23 Jun 2022 Mr Peter John Moorby · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 2 Failure of the low wall to provide effective protection from the significant drop into the river View source Lack of lighting in the area at night 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
Mr Peter John Moorby · 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
Peter John Moorby fell approximately 8–10 feet over a low wall into a beck in an unlit area and sustained severe head injuries. He died in hospital on 5 September 2021. The concern was that the low wall offered little protection from the drop and that the area was unlit at night, creating a risk of future deaths.
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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 Cumbria County Council; that does not assign responsibility.
PFD Monitor interpretation Failure of the low wall to provide effective protection from the significant drop into the river
Wider context from the report “I am concerned about the risk of future deaths posed by the low wall. The wall is less than knee height and offers no real protection from the significant drop of 8-10 feet into the River Eea which has a rock-strewn riverbed. The area is also unlit at night.
” 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 Cumbria County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of lighting in the area at night
Wider context from the report “I am concerned about the risk of future deaths posed by the low wall. The wall is less than knee height and offers no real protection from the significant drop of 8-10 feet into the River Eea which has a rock-strewn riverbed. The area is also unlit at night.
” 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 Work with residents to support measures reducing the risk of accidents from the wall.
Verbatim wording from the response “The Council commits to fulfil its duty as a Street Authority under the Highways Act and will work with the residents to support them to take action to reduce the risk and likelihood of future accidents from the wall.” Source location Response from Cumbria 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 appropriate enforcement action if agreement on reducing the risk is not reached.
Verbatim wording from the response “The Council aims to meet with residents not later than the end of November 2022 to try to reach agreement on a way forward not later than the end of January 2023. Failing that, the Council will take the appropriate enforcement action, with a view to completion of the necessary works as soon as possible thereafter.” Source location Response from Cumbria County Council
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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 Primary responsibility for action regarding the wall lies with property owners fronting the private street.
Verbatim wording from the response “The Council has considered the Regulation 28 report to prevent future deaths and notes that as the wall is on a private street, that primary responsibility for action lies with the owners of the properties fronting the street.” Source location Response from Cumbria County Council
Open published response
3 Feb 2022 Stephen Cloudsdale · Prevention of Future Deaths report Cumbria
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Concerns raised 4 Speed of traffic on the A66 stretch View source Insufficient central-reservation width for large vehicles View source Lack of lighting at the A66 dual carriageway crossing point View source Lack of appropriately positioned warning signage for vehicles crossing from the café View source See 1 more concern
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
Stephen Cloudsdale · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Stephen Cloudsdale died at the scene after his car collided with an LGV encroaching into the eastbound lane of the A66 in darkness and heavy rain. The concerns identified were the lack of lighting and warning signage, the speed of traffic, and whether the central reservation was wide enough to accommodate large vehicles safely.
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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 Cumbria County Council; that does not assign responsibility.
PFD Monitor interpretation Speed of traffic on the A66 stretch
Wider context from the report “1) The lack of lighting near to or at the point of the A66 dual carriageway where the collision occurred which renders the presence of vehicles crossing the carriageway from the café difficult to see by approaching drivers during the hours of darkness and/or during adverse weather conditions.
2) The lack of appropriately positioned signage, warning approaching drivers of the possibility of vehicles crossing the carriageway from the café.
3) The speed of traffic on this stretch of the A66 .
4) The sufficiency of the width of the central reservation to accommodate large vehicles fully without the danger of encroaching into either of the opposing carriageways.
” 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 Cumbria County Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient central-reservation width for large vehicles
Wider context from the report “1) The lack of lighting near to or at the point of the A66 dual carriageway where the collision occurred which renders the presence of vehicles crossing the carriageway from the café difficult to see by approaching drivers during the hours of darkness and/or during adverse weather conditions.
2) The lack of appropriately positioned signage, warning approaching drivers of the possibility of vehicles crossing the carriageway from the café.
3) The speed of traffic on this stretch of the A66.
4) The sufficiency of the width of the central reservation to accommodate large vehicles fully without the danger of encroaching into either of the opposing carriageways .
” 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 Cumbria County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of lighting at the A66 dual carriageway crossing point
Wider context from the report “1) The lack of lighting near to or at the point of the A66 dual carriageway where the collision occurred which renders the presence of vehicles crossing the carriageway from the café difficult to see by approaching drivers during the hours of darkness and/or during adverse weather conditions .
2) The lack of appropriately positioned signage, warning approaching drivers of the possibility of vehicles crossing the carriageway from the café.
3) The speed of traffic on this stretch of the A66.
4) The sufficiency of the width of the central reservation to accommodate large vehicles fully without the danger of encroaching into either of the opposing carriageways.
” 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 Cumbria County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of appropriately positioned warning signage for vehicles crossing from the café
Wider context from the report “1) The lack of lighting near to or at the point of the A66 dual carriageway where the collision occurred which renders the presence of vehicles crossing the carriageway from the café difficult to see by approaching drivers during the hours of darkness and/or during adverse weather conditions.
2) The lack of appropriately positioned signage , warning approaching drivers of the possibility of vehicles crossing the carriageway from the café .
3) The speed of traffic on this stretch of the A66.
4) The sufficiency of the width of the central reservation to accommodate large vehicles fully without the danger of encroaching into either of the opposing carriageways.
” Open source report
5 Oct 2021 Charlotte Duffield · Prevention of Future Deaths report Cumbria
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Concerns raised 2 Failure to take safeguarding action following significant safety concerns View source Failure to make an in-person visit after unanswered safeguarding contact attempts 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
Charlotte Duffield · 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
Charlotte Duffield, aged 40, was found deceased at home on 4 February 2021 after concerns that she had not been seen for several weeks; the exact cause of death could not be determined because of advanced decomposition. Concerns were raised that, after a referral to Adult Social Care and unsuccessful telephone contact, no physical visit or further safeguarding action appeared to have been taken despite concerns for her safety.
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 Cumbria County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to take safeguarding action following significant safety concerns
Wider context from the report “(1) On 3rd November 2020 Police officers attend Charlotte's home following a telephone call from her aunt expressing concern for her wellbeing. The Officers were concerned about the state of the property, Charlotte's clothing, her lack of emotional response and that she may not have access to money following the sudden loss of her father, Reviewing their report DS ████████ of Cumbria Constabulary made a referral to Adult Social Care on 5th November. Evidence seen at the inquest indicates that on receipt of the referral 3 attempts to telephone Charlotte were made on 6th, 9th & 10th November. As there was no reply a letter was sent asking her to contact them. There is a note that her case was discussed at a multidisciplinary meeting on 9th December 2021 but no further action seems to have been taken.
(2) Charlotte was referred due to significant concerns for her safety but no safeguarding action seems to have been taken. I am particularly concerned that after her failure to respond to attempted telephone contact no physical effort was made to visit her in person.
” 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 Cumbria County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to make an in-person visit after unanswered safeguarding contact attempts
Wider context from the report “(1) On 3rd November 2020 Police officers attend Charlotte's home following a telephone call from her aunt expressing concern for her wellbeing. The Officers were concerned about the state of the property, Charlotte's clothing, her lack of emotional response and that she may not have access to money following the sudden loss of her father, Reviewing their report DS ████████ of Cumbria Constabulary made a referral to Adult Social Care on 5th November. Evidence seen at the inquest indicates that on receipt of the referral 3 attempts to telephone Charlotte were made on 6th, 9th & 10th November. As there was no reply a letter was sent asking her to contact them. There is a note that her case was discussed at a multidisciplinary meeting on 9th December 2021 but no further action seems to have been taken.
