6 Apr 2026 Allan STEVENSON · Prevention of Future Deaths report Suffolk
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Concerns raised 8 Failure to provide Network Inspectors with information about deviations from the original temporary traffic scheme plan View source Lack of safety escalation when site operatives identify scheme safety issues View source Lack of a defect-notice mechanism for dangerous special-signage deficiencies View source Lack of enhanced safety review for complex temporary road traffic plans flipped at short notice View source Delayed and indirect replacement pathway for temporary traffic management signage View source Failure to consider required special signage after a temporary traffic plan is flipped View source Failure to answer the temporary traffic management defect line promptly View source Lack of spare signage for correcting identified temporary road traffic scheme errors View source See 5 more concerns
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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.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Anglian Water; that does not assign responsibility.
PFD Monitor interpretation Failure to provide Network Inspectors with information about deviations from the original temporary traffic scheme plan
Wider context from the report “5. I am concerned that there is no apparent system in place to inform Network Inspectors that a traffic scheme has been laid out, contrary to the original plan that was in place (as in this case when a plan has been flipped).
As a result of the Network Inspector having no access to, or sight of the original plan , he was unaware that the original plan had been flipped, unaware of the suspension of the cycle lanes approaching the roundabout and unaware that the special signage deemed necessary in the original plan, was completely absent in the flipped scheme that was put in place.
As such the Network Inspector’s ability to check the safety of the flipped scheme was seriously compromised .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Anglian Water; that does not assign responsibility.
PFD Monitor interpretation Lack of safety escalation when site operatives identify scheme safety issues
Wider context from the report “2. I am concerned that there is no apparent safety escalation process , when as in this case a relatively junior Traffic Management Operative identifies a safety issue with a scheme once it has begun operations .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Anglian Water; that does not assign responsibility.
PFD Monitor interpretation Lack of a defect-notice mechanism for dangerous special-signage deficiencies
Wider context from the report “3. I am concerned that the correct ‘special signage’ that would have undoubtedly made this scheme safer, was not even considered in this case (as a direct result of the flipping of the original plan).
I am further concerned that Network Inspectors have no power to declare a special sign (or the lack of a special sign) as a defect , as these signs fall outside the mandatory signage shown in the Red Book.
As such, even if a Network Inspector identified what they believed to be a dangerous temporary traffic management scheme, any danger being caused by the lack of special signage (or caused by special signage on site that is incorrect), there is no mechanism available for a Network Inspector to issue a defect notice to raise their concern .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Anglian Water; that does not assign responsibility.
PFD Monitor interpretation Lack of enhanced safety review for complex temporary road traffic plans flipped at short notice
Wider context from the report “1. I am concerned that what was agreed by witnesses to be a complex temporary road traffic plan, can be ‘flipped’ on the ground on the day it is installed without any identifiable process being in place to ensure the scheme is subsequently safe .
The court heard that some schemes (such as a single carriage way scheme controlled by only two sets of traffic lights) were straight forward to flip if required, but that no additional or enhanced review system was in place when a complex scheme needed to be flipped at short notice .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Anglian Water; that does not assign responsibility.
PFD Monitor interpretation Delayed and indirect replacement pathway for temporary traffic management signage
Wider context from the report “4. I am concerned of that the only recourse for a Network Inspector to get temporary traffic management signage replaced, is an apparently protected procedural route involving multiple individuals remote from the site , with the Network Inspector having limited or no contact with the Traffic Management Operatives at the site itself .
I am further concerned that there is no requirement for spare signage to be carried on vehicles used for setting up the schemes, for obvious or frequently occurring errors identified on temporary road traffic schemes (such as in this case the road narrow signs being the wrong way around).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Anglian Water; that does not assign responsibility.
PFD Monitor interpretation Failure to consider required special signage after a temporary traffic plan is flipped
Wider context from the report “3. I am concerned that the correct ‘special signage’ that would have undoubtedly made this scheme safer, was not even considered in this case (as a direct result of the flipping of the original plan ).
I am further concerned that Network Inspectors have no power to declare a special sign (or the lack of a special sign) as a defect, as these signs fall outside the mandatory signage shown in the Red Book.
As such, even if a Network Inspector identified what they believed to be a dangerous temporary traffic management scheme, any danger being caused by the lack of special signage (or caused by special signage on site that is incorrect), there is no mechanism available for a Network Inspector to issue a defect notice to raise their concern.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Anglian Water; that does not assign responsibility.
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
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Anglian Water; that does not assign responsibility.
PFD Monitor interpretation Lack of spare signage for correcting identified temporary road traffic scheme errors
Wider context from the report “4. I am concerned of that the only recourse for a Network Inspector to get temporary traffic management signage replaced, is an apparently protected procedural route involving multiple individuals remote from the site, with the Network Inspector having limited or no contact with the Traffic Management Operatives at the site itself.
I am further concerned that there is no requirement for spare signage to be carried on vehicles used for setting up the schemes , for obvious or frequently occurring errors identified on temporary road traffic schemes (such as in this case the road narrow signs being the wrong way around).
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation 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
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement 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
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The 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
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations