20 slip road
Wider context from the report
“(1) The grass verge which separates the M20 and M25/ M20 slip road does not have erected upon it any physical barriers to prevent traffic crossing the verge from either of the 2 roads referred to and entering a parallel lane the opposite side of the verge. (2) The evidence received from National Highways confirmed that under the present policy guidance, barriers would not normally be required as there are no features such as an incline on the slip road, bridge supports or trees requiring physical protection between the two merging roads of traffic travelling at similar speeds in the same direction. (3) The facts of the present case illustrate that in the event of a loss of control of a vehicle travelling on either the M20 or in the slip road there is the potential for that vehicle, without any warning to drivers travelling at or about the same area in the coastbound direction, cross the grass verge to their side and enter their lane of travel. As both the material roads are subject to the same national speed limit of 70MPH, the risk of a high speed collision and fatality arises. ”
Source location
Freddie SLATER · Prevention of Future Deaths report
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
Assess the barrier provision against current road restraint requirements using the Road Restraint Risk Assessment Process.

Verbatim wording from the response
“A review of the current barrier provision at this locality with reference to current requirements”

Source location
Response from National Highways
Page 2 · response
Published 19 May 2025
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 merge arrangements do not constitute a barrier-requiring hazard because traffic travels in the same direction.

Verbatim wording from the response
“As identified in paragraph 5(2) of the Regulation 28 report, current design requirements would not require a barrier to be erected within the grassed medium between the M25 link and the M20 link.”

Source location
Response from National Highways
Page 2 · response
Published 19 May 2025
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 or direct CD 377 amendment is intended because similar incidents are uncommon and changes must address safety and value for money.

Verbatim wording from the response
“A review of fatal incidents on the whole of the SRN in England has been undertaken to identify any other incidents where a vehicle has crossed over a strip at the end of the nosing at an on-slip road and impacted a vehicle on the adjacent slip road. This search has been limited to fatal incidents as there is typically insufficient detail available for serious, slight and damage-only incidents in order to make a detailed assessment of the circumstances of the incident.”

Source location
Response from National Highways
Page 3 · response
Published 19 May 2025
Open published response
23 Aug2024
Milton Keynes
Concerns raised5
1. Inadequate positioning and visibility of No Entry signage for wrong-way slip-road entry
2. Frequent wrong-way driving down the slip road into oncoming traffic
3. Slip-road geometry allowing wrong-way vehicles to enter and build up considerable speed
1. Failure to maintain adequate visibility of road-surface No Entry markings at the slip-road junction
2. Failure of commonly used satnav applications to provide unambiguous verbal directions at the junction
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 11
1. Action
  Install temporary large No Entry signs on A-frames at both sides of the A5 off-slip exit.
  Stated by National HighwaysStated completed
2. Action
  Complete a full safety review of the junction against the current Wrong Way Driving: Mitigation Toolkit.
  Stated by National HighwaysStated completed
3. Action
  Continue developing enhanced A5 off-slip mitigation options and establish which measures will be progressed, including improved signage and road markings.
  Stated by National HighwaysStated in progress
1. Action
  Undertake further work to assess junction capacity and whether the A5 off-slip bell-mouth width can be reduced with hatched markings.
  Stated by National HighwaysStated planned
2. Action
  Inspect the junction and assess signage and road markings for safety defects.
  Stated by Milton Keynes City CouncilStated completed
3. Action
  Review the junction situation later as part of the planned work programme.
  Stated by Milton Keynes City CouncilStated planned
4. Action
  Review navigation instructions near the junction by simulating driver-speed scenarios and assessing instruction timing.
  Stated by TomTom International B.V.Stated completed
5. Action
  Implement safeguards that time verbal navigation commands closer to the exit and after drivers pass the off-slip road.
  Stated by TomTom International B.V.Stated completed
6. Action
  Investigate and develop improvements to the timing of Google Maps audio guidance.
  Stated by Google UK LimitedStated in progress
7. Action
  Add special voice guidance directing westbound drivers to continue straight at the overpass and turn right onto the A5 toward Milton Keynes and Bletchley.
  Stated by Apple (UK) LimitedStated in progress
8. Action
  Reinspect the site after the incident and investigate whether an immediate safety hazard exists.
  Stated by Milton Keynes City CouncilStated completed
Respondent positions 5
1. Position
  The junction already has all standard wrong-way-driving mitigation measures required by the current toolkit.
  Stated by National HighwaysExisting arrangements considered sufficient
1. Position
  Existing signage and road markings appeared adequate under applicable regulations, although illumination might improve the no-entry signage.
  Stated by Milton Keynes City CouncilDisputes the concern
2. Position
  The council has no powers to improve the junction mouth, signage or road markings because these are outside its highway authority functions.
  Stated by Milton Keynes City CouncilOutside remit
3. Position
  National Highways is responsible for the slip road junction, its signage and road markings, so it must undertake related improvements.
  Stated by Milton Keynes City CouncilRedirects responsibility
4. Position
  Maps had no data or routing error that contributed to the deaths.
  Stated by Apple (UK) LimitedDisputes the concern
AI-generated summary

Amal Mohamed AHMED · Prevention of Future Deaths report

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

Report summary

Amal Mohamed Ahmed died at the scene after entering the A5 southbound off slip road in the wrong direction and colliding head-on with another vehicle. The other vehicle’s driver later died in hospital, and a passenger suffered life-threatening injuries. The principal concern was that inadequate, poorly positioned and poorly visible signage and the unlit, wide junction allowed drivers to enter the slip road incorrectly; other drivers were observed making the same manoeuvre.

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
Inadequate positioning and visibility of No Entry signage for wrong-way slip-road entry
Wider context from the report
“The exit point of the A5 "off" slip road at the Little Brickhill junction is wide. The signage indicating No Entry appears to be inadequate as there are two No Entry signs which are widely spaced at the junction. One is positioned to appear to forbid entry to the road over the bridge leading over the A5 and does not obviously relate to the slip road. The second is positioned such that it obliquely faces the road over the bridge and would not be visible to a driver turning right onto the slip road until they had completed the manoeuvre placing them at risk. There is a No Right Turn sign as the junction is approached. There is also No Entry in large white letters at the mouth of the slip road junction, however, this may be (1) obscured by vehicles leaving the slip road and (2) the junction is unlit and was said by a witness as being "pitch black". After the collision attention police officers saw three further vehicles perform exactly the same manoeuvre as Ms Ahmed and attempt to travel down the slip road in the wrong direction. Local residents have contacted police and claimed that it is a very common occurrence for drivers to mistakenly travel down the slip road in the wrong direction. The slip road is long and allows for the build up of considerable speed in turn facilitating what the police describe as a high energy impact. Following the collision, large temporary No Entry signs were positioned at the slip road junction. They were quickly removed apparently because the original signs were deemed to comply with necessary regulations. That seems wholly irrelevant to me because drivers are clearly commonly not seeing the signs because of the large numbers who mistakenly drive the wrong way onto the slip road. In my opinion, consideration should be given to alternative arrangements to prevent vehicles entering and travelling along the slip road in the wrong direction. ”
Source location
Amal Mohamed AHMED · Prevention of Future Deaths report
Page 1 · 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
Frequent wrong-way driving down the slip road into oncoming traffic
Wider context from the report
“I have made observations regarding the slip road at this junction in my initial pre-Inquest Report To Prevent Future Deaths dated the 21st December 2023. National Highways undertook a number of immediate remedial measures to try to prevent drivers turning and travelling the wrong way down this slip road, including narrowing the "mouth" of the slip road to one lane, placement of very large temporary "No Entry" signs and placement of signs indicating "Do Not Use Satnav" at the site. CCTV monitoring of driver behaviour was commenced. Police activity and monitoring by National Highways showed that despite these measures, drivers were still turning early and attempting to drive the wrong way down the slip road. Further enquiries by the police and information volunteered by members of the public who made the same incorrect manoeuvre led to the finding that while the visual map display on commonly used satnav applications at this junction displayed the correct information, the verbal commands gave information likely to confuse and direct drivers down the wrong slip road into the path of oncoming traffic. This was observed to happen frequently. ”
Source location
Amal Mohamed AHMED · Prevention of Future Deaths report
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
Slip-road geometry allowing wrong-way vehicles to enter and build up considerable speed
Wider context from the report
“The exit point of the A5 "off" slip road at the Little Brickhill junction is wide. The signage indicating No Entry appears to be inadequate as there are two No Entry signs which are widely spaced at the junction. One is positioned to appear to forbid entry to the road over the bridge leading over the A5 and does not obviously relate to the slip road. The second is positioned such that it obliquely faces the road over the bridge and would not be visible to a driver turning right onto the slip road until they had completed the manoeuvre placing them at risk. There is a No Right Turn sign as the junction is approached. There is also No Entry in large white letters at the mouth of the slip road junction, however, this may be (1) obscured by vehicles leaving the slip road and (2) the junction is unlit and was said by a witness as being "pitch black". After the collision attention police officers saw three further vehicles perform exactly the same manoeuvre as Ms Ahmed and attempt to travel down the slip road in the wrong direction. Local residents have contacted police and claimed that it is a very common occurrence for drivers to mistakenly travel down the slip road in the wrong direction. The slip road is long and allows for the build up of considerable speed in turn facilitating what the police describe as a high energy impact. Following the collision, large temporary No Entry signs were positioned at the slip road junction. They were quickly removed apparently because the original signs were deemed to comply with necessary regulations. That seems wholly irrelevant to me because drivers are clearly commonly not seeing the signs because of the large numbers who mistakenly drive the wrong way onto the slip road. In my opinion, consideration should be given to alternative arrangements to prevent vehicles entering and travelling along the slip road in the wrong direction. ”
Source location
Amal Mohamed AHMED · Prevention of Future Deaths report
Page 1 · 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 maintain adequate visibility of road-surface No Entry markings at the slip-road junction
Wider context from the report
“The exit point of the A5 "off" slip road at the Little Brickhill junction is wide. The signage indicating No Entry appears to be inadequate as there are two No Entry signs which are widely spaced at the junction. One is positioned to appear to forbid entry to the road over the bridge leading over the A5 and does not obviously relate to the slip road. The second is positioned such that it obliquely faces the road over the bridge and would not be visible to a driver turning right onto the slip road until they had completed the manoeuvre placing them at risk. There is a No Right Turn sign as the junction is approached. There is also No Entry in large white letters at the mouth of the slip road junction, however, this may be (1) obscured by vehicles leaving the slip road and (2) the junction is unlit and was said by a witness as being "pitch black". After the collision attention police officers saw three further vehicles perform exactly the same manoeuvre as Ms Ahmed and attempt to travel down the slip road in the wrong direction. Local residents have contacted police and claimed that it is a very common occurrence for drivers to mistakenly travel down the slip road in the wrong direction. The slip road is long and allows for the build up of considerable speed in turn facilitating what the police describe as a high energy impact. Following the collision, large temporary No Entry signs were positioned at the slip road junction. They were quickly removed apparently because the original signs were deemed to comply with necessary regulations. That seems wholly irrelevant to me because drivers are clearly commonly not seeing the signs because of the large numbers who mistakenly drive the wrong way onto the slip road. In my opinion, consideration should be given to alternative arrangements to prevent vehicles entering and travelling along the slip road in the wrong direction. ”
Source location
Amal Mohamed AHMED · Prevention of Future Deaths report
Page 1 · 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 commonly used satnav applications to provide unambiguous verbal directions at the junction
Wider context from the report
“I have made observations regarding the slip road at this junction in my initial pre-Inquest Report To Prevent Future Deaths dated the 21st December 2023. National Highways undertook a number of immediate remedial measures to try to prevent drivers turning and travelling the wrong way down this slip road, including narrowing the "mouth" of the slip road to one lane, placement of very large temporary "No Entry" signs and placement of signs indicating "Do Not Use Satnav" at the site. CCTV monitoring of driver behaviour was commenced. Police activity and monitoring by National Highways showed that despite these measures, drivers were still turning early and attempting to drive the wrong way down the slip road. Further enquiries by the police and information volunteered by members of the public who made the same incorrect manoeuvre led to the finding that while the visual map display on commonly used satnav applications at this junction displayed the correct information, the verbal commands gave information likely to confuse and direct drivers down the wrong slip road into the path of oncoming traffic. This was observed to happen frequently. ”
Source location
Amal Mohamed AHMED · Prevention of Future Deaths report
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
Install temporary large No Entry signs on A-frames at both sides of the A5 off-slip exit.

Verbatim wording from the response
“Further temporary signing has been put in place at the exit point of the A5 off slip at the Little Brickhill junction in the form of two large 1200mm ‘No Entry’ signs on A-frames on each side of the carriageway (Traffic Signs Regulations and General Directions (TSRGD), Diagram 616 No entry for vehicular traffic). These signs are intended to provide mitigation against further wrong way driving incidents while a full safety review of the junction has been undertaken.”

Source location
Response from Highways
Page 1 · response
Published 29 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
Complete a full safety review of the junction against the current Wrong Way Driving: Mitigation Toolkit.

Verbatim wording from the response
“The site visit has informed a full safety review of the junction, including an assessment of the junction against the latest version of National Highways’ Wrong Way Driving: Mitigation Toolkit (v1.2 January 2021). The junction had previously been assessed against the previous version of the toolkit (first issued in 2017).”

Source location
Response from Highways
Page 1 · response
Published 29 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
Continue developing enhanced A5 off-slip mitigation options and establish which measures will be progressed, including improved signage and road markings.

Verbatim wording from the response
“• The site assessment has established that, when measured against the Wrong Way Driving Toolkit, the junction has all the required ‘standard’ mitigation measures in place. However, potential improvements to road markings and signage on both National Highways and Milton Keynes City Council’s network have been identified.”

Source location
Response from Highways
Page 2 · response
Published 29 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
Undertake further work to assess junction capacity and whether the A5 off-slip bell-mouth width can be reduced with hatched markings.

Verbatim wording from the response
“○ Width of the junction bell mouth at the end of the A5 off slip – the A5 off slip and junction bell mouth is two lanes wide. The bell mouth is effectively widened by the concrete overrun area along the eastern edge of the bell mouth. Reducing the width of the junction with hatched road markings may increase the conspicuity of the ‘No Entry’ measures. Further work will be undertaken to understand the capacity of the junction and whether the junction width can be reduced.”

Source location
Response from Highways
Page 2 · response
Published 29 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
Inspect the junction and assess signage and road markings for safety defects.

Verbatim wording from the response
“We received a ‘Report-It’ made on 28 May 2023. The records show that in this case a highways inspector visited the location on 2 June 2023 and made the following note ‘Inspection on 02/06/23 enough signage and road marking on road saying no entry. No safety defects found all below investigatory levels’. This reflects his remit to consider the condition of those assets in respect of safety. A standardised response was sent to the customer.”

Source location
Response from Milton Keynes City Council
Page 2 · response
Published 29 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
Review the junction situation later as part of the planned work programme.

Verbatim wording from the response
“We have another ‘Report-It’ made on 21 November 2023 which was made following the incident. The same inspector visited the site again and again found no immediate safety hazard based on condition (of the asset) and highlighted to the resident on 13 January 2024 that we have investigated and intend to review the situation at a later date as part of our planned work programme. A standardised response was sent to the customer.”

Source location
Response from Milton Keynes City Council
Page 2 · response
Published 29 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
Review navigation instructions near the junction by simulating driver-speed scenarios and assessing instruction timing.

Verbatim wording from the response
“Following the report, we reviewed our navigation systems’ verbal instructions provided near the junction at hand. We have simulated different scenarios, including speed variations of 60mph and 30mph, to better understand how our navigation systems presented instructions based on driver speed. The scenarios assumed that the driver would either (i) maintain maximum speed until the junction; or (ii) slow down when approaching it. The outcome of the review revealed that instructions were given either (i) right when passing by the off-slip road; or (ii) after passing by the off-slip road, when on the overpass towards the exit.”

Source location
Response from TomTom
Page 1 · response
Published 29 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 safeguards that time verbal navigation commands closer to the exit and after drivers pass the off-slip road.

Verbatim wording from the response
“As part of our ongoing efforts to enhance road safety, we recently implemented additional safeguards, to limit drivers’ confusion where possible, regardless of their speed behavior on the road, by timing the verbal commands closer to the actual exit, and in any event after passing the off-slip road. However, please note that in order for these changes to be effective and visible by end users, they need to use the latest map and therefore in certain circumstances need to update their systems/devices.”

Source location
Response from TomTom
Page 1 · response
Published 29 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
Investigate and develop improvements to the timing of Google Maps audio guidance.

Verbatim wording from the response
“• We have liaised with National Highways and reviewed their helpful dashcam footage of the relevant junction. This has assisted our product and engineering teams in carefully investigating the audio guidance provided by Google Maps. Our teams are working on improvements to the timing of the audio guidance.”

Source location
Response from Google
Page 2 · response
Published 29 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
Add special voice guidance directing westbound drivers to continue straight at the overpass and turn right onto the A5 toward Milton Keynes and Bletchley.

Verbatim wording from the response
“However, to ensure we were following the very best approach we are taking an additional measure to add the following special voice guidance for drivers heading past the A5 offramp toward the A5 onramp, which we intend will be live by the start of next week. - Drivers heading past the A5 offramp toward the A5 onramp would be instructed to “Continue straight at the overpass” (that will happen as they are traveling westward from the offramp). - While on the overpass, drivers would be instructed to “Turn right onto A5 toward Milton Keynes, Bletchley.””

Source location
Response from Apple
Page 1 · response
Published 29 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
Reinspect the site after the incident and investigate whether an immediate safety hazard exists.

Verbatim wording from the response
“City highways officials visited the site on 20 November after the fatal incident with Thames Valley Police (TVP). TVP then conveyed a video call with MKCC and National Highways on 21 November and National Highways took subsequent actions on their junction. We would”

Source location
Response from Milton Keynes City Council
Page 1 · response
Published 29 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 junction already has all standard wrong-way-driving mitigation measures required by the current toolkit.

Verbatim wording from the response
“• The site assessment has established that, when measured against the Wrong Way Driving Toolkit, the junction has all the required ‘standard’ mitigation measures in place. However, potential improvements to road markings and signage on both National Highways and Milton Keynes City Council’s network have been identified.”

Source location
Response from Highways
Page 2 · response
Published 29 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 signage and road markings appeared adequate under applicable regulations, although illumination might improve the no-entry signage.

Verbatim wording from the response
“agree with National Highways that the signage appeared adequate to regulations, although we would suggest that the National Highways no-entry signage at the slip road junction may benefit from illumination (although the Traffic Signs Regulations and General Directions guidance does not require this).”

Source location
Response from Milton Keynes City Council
Page 2 · response
Published 29 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 has no powers to improve the junction mouth, signage or road markings because these are outside its highway authority functions.

Verbatim wording from the response
“The slip road, its junction with the local road, and the signage and road markings at the end of the slip road are part of the National Highways asset and they are therefore the responsible highway authority.”

Source location
Response from Milton Keynes City Council
Page 1 · response
Published 29 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
National Highways is responsible for the slip road junction, its signage and road markings, so it must undertake related improvements.

Verbatim wording from the response
“The slip road, its junction with the local road, and the signage and road markings at the end of the slip road are part of the National Highways asset and they are therefore the responsible highway authority.”

Source location
Response from Milton Keynes City Council
Page 1 · response
Published 29 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
Maps had no data or routing error that contributed to the deaths.

Verbatim wording from the response
“We immediately investigated the concerns raised and found no data or routing error on Maps which would have contributed to these tragic events.”

Source location
Response from Apple
Page 1 · response
Published 29 December 2023
Open published response
22 Aug2024
Milton Keynes
Concerns raised1
1. Frequent wrong-way driving on the slip road
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 14
1. Action
  Implement safeguards that time verbal commands closer to the exit and after the off-slip road.
  Stated by TomTom International B.V.Stated completed
2. Action
  Install additional temporary No-Entry signs at the A5 off-slip exit to mitigate wrong-way driving.
  Stated by National HighwaysStated completed
3. Action
  Restore and maintain the temporary and fixed No-Entry signing, including correcting sign orientation, removing graffiti and repairing sign-related defects.
  Stated by National HighwaysStated in progress
1. Action
  Close the offside slip-road lane and reposition the temporary No-Entry signs closer together to reduce apparent two-way-road movements.
  Stated by National HighwaysStated completed
2. Action
  Operate daily inspections of the temporary signing and cones to monitor their condition and alignment.
  Stated by National HighwaysStated completed
3. Action
  Deploy temporary ‘Do not follow Sat Nav’ and customer-information signs at the junction.
  Stated by National HighwaysStated completed
4. Action
  Investigate Sat Nav routing and liaise with Google Maps, Apple Maps and WAZE regarding potentially confusing audible instructions.
  Stated by National HighwaysStated in progress
5. Action
  Undertake seven-day, 24-hour CCTV monitoring to measure the effectiveness of the temporary layout.
  Stated by National HighwaysStated planned
6. Action
  Commission and complete consultant feasibility assessments of permanent junction options, including safety risk, effectiveness, cost, engineering difficulty and lighting appraisal.
  Stated by National HighwaysStated completed
7. Action
  Review feasibility outcomes with consultants and develop the preferred permanent option through a workshop, outline design, cost estimate and Stage 1 road-safety-audit documents.
  Stated by National HighwaysStated planned
8. Action
  Carry out detailed design and programme implementation of permanent junction works for the 2025/26 financial year.
  Stated by National HighwaysStated planned
9. Action
  Liaised with National Highways and reviewed dashcam footage of the junction to inform investigation of Google Maps audio guidance.
  Stated by Google UK LimitedStated completed
10. Action
  Investigate and develop improvements to the timing of Google Maps audio guidance.
  Stated by Google UK LimitedStated in progress
11. Action
  Add special voice guidance instructing drivers to continue straight at the overpass and turn right onto the A5 toward Milton Keynes, Bletchley.
  Stated by Apple (UK) LimitedStated planned
AI-generated summary

Tracey Julie HAYBITTLE · Prevention of Future Deaths report

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

Report summary

Tracey Julie Haybittle died at the John Radcliffe Hospital after a head-on collision when another driver entered the wrong slip road at the Little Brickhill junction. The report raised concerns that verbal commands from commonly used satnav applications could confuse and direct drivers down the wrong slip road into oncoming traffic, and that this occurred frequently despite remedial measures.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Frequent wrong-way driving on the slip road
Wider context from the report
“I have made observations regarding the slip road at this junction in my initial pre-Inquest Report To Prevent Future Deaths dated the 21st December 2023 in respect of the linked case of Amal Mohamed Ahmood. National Highways undertook a number of immediate remedial measures to try to prevent drivers turning and travelling the wrong way down this slip road, including narrowing the "mouth" of the slip road to one lane, placement of very large temporary "No Entry" signs and placement of signs indicating "Do Not Use Satnav" at the site. CCTV monitoring of driver behaviour was commenced. Police activity and monitoring by National Highways showed that despite these measures, drivers were still turning early and attempting to drive the wrong way down the slip road. Further enquiries by the police and information volunteered by members of the public who made the same incorrect manoeuvre led to the finding that while the visual map display on commonly used satnav applications at this junction displayed the correct information, the verbal commands gave information likely to confuse and direct drivers down the wrong slip road into the path of oncoming traffic. This was observed to happen frequently. ”
Source location
Tracey Julie HAYBITTLE · Prevention of Future Deaths report
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 safeguards that time verbal commands closer to the exit and after the off-slip road.

Verbatim wording from the response
“As part of our ongoing efforts to enhance road safety, we recently implemented additional safeguards, to limit drivers’ confusion where possible, regardless of their speed behavior on the road, by timing the verbal commands closer to the actual exit, and in any event after passing the off-slip road. However, please note that in order for these changes to be effective and visible by end users, they need to use the latest map and therefore in certain circumstances need to update their systems/devices.”

Source location
Response from TomTom
Page 1 · response
Published 30 August 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 additional temporary No-Entry signs at the A5 off-slip exit to mitigate wrong-way driving.

Verbatim wording from the response
“Additional temporary signing has been put in place at the exit point of the A5 off slip at the Little Brickhill junction in the form of two large 1200mm ‘No Entry’ signs on A-frames on each side of the carriageway (Traffic Signs Regulations and General Directions (TSRGD), Diagram 616 No entry for vehicular traffic). These signs are intended to provide mitigation against further wrong way driving incidents while a full safety review of the junction has been undertaken.”

Source location
Response from National Highways
Page 1 · response
Published 30 August 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
Restore and maintain the temporary and fixed No-Entry signing, including correcting sign orientation, removing graffiti and repairing sign-related defects.

Verbatim wording from the response
“Following a site inspection on 24 April 2024, it was observed that the offside fixed (permanent) No-Entry sign had been rotated to face westwards (facing the Little Brickhill approach). This alteration had not been instructed or carried out by National Highways.”

Source location
Response from National Highways
Page 1 · response
Published 30 August 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
Close the offside slip-road lane and reposition the temporary No-Entry signs closer together to reduce apparent two-way-road movements.

Verbatim wording from the response
“These further changes involved closing the offside lane of the slip road to remove the potential ‘appearance’ of a two-way road. This also enabled the two large diameter No-Entry signs to be positioned closer together, see images below:”

Source location
Response from National Highways
Page 4 · response
Published 30 August 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
Operate daily inspections of the temporary signing and cones to monitor their condition and alignment.

Verbatim wording from the response
“These works were undertaken on the night of the 24 April 2024. A daily inspection regime was put in place to monitor the signs and cones, and this is ongoing.”

Source location
Response from National Highways
Page 5 · response
Published 30 August 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
Deploy temporary ‘Do not follow Sat Nav’ and customer-information signs at the junction.

Verbatim wording from the response
“Again, on the 29 April 2024, the location was visited by National Highways and Thames Valley Police (Traffic Management Officer). During the site visit, a vehicle was observed to attempt to turn right into the slip road against the No-Entry signing. The driver was flagged down and aborted the turn. On speaking to the driver, they said that the Sat Nav app said to turn right. This raised concerns that Sat Nav instructions may have been leading to driver confusion.”

Source location
Response from National Highways
Page 5 · response
Published 30 August 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
Investigate Sat Nav routing and liaise with Google Maps, Apple Maps and WAZE regarding potentially confusing audible instructions.

Verbatim wording from the response
“Investigations have been undertaken to understand the potential influence Sat Nav instructions are having on driver behaviour. Route drives were undertaken using various Sat Nav apps (Google Maps, Apple Maps and WAZE) to review route guidance given to drivers.”

Source location
Response from National Highways
Page 6 · response
Published 30 August 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 seven-day, 24-hour CCTV monitoring to measure the effectiveness of the temporary layout.

Verbatim wording from the response
“As part of continued monitoring of the junction, we are planning to undertake CCTV monitoring, initially for 24hours a day for a period of 7 days, to measure the effectiveness of the temporary layout.”

Source location
Response from National Highways
Page 7 · response
Published 30 August 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
Commission and complete consultant feasibility assessments of permanent junction options, including safety risk, effectiveness, cost, engineering difficulty and lighting appraisal.

Verbatim wording from the response
“Following receipt of the Regulation 28 Report to Prevent future Deaths, we commissioned our external design consultant (WSP) to carry out feasibility work to determine and recommend appropriate permanent changes at the junction, including the following key activities:”

Source location
Response from National Highways
Page 7 · response
Published 30 August 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
Review feasibility outcomes with consultants and develop the preferred permanent option through a workshop, outline design, cost estimate and Stage 1 road-safety-audit documents.

Verbatim wording from the response
“Details of the external design consultants’ initial assessment and options were submitted to National Highways on 14 June 2024, and we are currently reviewing the outcomes and planning the next steps, which include:”

Source location
Response from National Highways
Page 7 · response
Published 30 August 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
Carry out detailed design and programme implementation of permanent junction works for the 2025/26 financial year.

Verbatim wording from the response
“Following completion of above actions, detailed design will be carried out and implementation programmed for the 2025/26 financial year.”

Source location
Response from National Highways
Page 7 · response
Published 30 August 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
Liaised with National Highways and reviewed dashcam footage of the junction to inform investigation of Google Maps audio guidance.

Verbatim wording from the response
“• We have liaised with National Highways and reviewed their helpful dashcam footage of the relevant junction. This has assisted our product and engineering teams in carefully investigating the audio guidance provided by Google Maps. Our teams are working on improvements to the timing of the audio guidance.”

Source location
Response from Google
Page 2 · response
Published 30 August 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
Investigate and develop improvements to the timing of Google Maps audio guidance.

Verbatim wording from the response
“• We have liaised with National Highways and reviewed their helpful dashcam footage of the relevant junction. This has assisted our product and engineering teams in carefully investigating the audio guidance provided by Google Maps. Our teams are working on improvements to the timing of the audio guidance.”

Source location
Response from Google
Page 2 · response
Published 30 August 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
Add special voice guidance instructing drivers to continue straight at the overpass and turn right onto the A5 toward Milton Keynes, Bletchley.

Verbatim wording from the response
“However, to ensure we were following the very best approach we are taking an additional measure to add the following special voice guidance for drivers heading past the A5 offramp toward the A5 onramp, which we intend will be live by the start of next week. - Drivers heading past the A5 offramp toward the A5 onramp would be instructed to “Continue straight at the overpass” (that will happen as they are travelling west toward the offramp). - While on the overpass, drivers would be instructed to “Turn right onto A5 toward Milton Keynes, Bletchley.””

Source location
Response from Apple
Page 1 · response
Published 30 August 2024
Open published response
22 Sep2014
Teesside
Concerns raised2
1. Continuing hazard of drivers entering the exit slip road
2. Lack of advance road-sign information identifying the slip road as no entry
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Maintain supplementary illuminated “No entry” signs through regular inspection and prompt damage rectification.
  Stated by A-one+ Integrated Highway ServicesStated completed
2. Action
  Investigate options for safety improvements at the interchange following reported wrong-way driving incidents.
  Stated by A-one+ Integrated Highway ServicesStated completed
3. Action
  Submit a proposal for interchange safety improvement works during the next improvement-scheme funding round.
  Stated by A-one+ Integrated Highway ServicesStated planned
Respondent positions 3
1. Position
  Permanent signs cannot be installed in the block-paved area because escorted abnormal loads must pass through it.
  Stated by A-one+ Integrated Highway ServicesUnable to act
1. Position
  Proposed interchange improvements depend on securing funding through the Highways Agency's prioritised improvement-scheme bidding process.
  Stated by A-one+ Integrated Highway ServicesUnable to act
2. Position
  Responsibility for advance signs on local roads and roundabouts rests with Stockton-on-Tees Borough Council, not the Highways Agency or A-one+.
  Stated by A-one+ Integrated Highway ServicesRedirects responsibility
AI-generated summary

Jerome Antoine Marie GONNET · Prevention of Future Deaths report

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

Report summary

On 2 May 2012, Jerome Antoine Marie GONNET was a passenger in a car involved in a head-on collision after a female driver travelled the wrong way along the A66 eastbound carriageway. Concerns included unclear advance signage for the no-entry slip road and temporary no-entry signs that could be knocked over and become unnoticeable; two further drivers reportedly later used the exit slip road in the same way.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Continuing hazard of drivers entering the exit slip road
Wider context from the report
“(3) It has been brought to the Coroners attention that since Mr Gonnet’s passing a further two drivers have driven down the exit slip road, in the same manner as the female driver who caused Mr Gonnet’s passing. ”
Source location
Jerome Antoine Marie GONNET · Prevention of Future Deaths report
Page 1 · 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
Lack of advance road-sign information identifying the slip road as no entry
Wider context from the report
“(1) It is unclear in advance of approaching the junction that the slip road upon which the female drove is ‘no entry’ slip road. There is no information in this regard on the road signs surrounding the junction. ”
Source location
Jerome Antoine Marie GONNET · Prevention of Future Deaths report
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
Maintain supplementary illuminated “No entry” signs through regular inspection and prompt damage rectification.

Verbatim wording from the response
“In response to the road traffic collision of 2 May 2012, and at Cleveland Police’s request, supplementary ‘No entry’ signs, which are in addition to those mandated under statutory requirements, have been installed. However, one of these signs has been placed in a block paved area of carriageway and this sign is at times knocked over by passing vehicles, as indicated by the Report.”

Source location
2014-0415-Response-by-A-one.pdf
Page 3 · response
Published 22 September 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
Investigate options for safety improvements at the interchange following reported wrong-way driving incidents.

Verbatim wording from the response
“3. Two other incidents have been reported involving drivers travelling in the wrong direction on this exit slip road.”

Source location
2014-0415-Response-by-A-one.pdf
Page 3 · response
Published 22 September 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
Submit a proposal for interchange safety improvement works during the next improvement-scheme funding round.

Verbatim wording from the response
“Both A-one+ and the Highways Agency have been made aware of one of these incidents by Cleveland Police. I can advise that an investigation has been undertaken to identify options for improvement at this interchange. The improvements which are being considered include installing demountable bollards or marker posts in the block paved area and installing additional road markings.”

Source location
2014-0415-Response-by-A-one.pdf
Page 3 · response
Published 22 September 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
Permanent signs cannot be installed in the block-paved area because escorted abnormal loads must pass through it.

Verbatim wording from the response
“The block paved area at this location was installed to address problems associated with the lower than normal bridge deck level at Elton Interchange when the interchange was originally constructed. When abnormally tall and wide or long loads are being moved along the A66 eastbound carriageway, these vehicles are required to divert from the main carriageway of the A66 over the extents of this interchange. Some of these vehicles, under escort, need to pass through the block paved area and travel in an anticlockwise direction around the roundabout’s circulatory carriageway, in order to rejoin the A66.”

Source location
2014-0415-Response-by-A-one.pdf
Page 3 · response
Published 22 September 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
Proposed interchange improvements depend on securing funding through the Highways Agency's prioritised improvement-scheme bidding process.

Verbatim wording from the response
“Both A-one+ and the Highways Agency have been made aware of one of these incidents by Cleveland Police. I can advise that an investigation has been undertaken to identify options for improvement at this interchange. The improvements which are being considered include installing demountable bollards or marker posts in the block paved area and installing additional road markings.”

Source location
2014-0415-Response-by-A-one.pdf
Page 3 · response
Published 22 September 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
Responsibility for advance signs on local roads and roundabouts rests with Stockton-on-Tees Borough Council, not the Highways Agency or A-one+.

Verbatim wording from the response
“Local highway authorities are responsible for the management of maintenance of local roads, which are outside of the Highways Agency’s remit.”

Source location
2014-0415-Response-by-A-one.pdf
Page 2 · response
Published 22 September 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of physical barriers on the grass verge between the M20 and M25/M20 slip road

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised5

Inadequate positioning and visibility of No Entry signage for wrong-way slip-road entry

Frequent wrong-way driving down the slip road into oncoming traffic

Slip-road geometry allowing wrong-way vehicles to enter and build up considerable speed

Failure to maintain adequate visibility of road-surface No Entry markings at the slip-road junction

Failure of commonly used satnav applications to provide unambiguous verbal directions at the junction

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.11

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5

Concerns raised1

Frequent wrong-way driving on the slip road

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.14

Actions described in response 1

Respondent positions 2

Actions described in response 11

Respondent positions 5

Actions described in response 14