(2) Charlotte was referred due to significant concerns for her safety but no safeguarding action seems to have been taken. I am particularly concerned that after her failure to respond to attempted telephone contact no physical effort was made to visit her in person .
” 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 Deliver training sessions across partner organisations to embed revised self-neglect policy, procedure and guidance.
Verbatim wording from the response “4. This dedicated Safeguarding Adults service is undertaking the delivery of training sessions across all partners to embed the review of self-neglect policy, procedure, and guidance.” Source location 2021-0334-Response-from-Cumbria-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 Complete a systematic review of safeguarding adults self-neglect policies and procedures to clarify roles, responsibilities and duties.
Verbatim wording from the response “1. A systematic review of Cumbria Safeguarding Adults self-neglect policy and procedure documentation has been completed to clarify the roles, responsibilities, and duties across the safeguarding system.” Source location 2021-0334-Response-from-Cumbria-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 Implement a countywide operational Safeguarding Adults service with a dedicated team providing consistent responses to safeguarding concerns.
Verbatim wording from the response “3. The Council has implemented a countywide operational Safeguarding Adults service, a dedicated safeguarding team providing support across the county, to ensure a consistent and compliant response for all safeguarding concerns, including concerns of self-neglect.” Source location 2021-0334-Response-from-Cumbria-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 Review and revise operational guidance for self-neglect concerns to require face-to-face visits for assessment and safety assurance.
Verbatim wording from the response “2. The operational practice guidance in relation to self-neglect concerns has been reviewed and revised. The guidance reinforces the Council’s position that a face-to-face visit, in order to complete assessment and ensure the safety of the person at risk, must be undertaken to satisfy operational practice requirements and standards.” Source location 2021-0334-Response-from-Cumbria-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 Undertake a practice learning session with the involved team to establish a clear operational response to self-neglect concerns.
Verbatim wording from the response “5. Finally, a discrete practice learning session is being undertaken with the team directly involved in this case to ensure, from an operational point of view, that there is a clear and unequivocal position on how to respond to self-neglect concerns.” Source location 2021-0334-Response-from-Cumbria-County-Council_Published
Open published response
16 Nov 2020 Daniel Bancroft · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 3 Failure to control traffic speed on the initial stretch of the A66 View source Lack of measures discouraging pedestrians from walking along the A66 View source Lack of lighting on the initial stretch of the A66 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.
×
AI-generated summary
Daniel Bancroft · 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 Bancroft, an ex-serviceman and father of three, became extremely inebriated after a night out and was struck by a motor vehicle while walking along the A66 in the early hours. He died from the resultant injuries. The substantive concerns were the lack of pedestrian warning signage, the rapid acceleration and speed of traffic, and the lack of lighting on the initial stretch of the A66.
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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 Cumbria County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to control traffic speed on the initial stretch of the A66
Wider context from the report “1. There is nothing to discourage pedestrians from walking along the A66 eg signage
2. Cars are rapidly accelerating from the well-lit roundabout at Stainburn onto an unlit section of the A66 as the national speed limit sign is very close to the roundabout.
3. The speed of traffic on this initial stretch of the A66
4. The lack of lighting on this initial stretch of the A66
” 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 Cumbria County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of measures discouraging pedestrians from walking along the A66
Wider context from the report “1. There is nothing to discourage pedestrians from walking along the A66 eg signage
2. Cars are rapidly accelerating from the well-lit roundabout at Stainburn onto an unlit section of the A66 as the national speed limit sign is very close to the roundabout.
3. The speed of traffic on this initial stretch of the A66
4. The lack of lighting on this initial stretch of the A66
” 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 Cumbria County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of lighting on the initial stretch of the A66
Wider context from the report “1. There is nothing to discourage pedestrians from walking along the A66 eg signage
2. Cars are rapidly accelerating from the well-lit roundabout at Stainburn onto an unlit section of the A66 as the national speed limit sign is very close to the roundabout.
3. The speed of traffic on this initial stretch of the A66
4. The lack of lighting on this initial stretch of the A66
” Open source report
6 Mar 2019 Michael Andrew HENDERSON and Stephen Brian CHAMBERS · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 1 Road conditions permitting excessive speeds and further deaths 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
Michael Andrew HENDERSON and Stephen Brian CHAMBERS · 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
Michael Andrew HENDERSON and Stephen Brian CHAMBERS died at the scene after their car collided with a concrete lamp-post on the A5094 New Road on 1 May 2018. The collision involved alcohol, excessive speed and poorly maintained rear tyres. The principal concern was the risk of further serious collisions or deaths on New Road because its features may enable drivers to attain high speeds and may not sufficiently reinforce compliance with the 40 mph speed limit.
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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 Cumbria County Council; that does not assign responsibility.
PFD Monitor interpretation Road conditions permitting excessive speeds and further deaths
Wider context from the report “The Collision Investigator advised me that it is feasible to considerably exceed the speed limit on New Road to 60 or 70 mph or even greater . He advised me that the road has a number of unusual features – it is very wide with embankments and woodland on each side. It is not in a built up area. This may give the impression (despite signage) that the speed limit is much greater than 40 mph . The road travels downhill towards Whitehaven and has a number of bends.
The Collision Investigator was concerned that there could be further future deaths on this road because of the speeds that can be attained . His considered opinion was that there were measures that could be taken to reinforce and encourage compliance with the speed limit.
” 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 Undertake a traffic speed survey along New Road.
Verbatim wording from the response “The recommendations stated in the Regulation 28 letter that “traffic calming measures” on New Road may reduce the risk of future serious collisions were discussed and considered at the Casualty Reduction and Safer Highways Group (CRASH) on Tuesday 14 May where it was agreed that a traffic speed survey be undertaken along with further investigations to determine what, if any, measures are required.” Source location 2019-0037A-Response-by-Cumbria-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 further investigations to determine whether additional road safety measures are required.
Verbatim wording from the response “The recommendations stated in the Regulation 28 letter that “traffic calming measures” on New Road may reduce the risk of future serious collisions were discussed and considered at the Casualty Reduction and Safer Highways Group (CRASH) on Tuesday 14 May where it was agreed that a traffic speed survey be undertaken along with further investigations to determine what, if any, measures are required.” Source location 2019-0037A-Response-by-Cumbria-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 Enhance the New Road gateway through planned improvements to the Bransty Row and North Shore Road junction.
Verbatim wording from the response “Additionally, Cumbria County Council is about to start work improving the junction of Bransty Row and North Shore Road, Whitehaven as part of a major development project in the town. As part of these works, it is planned to significantly enhance the gateway on New Road and this should positively impact driver behaviour in this area.” Source location 2019-0037-Response-by-Cumbria-County-Council2
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 Hold a multi-agency review and site visit to assess collision records and consider highway safety options.
Verbatim wording from the response “An item was raised at the Casualty Reduction and Safer Highways (CRASH) partnership group meeting on May 14th 2019 following the Regulation 28 Report submitted to Cumbria County Council resulting from the fatal collision on New Road, Whitehaven on 1 May 2018. The CRASH group actioned that all available collision and traffic data be collated and that Cumbria Constabulary’s Collision Reduction Officer and Cumbria County Council’s Traffic Management Officer for the area meet to discuss all records and conduct a site visit to consider options.” Source location 2019-0037-Response-by-Cumbria-County-Council2
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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 Direct traffic calming measures are not recommended at this time because few options would reduce speeds without adversely affecting traffic flow.
Verbatim wording from the response “At the site visit, it was noted that the road is constructed to a high standard, acting as a key route into the town. Discussion took place considering the available engineering measures along the stretch of highway, concluding that there are very few traffic calming options that would effectively reduce driver speeds without having an adverse impact on traffic flow in and around Whitehaven. Given the overall compliance with the posted speed limit, and collision causation factors attributed to driver error, it is not recommended to pursue any direct traffic calming measures at this time.” Source location 2019-0037-Response-by-Cumbria-County-Council2
Open published response
10 Nov 2017 Graeme Stafford Flatman · Prevention of Future Deaths report Newcastle upon Tyne
View report summary
Concerns raised 3 Inappropriateness of a 60 mile per hour speed limit on a single carriageway road View source Absence of appropriate signage warning of visibility limitations on the road ahead View source Absence of appropriate signage warning of severe incline or decline on the road ahead 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
Graeme Stafford Flatman · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Graeme Stafford Flatman, an experienced pedal cyclist, suffered fatal injuries when he collided with a Nissan Qashqai while riding on the A593 at Oxen Fell, Skelwith, Ambleside. The concerns identified were the absence of warning signs about the severe gradient and limited visibility, and whether the 60-mile-per-hour speed limit was appropriate for the road.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria County Council; that does not assign responsibility.
PFD Monitor interpretation Inappropriateness of a 60 mile per hour speed limit on a single carriageway road
Wider context from the report “The A593 is a scenic cross country road with a speed limit of 60 miles per hour. No signage is present within the area in which the collision occurred, warning road users of the severity of the road gradient or the limitations upon visibility. Coroners concerns are:
1. The absence of appropriate signage to warn road users approaching severe incline/decline on the road ahead
2. The absence of appropriate signage warning of visibility limitations on the road ahead
3. The appropriateness of a 60 mile per hour speed limit on a single carriageway road, with one lane in each direction containing numerous straight sections, bends and gradient changes
” 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 Cumbria County Council; that does not assign responsibility.
PFD Monitor interpretation Absence of appropriate signage warning of visibility limitations on the road ahead
Wider context from the report “The A593 is a scenic cross country road with a speed limit of 60 miles per hour. No signage is present within the area in which the collision occurred, warning road users of the severity of the road gradient or the limitations upon visibility. Coroners concerns are:
1. The absence of appropriate signage to warn road users approaching severe incline/decline on the road ahead
2. The absence of appropriate signage warning of visibility limitations on the road ahead
3. The appropriateness of a 60 mile per hour speed limit on a single carriageway road, with one lane in each direction containing numerous straight sections, bends and gradient changes
” 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 Cumbria County Council; that does not assign responsibility.
PFD Monitor interpretation Absence of appropriate signage warning of severe incline or decline on the road ahead
Wider context from the report “The A593 is a scenic cross country road with a speed limit of 60 miles per hour. No signage is present within the area in which the collision occurred, warning road users of the severity of the road gradient or the limitations upon visibility. Coroners concerns are:
1. The absence of appropriate signage to warn road users approaching severe incline/decline on the road ahead
2. The absence of appropriate signage warning of visibility limitations on the road ahead
3. The appropriateness of a 60 mile per hour speed limit on a single carriageway road, with one lane in each direction containing numerous straight sections, bends and gradient changes
” 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 Review the appropriateness of the 60 mph speed limit at the location.
Verbatim wording from the response “The speed limit of 60 mph is typical for the rural roads in the County but this will also be looked at with regard its appropriateness. Any changes to this will require a consultation and legal process which will take at least 6 months to complete.” Source location Response from Cumbria County Council
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 Visit the collision site and review signage, involving police if possible.
Verbatim wording from the response “As a result of the Regulation 28 report we will visit the site, with the police if possible, and review the signage at the collision location. It is hoped to organise this site meeting early in the New Year and install any measures before the end of March.” Source location Response from Cumbria 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 Changes to the speed limit cannot be completed immediately because consultation and legal processes will take at least six months.
Verbatim wording from the response “The speed limit of 60 mph is typical for the rural roads in the County but this will also be looked at with regard its appropriateness. Any changes to this will require a consultation and legal process which will take at least 6 months to complete.” Source location Response from Cumbria County Council
Open published response
9 Jun 2017 Jeffrey William Matthews · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 4 Failure to implement identified highway safety measures View source Failure to maintain roadside vegetation so that the crossroads remains visible View source Failure of independent highway safety investigations to identify obscured junction visibility View source Inadequate warning signage on the north-westerly approach to the junction View source See 1 more concern
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
Jeffrey William Matthews · 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
Jeffrey William Matthews suffered fatal injuries when his motorcycle collided with a Nissan Juke at the C2051 crossroads on 26 March 2017. The report raised concerns that the crossroads and Give Way sign were obscured by hedgerows and that warning signage was inadequate, with previously recommended safety measures not implemented due to a lack of resources.
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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 Cumbria County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to implement identified highway safety measures
Wider context from the report “The C1021 is a minor country road that runs from the A595 at Orton Grange Roundabout in a north westerly direction and terminates when it joins the C2051 at Great Orton village. The road is generally unmarked and just wide enough for two vehicles to pass in opposite directions. The statutory speed limit is 60 mph. Approximately 220 metres prior to the scene of the collision on the C1021, is a left hand bend as you approach from the A595. The bend travels through an angle of approximately 16 degrees before the road straightens on the approach to the crossroads.
The C1021 is straight for approximately 196 metres from the bend to the crossroad and continues straight beyond the crossroads for approximately 159 metres before entering another left hand bend. The police collision investigation report dated 14th August 2017 identifies at paragraph 4.4 that at this point, the presence of the crossroad junction is not obvious to any approaching vehicle. The height of the roadside hedgerows and their close proximity cause a tunnel effect and as such obscure any sign of the crossroads. It is also noted that the presence of the 'Give Way' sign at the crossroad junction is lost in the background and therefore not obviously visible to approaching drivers from a distance.
Cumbria County Council is responsible for implementing measures on the county highway network that aim to reduce casualties and the risk of collisions. The C2051 Great Orton Crossroad was previously identified as having a sufficiently serious collision record during the period 1st October 2012 up to 30th September 2015. Capita were commissioned to carry out an independent investigation and inspection.
The finding in the police investigation report at paragraph 4.4 as set out above was not identified by Capita.
Evidence was heard at the inquest that the recommendations made by Capita in their report dated May 2016 were not implemented due to a lack of resources. The recommendations were;
1. The application of High Friction Surfacing on the north and southbound approached
2. Vegetation trimming – cutting back vegetation to the south-east, north-east and north-west quadrant verge areas
3. Additional Road markings on C1021 junction approaches – provide ‘SLOW’ markings on red patch on the C1021 approaches, adjacent to warning signs.
(1) The current warning signage on approach to the junction from a north westerly direction is inadequate.
(2) The height of the roadside hedgerows and their close proximity causes a tunnel effect obscuring any sign of the crossroads restricting visibility.
(3) Modifications to the junction on approach as recommended by Capita should be re-considered to minimise the risk of incidents and death in the future.
” 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 Cumbria County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain roadside vegetation so that the crossroads remains visible
Wider context from the report “The C1021 is a minor country road that runs from the A595 at Orton Grange Roundabout in a north westerly direction and terminates when it joins the C2051 at Great Orton village. The road is generally unmarked and just wide enough for two vehicles to pass in opposite directions. The statutory speed limit is 60 mph. Approximately 220 metres prior to the scene of the collision on the C1021, is a left hand bend as you approach from the A595. The bend travels through an angle of approximately 16 degrees before the road straightens on the approach to the crossroads.
The C1021 is straight for approximately 196 metres from the bend to the crossroad and continues straight beyond the crossroads for approximately 159 metres before entering another left hand bend. The police collision investigation report dated 14th August 2017 identifies at paragraph 4.4 that at this point, the presence of the crossroad junction is not obvious to any approaching vehicle. The height of the roadside hedgerows and their close proximity cause a tunnel effect and as such obscure any sign of the crossroads. It is also noted that the presence of the 'Give Way' sign at the crossroad junction is lost in the background and therefore not obviously visible to approaching drivers from a distance.
Cumbria County Council is responsible for implementing measures on the county highway network that aim to reduce casualties and the risk of collisions. The C2051 Great Orton Crossroad was previously identified as having a sufficiently serious collision record during the period 1st October 2012 up to 30th September 2015. Capita were commissioned to carry out an independent investigation and inspection.
The finding in the police investigation report at paragraph 4.4 as set out above was not identified by Capita.
Evidence was heard at the inquest that the recommendations made by Capita in their report dated May 2016 were not implemented due to a lack of resources. The recommendations were;
1. The application of High Friction Surfacing on the north and southbound approached
2. Vegetation trimming – cutting back vegetation to the south-east, north-east and north-west quadrant verge areas
3. Additional Road markings on C1021 junction approaches – provide ‘SLOW’ markings on red patch on the C1021 approaches, adjacent to warning signs.
(1) The current warning signage on approach to the junction from a north westerly direction is inadequate.
(2) The height of the roadside hedgerows and their close proximity causes a tunnel effect obscuring any sign of the crossroads restricting visibility.
(3) Modifications to the junction on approach as recommended by Capita should be re-considered to minimise the risk of incidents and death in the future.
” 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 Cumbria County Council; that does not assign responsibility.
PFD Monitor interpretation Failure of independent highway safety investigations to identify obscured junction visibility
Wider context from the report “The C1021 is a minor country road that runs from the A595 at Orton Grange Roundabout in a north westerly direction and terminates when it joins the C2051 at Great Orton village. The road is generally unmarked and just wide enough for two vehicles to pass in opposite directions. The statutory speed limit is 60 mph. Approximately 220 metres prior to the scene of the collision on the C1021, is a left hand bend as you approach from the A595. The bend travels through an angle of approximately 16 degrees before the road straightens on the approach to the crossroads.
The C1021 is straight for approximately 196 metres from the bend to the crossroad and continues straight beyond the crossroads for approximately 159 metres before entering another left hand bend. The police collision investigation report dated 14th August 2017 identifies at paragraph 4.4 that at this point, the presence of the crossroad junction is not obvious to any approaching vehicle. The height of the roadside hedgerows and their close proximity cause a tunnel effect and as such obscure any sign of the crossroads. It is also noted that the presence of the 'Give Way' sign at the crossroad junction is lost in the background and therefore not obviously visible to approaching drivers from a distance.
Cumbria County Council is responsible for implementing measures on the county highway network that aim to reduce casualties and the risk of collisions. The C2051 Great Orton Crossroad was previously identified as having a sufficiently serious collision record during the period 1st October 2012 up to 30th September 2015. Capita were commissioned to carry out an independent investigation and inspection.
The finding in the police investigation report at paragraph 4.4 as set out above was not identified by Capita.
Evidence was heard at the inquest that the recommendations made by Capita in their report dated May 2016 were not implemented due to a lack of resources. The recommendations were;
1. The application of High Friction Surfacing on the north and southbound approached
2. Vegetation trimming – cutting back vegetation to the south-east, north-east and north-west quadrant verge areas
3. Additional Road markings on C1021 junction approaches – provide ‘SLOW’ markings on red patch on the C1021 approaches, adjacent to warning signs.
(1) The current warning signage on approach to the junction from a north westerly direction is inadequate.
(2) The height of the roadside hedgerows and their close proximity causes a tunnel effect obscuring any sign of the crossroads restricting visibility.
(3) Modifications to the junction on approach as recommended by Capita should be re-considered to minimise the risk of incidents and death in the future.
” 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 Cumbria County Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate warning signage on the north-westerly approach to the junction
Wider context from the report “The C1021 is a minor country road that runs from the A595 at Orton Grange Roundabout in a north westerly direction and terminates when it joins the C2051 at Great Orton village. The road is generally unmarked and just wide enough for two vehicles to pass in opposite directions. The statutory speed limit is 60 mph. Approximately 220 metres prior to the scene of the collision on the C1021, is a left hand bend as you approach from the A595. The bend travels through an angle of approximately 16 degrees before the road straightens on the approach to the crossroads.
The C1021 is straight for approximately 196 metres from the bend to the crossroad and continues straight beyond the crossroads for approximately 159 metres before entering another left hand bend. The police collision investigation report dated 14th August 2017 identifies at paragraph 4.4 that at this point, the presence of the crossroad junction is not obvious to any approaching vehicle. The height of the roadside hedgerows and their close proximity cause a tunnel effect and as such obscure any sign of the crossroads. It is also noted that the presence of the 'Give Way' sign at the crossroad junction is lost in the background and therefore not obviously visible to approaching drivers from a distance.
Cumbria County Council is responsible for implementing measures on the county highway network that aim to reduce casualties and the risk of collisions. The C2051 Great Orton Crossroad was previously identified as having a sufficiently serious collision record during the period 1st October 2012 up to 30th September 2015. Capita were commissioned to carry out an independent investigation and inspection.
The finding in the police investigation report at paragraph 4.4 as set out above was not identified by Capita.
Evidence was heard at the inquest that the recommendations made by Capita in their report dated May 2016 were not implemented due to a lack of resources. The recommendations were;
1. The application of High Friction Surfacing on the north and southbound approached
2. Vegetation trimming – cutting back vegetation to the south-east, north-east and north-west quadrant verge areas
3. Additional Road markings on C1021 junction approaches – provide ‘SLOW’ markings on red patch on the C1021 approaches, adjacent to warning signs.
(1) The current warning signage on approach to the junction from a north westerly direction is inadequate.
(2) The height of the roadside hedgerows and their close proximity causes a tunnel effect obscuring any sign of the crossroads restricting visibility.
(3) Modifications to the junction on approach as recommended by Capita should be re-considered to minimise the risk of incidents and death in the future.
” 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 Hold a further police site visit after installing the measures to identify necessary amendments or further improvements.
Verbatim wording from the response “Once all measures have been installed a further site visit will be held with the police to see if any amendments need to be made or if any further improvements are required.” Source location Jeffrey-Matthews-Response
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 Consult the police, Parish Council and County Councillor on proposed high-friction surfacing, road-marking and signage improvements.
Verbatim wording from the response “The scheme to introduce the high friction surfacing, improved road marking and signage is currently out to consultation with the police, the Parish Council and the local County Councillor and subject to agreement, the measures will be introduced as soon as practicable. The vegetation has already been reduced by the local landowners, presumably as a result of the media coverage of the inquest.” Source location Jeffrey-Matthews-Response
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 Allocate funding to implement the collision study’s safety recommendations in 2017/18.
Verbatim wording from the response “As you state in your report a study into road traffic collisions over the 3 year period, October 2012 to September 2015, was carried out by Capita and the report was published in May 2016. As a consequence of this report funding was allocated to implement the recommendations in the current financial year, 2017/18. This is standard practice in allocating funds for safety improvements i.e. the study is carried out in one financial year and depending on priorities the recommendations are implemented in the following financial year.” Source location Jeffrey-Matthews-Response
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 recommendations were not delayed by insufficient resources; funding had already been allocated for 2016/17 and the following year.
Verbatim wording from the response “A statement is made in your letter that the Capita recommendations were not installed due to a lack of resources but they were not installed as by May 2016 the funding had already been allocated for the 2016/17 financial and funding was allocated for the following year, as explained previously.” Source location Jeffrey-Matthews-Response
Open published response
10 Aug 2016 Kevin David RITSON · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 2 Unavailability of a chevron warning sign at a hazardous road location View source Failure to maintain the road surface in a safe condition 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.
×
AI-generated summary
Kevin David RITSON · 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 4 August 2015, Kevin David RITSON lost control of his motorcycle on a bend on the A595 in Cumbria and died at Preston Hospital from unsurvivable injuries. The report raised concerns about the road surface, including poor adhesion, patched holes and the absence of a chevron warning sign removed after an earlier accident.
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 Cumbria County Council; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a chevron warning sign at a hazardous road location
Wider context from the report “(1) The deceased was riding his motor bike through Stangrah Farm near Whitbeck. This had been the scene of an earlier accident damage from which had removed a chevron warning sign . It was clear from photographs that the road surface was not in good condition and holes had been patched. Evidence also showed the road surface adhesion to be below standard.
” 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 Cumbria County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain the road surface in a safe condition
Wider context from the report “(1) The deceased was riding his motor bike through Stangrah Farm near Whitbeck. This had been the scene of an earlier accident damage from which had removed a chevron warning sign. It was clear from photographs that the road surface was not in good condition and holes had been patched . Evidence also showed the road surface adhesion to be below standard .
” Open source report
28 Jan 2016 Andrew William Telford Coates and Polly Sarah Connor · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 5 Failure to specify the type of firework or explosive authorised for storage View source Failure to prevent combustible and incompatible material and equipment from the firework-store access route View source Failure to designate a specific licensed explosives-storage site View source Inadequate inspection records for the explosives store View source Unsuitable structure for a firework store View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Andrew William Telford Coates and Polly Sarah Connor · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 30 August 2014, an unexplained explosion in the Fireworks Store at Larch Cottage trapped Andrew William Telford Coates and Polly Sarah Connor, and the building was consumed by fire. Both died from a fatal level of carbon monoxide inhalation. Concerns included the suitability and contents of the fireworks store, deficiencies in the licence, and sketchy inspection records, with the store's construction and non-firework contents said to have exacerbated the fire.
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 Cumbria County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to specify the type of firework or explosive authorised for storage
Wider context from the report “The Fireworks Store at Larch Cottage was, in 2008, licenced under the terms of the Manufacture and Storage of Explosives Regulations 2005. The premises had been subject to a Registration since 2004.
It is questionable as to whether what amounted to a wooden shed comprised within a vehicle garage was a suitable structure for a firework store, particularly one licenced for 1000 kg.
Evidence was given that the store contained a large amount of other material some of it combustible and access could only be made to the store via an adjoining compartment containing two petrol driven machines. It seemed that this state of affairs had obtained for a number of years, notwithstanding apparently compliant inspections.
In addition the licence granted was deficient in that it effectively licenced the entire property instead of designating a specific site. The licence did not specify the type of firework or explosive to be stored.
The effect was to give authority to store explosives of any type up to a net explosive quantity of 1000 kg. The records of inspections were sketchy.
The construction and none firework content of the store at the very least exacerbated the ensuing fire.
The Fireworks Store at Larch Cottage was, in 2008, licenced under the terms of the Manufacture and Storage of Explosives Regulations 2005. The premises had been subject to a Registration since 2004.
It is questionable as to whether what amounted to a wooden shed comprised within a vehicle garage was a suitable structure for a firework store, particularly one licenced for 1000 kg.
Evidence was given that the store contained a large amount of other material some of it combustible and access could only be made to the store via an adjoining compartment containing two petrol driven machines. It seemed that this state of affairs had obtained for a number of years, notwithstanding apparently compliant inspections.
In addition the licence granted was deficient in that it effectively licenced the entire property instead of designating a specific site. The licence did not specify the type of firework or explosive to be stored.
The effect was to give authority to store explosives of any type up to a net explosive quantity of 1000 kg. The records of inspections were sketchy.
The construction and none firework content of the store at the very least exacerbated the ensuing fire.
” 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 Cumbria County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent combustible and incompatible material and equipment from the firework-store access route
Wider context from the report “The Fireworks Store at Larch Cottage was, in 2008, licenced under the terms of the Manufacture and Storage of Explosives Regulations 2005. The premises had been subject to a Registration since 2004.
It is questionable as to whether what amounted to a wooden shed comprised within a vehicle garage was a suitable structure for a firework store, particularly one licenced for 1000 kg.
Evidence was given that the store contained a large amount of other material some of it combustible and access could only be made to the store via an adjoining compartment containing two petrol driven machines. It seemed that this state of affairs had obtained for a number of years, notwithstanding apparently compliant inspections.
In addition the licence granted was deficient in that it effectively licenced the entire property instead of designating a specific site. The licence did not specify the type of firework or explosive to be stored.
The effect was to give authority to store explosives of any type up to a net explosive quantity of 1000 kg. The records of inspections were sketchy.
The construction and none firework content of the store at the very least exacerbated the ensuing fire.
The Fireworks Store at Larch Cottage was, in 2008, licenced under the terms of the Manufacture and Storage of Explosives Regulations 2005. The premises had been subject to a Registration since 2004.
It is questionable as to whether what amounted to a wooden shed comprised within a vehicle garage was a suitable structure for a firework store, particularly one licenced for 1000 kg.
Evidence was given that the store contained a large amount of other material some of it combustible and access could only be made to the store via an adjoining compartment containing two petrol driven machines. It seemed that this state of affairs had obtained for a number of years, notwithstanding apparently compliant inspections.
In addition the licence granted was deficient in that it effectively licenced the entire property instead of designating a specific site. The licence did not specify the type of firework or explosive to be stored.
The effect was to give authority to store explosives of any type up to a net explosive quantity of 1000 kg. The records of inspections were sketchy.
The construction and none firework content of the store at the very least exacerbated the ensuing fire.
” 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 Cumbria County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to designate a specific licensed explosives-storage site
Wider context from the report “The Fireworks Store at Larch Cottage was, in 2008, licenced under the terms of the Manufacture and Storage of Explosives Regulations 2005. The premises had been subject to a Registration since 2004.
It is questionable as to whether what amounted to a wooden shed comprised within a vehicle garage was a suitable structure for a firework store, particularly one licenced for 1000 kg.
Evidence was given that the store contained a large amount of other material some of it combustible and access could only be made to the store via an adjoining compartment containing two petrol driven machines. It seemed that this state of affairs had obtained for a number of years, notwithstanding apparently compliant inspections.
In addition the licence granted was deficient in that it effectively licenced the entire property instead of designating a specific site. The licence did not specify the type of firework or explosive to be stored.
The effect was to give authority to store explosives of any type up to a net explosive quantity of 1000 kg. The records of inspections were sketchy.
The construction and none firework content of the store at the very least exacerbated the ensuing fire.
The Fireworks Store at Larch Cottage was, in 2008, licenced under the terms of the Manufacture and Storage of Explosives Regulations 2005. The premises had been subject to a Registration since 2004.
It is questionable as to whether what amounted to a wooden shed comprised within a vehicle garage was a suitable structure for a firework store, particularly one licenced for 1000 kg.
Evidence was given that the store contained a large amount of other material some of it combustible and access could only be made to the store via an adjoining compartment containing two petrol driven machines. It seemed that this state of affairs had obtained for a number of years, notwithstanding apparently compliant inspections.
In addition the licence granted was deficient in that it effectively licenced the entire property instead of designating a specific site. The licence did not specify the type of firework or explosive to be stored.
The effect was to give authority to store explosives of any type up to a net explosive quantity of 1000 kg. The records of inspections were sketchy.
The construction and none firework content of the store at the very least exacerbated the ensuing fire.
” 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 Cumbria County Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate inspection records for the explosives store
Wider context from the report “The Fireworks Store at Larch Cottage was, in 2008, licenced under the terms of the Manufacture and Storage of Explosives Regulations 2005. The premises had been subject to a Registration since 2004.
It is questionable as to whether what amounted to a wooden shed comprised within a vehicle garage was a suitable structure for a firework store, particularly one licenced for 1000 kg.
Evidence was given that the store contained a large amount of other material some of it combustible and access could only be made to the store via an adjoining compartment containing two petrol driven machines. It seemed that this state of affairs had obtained for a number of years, notwithstanding apparently compliant inspections.
In addition the licence granted was deficient in that it effectively licenced the entire property instead of designating a specific site. The licence did not specify the type of firework or explosive to be stored.
The effect was to give authority to store explosives of any type up to a net explosive quantity of 1000 kg. The records of inspections were sketchy.
The construction and none firework content of the store at the very least exacerbated the ensuing fire.
The Fireworks Store at Larch Cottage was, in 2008, licenced under the terms of the Manufacture and Storage of Explosives Regulations 2005. The premises had been subject to a Registration since 2004.
It is questionable as to whether what amounted to a wooden shed comprised within a vehicle garage was a suitable structure for a firework store, particularly one licenced for 1000 kg.
Evidence was given that the store contained a large amount of other material some of it combustible and access could only be made to the store via an adjoining compartment containing two petrol driven machines. It seemed that this state of affairs had obtained for a number of years, notwithstanding apparently compliant inspections.
In addition the licence granted was deficient in that it effectively licenced the entire property instead of designating a specific site. The licence did not specify the type of firework or explosive to be stored.
The effect was to give authority to store explosives of any type up to a net explosive quantity of 1000 kg. The records of inspections were sketchy.
The construction and none firework content of the store at the very least exacerbated the ensuing fire.
” 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 Cumbria County Council; that does not assign responsibility.
PFD Monitor interpretation Unsuitable structure for a firework store
Wider context from the report “The Fireworks Store at Larch Cottage was, in 2008, licenced under the terms of the Manufacture and Storage of Explosives Regulations 2005. The premises had been subject to a Registration since 2004.
It is questionable as to whether what amounted to a wooden shed comprised within a vehicle garage was a suitable structure for a firework store, particularly one licenced for 1000 kg.
Evidence was given that the store contained a large amount of other material some of it combustible and access could only be made to the store via an adjoining compartment containing two petrol driven machines. It seemed that this state of affairs had obtained for a number of years, notwithstanding apparently compliant inspections.
In addition the licence granted was deficient in that it effectively licenced the entire property instead of designating a specific site. The licence did not specify the type of firework or explosive to be stored.
The effect was to give authority to store explosives of any type up to a net explosive quantity of 1000 kg. The records of inspections were sketchy.
The construction and none firework content of the store at the very least exacerbated the ensuing fire.
The Fireworks Store at Larch Cottage was, in 2008, licenced under the terms of the Manufacture and Storage of Explosives Regulations 2005. The premises had been subject to a Registration since 2004.
It is questionable as to whether what amounted to a wooden shed comprised within a vehicle garage was a suitable structure for a firework store, particularly one licenced for 1000 kg.
Evidence was given that the store contained a large amount of other material some of it combustible and access could only be made to the store via an adjoining compartment containing two petrol driven machines. It seemed that this state of affairs had obtained for a number of years, notwithstanding apparently compliant inspections.
In addition the licence granted was deficient in that it effectively licenced the entire property instead of designating a specific site. The licence did not specify the type of firework or explosive to be stored.
The effect was to give authority to store explosives of any type up to a net explosive quantity of 1000 kg. The records of inspections were sketchy.
The construction and none firework content of the store at the very least exacerbated the ensuing fire.
” 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 Audit large Cumbrian firework stores and associated licences, correcting the identified quantity and separation-distance issue.
Verbatim wording from the response “• Externally validate the large firework stores in Cumbria, so that expert opinion on the construction, suitability and compliance with the regulations could be sought.” Source location 2016-0025-Response-by-Cumbria-County-Council
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 Train all operational Trading Standards officers and fireworks administrators on explosive-regulation requirements, including firework storage and construction standards.
Verbatim wording from the response “for the Chartered Trading Standards Institute, and is a Fellow of the Association for Petroleum and Explosive Administration with over 25 years experience.
I can confirm that the following actions have been undertaken to address your concerns:” Source location 2016-0025-Response-by-Cumbria-County-Council
Open published response
8 Jul 2015 Meryl Parry · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 2 Lack of appropriate arrangements to ensure residents' safety and welfare after discharge View source Lack of a system requiring residential home managers to seek Social Services advice before discharging residents 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.
×
AI-generated summary
Meryl Parry · 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
Meryl Parry, who had Alzheimer’s disease and tended to wander, was discharged from a residential home on 1 September 2014 after leaving it unobserved and was returned home. She was subsequently unlawfully killed by her husband; concerns included the absence of a system requiring residential homes to seek Social Services advice before discharge and risks to residents’ safety and welfare afterwards.
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 Cumbria County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of appropriate arrangements to ensure residents' safety and welfare after discharge
Wider context from the report “(1) There appears to be no system in place whereby the managers of a residential home are required to seek advice from Social Services before discharging a resident
(2) There is therefore a serious risk that there are no appropriate arrangements in place to ensure the safety and welfare of the resident after discharge .
(3) The system for seeking advice from Social Services should apply irrespective of whether Social Services had placed the resident at the home or whether the placement had been a private one. In the latter case it is likely that a social worker will have been aware of, or had some involvement in, the placement.
” 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 Cumbria County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a system requiring residential home managers to seek Social Services advice before discharging residents
Wider context from the report “(1) There appears to be no system in place whereby the managers of a residential home are required to seek advice from Social Services before discharging a resident
(2) There is therefore a serious risk that there are no appropriate arrangements in place to ensure the safety and welfare of the resident after discharge.
(3) The system for seeking advice from Social Services should apply irrespective of whether Social Services had placed the resident at the home or whether the placement had been a private one . In the latter case it is likely that a social worker will have been aware of, or had some involvement in, the placement.
” Open source report
3 Jul 2014 Helena Kathleen Farrell · Prevention of Future Deaths report South and East Cumbria
View report summary
Concerns raised 8 Unrealistic school nurse service workload expectations View source Failure to recognise escalating incident seriousness and frequency View source Inadequate CAMHS staffing numbers View source Failure to verify school counsellor updating, training and professional registration View source Failure to verify school counsellor qualifications and competence View source Failure to follow up urgent CAMHS referrals after triage View source Failure of the CAMHS referral system to function adequately View source Insufficient CAMHS staff experience and training in working with teenagers View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Helena Kathleen Farrell · 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
Helena Kathleen Farrell had bulimia, had been sexually assaulted, took an overdose, self-harmed, and wrote letters that appeared to be suicide letters after her death. She died from hanging following a period in which she was not seen by CAMHS until the day before her death, and those dealing with her did not recognise her suicidal feelings and intentions. The concerns included failures in the CAMHS referral and follow-up system, inadequate staffing and training, failure to recognise escalating seriousness, unrealistic demands on the school nurse, and insufficient checking of the school counsellor’s credentials.
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 Cumbria County Council; that does not assign responsibility.
PFD Monitor interpretation Unrealistic school nurse service workload expectations
Wider context from the report “(4) As far as Cumbria County Council is concerned, they are involved because I understand they are responsible for provision of the school nurse service although they contract this out to the Partnership Trust but nonetheless the responsibility lies with Cumbria County Council. I thought that the expectations of the school nurse in this particular case were totally unrealistic. I heard in evidence that she was responsible for 5 senior schools and 20 or more feeder schools to those 5 senior schools and although the total number of pupils involved was not clear, it is obviously thousands rather than hundreds. She worked a 26 hour week, had 40 current cases at Kirkbie Kendal School alone. The provision of service at this level is totally unfair on the school nurse concerned , unrealistic in the sense that she seems to have expectations of a school nurse which one part time provider cannot meet .
” 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 Cumbria County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise escalating incident seriousness and frequency
Wider context from the report “(3) Those dealing with Helena failed to recognise the escalation of the incidents in which she was involved in terms of their seriousness and their increasing frequency .
” 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 Cumbria County Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate CAMHS staffing numbers
Wider context from the report “(2) Staffing levels at CAMHS were inadequate in terms of pure numbers and also in terms of experience and training in connection with teenagers.
” 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 Cumbria County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to verify school counsellor updating, training and professional registration
Wider context from the report “(5) The school’s counsellor had been in post for many years and there was no proof of her qualifications or her competence nor of update and training or registration with any professional body . The County Council needs to be more thorough with checking credentials.
” 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 Cumbria County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to verify school counsellor qualifications and competence
Wider context from the report “(5) The school’s counsellor had been in post for many years and there was no proof of her qualifications or her competence nor of update and training or registration with any professional body. The County Council needs to be more thorough with checking credentials.
” 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 Cumbria County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to follow up urgent CAMHS referrals after triage
Wider context from the report “(1) As for CAMHS (part of the Foundation Trust) the referral system was not working adequately and the referral was not followed up after triage even though it was classified as urgent .
” 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 Cumbria County Council; that does not assign responsibility.
PFD Monitor interpretation Failure of the CAMHS referral system to function adequately
Wider context from the report “(1) As for CAMHS (part of the Foundation Trust) the referral system was not working adequately and the referral was not followed up after triage even though it was classified as urgent.
” 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 Cumbria County Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient CAMHS staff experience and training in working with teenagers
Wider context from the report “(2) Staffing levels at CAMHS were inadequate in terms of pure numbers and also in terms of experience and training in connection with teenagers .
” 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 Work with the Local Safeguarding Children Board to amend multiagency safeguarding systems.
Verbatim wording from the response “We are working with the Local Safeguarding Children Board to amend the multiagency systems appropriately, and with Cumbria Partnership Foundation Trust to make the necessary changes within the School Nursing Service on a voluntary basis within the context of the existing contract. We will be building all necessary changes into the new service specification to be commissioned from October 2015.” Source location 2014-0309-Response-by-Cumbria-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 Audit a sample of schools’ compliance with counsellor qualification and clinical supervision duties, and present the results to the Local Safeguarding Children Board.
Verbatim wording from the response “The Council has in the past reminded schools of their duty to ensure that counsellors are appropriately qualified with appropriate clinical supervision. Following your report we shall do so again by the end of September and will also undertake a sample audit later in the school year to ascertain from schools whether they have complied with their duty. The results of this audit will be presented to the Local Safeguarding Children’s Board.” Source location 2014-0309-Response-by-Cumbria-County-Council
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 Build necessary School Nursing Service changes into the specification for commissioning from October 2015.
Verbatim wording from the response “We are working with the Local Safeguarding Children Board to amend the multiagency systems appropriately, and with Cumbria Partnership Foundation Trust to make the necessary changes within the School Nursing Service on a voluntary basis within the context of the existing contract. We will be building all necessary changes into the new service specification to be commissioned from October 2015.” Source location 2014-0309-Response-by-Cumbria-County-Council
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 Work with Cumbria Partnership Foundation Trust to make necessary changes within the School Nursing Service under the existing contract.
Verbatim wording from the response “We are working with the Local Safeguarding Children Board to amend the multiagency systems appropriately, and with Cumbria Partnership Foundation Trust to make the necessary changes within the School Nursing Service on a voluntary basis within the context of the existing contract. We will be building all necessary changes into the new service specification to be commissioned from October 2015.” Source location 2014-0309-Response-by-Cumbria-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 Complete a case audit of safeguarding and child protection arrangements within the School Nursing Service.
Verbatim wording from the response “Your findings, together with the Cumbria Partnership Foundation Trust Serious Untoward Incident Report and the Serious Case Review Report, indicate a problem with capacity in the school nursing system meaning that school nurses are not able to devote the appropriate amount of time to cases that really need their input. We have therefore carried out a full case audit to determine whether the existing approach to safeguarding and child protection within the service could be improved. This audit has revealed a number of areas where the multiagency safeguarding system could be improved in order to reduce significantly the bureaucratic burden on school nursing, without increasing the risk to other children. This would clearly free up school nurse time to focus on other issues, including giving adequate time to individual cases where their input is most appropriate.” Source location 2014-0309-Response-by-Cumbria-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 Remind schools to ensure school counsellors are appropriately qualified and receive appropriate clinical supervision.
Verbatim wording from the response “The Council has in the past reminded schools of their duty to ensure that counsellors are appropriately qualified with appropriate clinical supervision. Following your report we shall do so again by the end of September and will also undertake a sample audit later in the school year to ascertain from schools whether they have complied with their duty. The results of this audit will be presented to the Local Safeguarding Children’s Board.” Source location 2014-0309-Response-by-Cumbria-County-Council
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 Fund three additional posts within the School Nursing Service to increase capacity.
Verbatim wording from the response “Recognising the immediate pressure on the School Nursing Service, since April 2013 the Council has funded a further three posts within the service. However this has always been seen as a short term solution to relieve pressure while a more fundamental review of the service is undertaken.” Source location 2014-0309-Response-by-Cumbria-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 Individual community and voluntary controlled schools are legally responsible for deciding appointments and completing relevant employment checks for counsellors.
Verbatim wording from the response “The Council does employ counsellors at Community and Voluntary Controlled Schools however deciding which staff are appointed and ensuring the relevant employment checks are completed is the legal responsibility of the individual school. The school must adhere to relevant safeguarding guidance and employment law.” Source location 2014-0309-Response-by-Cumbria-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 Academies and foundation or voluntary aided schools appoint and employ their counsellors, so responsibility for relevant checks rests with their governing bodies or academies.
Verbatim wording from the response “The Council is not the employer of counsellors at Academies such as Kirkbie Kendal School or in Foundation or Voluntary Aided Schools. The Governing Body or the Academy appoints and employs all staff in these schools.” Source location 2014-0309-Response-by-Cumbria-County-Council
Open published response
9 Apr 2014 Russell Edward Long · Prevention of Future Deaths report Cumbria (North & West)
View report summary
Concerns raised 1 Failure to maintain the bridge parapet in a safe condition 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
Russell Edward Long · 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
Russell Edward Long was driving at night in foggy conditions when his vehicle left the road, struck a bridge parapet, overturned and fell into a river. The report raised concern that the damaged, overgrown parapet formed a ramp that could cause a similar accident, and identified the need to consider repairing it and erecting a barrier.
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 Cumbria County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain the bridge parapet in a safe condition
Wider context from the report “The deceased was driving east on the B5307 Road approaching the bridge over the River Wampool between Fingland and Kirkbride. His vehicle left the road. The near side parapet of the bridge had been previously damaged some considerable time ago. Grass had overgrown the area, and end stones and coping stones had been dislodged. What remained amounted to a “ramp”. When the deceased’s vehicle hit this, the car became airborne and it overturned. It is entirely foreseeable that if the parapet remains in this condition a similar accident could occur in the future. Action should be considered to repair the parapet and erect a barrier to guide vehicles away from the hazard.
” 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 Raise the North West parapet wall to match the vehicle restraint system height.
Verbatim wording from the response “I can inform you that all the past month works have been carried out at this site which will address the issues you have raised.” Source location 2014-0165-Response-by-Cumbria-County-Council
Open published response
3 Feb 2014 Michael John Telford · Prevention of Future Deaths report Cumbria (North & West)
View report summary
Concerns raised 1 Regular water spillage onto the B5302 creating a 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
Michael John Telford · 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 6 December 2012, Michael John Telford was driving on the B5302 when another vehicle entered his carriageway after travelling through floodwater and collided with his car. Evidence at the inquest indicated that water spilling onto the road was a regular hazard, with concern that further accidents might occur if the issue was not addressed.
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 Cumbria County Council; that does not assign responsibility.
PFD Monitor interpretation Regular water spillage onto the B5302 creating a road hazard
Wider context from the report “Evidence given at the inquest revealed that water spilling onto the B5302 near Wheyrigg Hall on the road to Abbeytown was a regular hazard . The presence of the water resulted in an accident on the 6th December 2012. The position is likely to be exacerbated in freezing weather . The concern is that if this matter is not addressed further accidents may occur. (Plan attached).
” Open source report
31 Oct 2013 Wilhelmina Isobel Newton · Prevention of Future Deaths report North and West Cumbria
View report summary
Concerns raised 1 Lack of clear written guidance for responding to potential head injuries in elderly residents receiving medication affecting blood clotting View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Wilhelmina Isobel Newton · 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
Wilhelmina Isobel Newton, a resident at Grisedale Croft Residential Home, fell from her bed and was found on the floor at about 04.30 hours. She was not attended by a nurse until 09.45 hours, was later admitted to Cumberland Infirmary, and died on 15 May 2013 from a subdural haematoma following the fall. The principal concern was the apparent absence of clear written guidance for staff responding to potential head injuries in elderly residents, particularly those receiving medication affecting blood clotting.
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 Cumbria County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of clear written guidance for responding to potential head injuries in elderly residents receiving medication affecting blood clotting
Wider context from the report “On the evidence heard it appeared there was no clear written plan , protocol or guidance to the staff as to how they should respond to a potential head injury to an elderly resident, particularly one receiving medication which had the potential to affect the blood’s clotting ability : the absence of such guidance may apply to other residential homes operated by the Council
” 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 Cascade the new policy throughout the organisation and to the wider adult social care workforce through Services Care Sector Alliance Cumbria.
Verbatim wording from the response “These specific issues have been reviewed and Cumbria Care has drawn up a new Policy that clearly identifies the procedures to be followed and the checks that need to be undertaken. This document will be cascaded throughout the organisation and to the wider adult social care workforce via Services Care Sector Alliance Cumbria. I enclose a copy of the Policy for your reference.” Source location 2013-0283-Response-by-Cumbria-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 Develop a policy identifying procedures and checks for suspected stroke cases involving medication that affects blood clotting.
Verbatim wording from the response “These specific issues have been reviewed and Cumbria Care has drawn up a new Policy that clearly identifies the procedures to be followed and the checks that need to be undertaken. This document will be cascaded throughout the organisation and to the wider adult social care workforce via Services Care Sector Alliance Cumbria. I enclose a copy of the Policy for your reference.” Source location 2013-0283-Response-by-Cumbria-County-Council
Open published response
7 Aug 2013 Matthew Thomas Hamilton · Prevention of Future Deaths report North and West Cumbria
View report summary
Concerns raised 3 Lack of barrier or restriction at the end of the footpath View source Insufficient pavement width at the footpath end View source Obstructed visibility for footpath and road users 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.
×
AI-generated summary
Matthew Thomas Hamilton · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Matthew Thomas Hamilton was fatally injured when he was thrown from his pedal cycle after braking sharply as a car approached while he emerged from a footpath in Carlisle. Concerns were raised about the lack of a barrier or restriction, the narrow pavement, and restricted visibility from fencing and shrubbery, creating hazards for footpath and road users.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of barrier or restriction at the end of the footpath
Wider context from the report “There is no barrier or restriction at the end of the footpath , such as are commonly found on footpaths or at school gates. The pavement is only some 1.5metres wide. This means that children whether on foot or otherwise can emerge suddenly at speed straight into the line of traffic . It was also noted that the taller metal fence and shrubbery restricts the vision of both footpath and road users. These represent hazards which should be looked into, and some action might be taken to reduce the risk of future deaths.
” 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 Cumbria County Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient pavement width at the footpath end
Wider context from the report “There is no barrier or restriction at the end of the footpath, such as are commonly found on footpaths or at school gates. The pavement is only some 1.5metres wide . This means that children whether on foot or otherwise can emerge suddenly at speed straight into the line of traffic . It was also noted that the taller metal fence and shrubbery restricts the vision of both footpath and road users. These represent hazards which should be looked into, and some action might be taken to reduce the risk of future deaths.
” 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 Cumbria County Council; that does not assign responsibility.
PFD Monitor interpretation Obstructed visibility for footpath and road users
Wider context from the report “There is no barrier or restriction at the end of the footpath, such as are commonly found on footpaths or at school gates. The pavement is only some 1.5metres wide. This means that children whether on foot or otherwise can emerge suddenly at speed straight into the line of traffic. It was also noted that the taller metal fence and shrubbery restricts the vision of both footpath and road users . These represent hazards which should be looked into, and some action might be taken to reduce the risk of future deaths.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations