Concerns raised 7 Unavailability of a final vehicle-exclusion solution at the waterway View source Delays in risk-reduction action at cluster sites View source Unsafe speed limit for the road design and condition View source Delays in repairing highway degradation View source Failure to take prompt action following road safety representations View source Insufficiently rigorous road inspections View source Failure to audit the quality of road inspections View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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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. The report was sent to Cambridgeshire County Council; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a final vehicle-exclusion solution at the waterway
Wider context from the report “A Barrier to prevent entry to the waterway would be one effective measure that has been deployed in many other places to prevent a vehicle leaving the road and yet, I understand no final solution is in place .
” 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 Cambridgeshire County Council; that does not assign responsibility.
PFD Monitor interpretation Delays in risk-reduction action at cluster sites
Wider context from the report “Councils have a number of roads that feature on a cluster site analysis. By their nature, these will carry an obvious and serious risk of death or significant injury. Funding pressures in recent years have delayed prompt action in risk reduction at these sites.
” 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 Cambridgeshire County Council; that does not assign responsibility.
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.
” 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 Cambridgeshire County Council; that does not assign responsibility.
PFD Monitor interpretation Delays in repairing highway degradation
Wider context from the report “This has been an issue and I have a concern about prompt repairs being effected to the road and also the weight of vehicles which is a factor in damage to the verge adjacent to the road itself.
” 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 Cambridgeshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to take prompt action following road safety representations
Wider context from the report “The Fenland Road Safety Campaign (Charlotte's Way) have undertaken outstanding work as a charity in raising awareness of the dangers of Fenland roads given the unique environmental factors involved. It is not clear whether there has been prompt action taken following representations from them on safety matters.
” 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 Cambridgeshire County Council; that does not assign responsibility.
PFD Monitor interpretation Insufficiently rigorous road inspections
Wider context from the report “I have a concern that inspections of the road have not been sufficiently rigorous given a recurring issue of highway degradation from ‘rutting’ at the carriageway edge which can be a contributory factor causing loss of control of a vehicle.
It is unclear if the council have carried out audits to review the quality of inspections and whether there have been examples of substandard inspections.
” 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 Cambridgeshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to audit the quality of road inspections
Wider context from the report “I have a concern that inspections of the road have not been sufficiently rigorous given a recurring issue of highway degradation from ‘rutting’ at the carriageway edge which can be a contributory factor causing loss of control of a vehicle.
It is unclear if the council have carried out audits to review the quality of inspections and whether there have been examples of substandard inspections .
” 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 Conduct verge reinstatement trials to identify effective treatments for rutting, soil erosion and verge collapse.
Verbatim wording from the response “agricultural machinery that overruns the paved road. Verge reinstatement trials will begin in early 2025 where different sections of rutting will receive treatment to see which performs best under varying conditions, and when it is anticipated the verges will be at their softest and most susceptible to collapse or wash out. As part of a wide-ranging change programme within our Place and Sustainability directorate, the County Council is revising and tightening its assurance arrangements.” Source location Response from Cambridgeshire County Council
Open published response
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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 Take and analyse soil core samples to inform long-term remedial solutions for soil-affected sections of Puddock Road.
Verbatim wording from the response “Puddock Road is subject to a formal inspection every three months and regular visits from a Local Highway Officer. Where identified, necessary repairs are undertaken and where possible, rutting is back filled. This is an interim solution to a complex issue around soil erosion and climate factors. In July 2024 soil core samples were taken from random sections of Puddock Road to assist engineers in understanding what lies beneath the road and identify possible long term remedial solutions. The core samples have revealed a peat layer between 300 and 500mm deep, on top of which is a layer of silty clay.” Source location Response from Cambridgeshire County Council
Open published response
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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 Conduct a traffic flow survey to inform proposed closure or restricted access for Puddock Road.
Verbatim wording from the response “• A traffic flow survey will be conducted in early November 2024.” Source location Response from Cambridgeshire County Council
Open published response
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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 Consult engineers on measures to address rutting caused by heavy agricultural machinery overrunning the paved road.
Verbatim wording from the response “As with other Fenland roads, Puddock Road is identified as one of the roads that has been impacted by the behaviour of the soils on which the road has been built. Engineers are now consulting on how best to deal with the rutting caused by the use of heavy” Source location Response from Cambridgeshire County Council
Open published response
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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 Undertake informal engagement and submit a Traffic Regulation Order application for closure or restricted access to Puddock Road, subject to statutory consultation.
Verbatim wording from the response “• Informal engagement will be undertaken on the closure or restricted access for Puddock Road after the completion of the traffic flow survey. A formal application for a Traffic Regulation Order will be made and subject to a statutory consultation.” Source location Response from Cambridgeshire County Council
Open published response
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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 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
Open published response
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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 Maintain enhanced maintenance checks on Puddock Road to identify and address highway degradation, including rutting.
Verbatim wording from the response “The composition of Puddock Road presents the County Council with many challenges, not least of which is the sub soil that the road is built on. Repairs that have been completed do not last, and with the continued movement of the sub soil it is proving difficult to find a long-lasting solution. This is why the Council instigated the enhanced maintenance checks on Puddock Road. A weight restriction on the road was considered but is not being progressed at this time due to the access requirements for farm vehicles. The trial sections to treat rutting in the verge will be commencing in early 2025 will hopefully give us some longer-term solutions to the soil erosion issues.” Source location Response from Cambridgeshire County Council
Open published response
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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 Prioritise funding for Puddock Road remedial action through the Road Safety Programme.
Verbatim wording from the response “Following the fatalities, Puddock Road was identified as a priority for remedial action and funding prioritised as part of the Road Safety Programme agreed by the Highways and Transport Committee on 12 July 2022.” Source location Response from Cambridgeshire County Council
Open published response
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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 A rafting barrier was not pursued because its installation and maintenance costs and complexity were prohibitively high, without guaranteed long-term structural rigidity.
Verbatim wording from the response “Due to the nature of this road, the initial consideration was to review the use of a Vehicle Restraint System (VRS, or Barriers). Having carefully considered this option with expert technical advice, the project board made a recommendation to the Council’s Highways and Transport Committee that alternative measures be implemented. The VRS was not considered suitable due to the ground conditions, which may not be capable of withstanding an impact and the barrier may simply collapse. A rafting barrier solution that has been used by National Highways was also the considered, however the cost and complexity of such a system was prohibitively expensive, not only to install but also to maintain, and again with no guarantees of structural rigidity being retained over time.” Source location Response from Cambridgeshire County Council
Open published response
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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 A vehicle restraint system was not suitable because unstable ground conditions might cause the barrier to collapse after impact.
Verbatim wording from the response “Due to the nature of this road, the initial consideration was to review the use of a Vehicle Restraint System (VRS, or Barriers). Having carefully considered this option with expert technical advice, the project board made a recommendation to the Council’s Highways and Transport Committee that alternative measures be implemented. The VRS was not considered suitable due to the ground conditions, which may not be capable of withstanding an impact and the barrier may simply collapse. A rafting barrier solution that has been used by National Highways was also the considered, however the cost and complexity of such a system was prohibitively expensive, not only to install but also to maintain, and again with no guarantees of structural rigidity being retained over time.” Source location Response from Cambridgeshire County Council
Open published response
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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 A weight restriction was not progressed because farm vehicles require access to the road.
Verbatim wording from the response “The composition of Puddock Road presents the County Council with many challenges, not least of which is the sub soil that the road is built on. Repairs that have been completed do not last, and with the continued movement of the sub soil it is proving difficult to find a long-lasting solution. This is why the Council instigated the enhanced maintenance checks on Puddock Road. A weight restriction on the road was considered but is not being progressed at this time due to the access requirements for farm vehicles. The trial sections to treat rutting in the verge will be commencing in early 2025 will hopefully give us some longer-term solutions to the soil erosion issues.” Source location Response from Cambridgeshire County Council
Open published response
Concerns raised 2 Failure to manage and monitor flooding and standing water on the road View source Failure to reassess the risk of flooding and standing water on the road View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Colin Neil Duncan MCCALLUM · 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
Colin Neil Duncan McCallum died after his Ford Focus struck standing water on the A1307 in heavy rain, lost control, collided with a stationary vehicle and entered a treeline. The concern was that, unless the risk of flooding or standing water was reassessed and managed or monitored, future deaths could occur in similar circumstances.
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. The report was sent to Cambridgeshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to manage and monitor flooding and standing water on the road
Wider context from the report “I understand that responsibility for this stretch of road was passed to CCC by National Highways in Feb 2024. During the Inquest I heard evidence from National Highways Head Of Planning & Development (statement of ████████ attached). During the period Mar 2022 to Jul 2023 the Police were aware of 5 separate incidents on the stretch of the A1307 identified in ████████ statement where there had been personal injury or death to individuals caused after vehicles had hit patches of water before leaving the carriageway.
I am concerned that unless the risk of flooding/standing water is reassessed and managed/monitored moving forward that there is a risk of future deaths occurring in circumstances similar to that of the current case.
” 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 Cambridgeshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to reassess the risk of flooding and standing water on the road
Wider context from the report “I understand that responsibility for this stretch of road was passed to CCC by National Highways in Feb 2024. During the Inquest I heard evidence from National Highways Head Of Planning & Development (statement of ████████ attached). During the period Mar 2022 to Jul 2023 the Police were aware of 5 separate incidents on the stretch of the A1307 identified in ████████ statement where there had been personal injury or death to individuals caused after vehicles had hit patches of water before leaving the carriageway.
I am concerned that unless the risk of flooding/standing water is reassessed and managed/monitored moving forward that there is a risk of future deaths occurring in circumstances similar to that of the current case.
” 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 Skim carriageway verges and clear roadside gullies.
Verbatim wording from the response “A plan has been developed to remediate the issues that have been identified. Works are planned to commence in late July 2024 and should take 4 weeks to complete.” Source location Response from Cambridge County Council
Open published response
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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 Test and monitor the remediation works for effectiveness in removing flooding and surface-water risk.
Verbatim wording from the response “These works will be tested and monitored for effectiveness to ensure that the actions undertaken have been successful in removing the flooding and surface water risk. Only when the Council is satisfied that the measures taken have removed this risk will the Council be able to remove the 40mph speed limit.” Source location Response from Cambridge County Council
Open published response
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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 Inspect the A1307 monthly and increase monitoring during heavy rainfall events.
Verbatim wording from the response “The A1307 will be subject to monthly inspections by the Highways Inspector and the Local Highways Officer for the area, as well as enhanced monitoring when we experience heavy rainfall events.” Source location Response from Cambridge County Council
Open published response
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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 Clear the French Drain, expose and assess its drainage pipe, undertake any necessary clearing or replacement, and reinstate the drainage media.
Verbatim wording from the response “A plan has been developed to remediate the issues that have been identified. Works are planned to commence in late July 2024 and should take 4 weeks to complete.” Source location Response from Cambridge County Council
Open published response
Concerns raised 3 Failure to record and track highway hazard and defect reports View source Failure to remedy reported highway hazards and defects View source Failure to record completion and specification of highway remedial works View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Joanne Constable · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Joanne Constable was a passenger on a motorbike that collided with a tractor-trailer on the A141 Isle of Ely Way on 2 August 2020. Vegetation on the highway verge obstructed the tractor driver's view, and Mrs Constable sustained multiple injuries and was pronounced deceased. The report raised concerns about inadequate systems for recording, tracking and addressing highway hazards and defects, creating a risk of further fatal collisions.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cambridgeshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to record and track highway hazard and defect reports
Wider context from the report “• In the course of evidence from the local authority's highway maintenance manager, I heard concerning testimony as to the apparent lack of systems and processes in place to record complaints or reports of hazards or defects with the highway . Consequently, there seemed to be no way of identifying which reports had been actioned or inspected and even when the system indicated that an inspection had taken place and led to a recommendation for work to be carried out within a statutory timeframe, there was no information available on the system to show if or when any work was carried out, much less to what specification.
• On the evidence I heard, the circumstances prevailing at the entrance to Bypass Field onto the A141 Isle of Ely Way are replicated at many points across the county and therefore, should those with a statutory responsibility to maintain the highways, including verges, at public cost be unaware of the status of reported hazards or defects, there is a clear risk of future deaths occurring due to those with the responsibility not taking steps to remedy the problem and more fatal road traffic collisions occurring.
” 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 Cambridgeshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to remedy reported highway hazards and defects
Wider context from the report “• In the course of evidence from the local authority's highway maintenance manager, I heard concerning testimony as to the apparent lack of systems and processes in place to record complaints or reports of hazards or defects with the highway. Consequently, there seemed to be no way of identifying which reports had been actioned or inspected and even when the system indicated that an inspection had taken place and led to a recommendation for work to be carried out within a statutory timeframe, there was no information available on the system to show if or when any work was carried out, much less to what specification.
• On the evidence I heard, the circumstances prevailing at the entrance to Bypass Field onto the A141 Isle of Ely Way are replicated at many points across the county and therefore, should those with a statutory responsibility to maintain the highways, including verges, at public cost be unaware of the status of reported hazards or defects, there is a clear risk of future deaths occurring due to those with the responsibility not taking steps to remedy the problem and more fatal road traffic collisions occurring.
” 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 Cambridgeshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to record completion and specification of highway remedial works
Wider context from the report “• In the course of evidence from the local authority's highway maintenance manager, I heard concerning testimony as to the apparent lack of systems and processes in place to record complaints or reports of hazards or defects with the highway. Consequently, there seemed to be no way of identifying which reports had been actioned or inspected and even when the system indicated that an inspection had taken place and led to a recommendation for work to be carried out within a statutory timeframe, there was no information available on the system to show if or when any work was carried out, much less to what specification .
• On the evidence I heard, the circumstances prevailing at the entrance to Bypass Field onto the A141 Isle of Ely Way are replicated at many points across the county and therefore, should those with a statutory responsibility to maintain the highways, including verges, at public cost be unaware of the status of reported hazards or defects, there is a clear risk of future deaths occurring due to those with the responsibility not taking steps to remedy the problem and more fatal road traffic collisions occurring.
” 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 Implement a new integrated Highways Asset Management and public reporting system linking reports, works, completion records and customer feedback.
Verbatim wording from the response “The County Council is implementing a new Highways Asset Management System which will replace and improve on the current IT system. The new system has been specified to deliver a range of enhancements, alongside a new public reporting system. This report system will function as an integral part of the wider” Source location Response from Cambridgeshire County Council
Open published response
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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 Operate a risk-based highway inspection regime and record identified defects in the highways asset management system.
Verbatim wording from the response “• A clear process is in place for the inspection of the highway network. The inspection regime used by the Council is risk based and operates in accordance with UK Roads Liaison Group (UKRLG) Code of Practice ‘Well-managed highway infrastructure. The County Council’s Highway Operational Standards¹ document sets out our operational policies and identifies the types of defects to be inspected also details the required intervention and repair timescales for these defects. These standards are reviewed on a regular basis.” Source location Response from Cambridgeshire County Council
Open published response
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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 Proactively identify vegetation risks and arrange cyclic and reactive cutting, including cutting vegetation on major roads requiring maintenance.
Verbatim wording from the response “• The Green Infrastructure Team is resourced so that it can proactively manage areas of known risk and identify similar locations, raising works orders to attend to overgrowing vegetation on a cyclic and reactive basis. This will include proactively cutting back vegetation on major stretches of road that require maintenance.” Source location Response from Cambridgeshire County Council
Open published response
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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 Council disputes that it lacks systems and processes to record highway hazard and defect reports.
Verbatim wording from the response “The County Council has considered with care the issues that you have raised. The Council does have systems and processes in place to record reports of hazards or defects, which I will refer to later in this letter. However, the Council also continuously develops its systems and approaches to improve the management of the highway and to ensure that we meet our statutory duty to maintain them safely.” Source location Response from Cambridgeshire County Council
Open published response
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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 Existing highway management systems are considered appropriate to manage risk and minimise future deaths as far as practicable.
Verbatim wording from the response “Summary
The County Council’s Highways Service has appropriate systems in place to manage risk on the highway and is taking action to further improve these to ensure the risk of future deaths from similar circumstances and situations is minimised as far as practicable.” Source location Response from Cambridgeshire County Council
Open published response
Concerns raised 2 Failure to correctly apply the Settlement Policy for a 30mph speed limit View source Lack of independent medical scrutiny of the continued ability of drivers aged over 70 to drive View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Louis Steven James THOROLD · 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
Louis Steven James THOROLD died in hospital after being struck by a van that left the road following a collision on the A10 Ely Road. The report raised concern that drivers over 70 could continue driving through an online self-certification process without independent medical scrutiny, including where undiagnosed dementia may affect their ability to perceive hazards.
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. The report was sent to Cambridgeshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to correctly apply the Settlement Policy for a 30mph speed limit
Wider context from the report “Louis’ father gave evidence at the inquest stating that he understood that this particular location fell within CCC’s ‘Settlement Policy’ for a 30mph speed limit(link included below). The inquest also heard evidence that, unsurprisingly, the risk to life as a result of a road traffic collision reduces with the speed of any impact involving a vehicle.
https://www.cambridgeshire.gov.uk/residents/travel-roads-and-parking/roads-and-pathways/improving-the-local-highway/speeding/alternative-speed-measures
I am therefore concerned that there is a risk of death occurring in similar circumstances if it is correct that CCC’s ‘Settlement Policy’ is not being correctly applied .
” 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 Cambridgeshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of independent medical scrutiny of the continued ability of drivers aged over 70 to drive
Wider context from the report “During the inquest I heard evidence that drivers who reach 70 years of age and are therefore required to reapply for their driving licence at that point(and thereafter every 3 years) do so via an online self-certification process and that there is no need for independent medical scrutiny or input unless there is an issue which is specifically drawn to the attention of a medical practitioner . In this case one of the drivers involved in the road traffic collision was driving with undiagnosed dementia which effected their cognitive ability to perceive hazards on the road.
I am concerned that if drivers beyond the age of 70 continue to drive without independent medical scrutiny of their continued ability to drive then there is a risk of deaths occurring in similar circumstances.
” 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 Implement a 40mph speed limit on the relevant Car Dyke Road area.
Verbatim wording from the response “Since the collision, the County Council, in collaboration with Cambridgeshire Constabulary and developers Urban and Civic, have implemented a reduced speed limit in this area to 40mph, and have overseen the delivery of improvements associated with the Waterbeach New Town development, including a pedestrian crossing, and enhanced walking and cycling provision on the A10. A separate note was provided to the inquest outlining these changes.” Source location Response from Cambridge County Council
Open published response
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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 Keep A10 speeds under review as the route’s physical design and safety arrangements develop.
Verbatim wording from the response “However, speeds on the A10 will remain under review, and road safety forms a key component of the A10 Outline Business Case (due to report in Summer 2024), which has potential to change the physical nature of the route.” Source location Response from Cambridge County Council
Open published response
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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 Car Dyke Road section does not meet the policy definition of a settlement warranting a 30mph limit.
Verbatim wording from the response “The County Council will work towards the introduction of a 30mph speed limit in the developed parts of all settlements in the County where appropriate in relation to the nature of the street frontage, activity, environment, and density. Where suitable and affordable, complementary features may be required to encourage drivers to travel at an appropriate speed. Each location will be considered on its own merit.” Source location Response from Cambridge County Council
Open published response
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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 No further speed-limit reduction is proposed, based on the route, observed speeds, policies and police safety assessment.
Verbatim wording from the response “At the present time, based on (i) the nature of the route, (ii) observed vehicle speeds, (iii) national and local policies and (iv) comments from Cambridgeshire Police support, we do not propose to reduce the speed further.” Source location Response from Cambridge County Council
Open published response
Concerns raised 2 Lack of signage alerting westbound traffic to the sharp left hand bend View source Water beyond the bend creating an additional road hazard View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Milan Peter HAMZA (Otherwise known as Milan Peter RADOCZ) · 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
Milan Peter Hamza, also known as Milan Peter Radocz, was an 8-year-old front-seat passenger in a vehicle that left the road, entered a pond and became submerged on 3 September 2022. He was unable to escape and died from drowning. The principal concern was the lack of signage warning westbound drivers about the sharp bend, despite the water hazard beyond it.
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. The report was sent to Cambridgeshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of signage alerting westbound traffic to the sharp left hand bend
Wider context from the report “The vehicle involved in the collision failed to negotiate the left hand bend on the westbound Old Oundle Road at Wittering adjacent to the rear crash gates of RAF Wittering. The vehicle left the road to its offside and entered a pond where it became submerged in water. The 2 occupants of the vehicle drowned as a result.
There is sharp route deviation signage for vehicles travelling in the opposite direction but nothing to alert westbound drivers of the sharp left hand bend . The water beyond the bend clearly creates an additional hazard.
Whilst the precise reason the vehicle failed to negotiate the left hand bend on this occasion is unclear I am concerned that the lack of signage alerting westbound traffic of the bend at this location creates a risk of future incidents and death , not least because of the water beyond.
” 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 Cambridgeshire County Council; that does not assign responsibility.
PFD Monitor interpretation Water beyond the bend creating an additional road hazard
Wider context from the report “The vehicle involved in the collision failed to negotiate the left hand bend on the westbound Old Oundle Road at Wittering adjacent to the rear crash gates of RAF Wittering. The vehicle left the road to its offside and entered a pond where it became submerged in water. The 2 occupants of the vehicle drowned as a result.
There is sharp route deviation signage for vehicles travelling in the opposite direction but nothing to alert westbound drivers of the sharp left hand bend. The water beyond the bend clearly creates an additional hazard .
Whilst the precise reason the vehicle failed to negotiate the left hand bend on this occasion is unclear I am concerned that the lack of signage alerting westbound traffic of the bend at this location creates a risk of future incidents and death, not least because of the water beyond .
” Open source report
Concerns raised 3 Shortage of availability for psychological therapies such as CBT View source Delays in obtaining Gender Identity Clinic appointments View source Delays and gaps in psychological therapy support pending substantive treatment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Daniel France · 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
Daniel France was a 17-year-old vulnerable teenager living in a YMCA hostel who died by asphyxiation by hanging; the inquest concluded that his death was suicide. The principal concern was that vulnerable young people known to local authorities and mental health services may not receive adequate support while awaiting substantive treatment, particularly where they are assessed as not requiring urgent intervention but face lengthy waits for psychological therapy.
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. The report was sent to Cambridgeshire County Council; that does not assign responsibility.
PFD Monitor interpretation Shortage of availability for psychological therapies such as CBT
Wider context from the report “The inquest heard evidence about the considerable delay in obtaining appointments for the Gender Identity Clinic, and about the shortage of availability for psychological therapies such as CBT .
” 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 Cambridgeshire County Council; that does not assign responsibility.
PFD Monitor interpretation Delays in obtaining Gender Identity Clinic appointments
Wider context from the report “The inquest heard evidence about the considerable delay in obtaining appointments for the Gender Identity Clinic , and about the shortage of availability for psychological therapies such as CBT.
” 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 Cambridgeshire County Council; that does not assign responsibility.
PFD Monitor interpretation Delays and gaps in psychological therapy support pending substantive treatment
Wider context from the report “My concern in this case is that a vulnerable young person can be known to the County Council and Mental Health Trust and yet not receive the support they need pending substantive treatment . Danny was repeatedly assessed as not meeting the criteria for urgent intervention and yet the waiting list for psychological therapy was likely to be over a year from point of first presentation . That gap between urgent and non-urgent services is potentially dangerous for a vulnerable young person , where there is a chronic risk of an impulsive act. I understand that there is a long term plan to extend young people’s services to age 25, but I remain concerned about the ongoing situation, and that a young person today could be faced with the same challenges in finding support pending substantive treatment.
” Open source report
Concerns raised 8 Failure of managerial policy-change controls to prevent recurrence of superseded-policy confusion View source Insufficient knowledge, guidance and supervision among education inclusion officers and social workers supporting adolescents at risk of self-harm or suicide View source Reluctance to use a Borderline Personality Disorder diagnosis View source Unavailability of in-area supported accommodation for adolescent mental health patients View source AWOL policy failing to provide concise and usable live-incident guidance View source Lack of an agreed pathway for securing overnight assistance for adolescent mental health patients cared for at home View source Lack of drills, training exercises and information packs for nurses managing AWOL incidents View source Conflicting or confusing AWOL policies View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
SAMANTHA JANE GOULD and CHRISTINE ELIZABETH GOULD · 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
Sam died by suicide from an overdose of prescribed medication on 2 September 2018, aged 16. Chris died by suicide after deliberately stepping in front of a passing train on 26 January 2019, aged 17. The principal concerns included insufficient overnight support for adolescents cared for at home, shortcomings in local authority support and coordination, reluctance to use a Borderline Personality Disorder diagnosis, and unclear and inadequately implemented procedures for patients absent without leave.
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. The report was sent to Cambridgeshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure of managerial policy-change controls to prevent recurrence of superseded-policy confusion
Wider context from the report “(4) AWOL patients from Darwin Centre for Young People (For CPFT). I heard evidence that since Chris’ death, staff have been reminded of the applicable policies; and that an audit has shown good compliance with the provision for calling the local signallers. I heard evidence that there is to be a further review of CPFT’s own AWOL policy. I remain concerned that: (i) CPFT’s own policy is too lengthy and complex to serve as reference-guidance during a live AWOL incident. In particular the flow chart summary is unnecessarily complex and hard to follow (at least as a tool to consult during a stressful incident); (ii) there is a risk of confusion in having two policies both of which are meant to be followed; (iii) there did not appear be desktop-drills / other training exercises / information grab-packs (etc.) to ensure that all nurses in charge are properly equipped and trained to deal with AWOL incidents effectively (iv) steps ought to be taken at managerial level to ensure that the confusion over the two policies and whether one had been superseded (evidence of which only emerged during the inquest) cannot recur in this, or other areas, when new policies are introduced.
” 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 Cambridgeshire County Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient knowledge, guidance and supervision among education inclusion officers and social workers supporting adolescents at risk of self-harm or suicide
Wider context from the report “(2) Involvement of CCC alongside CPFT in complex adolescent mental health cases where the risk is of suicide / self-harm (For CCC). In some respects CCC’s involvement in Chris and Sam’s care (social care and education) lacked direction, focus, knowledge and efficiency. I heard evidence of improvements in training in the relevant education and social work teams, and concerning the new Strong Families, Strong Communities Securing Best Outcomes for Children Strategy (March 2021). Further, that CCC is restructuring all of its early help and adolescent services and will be implementing a formal contextual safeguarding framework and that these developments will be in place by the end of 2021. I am concerned that in the midst of restructuring and new guidance, there remains a risk that education inclusion officers and social workers on the ground may still not have sufficient knowledge, guidance and supervision to ensure that CCC give practical and robust support to parents and adolescent patients, alongside treating healthcare agencies, where the main risk of serious harm to the child is from self-harm or suicide arising from adolescent mental health disorders , rather than neglect of harm by a third party.
” 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 Cambridgeshire County Council; that does not assign responsibility.
PFD Monitor interpretation Reluctance to use a Borderline Personality Disorder diagnosis
Wider context from the report “(3) Diagnosis of Borderline Personality Disorder (For CPFT). I am concerned that the evidence in Chris’ case, in particular, suggested a degree of age-related reluctance consistently to use the terminology of Borderline Personality Disorder (or Emerging Personality Disorder or EUPD) , even when a highly specialist second opinion had supported this and appeared to have been accepted. There are risks associated with a reluctance to use a personality disorder diagnosis (c.f. Position Statement from the Royal College of Psychiatrists dated January 2020). I received evidence that there have already been some changes/improvements in the preparedness to recognise Borderline Personality Disorder and that further consideration will be given in the context of the new ICD 11.
” 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 Cambridgeshire County Council; that does not assign responsibility.
PFD Monitor interpretation Unavailability of in-area supported accommodation for adolescent mental health patients
Wider context from the report “(1) Overnight assistance for adolescent mental health patients being cared for at home but with high levels of need (For CPFT and CCC). I heard evidence of increased funding for CPFT being used to extend home treatment options, but that this would be unlikely to extend to a 24/7 service. I also heard evidence from CCC that available support would now be considered under s17 Children Act or s117 Mental Health Act or both but that this would need to be jointly funded between social care and health. I remain concerned that a clear pathway to securing overnight assistance (even if only on a respite basis) for similar cases of exceptional need has not yet been clearly agreed between CPFT and CCC. I am concerned that if alternative supported accommodation in the community were the best solution, there does not appear to be provision for it in-area , so that admission to a mental health unit becomes more likely.
” 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 Cambridgeshire County Council; that does not assign responsibility.
PFD Monitor interpretation AWOL policy failing to provide concise and usable live-incident guidance
Wider context from the report “(4) AWOL patients from Darwin Centre for Young People (For CPFT). I heard evidence that since Chris’ death, staff have been reminded of the applicable policies; and that an audit has shown good compliance with the provision for calling the local signallers. I heard evidence that there is to be a further review of CPFT’s own AWOL policy. I remain concerned that: (i) CPFT’s own policy is too lengthy and complex to serve as reference-guidance during a live AWOL incident . In particular the flow chart summary is unnecessarily complex and hard to follow (at least as a tool to consult during a stressful incident); (ii) there is a risk of confusion in having two policies both of which are meant to be followed; (iii) there did not appear be desktop-drills / other training exercises / information grab-packs (etc.) to ensure that all nurses in charge are properly equipped and trained to deal with AWOL incidents effectively (iv) steps ought to be taken at managerial level to ensure that the confusion over the two policies and whether one had been superseded (evidence of which only emerged during the inquest) cannot recur in this, or other areas, when new policies are introduced.
” 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 Cambridgeshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of an agreed pathway for securing overnight assistance for adolescent mental health patients cared for at home
Wider context from the report “(1) Overnight assistance for adolescent mental health patients being cared for at home but with high levels of need (For CPFT and CCC). I heard evidence of increased funding for CPFT being used to extend home treatment options, but that this would be unlikely to extend to a 24/7 service. I also heard evidence from CCC that available support would now be considered under s17 Children Act or s117 Mental Health Act or both but that this would need to be jointly funded between social care and health. I remain concerned that a clear pathway to securing overnight assistance (even if only on a respite basis) for similar cases of exceptional need has not yet been clearly agreed between CPFT and CCC . I am concerned that if alternative supported accommodation in the community were the best solution, there does not appear to be provision for it in-area, so that admission to a mental health unit becomes more likely.
” 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 Cambridgeshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of drills, training exercises and information packs for nurses managing AWOL incidents
Wider context from the report “(4) AWOL patients from Darwin Centre for Young People (For CPFT). I heard evidence that since Chris’ death, staff have been reminded of the applicable policies; and that an audit has shown good compliance with the provision for calling the local signallers. I heard evidence that there is to be a further review of CPFT’s own AWOL policy. I remain concerned that: (i) CPFT’s own policy is too lengthy and complex to serve as reference-guidance during a live AWOL incident. In particular the flow chart summary is unnecessarily complex and hard to follow (at least as a tool to consult during a stressful incident); (ii) there is a risk of confusion in having two policies both of which are meant to be followed; (iii) there did not appear be desktop-drills / other training exercises / information grab-packs (etc.) to ensure that all nurses in charge are properly equipped and trained to deal with AWOL incidents effectively (iv) steps ought to be taken at managerial level to ensure that the confusion over the two policies and whether one had been superseded (evidence of which only emerged during the inquest) cannot recur in this, or other areas, when new policies are introduced.
” 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 Cambridgeshire County Council; that does not assign responsibility.
PFD Monitor interpretation Conflicting or confusing AWOL policies
Wider context from the report “(4) AWOL patients from Darwin Centre for Young People (For CPFT). I heard evidence that since Chris’ death, staff have been reminded of the applicable policies; and that an audit has shown good compliance with the provision for calling the local signallers. I heard evidence that there is to be a further review of CPFT’s own AWOL policy. I remain concerned that: (i) CPFT’s own policy is too lengthy and complex to serve as reference-guidance during a live AWOL incident. In particular the flow chart summary is unnecessarily complex and hard to follow (at least as a tool to consult during a stressful incident); (ii) there is a risk of confusion in having two policies both of which are meant to be followed ; (iii) there did not appear be desktop-drills / other training exercises / information grab-packs (etc.) to ensure that all nurses in charge are properly equipped and trained to deal with AWOL incidents effectively (iv) steps ought to be taken at managerial level to ensure that the confusion over the two policies and whether one had been superseded (evidence of which only emerged during the inquest) cannot recur in this, or other areas, when new policies are introduced.
” 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 Operate the Joint Access to Support Panel and joint funding protocol to identify risks, coordinate multi-agency support, and agree auditable funding arrangements.
Verbatim wording from the response “The whole multi-agency process is supported by the Joint Access to Support Panel (JASP). It is able to offer support in terms of identified and emerging risks and advise on prevention, mitigation and management. Identifying themes and gaps in provision through JASP also informs strategy and assists in the future planning and commissioning of services for local children and young people. JASP also ensures a focus on individualised child focused plans, independence and empowerment and remaining close to home where at all possible.” Source location 2021-0184-Response-from-Cambridgeshire-County-Council_Published
Open published response
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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 discussions with health commissioners and the local authority about the need for 24/7 in-home care and whether bespoke or fully funded provision is required.
Verbatim wording from the response “This service is not commissioned to provide 24/7 in home support for young people. If this level of support were needed then this would be raised through either the joint funding panel or through the CCG Section 117 funding stream.” Source location 2021-0184-Response-from-Cambridgeshire-County-Council_Published
Open published response
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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 Audit contacts to the Integrated Front Door and address uncertainty about statutory duties and relevant mental health policies.
Verbatim wording from the response “the specific teams that hold most of these type of cases. There is one route through which new contacts in relation to young people with mental health difficulties can be made, and staff in the Integrated Front Door (who review all such requests for services) have been required to familiarise themselves with our statutory duties and the relevant policy documents. We operate a frequent audit dip sample process around all contacts, and any areas where there may still be uncertainty are picked up through that process and addressed.” Source location 2021-0184-Response-from-Cambridgeshire-County-Council_Published
Open published response
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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 Any need for 24/7 in-home care must be considered through joint CCG and local-authority funding arrangements.
Verbatim wording from the response “This service is not commissioned to provide 24/7 in home support for young people. If this level of support were needed then this would be raised through either the joint funding panel or through the CCG Section 117 funding stream.” Source location 2021-0184-Response-from-Cambridgeshire-County-Council_Published
Open published response
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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 commissioned mental-health service is not commissioned to provide 24/7 in-home support.
Verbatim wording from the response “This service is not commissioned to provide 24/7 in home support for young people. If this level of support were needed then this would be raised through either the joint funding panel or through the CCG Section 117 funding stream.” Source location 2021-0184-Response-from-Cambridgeshire-County-Council_Published
Open published response
21 Mar 2014 DERRICK ARTHUR PLATER · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 1 Failure to ensure clear, disseminated and understood guidelines or protocols for when care home visits should be undertaken during assessment and placement View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
DERRICK ARTHUR PLATER · 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
Derrick Arthur Plater was a resident of Goodwins Hall nursing home who developed a pressure sore after hospital admission on 1 May 2011, was readmitted on 25 May 2011, and died on 7 June 2011. Concerns were raised that the local authority placed him in the care home without visiting it, relying on assurances despite his complex needs, and that it was unclear whether guidance or protocols existed for when such visits should be undertaken.
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. The report was sent to Cambridgeshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure clear, disseminated and understood guidelines or protocols for when care home visits should be undertaken during assessment and placement
Wider context from the report “I was told that it was not the time normal practice to undertake a visit of the care home being considered for placement, notwithstanding that Mr Plater had complex needs having undergone a laryngectomy and had a stoma. Accordingly there was a total reliance upon assurances given by the care home in considering whether it could in fact meet the assessed needs. It was indicated that if similar circumstances arose today it is likely that a visit would be undertaken. However the witness was unable to confirm whether there were guidelines or protocols for when a visit should be undertaken as part of the assessment and placing process .
I am therefore concerned that:
1. If there are guidelines and/or protocols for when a visit of care home should be considered and/or undertaken as part of the assessment and placement process there may need to be a review of the dissemination and awareness of any such guidelines and/or protocols
2. If there are no such guidelines and/or protocols there may need to be a review as to whether such should be drawn up
” Open source report
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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 A social worker’s pre-placement visit would not provide added assurance or be likely to prevent similar deaths.
Verbatim wording from the response “In Mr Platter’s case, where there were complex health and social care needs, a visit to the home by a social worker would not, in my opinion, have provided any added assurance because social workers are not professionally competent to make judgments on whether Mr Plater’s health needs were likely to be met at Goodwins Hall. Therefore, I believe that it is unlikely that a pre-placement visit in these circumstances would help to prevent future deaths in similar circumstances.” Source location 2014-0130-Response
Open published response
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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 Social workers are not professionally competent to judge whether complex health needs can be met by the care home.
Verbatim wording from the response “In Mr Platter’s case, where there were complex health and social care needs, a visit to the home by a social worker would not, in my opinion, have provided any added assurance because social workers are not professionally competent to make judgments on whether Mr Plater’s health needs were likely to be met at Goodwins Hall. Therefore, I believe that it is unlikely that a pre-placement visit in these circumstances would help to prevent future deaths in similar circumstances.” Source location 2014-0130-Response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations