6 Apr 2026 Allan STEVENSON · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 8 Failure to provide Network Inspectors with information about deviations from the original temporary traffic scheme plan View source Lack of safety escalation when site operatives identify scheme safety issues View source Lack of a defect-notice mechanism for dangerous special-signage deficiencies View source Lack of enhanced safety review for complex temporary road traffic plans flipped at short notice View source Delayed and indirect replacement pathway for temporary traffic management signage View source Failure to consider required special signage after a temporary traffic plan is flipped View source Failure to answer the temporary traffic management defect line promptly View source Lack of spare signage for correcting identified temporary road traffic scheme errors View source See 5 more concerns
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
Allan STEVENSON · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Allan Stevenson, a 73-year-old cyclist, died from injuries sustained in a road traffic collision involving an HGV at a roundabout with a temporary traffic management system. The inquest concluded that his death was contributed to by the temporary road layout. Concerns included the flipping of a complex traffic management plan without an enhanced safety review, inadequate or missing signage, limited escalation and inspection processes, delayed responses to reported defects, and the absence of spare signage for immediate changes.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure to provide Network Inspectors with information about deviations from the original temporary traffic scheme plan
Wider context from the report “5. I am concerned that there is no apparent system in place to inform Network Inspectors that a traffic scheme has been laid out, contrary to the original plan that was in place (as in this case when a plan has been flipped).
As a result of the Network Inspector having no access to, or sight of the original plan , he was unaware that the original plan had been flipped, unaware of the suspension of the cycle lanes approaching the roundabout and unaware that the special signage deemed necessary in the original plan, was completely absent in the flipped scheme that was put in place.
As such the Network Inspector’s ability to check the safety of the flipped scheme was seriously compromised .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of safety escalation when site operatives identify scheme safety issues
Wider context from the report “2. I am concerned that there is no apparent safety escalation process , when as in this case a relatively junior Traffic Management Operative identifies a safety issue with a scheme once it has begun operations .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of a defect-notice mechanism for dangerous special-signage deficiencies
Wider context from the report “3. I am concerned that the correct ‘special signage’ that would have undoubtedly made this scheme safer, was not even considered in this case (as a direct result of the flipping of the original plan).
I am further concerned that Network Inspectors have no power to declare a special sign (or the lack of a special sign) as a defect , as these signs fall outside the mandatory signage shown in the Red Book.
As such, even if a Network Inspector identified what they believed to be a dangerous temporary traffic management scheme, any danger being caused by the lack of special signage (or caused by special signage on site that is incorrect), there is no mechanism available for a Network Inspector to issue a defect notice to raise their concern .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of enhanced safety review for complex temporary road traffic plans flipped at short notice
Wider context from the report “1. I am concerned that what was agreed by witnesses to be a complex temporary road traffic plan, can be ‘flipped’ on the ground on the day it is installed without any identifiable process being in place to ensure the scheme is subsequently safe .
The court heard that some schemes (such as a single carriage way scheme controlled by only two sets of traffic lights) were straight forward to flip if required, but that no additional or enhanced review system was in place when a complex scheme needed to be flipped at short notice .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Delayed and indirect replacement pathway for temporary traffic management signage
Wider context from the report “4. I am concerned of that the only recourse for a Network Inspector to get temporary traffic management signage replaced, is an apparently protected procedural route involving multiple individuals remote from the site , with the Network Inspector having limited or no contact with the Traffic Management Operatives at the site itself .
I am further concerned that there is no requirement for spare signage to be carried on vehicles used for setting up the schemes, for obvious or frequently occurring errors identified on temporary road traffic schemes (such as in this case the road narrow signs being the wrong way around).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure to consider required special signage after a temporary traffic plan is flipped
Wider context from the report “3. I am concerned that the correct ‘special signage’ that would have undoubtedly made this scheme safer, was not even considered in this case (as a direct result of the flipping of the original plan ).
I am further concerned that Network Inspectors have no power to declare a special sign (or the lack of a special sign) as a defect, as these signs fall outside the mandatory signage shown in the Red Book.
As such, even if a Network Inspector identified what they believed to be a dangerous temporary traffic management scheme, any danger being caused by the lack of special signage (or caused by special signage on site that is incorrect), there is no mechanism available for a Network Inspector to issue a defect notice to raise their concern.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure to answer the temporary traffic management defect line promptly
Wider context from the report “6. I am concerned that the ‘defect line’ operated by Anglian Water was not answered or responded to on the day of this incident , adding unnecessary delay to the changes required to the scheme signage . It is acknowledged that the signage defect identified on the 24th October 2022 would not have affected the tragic outcome of this case, however that may not be the case in future incidents
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of spare signage for correcting identified temporary road traffic scheme errors
Wider context from the report “4. I am concerned of that the only recourse for a Network Inspector to get temporary traffic management signage replaced, is an apparently protected procedural route involving multiple individuals remote from the site, with the Network Inspector having limited or no contact with the Traffic Management Operatives at the site itself.
I am further concerned that there is no requirement for spare signage to be carried on vehicles used for setting up the schemes , for obvious or frequently occurring errors identified on temporary road traffic schemes (such as in this case the road narrow signs being the wrong way around).
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consult on proposed updates to the Safety at Street Works and Road Works Code of Practice.
Verbatim wording from the response “The Department considers that, when applied effectively, this framework provides a robust basis for the safe management of works on the highway. We are currently reviewing the Code of Practice and intend to consult on proposed updates later this year. This work will build on the existing framework, including strengthening expectations in relation to cyclists and improving the clarity of temporary traffic arrangements, and will take into account the concerns raised in your report.” Source location Response from Department for Transport
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 the Safety at Street Works and Road Works Code of Practice, including cyclist safety and clearer temporary traffic arrangements.
Verbatim wording from the response “The Department considers that, when applied effectively, this framework provides a robust basis for the safe management of works on the highway. We are currently reviewing the Code of Practice and intend to consult on proposed updates later this year. This work will build on the existing framework, including strengthening expectations in relation to cyclists and improving the clarity of temporary traffic arrangements, and will take into account the concerns raised in your report.” Source location Response from Department for Transport
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 Works promoters and highway authorities are responsible for designing, approving, monitoring and implementing temporary traffic management arrangements.
Verbatim wording from the response “The Department’s role is to set the overarching legal and policy framework for road safety and to provide guidance. Responsibility for the design, approval and monitoring of temporary traffic management arrangements sits with those undertaking the works and the relevant highway authority. These parties are responsible for ensuring that arrangements are appropriate for the specific circumstances on site.” Source location Response from Department for Transport
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The existing principles-based Code provides a robust basis for safely managing temporary traffic management, including adapting arrangements to site conditions.
Verbatim wording from the response “The Department considers that, when applied effectively, this framework provides a robust basis for the safe management of works on the highway. We are currently reviewing the Code of Practice and intend to consult on proposed updates later this year. This work will build on the existing framework, including strengthening expectations in relation to cyclists and improving the clarity of temporary traffic arrangements, and will take into account the concerns raised in your report.” Source location Response from Department for Transport
Open published response
1 Apr 2026 Susan Jane WHITTLES · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 3 Lack of examiner provision to withdraw unsupervised driving after failure to meet required standards View source Ability of non-designated-country nationals who fail GB driving tests to revert to driving on a foreign or international licence View source Lack of equivalent supervision and inexperience-warning restrictions for non-designated-country nationals who fail a GB driving test 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
Susan Jane WHITTLES · 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
Susan Jane WHITTLES died at the scene of a road traffic collision on 24 November 2023 after another vehicle failed to give way and collided with her vehicle. The substantive concerns relate to non-designated-country nationals being able to continue driving in Great Britain on a foreign or international licence after failing GB driving tests, without appropriate supervision, potentially creating a risk of serious injury or harm to other 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of examiner provision to withdraw unsupervised driving after failure to meet required standards
Wider context from the report “(4) There appears no provision for an examiner to withdraw the ability to drive without appropriate supervision despite a person’s failure to meet the required standards .
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Ability of non-designated-country nationals who fail GB driving tests to revert to driving on a foreign or international licence
Wider context from the report “(3) If a national of a non-designated country fails any number of driving tests within the 12 month period they are still able to revert and rely on their 12 month limit to drive on their foreign/international licence in the UK , despite not meeting the safety standards set by the DVSA .
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of equivalent supervision and inexperience-warning restrictions for non-designated-country nationals who fail a GB driving test
Wider context from the report “(2) Nationals of non-designated countries who fail a GB driving test are not treated in the same way as a GB resident who fails a GB driving test . A GB resident is not allowed to drive without appropriate supervision and when they are driving they must display L plates to act as a warning to other vehicles of their inexperience .
” 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 Examine the domestic and international legal framework to identify measures addressing continued unsupervised driving after a failed practical test.
Verbatim wording from the response “However, my department and I are firmly of the view that there is no compelling policy rationale to justify allowing unsafe drivers to use our roads, and are committed to looking into this further. This requires detailed examination of the relevant domestic and international legal framework, and so may take some time, but I would like to assure you we are actively looking into what can be done, consistent with the UK's international obligations.” Source location Response from Department for Transport & Driver and Vehicle Standards Agency
Open published response
24 Mar 2026 James Scott COATES · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 2 Insufficiently robust arrangements for ensuring that drivers with serious conditions have their licences properly reviewed View source Failure of drivers to self-report potentially significant conditions to the DVLA 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
James Scott COATES · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
James Scott Coates died after a head-on collision while driving around a bend at approximately 90 mph on an unlit rural road, where 75% of the Cats Eye reflectors were not functioning. He sustained unsurvivable injuries and was declared dead at the roadside. The principal concern was that drivers with potentially significant conditions, including epilepsy and cannabis use, may not notify the DVLA, while legislation places the reporting responsibility on licence holders rather than doctors, which was considered insufficiently robust to ensure proper licence review.
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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Insufficiently robust arrangements for ensuring that drivers with serious conditions have their licences properly reviewed
Wider context from the report “I previously sent you a Prevention of Future Deaths Report (in relation to the deaths of Neil Errington and Gareth and Patricia Evans) highlighting my concern that the expectation that drivers would self-report their conditions (which arises as a matter of legislation) was not being followed.
The evidence in this inquest provides further cause for concern. Once again, the evidence is that a person with potentially significant conditions never notified the DVLA, and that his doctors did not draw it to the DVLA's attention because legislation places the onus on licence holders and not their doctors . I remain of the view that this is insufficiently robust to ensure that drivers with serious conditions are not having their licences properly reviewed .
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure of drivers to self-report potentially significant conditions to the DVLA
Wider context from the report “I previously sent you a Prevention of Future Deaths Report (in relation to the deaths of Neil Errington and Gareth and Patricia Evans) highlighting my concern that the expectation that drivers would self-report their conditions (which arises as a matter of legislation) was not being followed .
The evidence in this inquest provides further cause for concern. Once again, the evidence is that a person with potentially significant conditions never notified the DVLA , and that his doctors did not draw it to the DVLA's attention because legislation places the onus on licence holders and not their doctors. I remain of the view that this is insufficiently robust to ensure that drivers with serious conditions are not having their licences properly reviewed.
” Open source report
17 Mar 2026 Scott Maxwell Henry CATTON · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 2 Lack of a requirement for electric scooter riders to wear helmets View source Risk of death to electric scooter and bicycle riders not wearing protective headwear in collisions 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
Scott Maxwell Henry CATTON · 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
Scott Maxwell Henry Catton died on 7 June 2025 after a serious head injury sustained when he collided with the open door of a parked vehicle while travelling on an electric scooter. The report raised concern that electric scooter riders are not required to wear helmets, creating a risk of death for riders involved in collisions while not wearing protective headwear.
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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of a requirement for electric scooter riders to wear helmets
Wider context from the report “1. There is no requirement that riders of electric scooters wear helmets. Due to the expectation of their use on the roads, and their vulnerability, there is a risk of death to riders of electric scooters and bicycles not wearing protective headwear who are involved in collisions, even at lower speeds.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Risk of death to electric scooter and bicycle riders not wearing protective headwear in collisions
Wider context from the report “1. There is no requirement that riders of electric scooters wear helmets. Due to the expectation of their use on the roads, and their vulnerability, there is a risk of death to riders of electric scooters and bicycles not wearing protective headwear who are involved in collisions, even at lower speeds .
” 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 Ensure future e-scooter regulations consider a full range of evidence, including international comparisons.
Verbatim wording from the response “To support this, a second evaluation of the e-scooter trials is currently underway, due to conclude in Summer 2026 and published in early 2027. Among other things, the evaluation is looking at the impact of helmet provision and uptake amongst e-scooter users. I will ensure we consider a full range of evidence, including international comparisons.” Source location Response from Department for Transport
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 Publicly consult on proposed regulations, including any potential helmet-wearing requirement, before they come into force.
Verbatim wording from the response “Any regulations, including the potential requirement for helmet-wearing, will be publicly consulted on before coming into force so that all interested parties have a chance to shape the new regime.” Source location Response from Department for Transport
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 and publish the second evaluation of e-scooter trials, including evidence on helmet provision and uptake.
Verbatim wording from the response “To support this, a second evaluation of the e-scooter trials is currently underway, due to conclude in Summer 2026 and published in early 2027. Among other things, the evaluation is looking at the impact of helmet provision and uptake amongst e-scooter users. I will ensure we consider a full range of evidence, including international comparisons.” Source location Response from Department for Transport
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 Cycle helmets should remain strongly recommended but not legally mandatory because mandating them may reduce cycling and its wider health and environmental benefits.
Verbatim wording from the response “On the matter of helmets for cyclists, the question is complex. The Government must carefully balance the safety benefits of mandating helmets against the potential disbenefits. The Department carefully looked at the case for making helmet wearing mandatory in a comprehensive Cycling and Walking Safety Review in 2018.” Source location Response from Department for Transport
Open published response
Concerns raised 1 Lack of adult supervision restrictions for 17-year-old drivers after passing a driving test 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
Paul Walker GREEN · 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
Paul Walker Green, aged 16, died on 27 November 2024 after a car carrying him as a rear passenger collided with a tree and rolled onto its roof; he suffered fatal head injuries. Concerns included the driver’s recent qualification and inexperience, the passengers’ lack of adult supervision, and the ability of newly qualified 17-year-olds to drive without adult supervision, including on motorways.
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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of adult supervision restrictions for 17-year-old drivers after passing a driving test
Wider context from the report “The driver of the vehicle which crashed was 17 years of age. The three passengers in the car including Paul Green who died were also under 18. There were no adults in the car. I heard evidence from Forensic Collision Investigator ████████ that the collision was likely a result of understeering while negotiating a bend which was a result of the driver's inexperience. She had only passed her test a few weeks prior to the collision. I also heard evidence that the presence of other teenagers in the car (none of whom it appeared had driving experience) is a factor in a number of collisions. I am concerned that when 17 year olds pass a driving test, they can drive on any road in the UK including motorways without any adult supervision. I believe this current state of affairs is likely to lead to further fatal collisions if it remains unaddressed.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Further restrictions on newly qualified drivers, such as passenger limits, are not being considered because the proposed approach strikes an appropriate balance.
Verbatim wording from the response “Whilst we are not considering further restrictions on newly qualified drivers, such as carrying passengers, we are consulting on a Minimum Learning Period before learner drivers can take their practical driving test. This would allow learners more time to gain essential experience, for example in different weather conditions, before driving independently and reduce the risk to themselves and other drivers. We believe this strikes an appropriate balance between addressing specific risks pertaining to younger drivers, whilst allowing them to exercise new freedoms that passing your driving test can bring.” Source location Response from Minister of Local Transport
Open published response
Concerns raised 4 Hazardous road layout requiring right-turning vehicles to cross multiple traffic-control areas View source Ambiguity in legal guidance on right turns across double solid white lines View source Lack of left-turn-only signage at the Moss Farm Shop exit View source Failure of road markings to prevent prohibited overtaking and right turns 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
Nathan Thomas CYSTER · 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
Nathan Thomas Cyster died at the scene on 29 March 2025 after his motorcycle collided with a BMW X5 on the A5 Watling Street. The report identifies concerns about the hazardous right-turn layout at the Moss Farm Shop exit, the absence of left-turn-only signage, ineffective road markings against prohibited overtaking, and ambiguity in legal guidance about right turns across double white lines.
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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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Hazardous road layout requiring right-turning vehicles to cross multiple traffic-control areas
Wider context from the report “1. Hazardous Right-Turn Manoeuvre Across Multiple Lanes and Road Markings
Vehicles exiting Moss Farm Shop are currently required to cross a lane of traffic approaching from their right, traverse double solid white lines, and pass through a right-turn filter lane before entering the main carriageway. This configuration necessitates crossing areas specifically marked to restrict overtaking and protect turning movements, creating a complex and potentially hazardous manoeuvre for drivers.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Ambiguity in legal guidance on right turns across double solid white lines
Wider context from the report “4. Ambiguity in Legal Guidance Regarding Right Turns Across Double White Lines
The inquest was told that there is ambiguity and contradiction in the guidance regarding the legality of turning right out of premises across double solid white lines at the location of Moss Farm Shop. As per the police report:
“It would appear that the rules surrounding crossing double white lines to enter and exit junctions and premises is a little more ambiguous. The Highway Code mentioning only entry into, whilst a government website states entry and exit. ”
This contradiction may lead to different drivers having different understandings of the law and whether they would anticipate vehicles turning right out of the farm shop across double white lines.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of left-turn-only signage at the Moss Farm Shop exit
Wider context from the report “2. Absence of Left-Turn Only Signage at Moss Farm Shop
There is no “left turn only” signage—either in the form of a mandatory highway sign or an advisory sign positioned by the Farm itself—at the Moss Farm Shop exit. This is in contrast to other nearby businesses along the A5, which display such signage to discourage or prohibit right turns across the carriageway.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure of road markings to prevent prohibited overtaking and right turns
Wider context from the report “3. Ineffectiveness of Road Markings in Preventing Prohibited Overtaking
Although the road markings at this location—including double solid white lines and hatched areas—are intended to prohibit overtaking by vehicles (including motorcycles) travelling from Cannock and the Turf Island towards the Moss Farm junction, available evidence demonstrates that these markings are not effective in practice.
CCTV analysis from the day of the collision and a separate 3-hour review period revealed that, within that window, 31 vehicles (28% of all vehicles exiting) turned right out of the Moss Farm Shop, and 7 motorcycles and 1 car overtook on the prohibited section prior to the junction.
” 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 Consider the coroner’s concerns about ambiguity when next reprinting Know Your Traffic Signs.
Verbatim wording from the response “Thank you for flagging your concerns about an apparent ambiguity and contradiction between guidance in the Highway Code and information on a government webpage. The Department’s position is that there is no contradiction. The Department acknowledges that ‘Know Your Traffic Signs’ (KYTS) refers to turning movements into or out of a side road, while the Highways Code refers only to the entry into a side road. This difference arises because the statutory marking requirements captured in the Highway Code apply only to traffic on the road on which the marking is placed, while the KYTS webpage provides broader explanatory guidance covering both the main road and the side road. We will consider the coroners’ concerns about this ambiguity at a future reprint of Know Your Traffic Signs.” Source location 2026-0051 - Response from Department of Transport
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 National Highways is responsible for deciding appropriate road markings and signing at the specific site on its strategic road network.
Verbatim wording from the response “The Department’s role is to set the overarching legal and policy framework, and to provide guidance to local highway authorities on how to provide various traffic management measures. National Highways is a government-owned company, established under the Infrastructure Act 2015, and operates at arm’s length from ministers. It is responsible for the day-to-day operation, maintenance and improvement of the strategic road network.” Source location 2026-0051 - Response from Department of Transport
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The evidence does not necessarily show that drivers misunderstand the double white line marking; a site-specific factor may explain non-compliance.
Verbatim wording from the response “The Department believes that the meaning of this marking is well understood by drivers. Regarding the evidence provided, this does not necessarily translate to a lack of understanding of the road marking. There could be a specific site factor that causes the prohibition not to cross the white line marking to be disregarded.” Source location 2026-0051 - Response from Department of Transport
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The prescribed double white line marking and its inclusion in the Highway Code are considered sufficient for drivers to understand its meaning.
Verbatim wording from the response “In relation to your comments on the double white line markings’ effectiveness to prevent overtaking in practice, the road marking has been prescribed in the” Source location 2026-0051 - Response from Department of Transport
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 There is no contradiction between the Highway Code and Know Your Traffic Signs because they provide guidance with different scopes.
Verbatim wording from the response “Thank you for flagging your concerns about an apparent ambiguity and contradiction between guidance in the Highway Code and information on a government webpage. The Department’s position is that there is no contradiction. The Department acknowledges that ‘Know Your Traffic Signs’ (KYTS) refers to turning movements into or out of a side road, while the Highways Code refers only to the entry into a side road. This difference arises because the statutory marking requirements captured in the Highway Code apply only to traffic on the road on which the marking is placed, while the KYTS webpage provides broader explanatory guidance covering both the main road and the side road. We will consider the coroners’ concerns about this ambiguity at a future reprint of Know Your Traffic Signs.” Source location 2026-0051 - Response from Department of Transport
Open published response
29 Dec 2025 Brian Mitchell · Prevention of Future Deaths report East London
View report summary
Concerns raised 4 Lack of clear data demonstrating improved expedition and clarity of station staff communication in emergencies View source Lack of clear evidence that risks of fatal harm have been mitigated View source Lack of clear data demonstrating improved train-operator concentration and track observation during ATO operation View source Failure to implement technological measures detecting and alerting staff to persons on the tracks at Stratford station 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
Brian Mitchell · 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
Brian Mitchell, aged 72, was struck by multiple trains after falling onto the tracks at platform 13 at Stratford Underground Station on 26 December 2023. The report identifies concerns that train operators failed to notice him or override automatic train operation, and that technological measures and training intended to mitigate similar risks had not been clearly implemented or shown to improve performance.
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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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of clear data demonstrating improved expedition and clarity of station staff communication in emergencies
Wider context from the report “4. No clear data is available to demonstrate that station staff training has improved expedition or clarity of communication in emergency circumstances.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of clear evidence that risks of fatal harm have been mitigated
Wider context from the report “1. In the two years that have elapsed since Brian’s death investigations have been conducted by the British Transport Police, The Rail Accident Investigation Branch (“RAIB”) and TFL into the circumstances that led to this incident. There is no clear evidence to demonstrate that risks of fatal harm have been mitigated.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of clear data demonstrating improved train-operator concentration and track observation during ATO operation
Wider context from the report “3. No clear data is available to demonstrate that training provided to train operators (drivers) to ensure that they concentrate and look at the tracks before them whilst operating trains using ATO has resulted in positive improvement in performance.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure to implement technological measures detecting and alerting staff to persons on the tracks at Stratford station
Wider context from the report “2. Recommended technological measures to detect and alert staff to the presence of persons on the tracks have not been implemented at Stratford station.
” Open source report
×
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 London Underground is responsible for operational safety, accountable to Transport for London and ultimately the Mayor of London.
Verbatim wording from the response “Any death on the transport network is a tragedy, and I express my sincere condolences to Mr Mitchell’s family for their loss. Whilst a likely contributory factor to Brian’s death was alcohol intoxication, the fact that three separate train operators failed to notice him on the tracks is extremely serious and lessons must be learnt. Relevant transport operators need to ensure that they have systems in place to protect staff, travellers and the wider public, in line with their duties under the Health and Safety at Work Act (etc.) 1974. London Underground Ltd, as the safety duty holder in this case, is wholly responsible for the operational safety of the London Underground network. It is accountable for this to Transport for London and, ultimately, to the Mayor of London.” Source location Response from Department for Transport
Open published response
Concerns raised 19 Failure to assess new drivers’ understanding of passenger effects on braking, stability and handling View source Failure of licensing arrangements to address combined inexperience, peer presence and full vehicle loading View source Lack of a coordinated cross-sector approach to early indications of unsafe behaviour View source Unequal behavioural oversight of named drivers with similar early-stage risk profiles View source Failure of the standard driving test to require experience on challenging rural roads View source Inconsistent incorporation of safety considerations into young-driver insurance products View source Unclear detection and review of dangerous-driving content uploaded by minors View source Lack of safeguarding processes to identify repeated unsafe conduct among young users View source Uncertainty about wider algorithmic dissemination of dangerous-driving content View source Lack of a consistent method to identify concealed higher-than-expected use by young named drivers View source Insufficient understanding of peer influence, vehicle loading and rural road hazards View source Unclear insurer processes for collecting, interpreting and acting on telematics data View source Difficulty identifying true vehicle use by young named drivers View source Peer sharing of high-risk driving normalising and reinforcing risk-taking View source Failure of test requirements to assess passenger and load-related vehicle dynamics View source Unclear communication of telematics use and safety implications to young drivers and families View source Failure of qualification competencies to cover early independent-driving conditions View source Failure of licensing arrangements to provide structured progression aligned to early post-test risk View source Lack of a uniform approach to applying telematics View source See 16 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Harry Joseph Purcell and Matilda (Tilly) Grace Seccombe · 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
Harry Joseph Purcell and Matilda (Tilly) Grace Seccombe sustained fatal injuries in a single-vehicle collision on 21 April 2023, when a recently qualified 17-year-old driver travelled at excessive speed on a rural road and lost control. The report raised concerns about the combined risks of driver inexperience, peer passengers, vehicle loading and rural-road conditions, as well as issues concerning driver licensing, insurance oversight, unsafe-driving content shared on Snapchat and the lack of coordinated responses to unsafe behaviour.
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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure to assess new drivers’ understanding of passenger effects on braking, stability and handling
Wider context from the report “2. New drivers are not required to demonstrate an understanding of how passengers affect braking, stability and handling . The standard driving test does not require experience on rural roads with tight bends, undulations or variable grip. Given that collision risk is highest in the early post-test period, there is a concern as to whether current licensing arrangements adequately reflect the conditions young drivers commonly face or include a structured progression stage aligned to this risk.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure of licensing arrangements to address combined inexperience, peer presence and full vehicle loading
Wider context from the report “1. The inquest noted that newly qualified drivers may carry multiple peer-age passengers immediately after passing their test. This case suggests that inexperience, peer presence and full vehicle loading can combine to elevate risk , and it is unclear how current licensing arrangements address these combined factors .
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of a coordinated cross-sector approach to early indications of unsafe behaviour
Wider context from the report “10. There does not appear to be a coordinated approach linking driver training bodies, insurers, social media platforms and road-safety organisations in identifying or responding to early indications of unsafe behaviour among newly qualified drivers .
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Unequal behavioural oversight of named drivers with similar early-stage risk profiles
Wider context from the report “4. Evidence was heard about the practice of “fronting.” Although it did not apply in this case, it illustrates difficulties insurers may face in identifying the true pattern of vehicle use when young drivers are insured as named drivers. Named drivers may not be subject to telematics monitoring , which can result in differing levels of behavioural oversight for drivers with similar early-stage risk profiles .
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure of the standard driving test to require experience on challenging rural roads
Wider context from the report “2. New drivers are not required to demonstrate an understanding of how passengers affect braking, stability and handling. The standard driving test does not require experience on rural roads with tight bends, undulations or variable grip . Given that collision risk is highest in the early post-test period, there is a concern as to whether current licensing arrangements adequately reflect the conditions young drivers commonly face or include a structured progression stage aligned to this risk.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Inconsistent incorporation of safety considerations into young-driver insurance products
Wider context from the report “5. While telematics devices can monitor driving behaviour, it is unclear how insurers collect, interpret or act upon such data, or how consistently safety considerations are incorporated into insurance products designed for young drivers .
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Unclear detection and review of dangerous-driving content uploaded by minors
Wider context from the report “7. The inquest heard that unsafe driving behaviour was recorded and shared privately on Snapchat prior to the collision. It received no information on whether Snapchat is able to detect or review content depicting dangerous driving, including where uploaded by minors . It also remains unknown whether any such material was shared via public features, such as Spotlight or Public Stories, or whether algorithmic systems could have disseminated it more widely.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of safeguarding processes to identify repeated unsafe conduct among young users
Wider context from the report “8. The filming and sharing of high-risk driving among peers, apparently treated as entertainment, raised concern that such use may normalise, encourage or reinforce risk-taking behaviour. There is no publicly available information on whether Snapchat has considered these behavioural risks or has safeguarding processes capable of identifying repeated patterns of unsafe conduct among young users .
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Uncertainty about wider algorithmic dissemination of dangerous-driving content
Wider context from the report “7. The inquest heard that unsafe driving behaviour was recorded and shared privately on Snapchat prior to the collision. It received no information on whether Snapchat is able to detect or review content depicting dangerous driving, including where uploaded by minors. It also remains unknown whether any such material was shared via public features, such as Spotlight or Public Stories, or whether algorithmic systems could have disseminated it more widely .
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of a consistent method to identify concealed higher-than-expected use by young named drivers
Wider context from the report “6. Industry practice does not appear to include a consistent method for identifying when a named driver arrangement may conceal higher-than-expected use by a young driver, with implications for risk assessment and safety. There is also no uniform approach to how telematics is applied or the need for its use communicated to young drivers. The inquest noted uncertainty about how clearly insurers and brokers explain the safety-related aspects of telematics to young drivers or their families, which may influence decisions made when arranging insurance.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Insufficient understanding of peer influence, vehicle loading and rural road hazards
Wider context from the report “9. The circumstances of this case highlight the continued significance of peer influence, vehicle loading and rural road hazards for young drivers. It is unclear how well these risks are understood by young people, parents (particularly those organising insurance cover), or schools .
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Unclear insurer processes for collecting, interpreting and acting on telematics data
Wider context from the report “5. While telematics devices can monitor driving behaviour, it is unclear how insurers collect, interpret or act upon such data , or how consistently safety considerations are incorporated into insurance products designed for young drivers.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Difficulty identifying true vehicle use by young named drivers
Wider context from the report “4. Evidence was heard about the practice of “fronting.” Although it did not apply in this case, it illustrates difficulties insurers may face in identifying the true pattern of vehicle use when young drivers are insured as named drivers . Named drivers may not be subject to telematics monitoring, which can result in differing levels of behavioural oversight for drivers with similar early-stage risk profiles.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Peer sharing of high-risk driving normalising and reinforcing risk-taking
Wider context from the report “8. The filming and sharing of high-risk driving among peers, apparently treated as entertainment, raised concern that such use may normalise, encourage or reinforce risk-taking behaviour . There is no publicly available information on whether Snapchat has considered these behavioural risks or has safeguarding processes capable of identifying repeated patterns of unsafe conduct among young users.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure of test requirements to assess passenger and load-related vehicle dynamics
Wider context from the report “3. The inquest heard that newly qualified drivers may have limited experience of rural roads, vehicles under load or situations that significantly affect handling. Test requirements do not involve passengers or load-related vehicle dynamics , raising concern about whether the competencies assessed at qualification correspond to those required during the early stages of independent driving.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Unclear communication of telematics use and safety implications to young drivers and families
Wider context from the report “6. Industry practice does not appear to include a consistent method for identifying when a named driver arrangement may conceal higher-than-expected use by a young driver, with implications for risk assessment and safety. There is also no uniform approach to how telematics is applied or the need for its use communicated to young drivers . The inquest noted uncertainty about how clearly insurers and brokers explain the safety-related aspects of telematics to young drivers or their families , which may influence decisions made when arranging insurance.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure of qualification competencies to cover early independent-driving conditions
Wider context from the report “3. The inquest heard that newly qualified drivers may have limited experience of rural roads, vehicles under load or situations that significantly affect handling . Test requirements do not involve passengers or load-related vehicle dynamics, raising concern about whether the competencies assessed at qualification correspond to those required during the early stages of independent driving .
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure of licensing arrangements to provide structured progression aligned to early post-test risk
Wider context from the report “2. New drivers are not required to demonstrate an understanding of how passengers affect braking, stability and handling. The standard driving test does not require experience on rural roads with tight bends, undulations or variable grip. Given that collision risk is highest in the early post-test period, there is a concern as to whether current licensing arrangements adequately reflect the conditions young drivers commonly face or include a structured progression stage aligned to this risk .
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of a uniform approach to applying telematics
Wider context from the report “6. Industry practice does not appear to include a consistent method for identifying when a named driver arrangement may conceal higher-than-expected use by a young driver, with implications for risk assessment and safety. There is also no uniform approach to how telematics is applied or the need for its use communicated to young drivers. The inquest noted uncertainty about how clearly insurers and brokers explain the safety-related aspects of telematics to young drivers or their families, which may influence decisions made when arranging insurance.
” 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 Consult on a Minimum Learning Period and related pre-test measures, including a possible mandatory modular learner syllabus.
Verbatim wording from the response “Whilst we are not considering further restrictions on newly qualified drivers such as carrying passengers or driving at night, we are consulting on a Minimum Learning Period in England, Scotland, and Wales before learner drivers can take their practical driving test.” Source location Response from Department for Transport and DVSA
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and update driving-test-centre routes to include relevant high-speed, high-risk rural roads where locations allow.
Verbatim wording from the response “Reviewing and refreshing all current routes will take time. The expectation is that by 31 March 2026, each Driving Test Centre will have reviewed and updated all routes to be more relevant and to include high speed, high risk rural roads where location allows.” Source location Response from Department for Transport and DVSA
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement updates to the car practical driving test, including additional higher-speed-road driving where locations allow.
Verbatim wording from the response “Following a successful five-month trial, the DVSA introduced updates to the car practical driving test from Monday 24 November 2025. As a result of these changes, learner drivers will spend more time on higher-speed roads during their driving test, where location allows. These changes aim to enhance road safety, address collision rates in rural areas and align the test more closely with real-world driving conditions.” Source location Response from Department for Transport and DVSA
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 Further restrictions on newly qualified drivers, including passenger or nighttime limits, are not currently being considered.
Verbatim wording from the response “Whilst we are not considering further restrictions on newly qualified drivers such as carrying passengers or driving at night, we are consulting on a Minimum Learning Period in England, Scotland, and Wales before learner drivers can take their practical driving test.” Source location Response from Department for Transport and DVSA
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 driving test cannot replicate every scenario a driver may encounter after qualification.
Verbatim wording from the response “Turning to the concerns raised regarding the scope of the current driving test: the object of the driving test is to ensure that the candidate is well grounded in the basic principles of safe driving and is sufficiently practised in them to be able to show, at the time of the test, that they are a competent and considerate driver and are not a source of danger to themselves or to other road users. If a candidate reaches the required standard they will pass their test. However, it is not intended to, and could not, replicate every scenario a driver may encounter after qualification.” Source location Response from Department for Transport and DVSA
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 Because vehicle loading and passenger dynamics vary, the test relies on core competencies to support safe adaptation across different conditions.
Verbatim wording from the response “Vehicle loading and passenger dynamics are important aspects of safe driving, but these situations vary significantly depending on vehicle type and usage. For this reason, the test focuses on core competencies such as hazard perception, vehicle control, and decision-making, which are fundamental to adapting safely to different conditions. Learner drivers have the option to carry passengers during their learning journeys.” Source location Response from Department for Transport and DVSA
Open published response
5 Dec 2025 Leonardo Cardoso Machado · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 3 Children working alone at night delivering to private homes View source Risk of road traffic collisions involving children working at night on powered two-wheeled vehicles View source Lack of oversight of the rental of food delivery licences to children under 18 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
Leonardo Cardoso Machado · 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
Leonardo Cardoso Machado, aged 17, died on 16 April 2023 after losing control of a motorcycle while travelling at speed and colliding with metal railings. The report raised concerns about limited oversight of rented food delivery licences being provided to children under 18, and the resulting risks of lone night work and road traffic collisions.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Children working alone at night delivering to private homes
Wider context from the report “1. During the inquest evidence was heard that:
i. There is significant national concern about the “rental” of food delivery licences to under 18s. In general terms, food delivery platforms place age restrictions on those who can obtain a licence to deliver food. However, there appears to be no oversight of the rental of these licences to those under the age limit. This places children in a vulnerable position: lone working, often at night, riding electric or motorised scooters, mopeds or motorcycles and delivering to individuals that are not known to the drivers.
2. I have concerns with regard to the following:
i. There appears to be no or limited oversight of the practice of “renting” a food delivery licence to children under 18 years of age, which I hear is a national issue;
ii. As a consequence, children are working in the food delivery economy, which involves lone working at night, with deliveries being made to the home addresses of private individuals, placing the children in a vulnerable position ;
iii. That placing a child in a lone working environment at night and on the roads on electric or motorised scooters, mopeds or motorcycles also increases the risks of them coming to harm through a road traffic collision, leading to a risk of death.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Risk of road traffic collisions involving children working at night on powered two-wheeled vehicles
Wider context from the report “1. During the inquest evidence was heard that:
i. There is significant national concern about the “rental” of food delivery licences to under 18s. In general terms, food delivery platforms place age restrictions on those who can obtain a licence to deliver food. However, there appears to be no oversight of the rental of these licences to those under the age limit. This places children in a vulnerable position: lone working, often at night, riding electric or motorised scooters, mopeds or motorcycles and delivering to individuals that are not known to the drivers.
2. I have concerns with regard to the following:
i. There appears to be no or limited oversight of the practice of “renting” a food delivery licence to children under 18 years of age, which I hear is a national issue;
ii. As a consequence, children are working in the food delivery economy, which involves lone working at night, with deliveries being made to the home addresses of private individuals, placing the children in a vulnerable position;
iii. That placing a child in a lone working environment at night and on the roads on electric or motorised scooters, mopeds or motorcycles also increases the risks of them coming to harm through a road traffic collision, leading to a risk of death .
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of oversight of the rental of food delivery licences to children under 18
Wider context from the report “1. During the inquest evidence was heard that:
i. There is significant national concern about the “rental” of food delivery licences to under 18s. In general terms, food delivery platforms place age restrictions on those who can obtain a licence to deliver food. However, there appears to be no oversight of the rental of these licences to those under the age limit . This places children in a vulnerable position: lone working, often at night, riding electric or motorised scooters, mopeds or motorcycles and delivering to individuals that are not known to the drivers.
2. I have concerns with regard to the following:
i. There appears to be no or limited oversight of the practice of “renting” a food delivery licence to children under 18 years of age , which I hear is a national issue;
ii. As a consequence, children are working in the food delivery economy, which involves lone working at night, with deliveries being made to the home addresses of private individuals, placing the children in a vulnerable position;
iii. That placing a child in a lone working environment at night and on the roads on electric or motorised scooters, mopeds or motorcycles also increases the risks of them coming to harm through a road traffic collision, leading to a risk of death.
” Open source report
20 Nov 2025 Lisa Marie Bowen · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 5 Failure of anti-locking braking systems to reliably recognise tyre detachment View source Lack of regulatory requirements for under-run protection device strength View source Lack of industry testing and data collection on braking following tyre detachment View source Insufficient strength of under-run protection devices View source Failure of anti-locking braking regulations to specify requirements for tyre detachment 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
Lisa Marie Bowen · 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
Lisa Marie Bowen died instantaneously from fatal injuries after her Toyota Corolla’s tyre detached while she was driving on the M25, and the vehicle failed to stop before colliding with a stationary lorry. The principal concerns were that the anti-locking braking system substantially reduced braking after tyre detachment, and that the lorry’s under-run protection device was insufficiently strong to prevent or reduce the under-run. The report also raised concerns about the adequacy of relevant testing, regulations and protection requirements.
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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure of anti-locking braking systems to reliably recognise tyre detachment
Wider context from the report “Concern 1
As stated above, the brakes on the Deceased’s Toyota Corolla did not work effectively because, when the brake pedal was pressed, the vehicle’s anti-locking braking system was activated, and it operated to reduce the braking effect almost entirely. At the inquest I heard evidence that:
(i) Following the tyre detachment, the speed of the wheel with a detached tyre was much higher than the speed of the three other wheels with undamaged tyres.
(ii) The anti-locking braking system recognised this differential in speed, but perceived that the problem lay with the three slower wheels and assumed that they had locked or were at risk of doing so.
(iii) Consequently, each time the brake was applied, the anti-locking braking system immediately released the braking pressure to the three slower wheels in order to avoid them locking, thereby prioritising the preservation stability and steerability over braking.
(iv) In this way, the anti-locking braking system was working in accordance with its design.
(v) The system was unable to recognise that the problem in fact lay with the fourth wheel which was rotating much more quickly than the other wheels because its tyre had detached.
(vi) The outcome was an unintended effect of the system’s design which arose because the specific scenario, of tyre detachment occurring whilst the vehicle was being driven, which was thought to be a rare occurrence, had not been taken into account in the design process.
(vii) Testing of anti-locking braking systems and braking performance, following a tyre detachment, is not undertaken by the industry as a whole and, therefore, relevant data is not collated.
At the inquest and PFD hearing I was informed that –
(i) A large number Toyota Corolla motor cars continue to be driven on the roads of the UK with the same anti-locking braking system as was in Ms Bowen’s vehicle.
(ii) Anti-locking braking systems are developed by a small number of specialist companies and it may well be that other vehicles currently on the roads of the UK have systems similar to that in Ms Bowen’s car.
(iii) The company which developed the anti-locking braking system used in Ms Bowen’s car (Advics) has since developed and improved its system so that it is better able to recognise if one wheel speed is so different from the others that the data from that wheel should be ignored as unreliable. However, the improvements are not foolproof , not least because acceleration or deceleration of the vehicle affects this function.
(iv) The anti-locking braking system now used in Toyota Corolla motor cars has been developed by a different company (Bosch) and it is not known by Toyota precisely how it would respond following a tyre detachment whilst the vehicle is being driven .
(v) It seems that relevant regulations concerning anti-locking braking systems do not address or specify requirements relating to the scenario faced by Ms Bowen.
Although the detachment of a tyre whilst a vehicle is being driven is thought to be a rare occurrence, I am concerned that that may not be the case and that if it were to happen again, in the same or similar circumstances, the risk of future death continues.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of regulatory requirements for under-run protection device strength
Wider context from the report “Concern 2
This concern relates to the catastrophic failure of the under-run protection bar (“the Device”) that was in place on the piece of the lorry with which Ms Bowen collided. At the inquest I heard and accepted expert evidence which established that:
(i) The Device was compliant with all relevant regulations and legal requirements, save only that fixing bolts of an incorrect strength had been used to attach it to the lorry’s chassis.
(ii) The strength of the Device was grossly insufficient, either to have prevented any underrun, or even to have reduced the extent of the Toyota’s under-run.
(iii) The Device would not have been strong enough to do so even if the correct fixing bolts had been used.
One expert stated that he was aware that some under-run protection devices are capable of providing protection against much greater forces than is currently required under the law and he expressed disappointment that the relevant legislation and regulations are not more robustly framed, so as to require the use of these much stronger devices.
I am concerned that, in the absence of more stringent requirements in relation to the degree of force that an under-run protection device should be capable of withstanding , a risk of future death arises.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of industry testing and data collection on braking following tyre detachment
Wider context from the report “Concern 1
As stated above, the brakes on the Deceased’s Toyota Corolla did not work effectively because, when the brake pedal was pressed, the vehicle’s anti-locking braking system was activated, and it operated to reduce the braking effect almost entirely. At the inquest I heard evidence that:
(i) Following the tyre detachment, the speed of the wheel with a detached tyre was much higher than the speed of the three other wheels with undamaged tyres.
(ii) The anti-locking braking system recognised this differential in speed, but perceived that the problem lay with the three slower wheels and assumed that they had locked or were at risk of doing so.
(iii) Consequently, each time the brake was applied, the anti-locking braking system immediately released the braking pressure to the three slower wheels in order to avoid them locking, thereby prioritising the preservation stability and steerability over braking.
(iv) In this way, the anti-locking braking system was working in accordance with its design.
(v) The system was unable to recognise that the problem in fact lay with the fourth wheel which was rotating much more quickly than the other wheels because its tyre had detached.
(vi) The outcome was an unintended effect of the system’s design which arose because the specific scenario, of tyre detachment occurring whilst the vehicle was being driven, which was thought to be a rare occurrence, had not been taken into account in the design process.
(vii) Testing of anti-locking braking systems and braking performance, following a tyre detachment, is not undertaken by the industry as a whole and, therefore, relevant data is not collated .
At the inquest and PFD hearing I was informed that –
(i) A large number Toyota Corolla motor cars continue to be driven on the roads of the UK with the same anti-locking braking system as was in Ms Bowen’s vehicle.
(ii) Anti-locking braking systems are developed by a small number of specialist companies and it may well be that other vehicles currently on the roads of the UK have systems similar to that in Ms Bowen’s car.
(iii) The company which developed the anti-locking braking system used in Ms Bowen’s car (Advics) has since developed and improved its system so that it is better able to recognise if one wheel speed is so different from the others that the data from that wheel should be ignored as unreliable. However, the improvements are not foolproof, not least because acceleration or deceleration of the vehicle affects this function.
(iv) The anti-locking braking system now used in Toyota Corolla motor cars has been developed by a different company (Bosch) and it is not known by Toyota precisely how it would respond following a tyre detachment whilst the vehicle is being driven.
(v) It seems that relevant regulations concerning anti-locking braking systems do not address or specify requirements relating to the scenario faced by Ms Bowen.
Although the detachment of a tyre whilst a vehicle is being driven is thought to be a rare occurrence, I am concerned that that may not be the case and that if it were to happen again, in the same or similar circumstances, the risk of future death continues.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Insufficient strength of under-run protection devices
Wider context from the report “Concern 2
This concern relates to the catastrophic failure of the under-run protection bar (“the Device”) that was in place on the piece of the lorry with which Ms Bowen collided. At the inquest I heard and accepted expert evidence which established that:
(i) The Device was compliant with all relevant regulations and legal requirements, save only that fixing bolts of an incorrect strength had been used to attach it to the lorry’s chassis.
(ii) The strength of the Device was grossly insufficient, either to have prevented any underrun, or even to have reduced the extent of the Toyota’s under-run.
(iii) The Device would not have been strong enough to do so even if the correct fixing bolts had been used.
One expert stated that he was aware that some under-run protection devices are capable of providing protection against much greater forces than is currently required under the law and he expressed disappointment that the relevant legislation and regulations are not more robustly framed, so as to require the use of these much stronger devices.
I am concerned that, in the absence of more stringent requirements in relation to the degree of force that an under-run protection device should be capable of withstanding, a risk of future death arises.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure of anti-locking braking regulations to specify requirements for tyre detachment
Wider context from the report “Concern 1
As stated above, the brakes on the Deceased’s Toyota Corolla did not work effectively because, when the brake pedal was pressed, the vehicle’s anti-locking braking system was activated, and it operated to reduce the braking effect almost entirely. At the inquest I heard evidence that:
(i) Following the tyre detachment, the speed of the wheel with a detached tyre was much higher than the speed of the three other wheels with undamaged tyres.
(ii) The anti-locking braking system recognised this differential in speed, but perceived that the problem lay with the three slower wheels and assumed that they had locked or were at risk of doing so.
(iii) Consequently, each time the brake was applied, the anti-locking braking system immediately released the braking pressure to the three slower wheels in order to avoid them locking, thereby prioritising the preservation stability and steerability over braking.
(iv) In this way, the anti-locking braking system was working in accordance with its design.
(v) The system was unable to recognise that the problem in fact lay with the fourth wheel which was rotating much more quickly than the other wheels because its tyre had detached.
(vi) The outcome was an unintended effect of the system’s design which arose because the specific scenario, of tyre detachment occurring whilst the vehicle was being driven, which was thought to be a rare occurrence, had not been taken into account in the design process.
(vii) Testing of anti-locking braking systems and braking performance, following a tyre detachment, is not undertaken by the industry as a whole and, therefore, relevant data is not collated.
At the inquest and PFD hearing I was informed that –
(i) A large number Toyota Corolla motor cars continue to be driven on the roads of the UK with the same anti-locking braking system as was in Ms Bowen’s vehicle.
(ii) Anti-locking braking systems are developed by a small number of specialist companies and it may well be that other vehicles currently on the roads of the UK have systems similar to that in Ms Bowen’s car.
(iii) The company which developed the anti-locking braking system used in Ms Bowen’s car (Advics) has since developed and improved its system so that it is better able to recognise if one wheel speed is so different from the others that the data from that wheel should be ignored as unreliable. However, the improvements are not foolproof, not least because acceleration or deceleration of the vehicle affects this function.
(iv) The anti-locking braking system now used in Toyota Corolla motor cars has been developed by a different company (Bosch) and it is not known by Toyota precisely how it would respond following a tyre detachment whilst the vehicle is being driven.
(v) It seems that relevant regulations concerning anti-locking braking systems do not address or specify requirements relating to the scenario faced by Ms Bowen .
Although the detachment of a tyre whilst a vehicle is being driven is thought to be a rare occurrence, I am concerned that that may not be the case and that if it were to happen again, in the same or similar circumstances, the risk of future death continues.
” 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 Examine the possibility of introducing further amendments to UNECE regulations addressing the identified concerns.
Verbatim wording from the response “Having reviewed your report, and considered the current provisions in UNECE Regulations, I have instructed my officials to examine the possibility of introducing further amendments to these regulations to address the concerns raised.
The Vehicle Certification Agency (VCA) confirmed that the braking system of the car involved in the collision was approved to R13H. Recent amendments have been made to the provisions of R13H to allow approval authorities more scrutiny over the functioning of brake systems in non-fault conditions, but these are applied at the discretion of the issuing authority.” Source location Response from Department for Transport
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Gather information over the coming months to better understand risks to existing vehicles on the road.
Verbatim wording from the response “The above measures will only resolve the risk in new vehicles. Since there is considerable uncertainty over the potential risk to existing vehicles on the road, I have asked my officials to gather what relevant information they can over the coming months to better understand the situation. From this my department will consider whether any retrospective action should be taken.” Source location Response from Department for Transport
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 Present the case at the relevant UNECE forum and collaborate on whether specific R13H provisions are necessary.
Verbatim wording from the response “My officials will therefore highlight the particulars of this case at the relevant UNECE forum in May and collaborate with members of that forum on whether specific provisions are necessary for R13H.” Source location Response from Department for Transport
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 Uncertainty about risks to existing vehicles prevents immediate decisions on retrospective safety action.
Verbatim wording from the response “The above measures will only resolve the risk in new vehicles. Since there is considerable uncertainty over the potential risk to existing vehicles on the road, I have asked my officials to gather what relevant information they can over the coming months to better understand the situation. From this my department will consider whether any retrospective action should be taken.” Source location Response from Department for Transport
Open published response
12 Nov 2025 Christopher Graham Ayerst SAMPSON · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 7 Absence of a national road safety strategy View source Insufficient awareness among medical professionals of guidance on notifying the DVLA View source Uncertainty about the effectiveness of mechanisms for doctors to report patients' health issues to the DVLA View source Failure of medical professionals to report patients' health issues to the DVLA View source Failure to ensure drivers understand how and when to notify the DVLA of medical conditions View source Failure of drivers to self-report medical conditions to the DVLA View source Lack of published statistical evidence on DVLA health-issue reporting mechanisms View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Christopher Graham Ayerst SAMPSON · 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
Christopher Graham Ayerst Sampson was a front-seat passenger in a Mazda that was struck by a Mercedes travelling at speeds exceeding 100 mph after its driver suffered an unexpected medical event. Christopher sustained unsurvivable injuries and was declared deceased at the scene. The principal concern was the risk of future deaths arising from drivers failing to self-report medical conditions to the DVLA, and uncertainty about the effectiveness and awareness of medical professionals’ reporting guidance.
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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Absence of a national road safety strategy
Wider context from the report “5. Following scrutiny of those reports, it is apparent that the DVLA and Department of Transport previously called for evidence in 2023 seeking views on the current legislative basis for establishing whether a person was medically fit to drive. At that time, officials were considering what that evidence and considering policy options as part of the government’s road safety strategy which was being developed and the details would be provided, “in due course”.
6. Two years later from that call for evidence, and still no national strategy has been announced . I understand that in August 2025 His Majesty's Government announced that a new Road Safety Strategy would be published in the Autumn of 2025. However, we are now in the depths of November and there is no sign currently of any Road Safety Strategy being published .
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Insufficient awareness among medical professionals of guidance on notifying the DVLA
Wider context from the report “7. I am aware that the DVLA publishes guidance on GOV.UK called “Assessing fitness to drive: a guide for medical professionals” to support healthcare professionals (https://www.gov.uk/government/publications/assessing-fitness-to-drive-a-guide-for-medical-professionals). What is unclear, however, is whether a) that guidance is well known amongst medical professionals, and b) whether that process is an effective mechanism for doctors to report patients with health issues, as there does not appear to be any published statistical evidence on the issue.
8. I am also aware that The General Medical Council (GMC) and the General Optical Council (GOC) offer guidance about notifying DVLA when the person cannot or will not exercise their own legal duty to do so. Again, it is unclear whether a) that guidance is well known amongst medical professionals , and b) whether that process is an effective mechanism for doctors to report patients with health issues, as there does not appear to be any published statistical evidence on the issue.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Uncertainty about the effectiveness of mechanisms for doctors to report patients' health issues to the DVLA
Wider context from the report “7. I am aware that the DVLA publishes guidance on GOV.UK called “Assessing fitness to drive: a guide for medical professionals” to support healthcare professionals (https://www.gov.uk/government/publications/assessing-fitness-to-drive-a-guide-for-medical-professionals). What is unclear, however, is whether a) that guidance is well known amongst medical professionals, and b) whether that process is an effective mechanism for doctors to report patients with health issues, as there does not appear to be any published statistical evidence on the issue.
8. I am also aware that The General Medical Council (GMC) and the General Optical Council (GOC) offer guidance about notifying DVLA when the person cannot or will not exercise their own legal duty to do so. Again, it is unclear whether a) that guidance is well known amongst medical professionals, and b) whether that process is an effective mechanism for doctors to report patients with health issues, as there does not appear to be any published statistical evidence on the issue.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure of medical professionals to report patients' health issues to the DVLA
Wider context from the report “9. Drivers may not self-report medical conditions due to a variety of reasons. This can be due to a lack of understanding, insight, or simply because someone has not explicitly told them what to do or how to do it. There are then those who are reckless and knowingly avoid notifying the DVLA of a health condition when explicitly told to do so - either through arrogance, pride or through fear of losing employment. The end result is the same: people are dying needlessly on our roads due to people who, legally, should not be on our roads.
10. There is a risk of future deaths occurring where drivers do not self-refer their conditions to the DVLA, or where medical professionals do not report those health issues to protect the wider public .
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure drivers understand how and when to notify the DVLA of medical conditions
Wider context from the report “9. Drivers may not self-report medical conditions due to a variety of reasons. This can be due to a lack of understanding, insight, or simply because someone has not explicitly told them what to do or how to do it . There are then those who are reckless and knowingly avoid notifying the DVLA of a health condition when explicitly told to do so - either through arrogance, pride or through fear of losing employment. The end result is the same: people are dying needlessly on our roads due to people who, legally, should not be on our roads.
10. There is a risk of future deaths occurring where drivers do not self-refer their conditions to the DVLA, or where medical professionals do not report those health issues to protect the wider public.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure of drivers to self-report medical conditions to the DVLA
Wider context from the report “9. Drivers may not self-report medical conditions due to a variety of reasons. This can be due to a lack of understanding, insight, or simply because someone has not explicitly told them what to do or how to do it. There are then those who are reckless and knowingly avoid notifying the DVLA of a health condition when explicitly told to do so - either through arrogance, pride or through fear of losing employment. The end result is the same: people are dying needlessly on our roads due to people who, legally, should not be on our roads.
10. There is a risk of future deaths occurring where drivers do not self-refer their conditions to the DVLA , or where medical professionals do not report those health issues to protect the wider public.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of published statistical evidence on DVLA health-issue reporting mechanisms
Wider context from the report “7. I am aware that the DVLA publishes guidance on GOV.UK called “Assessing fitness to drive: a guide for medical professionals” to support healthcare professionals (https://www.gov.uk/government/publications/assessing-fitness-to-drive-a-guide-for-medical-professionals). What is unclear, however, is whether a) that guidance is well known amongst medical professionals, and b) whether that process is an effective mechanism for doctors to report patients with health issues, as there does not appear to be any published statistical evidence on the issue.
8. I am also aware that The General Medical Council (GMC) and the General Optical Council (GOC) offer guidance about notifying DVLA when the person cannot or will not exercise their own legal duty to do so. Again, it is unclear whether a) that guidance is well known amongst medical professionals, and b) whether that process is an effective mechanism for doctors to report patients with health issues, as there does not appear to be any published statistical evidence on the issue.
” 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 Consider the self-declaration process alongside evidence from the 2023 call for evidence and findings from recent inquests.
Verbatim wording from the response “My department also recognises that the volume and complexity of driving licence applications for those with one or more medical conditions is increasing, reflecting both an ageing population and a strong desire among drivers to maintain the independence that driving provides. We are considering the evidence gathered during the 2023 call for evidence, alongside findings from recent inquests, and as part of this work, consideration will be given to the process of self-declaration. Road safety measures have not been reviewed for over a decade, and my department has developed a new Road Safety Strategy, which has been published today, 7 January.” Source location Response from Department for Transport
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue engaging healthcare professionals and regulatory bodies to reinforce notification of the DVLA when drivers cannot or will not self-report medical conditions.
Verbatim wording from the response “Officials will also continue to engage with healthcare professionals and their regulatory bodies to reinforce the importance of notifying the DVLA if their patient lacks the capacity or willingness to inform the DVLA of their condition themselves.” Source location Response from Department for Transport
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 Publish a new Road Safety Strategy adopting a Safe System approach and covering preventative interventions, driver education, enforcement and vulnerable road users.
Verbatim wording from the response “My department also recognises that the volume and complexity of driving licence applications for those with one or more medical conditions is increasing, reflecting both an ageing population and a strong desire among drivers to maintain the independence that driving provides. We are considering the evidence gathered during the 2023 call for evidence, alongside findings from recent inquests, and as part of this work, consideration will be given to the process of self-declaration. Road safety measures have not been reviewed for over a decade, and my department has developed a new Road Safety Strategy, which has been published today, 7 January.” Source location Response from Department for Transport
Open published response
16 Oct 2025 Martin Gareth EVANS and 2 others · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 1 Reliance on drivers to self-refer medical impairments to the DVLA View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Martin Gareth EVANS and 2 others · 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
Martin Gareth Evans and Patricia Mary Evans died after another driver experienced syncope and collided with their vehicle on 13 February 2023. Neil Errington died after another driver had a seizure and collided with his vehicle; he died in hospital on 12 May 2022. The substantive concern was that relying on drivers with medical impairments to self-report to the DVLA may allow some to continue driving despite advice not to do so, risking future deaths.
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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Reliance on drivers to self-refer medical impairments to the DVLA
Wider context from the report “(1) The DVLA witnesses confirmed to me that the scheme created by section 94 of the Road Traffic Act 1988 requires that 'licence holders' notify the DVLA if they suffer from a relevant or prospective disability. In turn the DVLA place the emphasis on the expectation that licence holders will themselves honestly inform the DVLA of their condition. Although medical professionals can inform the DVLA of a patient's unfitness to drive, the DVLA proceed on the basis that notifications will not usually come via this route.
In each of these three inquests the drivers responsible for the collisions had repeatedly lied to the DVLA about their fitness to drive. I was told that this was 'disappointing' but not wholly surprising.
I am aware that HM Senior Coroner for Lancashire and Blackburn with Darwen addressed a PFD report to you (ref: 2025-0196) on April 24th 2025 in which a death had been caused by a driver who, by reason of their condition, lacked the necessary insight to self-refer to the DVLA.
Each of these cases illustrate the problem with expecting that those who have medical impairments should self-refer to the DVLA. There will be cases where, despite repeated advice not to drive, a person is unable or unwilling to inform the DVLA of their situation. My concern is that this risks future deaths. I consider that whilst self-referral remains the default position, more drivers will be able to continue driving whilst endangering lawful road users.
” 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 existing evidence alongside findings from recent inquests.
Verbatim wording from the response “My department also recognises that the volume and complexity of driving licence applications for those with one or more medical conditions is increasing, reflecting both an ageing population and a strong desire among drivers to maintain the independence that driving provides. We are reviewing the evidence already gathered alongside the findings from recent inquests. As part of this work consideration will be given to the process of self-declaration.” Source location Response from Department of Transport
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 Consider ways to raise awareness of notifying the DVLA and the consequences of failing to do so.
Verbatim wording from the response “Although the self-declaration process for notifying medical conditions to the DVLA is intended to empower drivers to take personal responsibility for their fitness to drive, I recognise that some drivers wilfully ignore medical advice and will not notify the DVLA and continue driving. This can have potentially devastating consequences. Officials will carry out a comprehensive review of the self-declaration forms and consider ways to further raise awareness of the importance of notifying conditions to the DVLA and the potential far reaching consequences of failing to do so. Officials will also continue to engage with healthcare professionals and their regulatory bodies to reinforce the importance of notifying the DVLA if their patient lacks the capacity or willingness to inform the DVLA of their condition themselves.” Source location Response from Department of Transport
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Carry out a comprehensive review of the self-declaration forms.
Verbatim wording from the response “Although the self-declaration process for notifying medical conditions to the DVLA is intended to empower drivers to take personal responsibility for their fitness to drive, I recognise that some drivers wilfully ignore medical advice and will not notify the DVLA and continue driving. This can have potentially devastating consequences. Officials will carry out a comprehensive review of the self-declaration forms and consider ways to further raise awareness of the importance of notifying conditions to the DVLA and the potential far reaching consequences of failing to do so. Officials will also continue to engage with healthcare professionals and their regulatory bodies to reinforce the importance of notifying the DVLA if their patient lacks the capacity or willingness to inform the DVLA of their condition themselves.” Source location Response from Department of Transport
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 Consider the process for self-declaration as part of the evidence review.
Verbatim wording from the response “My department also recognises that the volume and complexity of driving licence applications for those with one or more medical conditions is increasing, reflecting both an ageing population and a strong desire among drivers to maintain the independence that driving provides. We are reviewing the evidence already gathered alongside the findings from recent inquests. As part of this work consideration will be given to the process of self-declaration.” Source location Response from Department of Transport
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue engaging healthcare professionals and regulatory bodies to reinforce notification when patients cannot or will not notify the DVLA.
Verbatim wording from the response “Although the self-declaration process for notifying medical conditions to the DVLA is intended to empower drivers to take personal responsibility for their fitness to drive, I recognise that some drivers wilfully ignore medical advice and will not notify the DVLA and continue driving. This can have potentially devastating consequences. Officials will carry out a comprehensive review of the self-declaration forms and consider ways to further raise awareness of the importance of notifying conditions to the DVLA and the potential far reaching consequences of failing to do so. Officials will also continue to engage with healthcare professionals and their regulatory bodies to reinforce the importance of notifying the DVLA if their patient lacks the capacity or willingness to inform the DVLA of their condition themselves.” Source location Response from Department of Transport
Open published response
Concerns raised 1 Lack of legal requirements for servicing and maintenance of agricultural tractors outside road traffic requirements 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
Richard Ellis · 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
Richard Ellis died at the scene after a tractor’s handbrake failed while the tractor was on an incline, causing it to roll onto him as he detached a towing strap. The principal concern was that agricultural tractors may have no legal servicing or maintenance requirements, leaving maintenance dependent on vehicle owners’ discretion.
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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of legal requirements for servicing and maintenance of agricultural tractors outside road traffic requirements
Wider context from the report “The evidence was that there are no legal requirements for the servicing and maintenance of agricultural tractors which do not fall within the requirements of the Road Traffic Act 1988 and the associated regulations . As such, the maintenance of these vehicles is dependent on the discretion of the vehicle owners .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue monitoring the effectiveness of vehicle safety regulations to identify potential amendments.
Verbatim wording from the response “The Department will continue to monitor the effectiveness of vehicle safety regulations to identify any potential amendments.” Source location Response from Department of Transport
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 For private-land incidents covered by health and safety legislation, enforcement responsibility rests with the Health and Safety Executive.
Verbatim wording from the response “If the incident took place on a private land, there is health and safety legislation (Health and Safety at Work Act 1974) that covers the maintenance and servicing of agricultural vehicles. This legislation is enforced by the Health & Safety Executive and an employer is required to ensure, so far is reasonably practicable, the health, safety and welfare of both their employees and non-employees who may be affected by their undertaking. The Provision and Use of Work Equipment Regulations 1998 (“PUWER”) provide a set of more specific duties in relation to work equipment, including that employers ensure their work equipment is maintained in an efficient state, in efficient working order and in good repair. This is also maintained by the HSE and we suggest that you consider writing to them should the circumstances of this case fall under this legislation.” Source location Response from Department of Transport
Open published response
25 Jul 2025 Robert Grey English · Prevention of Future Deaths report North London
View report summary
Concerns raised 2 Absence of suitable lights for locating people on or near railway lines at night View source Failure to provide distinct night-time protection for railway trespassers 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
Robert Grey English · 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
Robert Grey English, aged 32, was electrocuted after entering a railway track at night, and was subsequently run over by a train searching the track. The report identifies concerns about failures to follow the process for switching the rail power back on and about inadequate lighting and equipment for locating a person on the railway at night.
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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Absence of suitable lights for locating people on or near railway lines at night
Wider context from the report “The provision to protect a trespasser at night are the same as those during the day. The ability to locate a person close to or on the railway lines at night is made more difficult by the absence of suitable lights on the track or the train. In this case Mr English was not seen and run over by the train that has been asked to look for a person on the line.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure to provide distinct night-time protection for railway trespassers
Wider context from the report “The provision to protect a trespasser at night are the same as those during the day. The ability to locate a person close to or on the railway lines at night is made more difficult by the absence of suitable lights on the track or the train. In this case Mr English was not seen and run over by the train that has been asked to look for a person on the line.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation TfL is wholly responsible for the operational safety of the London Underground network and is addressing the report’s findings.
Verbatim wording from the response “Transport for London (TfL) are wholly responsible for the operational safety of the London Underground network, and I understand that they have now responded to you, setting out how they are addressing the findings of your report. I understand that the actions TfL are taking will be implemented rapidly, which reflects the seriousness with which they take their responsibilities.” Source location Response from Department for Transport
Open published response
Concerns raised 3 Lack of guidance on signage following application of thin surface treatments View source Failure to adapt vehicle speeds to the early-life properties of thin surface treatments View source Unpredictable vehicle behaviour from reduced or changing friction during the early life of thin surface treatments 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
Paul David RANSOM · 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
Paul David Ransom died on 24 May 2023 after losing control of his motorcycle on the A272 and colliding with a lorry. The road had received a thin surface treatment less than six hours earlier, and the slippery surface caused or substantially contributed to the collision; concerns were raised about reduced and unpredictable friction during the treatment’s early life, particularly for motorcycles, without guidance requiring warning signage.
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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on signage following application of thin surface treatments
Wider context from the report “The resurfacing that had been carried out was an asphalt preservation treatment known as a “thin surface treatment” wherein a bituminous solution is cold sprayed onto the surface, overlaid with a silicate grit. This is a commonly used method. I heard evidence that in the initial period after laying thin surface treatment has a particular property (“early life effects”) in dry conditions the level of friction available can be akin to that of a wet road. There is no guidance that signage be provided. There is also the potential for unpredictable vehicle behaviour, particularly at lower speeds or when road surface temperatures are high, by reason of a change in the level of friction available to a vehicle during a steering manoeuvre or braking. This may have a greater effect on motorcycles.
The newly applied surface looks like an ordinary tarmac road albeit pristine.
There has been research into accident rates following application of thin surface treatments. The research had the effect of allaying concerns but I was informed that the research may not have been able to look specifically at motorcycle accidents, and further informed that the issue of signage has been the subject of discussion in at least some highways authorities . Thin surface treatments are to be distinguished from surface dressing wherein aggregates are applied, following which loose chipping warning signs are usually erected and a reduced speed limit applied for the days following application.
Following thin surface treatment the drivers of vehicles, including motorcycles are likely to assume that in dry conditions the road surface is going to have the same properties as any established dry asphalt road surface.
I am concerned that where the road is, for example, downhill and/or twisting and/or with limited sight lines it may be a particular problem if speeds are not adapted for the early life properties of thin surface treatments: particularly in the case of motorcycles.
I recommend review of actions to be taken for the safety of road users, particularly motorcycles, following application of thin surface treatments, during the early life phase following thin surface treatment.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure to adapt vehicle speeds to the early-life properties of thin surface treatments
Wider context from the report “The resurfacing that had been carried out was an asphalt preservation treatment known as a “thin surface treatment” wherein a bituminous solution is cold sprayed onto the surface, overlaid with a silicate grit. This is a commonly used method. I heard evidence that in the initial period after laying thin surface treatment has a particular property (“early life effects”) in dry conditions the level of friction available can be akin to that of a wet road. There is no guidance that signage be provided. There is also the potential for unpredictable vehicle behaviour, particularly at lower speeds or when road surface temperatures are high, by reason of a change in the level of friction available to a vehicle during a steering manoeuvre or braking. This may have a greater effect on motorcycles.
The newly applied surface looks like an ordinary tarmac road albeit pristine.
There has been research into accident rates following application of thin surface treatments. The research had the effect of allaying concerns but I was informed that the research may not have been able to look specifically at motorcycle accidents, and further informed that the issue of signage has been the subject of discussion in at least some highways authorities. Thin surface treatments are to be distinguished from surface dressing wherein aggregates are applied, following which loose chipping warning signs are usually erected and a reduced speed limit applied for the days following application.
Following thin surface treatment the drivers of vehicles, including motorcycles are likely to assume that in dry conditions the road surface is going to have the same properties as any established dry asphalt road surface.
I am concerned that where the road is, for example, downhill and/or twisting and/or with limited sight lines it may be a particular problem if speeds are not adapted for the early life properties of thin surface treatments: particularly in the case of motorcycles.
I recommend review of actions to be taken for the safety of road users, particularly motorcycles, following application of thin surface treatments, during the early life phase following thin surface treatment.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Unpredictable vehicle behaviour from reduced or changing friction during the early life of thin surface treatments
Wider context from the report “The resurfacing that had been carried out was an asphalt preservation treatment known as a “thin surface treatment” wherein a bituminous solution is cold sprayed onto the surface, overlaid with a silicate grit. This is a commonly used method. I heard evidence that in the initial period after laying thin surface treatment has a particular property (“early life effects”) in dry conditions the level of friction available can be akin to that of a wet road. There is no guidance that signage be provided. There is also the potential for unpredictable vehicle behaviour, particularly at lower speeds or when road surface temperatures are high, by reason of a change in the level of friction available to a vehicle during a steering manoeuvre or braking. This may have a greater effect on motorcycles.
The newly applied surface looks like an ordinary tarmac road albeit pristine.
There has been research into accident rates following application of thin surface treatments. The research had the effect of allaying concerns but I was informed that the research may not have been able to look specifically at motorcycle accidents, and further informed that the issue of signage has been the subject of discussion in at least some highways authorities. Thin surface treatments are to be distinguished from surface dressing wherein aggregates are applied, following which loose chipping warning signs are usually erected and a reduced speed limit applied for the days following application.
Following thin surface treatment the drivers of vehicles, including motorcycles are likely to assume that in dry conditions the road surface is going to have the same properties as any established dry asphalt road surface.
I am concerned that where the road is, for example, downhill and/or twisting and/or with limited sight lines it may be a particular problem if speeds are not adapted for the early life properties of thin surface treatments: particularly in the case of motorcycles.
I recommend review of actions to be taken for the safety of road users, particularly motorcycles, following application of thin surface treatments, during the early life phase following thin surface treatment.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and update the Well Managed Highways Infrastructure Code of Practice to address the report’s recommendations and concerns.
Verbatim wording from the response “However, I recognise the seriousness of what has occurred regarding the road surfacing which your report cites as having caused or substantially contributed to the collision involving Mr Ransom, and the need to ensure, as far as possible, there is no recurrence. For that reason, I have committed to undertaking several measures, described below.” Source location Response from Department for Transport
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 Consider whether signage should identify locations where thin surface treatments have been applied.
Verbatim wording from the response “However, I recognise the seriousness of what has occurred regarding the road surfacing which your report cites as having caused or substantially contributed to the collision involving Mr Ransom, and the need to ensure, as far as possible, there is no recurrence. For that reason, I have committed to undertaking several measures, described below.” Source location Response from Department for Transport
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 Local highway authorities are responsible for maintaining their networks and determining maintenance standards based on local knowledge and circumstances.
Verbatim wording from the response “This government takes the condition of our country’s roads very seriously and is committed to supporting local highway authorities in maintaining the local highway network and keeping it safe. Responsibility for highways maintenance is devolved; the local highway authorities have a duty under Section 41 of the Highways Act 1980 to maintain the highways network in their area. The Act does not set out specific standards of maintenance, as it is for each local highway authority to assess which parts of its network need repair and to what standards based upon local knowledge and circumstance.” Source location Response from Department for Transport
Open published response
Concerns raised 7 Failure to produce timely final reports and interim statements on investigation progress and safety issues View source Failure to recognise oxygen fires and immediately cut off the oxygen supply View source Uncertainty about the effectiveness of Halon fire extinguishers for onboard fires View source Failure to prevent cigarettes and related flammable items and materials in the cockpit View source Unavailability of protective equipment for cockpit fires View source Lack of evidence access for states entitled to participate in an investigation when excluded by the State of Occurrence View source Failure of risk analyses to account for overpressure in the oxygen distribution system View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Richard Mohamed Fekry Osman · 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
Richard Mohamed Fekry Osman was a passenger on flight MS804, which crashed into the Mediterranean Sea on 19 May 2016 after a fire broke out on the flight deck; there were no survivors. The inquest stated that the fire was caused by an ignition source of unknown origin, most likely associated with the first officer’s oxygen supply system. The substantive concerns included cockpit fire and smoke procedures, oxygen-system risks, fire-protection equipment and extinguishers, smoking regulations, and arrangements for participation in or transfer of aircraft accident investigations.
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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure to produce timely final reports and interim statements on investigation progress and safety issues
Wider context from the report “(2) That a drafting committee be convened to consider amending Annex 13 of the Convention on International Civil Aviation signed at Chicago on 7 December 1944 to provide:
(a) a right for states entitled to participate in an investigation to have access to evidence to enable those participating states to release a statement in accordance with Chapter 6.6.1 in circumstances where they have been excluded from an investigation by the State of Occurrence;
(b) a right of states entitled to participate in an investigation to take over conduct of an investigation in circumstances where a State of Occurrence does not produce a Final Report within a reasonable timeframe and does not produce interim statements indicating the progress of the investigation and safety issues raised within a reasonable timeframe and has not otherwise consented to the delegation of the investigation in accordance with Chapter 5.1.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise oxygen fires and immediately cut off the oxygen supply
Wider context from the report “(1) That a full review of cockpit fire/smoke procedures be undertaken to include, but not limited to:
- the recognition of an oxygen fire (identifiable by a characteristic noise comparable to that of a blowtorch) and the immediate cutting off this oxygen supply.
- the installation or carrying of protective equipment to deal with any cockpit fires.
- a review of the effectiveness of Halon fire extinguishers to deal with onboard fires.
- a review of regulations (if required) to prevent the use of cigarettes in the cockpit and related flammable items and materials.
- the additional risk analyses to take into account the hypothesis of an overpressure in the oxygen distribution system.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Uncertainty about the effectiveness of Halon fire extinguishers for onboard fires
Wider context from the report “(1) That a full review of cockpit fire/smoke procedures be undertaken to include, but not limited to:
- the recognition of an oxygen fire (identifiable by a characteristic noise comparable to that of a blowtorch) and the immediate cutting off this oxygen supply.
- the installation or carrying of protective equipment to deal with any cockpit fires.
- a review of the effectiveness of Halon fire extinguishers to deal with onboard fires.
- a review of regulations (if required) to prevent the use of cigarettes in the cockpit and related flammable items and materials.
- the additional risk analyses to take into account the hypothesis of an overpressure in the oxygen distribution system.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent cigarettes and related flammable items and materials in the cockpit
Wider context from the report “(1) That a full review of cockpit fire/smoke procedures be undertaken to include, but not limited to:
- the recognition of an oxygen fire (identifiable by a characteristic noise comparable to that of a blowtorch) and the immediate cutting off this oxygen supply.
- the installation or carrying of protective equipment to deal with any cockpit fires.
- a review of the effectiveness of Halon fire extinguishers to deal with onboard fires.
- a review of regulations (if required) to prevent the use of cigarettes in the cockpit and related flammable items and materials.
- the additional risk analyses to take into account the hypothesis of an overpressure in the oxygen distribution system.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Unavailability of protective equipment for cockpit fires
Wider context from the report “(1) That a full review of cockpit fire/smoke procedures be undertaken to include, but not limited to:
- the recognition of an oxygen fire (identifiable by a characteristic noise comparable to that of a blowtorch) and the immediate cutting off this oxygen supply.
- the installation or carrying of protective equipment to deal with any cockpit fires.
- a review of the effectiveness of Halon fire extinguishers to deal with onboard fires.
- a review of regulations (if required) to prevent the use of cigarettes in the cockpit and related flammable items and materials.
- the additional risk analyses to take into account the hypothesis of an overpressure in the oxygen distribution system.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of evidence access for states entitled to participate in an investigation when excluded by the State of Occurrence
Wider context from the report “(2) That a drafting committee be convened to consider amending Annex 13 of the Convention on International Civil Aviation signed at Chicago on 7 December 1944 to provide:
(a) a right for states entitled to participate in an investigation to have access to evidence to enable those participating states to release a statement in accordance with Chapter 6.6.1 in circumstances where they have been excluded from an investigation by the State of Occurrence ;
(b) a right of states entitled to participate in an investigation to take over conduct of an investigation in circumstances where a State of Occurrence does not produce a Final Report within a reasonable timeframe and does not produce interim statements indicating the progress of the investigation and safety issues raised within a reasonable timeframe and has not otherwise consented to the delegation of the investigation in accordance with Chapter 5.1.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure of risk analyses to account for overpressure in the oxygen distribution system
Wider context from the report “(1) That a full review of cockpit fire/smoke procedures be undertaken to include, but not limited to:
- the recognition of an oxygen fire (identifiable by a characteristic noise comparable to that of a blowtorch) and the immediate cutting off this oxygen supply.
- the installation or carrying of protective equipment to deal with any cockpit fires.
- a review of the effectiveness of Halon fire extinguishers to deal with onboard fires.
- a review of regulations (if required) to prevent the use of cigarettes in the cockpit and related flammable items and materials.
- the additional risk analyses to take into account the hypothesis of an overpressure in the oxygen distribution system.
” Open source report
×
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 ICAO’s amended arrangements and public-information encouragement provide adequate assurance without further rights to take over investigations.
Verbatim wording from the response “In relation to Point 2b, since the accident ICAO has amended Annex 13 via SARP 5.1.3 (Amendment 17 of Annex 13) introducing the right for another state to request that they take over investigative responsibility should no investigation be initiated within thirty days and giving states the right to do their own investigation using widely available information if no investigation is then initiated. ICAO also encourages states to release information publicly in the early days of the investigation. It is important to maintain clear roles and parameters for involvement in accident investigations to ensure they remain impartial, they are investigated thoroughly and lessons are learned to prevent future recurrence.” Source location Response from Department of Transport
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing accredited representatives’ full evidence access and safeguards make further amendments on access to evidence unnecessary.
Verbatim wording from the response “It is already the case that accredited representatives (usually investigators from the state of design, operation or registry) have full access to the investigation materials and evidence. There are safeguards in place to protect evidence in accident investigations being more widely available for very good reasons. These include people being more likely to cooperate knowing any evidence they provide will not be used against them in civil or criminal proceedings. This contributes to a “just culture” of being open and honest and prioritising learning over assigning blame. There are also ethical considerations about protecting individuals involved and controlling access to evidence which also helps maintain the chain of custody. Therefore with regard to Point 2a, we do not believe further amendments regarding access to evidence are necessary.” Source location Response from Department of Transport
Open published response
Concerns raised 1 Failure of national temporary-signage regulations to ensure adequate warning at collision sites View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Patricia Heidi BUSHELL · 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
Patricia Heidi BUSHELL was a pillion passenger on a motorcycle that was struck by a car at a junction on 9 September 2023. She sustained fatal injuries and died in hospital the same day. The principal concern was that temporary signage regarded as compliant with national guidance was nevertheless inadequate to alert drivers to the junction, raising a potentially wider national issue about temporary signage regulations.
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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure of national temporary-signage regulations to ensure adequate warning at collision sites
Wider context from the report “I indicated at the conclusion of the inquest that I will not be making a report in respect of the missed opportunities identified in relation to Leicestershire County Council employees. Significant changes have been made. I am however concerned that in respect of the national regulations, I am told that the temporary signage installed at the collision site was compliant with the guidance. Reference was made to The Road Traffic Regulations and the Traffic Signs Manual and it remains the view of LCC that the single temporary sign in place on the road was appropriate and complied with the guidance. It was nevertheless inadequate.
I refer specifically to Chapter 16 paragraph 20 of the Coroners Bench Book, ”Where the identified risk to life has already been ameliorated by local changes the coroner may wish to consider whether the matter is an issue that only affects the relevant local organisation or is a wider or national issue. In the latter case then directing a report to a national, professional or regulatory body might enable them to also consider relevant changes that might protect lives.” I conclude that this is potentially a wider national issue and I am writing to you, as you have responsibility for ensuring the transport network is safe and I wish to highlight the issues raised during this investigation and at the inquest particularly in relation to the current regulations with regard to temporary signage.
” 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 Consider the highlighted temporary-signage issue while updating the Code of Practice.
Verbatim wording from the response “However, my Department is currently undertaking work to update the Code of Practice and we will ensure that the issue you highlight is considered as part of that work.” Source location Response from Department for Transport
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing departmental guidance and local authorities’ risk assessments are considered sufficient to ensure a safe road network.
Verbatim wording from the response “The Department considers that with the guidance provided, and local authorities’ responsibility to undertake risk assessments, this should be sufficient to ensure the local authority can provide a safe road network.” Source location Response from Department for Transport
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 Local highway authorities are responsible for deciding how to fulfil their statutory duty to maintain traffic signs.
Verbatim wording from the response “The Department’s role is to set the overarching legal and policy framework, and to provide guidance to local highway authorities. All local highway authorities are required to ensure that traffic signs are maintained so that they can be seen by motorists. This stems from their general duty of care contained in Section 122 of the Road Traffic Regulation Act 1984, together with their statutory responsibility for maintaining the highway conferred in Section 41 of the Highways Act 1980.” Source location Response from Department for Transport
Open published response
6 May 2025 Charlotte Katie Mae Avis · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 2 Hazardous road layout at Loscombe Crossroads View source Continuing risk of road traffic collisions at Loscombe Crossroads View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Charlotte Katie Mae Avis · 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 Katie Mae Avis died at the scene after her car was struck head-on by a vehicle that had lost control and crossed into the opposite carriageway on 1 December 2022. The report raises concerns about the layout of Loscombe Crossroads and the number of collisions and fatalities at the site, with concern that future deaths could occur.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Hazardous road layout at Loscombe Crossroads
Wider context from the report “(1) Evidence has been provided that between 01.01.2014 and 24.03.2025 there have been 8 road traffic collisions at the site of Charlotte’s death which is referred to as Loscombe Crossroads, near Sherborne, Dorset. Those collisions have resulted in slight, serious and fatal injuries being sustained by those involved. There have been 4 fatalities from 3 of the collisions in a 4 year period. These fatalities occurred on 21.01.2020, 01.12.22 and 20.02.24.The last of these fatalities occurred after Charlotte’s death.
(2) Although the speed of the road was reduced by Dorset Council on 11th October 2024 from 70mph to 60mph, I have concerns around the layout of the road and the number of collisions in the area, and that there could be future deaths that occur.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Continuing risk of road traffic collisions at Loscombe Crossroads
Wider context from the report “(1) Evidence has been provided that between 01.01.2014 and 24.03.2025 there have been 8 road traffic collisions at the site of Charlotte’s death which is referred to as Loscombe Crossroads, near Sherborne, Dorset . Those collisions have resulted in slight, serious and fatal injuries being sustained by those involved. There have been 4 fatalities from 3 of the collisions in a 4 year period . These fatalities occurred on 21.01.2020, 01.12.22 and 20.02.24.The last of these fatalities occurred after Charlotte’s death.
(2) Although the speed of the road was reduced by Dorset Council on 11th October 2024 from 70mph to 60mph, I have concerns around the layout of the road and the number of collisions in the area , and that there could be future deaths that occur .
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Dorset Council, as the traffic authority, is responsible for decisions about road design, speed limits, traffic calming and road network management.
Verbatim wording from the response “You expressed concerns regarding the layout of the road as a factor in the collision. Responsibility for making decisions about the roads under its care rests with the traffic authority, based on its knowledge of the area and taking into account local needs and circumstances. Local authorities, in this case Dorset Council, are free to make their own decisions about the design of the roads and streets under their care, provided they take account of the relevant legislation. This includes setting local speed limits and introducing traffic calming measures such as speed cameras and speed activated warning signs.” Source location Response from Department for Transport
Open published response
2 May 2025 Rosemary MacAndrew · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 2 Risk of deaths from compromised driving ability among vulnerable older drivers View source Reliance of vehicle licensing on drivers’ self-reporting of medical conditions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Rosemary MacAndrew · 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
Rosemary MacAndrew, aged 64, died on 5 July 2024 after being struck by a reversing motor car while she was a pedestrian in a car park. The report raises concern that the current vehicle-licensing system relies largely on older drivers recognising and self-reporting medical conditions that may compromise their driving ability, creating a risk of future deaths.
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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Risk of deaths from compromised driving ability among vulnerable older drivers
Wider context from the report “The UK population is of increasing age and the number of older drivers is increasing rapidly. The current system for vehicle licensing relies largely upon the self-awareness of a driver and their willingness and/or ability to self-report medical conditions to the DVLA. I am concerned that older drivers with vulnerabilities, including age, decreasing mobility and cognitive decline pose a risk of future deaths through compromised driving ability thereby creating a risk of deaths 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Reliance of vehicle licensing on drivers’ self-reporting of medical conditions
Wider context from the report “The UK population is of increasing age and the number of older drivers is increasing rapidly. The current system for vehicle licensing relies largely upon the self-awareness of a driver and their willingness and/or ability to self-report medical conditions to the DVLA. I am concerned that older drivers with vulnerabilities, including age, decreasing mobility and cognitive decline pose a risk of future deaths through compromised driving ability thereby creating a risk of deaths in the future.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue engaging healthcare professionals and regulatory bodies to identify circumstances where appropriate DVLA notifications could be encouraged or supported.
Verbatim wording from the response “To ensure that the DVLA is notified about drivers who have conditions that may impair their insight into their health and driving abilities, my Department will continue to engage with healthcare professionals and their regulatory bodies to understand if there may be circumstances where doctors and health care professionals could be encouraged or supported in notifying the DVLA when appropriate.” Source location Response from Department for Transport
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with healthcare professionals, driving organisations and regulatory bodies to enhance road safety and identify and assess drivers who pose risks.
Verbatim wording from the response “The Government takes road safety very seriously and we are focused on ensuring that only those who are fit and safe to drive hold a valid driving licence. My Department will continue to work with healthcare professionals, driving organisations and regulatory bodies to enhance the safety of our roads and ensure that those who pose a risk to road safety are appropriately identified and assessed. The Department is also developing its Road Safety Strategy and will set out more details in due course.” Source location Response from Department for Transport
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 Current driver licensing arrangements are considered to balance road-safety risks, personal mobility and fairness proportionately.
Verbatim wording from the response “The current driver licensing arrangements are underpinned by the Road Traffic Act 1988, which makes it a legal requirement on all drivers to inform the Driver and Vehicle Licensing Agency (DVLA) if at any time they develop a medical condition that may affect safe driving. The current arrangements balance the risks that an individual poses to road safety with personal mobility and are designed to be fair and proportionate to all drivers who remain fit and competent to drive, regardless of their age.” Source location Response from Department for Transport
Open published response
23 Apr 2025 Raymond Barrie Thomas MILLS · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 4 Lack of a system for raising safety concerns with shipwreck owners View source Lack of a clear system for identifying shipwreck owners View source Lack of a safe system assigning responsibility for the management and safety of publicly accessible shipwrecks View source Insufficient on-site warnings about dangers at the shipwreck View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Raymond Barrie Thomas MILLS · 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 17 August 2024, Raymond Barrie Thomas Mills went into the sea while viewing a shipwreck off Brancaster beach, Norfolk, and was found unresponsive; he died after being airlifted to a local airport. The concerns were that no organisation was clearly responsible for the shipwreck’s management and safety, that owners could not be identified for raising safety concerns, and that there were insufficient warnings about the dangers of the tidal waters.
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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for raising safety concerns with shipwreck owners
Wider context from the report “2. With no clear system to ensure that the owners can be identified, there is no system to ensure that concerns can be raised with them when safety concerns arise .
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear system for identifying shipwreck owners
Wider context from the report “2. With no clear system to ensure that the owners can be identified , there is no system to ensure that concerns can be raised with them when safety concerns arise.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of a safe system assigning responsibility for the management and safety of publicly accessible shipwrecks
Wider context from the report “1. I am concerned that, in light of the above, there is no safe system in place to ensure that an organisation is responsible for the management and safety of such shipwrecks which are accessible by members of the public .
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Insufficient on-site warnings about dangers at the shipwreck
Wider context from the report “3. That that wreckage does not have sufficient warnings at the location to alert members of the public, particularly those who are not familiar with the tidal waters, of the dangers present at the wreck .
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Department will not take further action because it no longer owns the wreck and has no legal responsibility for it.
Verbatim wording from the response “The Department does not possess any further information that might assist in ascertaining whether title to the wreck was ever passed to anyone else or if a current owner exists. As the Department is no longer the owner of this wreck and has no legal responsibility pertaining to it, we are not proposing to take any further action on this occasion.” Source location Response from Department for Transport
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Department cannot assist in establishing the wreck’s current ownership because it has no further information about subsequent title transfers.
Verbatim wording from the response “The Department does not possess any further information that might assist in ascertaining whether title to the wreck was ever passed to anyone else or if a current owner exists. As the Department is no longer the owner of this wreck and has no legal responsibility pertaining to it, we are not proposing to take any further action on this occasion.” Source location Response from Department for Transport
Open published response
Concerns raised 8 Lack of periodic visual checks for licensed drivers View source Failure to assess visual fields during licence renewal View source Failure of driver self-reporting to verify visual fitness View source Unexplained reduction in driver self-reporting of major eye conditions View source Non-standardised collision data collection obscuring defective-eyesight involvement View source Failure to communicate unsafe visual assessments promptly to the DVLA View source Failure to refer non-compliant drivers for prosecution View source Inadequacy of the 20 m licence plate test for visual fitness assessment View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Mary Frances Cunningham and 3 others · 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
Mary Frances Cunningham, Grace Foulds, Anne Elizabeth Ferguson and Peter Anthony Westwell died in separate road traffic collisions involving drivers whose eyesight was below the legal standard for driving. The report raises concerns about the UK licensing system, including reliance on self-reporting, the lack of periodic visual checks, and the limitations of the number-plate test. It states that the DVLA continued to license the drivers involved despite their impaired vision.
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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of periodic visual checks for licensed drivers
Wider context from the report “A driver's visual acuity is only checked at the time of the driving test by reading a number plate at 20 m. A driver may then hold a licence until 70 years of age during which time there is no check that they meet the visual legal standards to drive a car . During this time a driver is required to self-monitor and self-refer visual conditions to the DVLA . During this time a variety of ocular diseases may develop, some of which are silent and of which the driver of which the driver may not be aware that that they are suffering from a disease that would compromise the driver's ability to comply with the legal standards to drive a car.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure to assess visual fields during licence renewal
Wider context from the report “At 70 years of age and every three years thereafter, a driver self-reports on a licence application that they can read a number plate 20 m and have not been informed that their vision falls beneath the legal limit for driving. Over the age of 70 the incidence of diseases that affect the eye rises sharply and not all can be detected by the driver unless they undergo an ophthalmic assessment. There is no question of the renewal application as to whether or not the driver's visual fields are sufficient to meet the legal standards for driving. Visual fields can only be assessed by an ophthalmic assessment using specialist equipment.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure of driver self-reporting to verify visual fitness
Wider context from the report “Self-reporting of visual conditions permits drivers to lie about their current driving status to those performing an ophthalmic assessment and avoid warnings not to drive. Drivers may also admit they drive but then ignore instructions not to drive and fail to notify the DVLA. In such circumstances, when the DVLA becomes aware, the DVLA does not refer such cases to the police for prosecution and consequently drivers can lie without sanction. All three drivers in this case either lied concerning the driving status wilfully misinterpreted questions to avoid driving advice not to drive, adopted fictions of their visual performance to allow them to drive, prioritised their own enjoyment and independence over the lives of other road users and repeatedly obtained licences from the DVLA due to a defective self-reporting system that does not confirm the driver meets the visual legal standards for driving and is open to abuse .
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Unexplained reduction in driver self-reporting of major eye conditions
Wider context from the report “Between 2019 and 2023 there has been a collapse of drivers self-reporting the four major conditions of diabetic retinopathy, cataracts, glaucoma and macular degeneration resulting in a 70 to 76% reduction in notifications . As the diseases are unchanged, the patient cohort is unchanged and the DVLA have not altered their processes, the DVLA have no explanation for this substantial reduction in driver self-reporting over such a short period.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Non-standardised collision data collection obscuring defective-eyesight involvement
Wider context from the report “The latest government figures record 1624 fatalities, 28,087 life changing serious injuries and 103,266 slight injuries accounting for 60,000 hospital admissions a year. Due to the Stats 19 data recording parameters, it is likely this is a substantial underestimate the actual number of road collisions from the National Travel Survey being approximately 600,000 and from the Department of Work and Pensions Compensation Recovery Unit 446,976. Data collection is further complicated by historical IT issues between constabularies resulting in a non-standardised reporting software . According to the Department for Transport uncorrected defective eyesight only occurred in 56 of the 15,355 road deaths recorded between January 2014 and January 2023, or 0.224% of all 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate unsafe visual assessments promptly to the DVLA
Wider context from the report “Doctor/optometrist-patient medical confidentiality is an entrenched aspect of UK medical practice and is only rarely breached and this only occurs after protracted patient negotiations during which time a driver continues to drive their car . Unless there were to be some form of requirement for a driver's visual assessment that is believed the legal limit to be communicated to the DVLA, this safeguard by which the DVLA may be notified of a driver continue to drive against advice produces only a minimal number of cases each year . This is already known to the DVLA.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure to refer non-compliant drivers for prosecution
Wider context from the report “Self-reporting of visual conditions permits drivers to lie about their current driving status to those performing an ophthalmic assessment and avoid warnings not to drive. Drivers may also admit they drive but then ignore instructions not to drive and fail to notify the DVLA. In such circumstances, when the DVLA becomes aware, the DVLA does not refer such cases to the police for prosecution and consequently drivers can lie without sanction . All three drivers in this case either lied concerning the driving status wilfully misinterpreted questions to avoid driving advice not to drive, adopted fictions of their visual performance to allow them to drive, prioritised their own enjoyment and independence over the lives of other road users and repeatedly obtained licences from the DVLA due to a defective self-reporting system that does not confirm the driver meets the visual legal standards for driving and is open to abuse.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Inadequacy of the 20 m licence plate test for visual fitness assessment
Wider context from the report “The 20 m licence plate test is a rough and ready roadside assessment of visual acuity. The 20 m licence plate test is unfit to accurately assess visual acuity to confirm that a driver meets the legal standard and makes no assessment of visual fields that are also a requirement. The European Council of Optometry and Optics in 2011 stated in respect of the 20 m licence plate test "this practice is unacceptable as the licence plate is not performed under control conditions and the results are not directly comparable with the underlying European standards which specify an assessment of visual acuity" and that member states using the licence plate test "should do more to improve their system of addressing drivers' vision". The UK took no action during the nine years it remained a member of the European Union.
The Association of Optometrists and the College of, optometrists both expressed the views of their organisation that the licence plate test was a poor proxy for a sight test both in terms of the information provided and the fact that it provided no visual health check to detect undiagnosed ocular and general diseases that may affect a driver's ability to drive.
” 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 Investigate the reduction in notifications of diabetic retinopathy, cataracts, glaucoma and macular degeneration and identify any necessary action.
Verbatim wording from the response “DVLA officials are also considering why there has been a reduction of notification of diabetic retinopathy, cataracts, glaucoma and macular degeneration between 2019 and 2023, with a view to understanding the cause and identifying what action may need to be taken.” Source location Response from Department for Transport
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 Work with eye healthcare professionals and regulatory bodies to identify and address barriers to notifying the DVLA when disclosure is in the public interest.
Verbatim wording from the response “However, I recognise that this may be challenging where there are concerns about confidentiality and the ethical implications of disclosing sensitive health information without a patient’s consent and where drivers dishonestly declare themselves to be non-drivers. I also acknowledge that this often involves protracted negotiations between healthcare professionals and their patients before a notification is made to the DVLA. My Department will work with eye healthcare professionals and their regulatory bodies to identify and aim to address any concerns and issues that may be preventing them from notifying the DVLA when it is in the public interest to do so.” Source location Response from Department for Transport
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with the visual-disorders advisory panel to discuss concerns and consider alternatives to the number-plate vision test.
Verbatim wording from the response “Its simplicity provides drivers with a good indication that they can meet the required visual acuity standards for driving and can scan information accurately from a distance. I acknowledge that there are concerns about the efficacy of the number plate test and the DVLA will continue to work closely with the Secretary of State for Transport’s Honorary Medical Advisory Panel on visual disorders and driving to discuss the points raised in your report and consider possible alternatives.” Source location Response from Department for Transport
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 Work with SCRICS to review and improve the collection and collation of STATS19 data on vision-related collision factors.
Verbatim wording from the response “My officials have advised that the STATS19 system for collecting and reporting road traffic collision data is unable to capture detailed information that identifies the causes of collisions. Many vision-related conditions may not manifest in ways that are immediately apparent following a road traffic collision. My Department will work with the Standing Committee on Road Injury Collision Statistics (SCRICS) to review and improve the collection and collation of STATS19 data. Officials will also continue to engage with police forces to develop a more standardised approach to roadside eyesight testing at the scene of the accident or shortly after to ensure that all relevant data is captured and reported accurately.” Source location Response from Department for Transport
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue engaging police forces to develop a more standardised approach to roadside eyesight testing at or shortly after collisions.
Verbatim wording from the response “My officials have advised that the STATS19 system for collecting and reporting road traffic collision data is unable to capture detailed information that identifies the causes of collisions. Many vision-related conditions may not manifest in ways that are immediately apparent following a road traffic collision. My Department will work with the Standing Committee on Road Injury Collision Statistics (SCRICS) to review and improve the collection and collation of STATS19 data. Officials will also continue to engage with police forces to develop a more standardised approach to roadside eyesight testing at the scene of the accident or shortly after to ensure that all relevant data is captured and reported accurately.” Source location Response from Department for Transport
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 Consider inquest evidence and potential legal changes to driver licensing for people with medical conditions, including self-declaration.
Verbatim wording from the response “The DVLA will also consider the evidence presented during the inquest hearing, to inform potential changes to the law that governs driver licensing for those with medical conditions. Work in this area is ongoing and includes consideration of the process of self-declaration and the challenges posed by an ageing population where certain conditions, including vision conditions, may become more prevalent. Consideration is also being given to policy options as part of the Government’s Road Safety Strategy, which is being developed and the details of which will be provided in due course.” Source location Response from Department for Transport
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The number plate test remains a practical baseline assessment because it is straightforward, cost-effective and functional in real time.
Verbatim wording from the response “The number plate test is currently the baseline assessment for visual acuity as it is straightforward, cost effective and easily administered, making it a practical and functional assessment of vision in real time.” Source location Response from Department for Transport
Open published response
Concerns raised 3 Failure of drivers with dementia to self-report medical conditions to the DVLA View source Failure to report multiple medical conditions requiring DVLA monitoring View source Under-recording of dementia in collision statistics 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
Sheila Margaret Edwards · 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
Sheila Margaret Edwards was a front-seat passenger in a car whose driver became unresponsive, leading to a head-on collision on 8 January 2023. The report identified concerns that drivers with dementia and other conditions may not recognise or report them to the DVLA, creating risks to other road users, and that such conditions may be under-recorded in collision data.
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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure of drivers with dementia to self-report medical conditions to the DVLA
Wider context from the report “1. Dementia affects approximately half a million sufferers in the United Kingdom of which the DVLA has only been notified of approximately 30,000 drivers. It would appear that there is significant underreporting of drivers who may suffer from dementia
2. The current system for vehicle licensing relies upon the self-awareness of a driver and their ability to self-report medical conditions to the DVLA . A system that relies upon the self-awareness of a person applying for a driving licence to self-report a medical condition of dementia where the condition itself is characterised by a lack of self-awareness is inherently unsafe and exposes other road users to the risk of death or serious injury
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure to report multiple medical conditions requiring DVLA monitoring
Wider context from the report “5. In this case, the driver suffered from focal epilepsy, which was the primary cause of the collision resulting Sheila Edwards' death. However, the memory deficit caused by dementia resulted in a lack of awareness of an underlying neurological condition. In such cases there is a substantial risk that neither of the conditions will be reported to the DVLA for monitoring . The result is that a driver with two conditions that should be monitored by the DVLA who is both unaware of their illnesses and the need to report themselves to the DVLA . This creates a substantial risk to other road users.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Under-recording of dementia in collision statistics
Wider context from the report “4. As a result of the way in which collision data is collected using Stats 19, there is a significant likelihood that dementia is under recorded in collision statistics . The nation this point regarding collision data regarding the visual aspect of collisions, the PFD report into the deaths of Mary Cunningham, Grace Foulds, Anne Ferguson and Peter Westwell should be consulted.
” 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 Consider research and evidence, including any additional research needed, to inform potential future changes to the driver licensing system.
Verbatim wording from the response “Officials are considering the research and evidence provided and what additional research may be needed to inform potential future changes. These considerations include the system of self-declaration and the potential for the introduction of age-based testing. Consideration is also being given to policy options as part of the Government’s Road Safety Strategy, which is being developed and the details of which will be provided in due course.” Source location Response from Department for Transport
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with healthcare professionals, driving organisations and regulatory bodies to identify and assess people who pose road-safety risks because of unrecognised medical conditions.
Verbatim wording from the response “My Department will continue to work with healthcare professionals, driving organisations and regulatory bodies to enhance the safety of our roads and ensure that those who pose a risk to road safety due to lack of awareness of their medical condition are appropriately identified and assessed.” Source location Response from Department for Transport
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue engaging healthcare professionals and regulatory bodies to identify and address obstacles to reporting conditions when patients lack insight or capacity.
Verbatim wording from the response “Although the process for establishing that a driver meets the medical standards for driving is based on self-declaration, I recognise that this may be difficult for those drivers with conditions that may impair their insight into their health status. My department will continue to engage with healthcare professionals and their regulatory bodies to identify and address any obstacles that may hinder the reporting process, particularly where their patient lacks the insight or capacity to inform the DVLA of their condition themselves.” Source location Response from Department for Transport
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 STATS19 cannot capture all medical contributory factors because detailed identification would impose practical burdens on police officers.
Verbatim wording from the response “I note that you have raised concerns about the STATS19 system used in GB for collecting and reporting road traffic collision data. The Department acknowledges that STATS19 has limitations in identifying the causes of collisions in detail, particularly regarding the recording of medical conditions such as dementia or cognitive impairment as a contributory factor. These limitations are set out in the guidance provided (for example, the guidance on contributory factors). Contributory factors are based on the judgement of police officers at the scene of an accident or shortly afterwards. As a result, conditions such as those affecting cognitive function may go unrecorded, especially if the impairment is not immediately apparent or if the officer is unaware of the driver’s medical history.” Source location Response from Department for Transport
Open published response
Concerns raised 1 Inexperienced drivers carrying young passengers during the first six months after passing their driving test View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
William Owen RADFORD · 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
William Owen RADFORD died on 13 June 2024 from fatal injuries sustained after losing control of his vehicle and being struck by an oncoming vehicle while driving on the A281 Brighton Road. He had only recently passed his driving test and was carrying a young passenger. The inquest heard that distraction from another young person could increase the risk of an accident for an inexperienced driver, amid public concern about young-passenger restrictions for newly qualified drivers.
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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Inexperienced drivers carrying young passengers during the first six months after passing their driving test
Wider context from the report “This Inquest concerned the death of a young man (aged 17) who had only just passed his driving test a few weeks before his death. At the time of his death he was driving his car accompanied by a young friend, also aged 17. I heard evidence that where an inexperienced driver has a distraction of another young person in the car this can increase their risk of having an accident. There is currently ongoing public concern that inexperienced drivers are able to carry young passengers within the first six months of having passed their test.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Graduated Driving Licences are not being considered, although young driver safety is being addressed through existing restrictions and the THINK! campaign.
Verbatim wording from the response “In Britain, there is a form of restricting novice drivers through the Road Traffic (New Drivers) Act 1995. On acquiring their first full licence, a new driver is on ‘probation’ for two years. During this time, they are subject to a limit of six penalty points received for any driving offences (including any received when in the learning stage). If six or more points are received, then a driver loses their full licence and must apply again for a provisional licence, and then re-take both their theory and practical test.” Source location Response from Department for Transport
Open published response
20 Feb 2025 Paul Stephen Collingridge · Prevention of Future Deaths report Essex
View report summary
Concerns raised 4 Inadequate Code of Practice guidance for calculating street works distances where standard reference points or markings are unavailable or variable View source Difficulties in calculating distances for roadworks set up in darkness View source Failure to place road works warning signs without obscuring visibility of joining traffic View source Absence of a requirement to notify fatalities within roadworks on permit applications View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Paul Stephen Collingridge · 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
Paul Stephen Collingridge, aged 28, died on 6 December 2022 from multiple traumatic injuries after his motorcycle high-sided near overnight roadworks and he was struck by oncoming traffic. The report raised concerns about the setting out and measurement of roadworks in darkness and on curved roads, the placement of a warning sign that obscured visibility, and the absence of a requirement to report a fatality on a retrospective permit application.
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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Inadequate Code of Practice guidance for calculating street works distances where standard reference points or markings are unavailable or variable
Wider context from the report “(2) The Safety of Street Works Code of Practice sets out how to take measurements to set out street works that include utilising street furniture that are at set distances and standard road markings that have standard lengths on carriageways with specific road speeds.
a. Some carriageways do not have street furniture
b. Some of the road markings on the carriage where the fatal collision did not comply to standard lengths and therefore the markings can have variations.
c. The Code of Practice does not set out how to calculate the distance where there is road curvature where the road markings have differing lengths on opposing sides where the markings are delineated on bends in a carriageway.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Difficulties in calculating distances for roadworks set up in darkness
Wider context from the report “(1) Where Road Works Permits are required by utility companies these are often urgent to carry out vital repairs. This can mean that roadworks are set up in hours of darkness and may cause difficulties calculating distances as set out in the Safety at Street Works Code of Practice.
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure to place road works warning signs without obscuring visibility of joining traffic
Wider context from the report “(3) A road works warning sign was placed at the junction that joined the carriageway of a road that obscured visibility of traffic joining the main carriageway . Whilst this did not cause or contribute to this incident this was not in accordance with the Code of Practice .
” 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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Absence of a requirement to notify fatalities within roadworks on permit applications
Wider context from the report “(4) The fatal incident that occurred on 6 December 2022 was not notified on the retrospective permit application for roadworks on the following day. There is no requirement for a fatality within roadworks be notified on application for an application for a permit .
” 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 Update the Safety Code through consultation, incorporating the report’s findings and publishing a revised version.
Verbatim wording from the response “The Safety Code was last published in 2013 and is currently in the process of being updated, with a consultation due to take place in early summer. We are inviting comments on whether there are any parts of the Safety Code that can be improved to maximise safety, and we plan to publish an updated version by the end of 2025. I will ensure that we take into account your report when completing this work.” Source location Response from Department for Transport
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 There is no requirement to record a site fatality on an immediate-works permit application because the permit concerns timings and durations.
Verbatim wording from the response “You raised a final concern that the fatality was not mentioned on the permit application for the works. For immediate works, permits can be submitted within two hours of arriving on site. If a fatality happens at the site, there is no requirement for it to be referred to on the permit application, as the permit is concerned with agreeing timings and durations of works. It is the Safety Code and the risk assessments that are carried out that take account of incidents to ensure sites are set up correctly.” Source location Response from Department for Transport
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 Those carrying out works are responsible for accurately measuring Safety Code distances, including during darkness.
Verbatim wording from the response “You made references to the use of street furniture and road markings to determine distances and measuring distances accurately in the hours of darkness. The Safety Code details the sequence for setting out a street work site with reference to a table of distances. These distances are determined with reference to the street work site and do not depend on the presence of street furniture or road markings. The Safety Code makes it clear that it is the responsibility of those carrying out the works to ensure that the distances are measured accurately. This also includes during the hours of darkness. Failure to comply with the distances set out in the Safety Code is evidence that an offence for failing to comply with the Safety Code has been committed.” Source location Response from Department for Transport
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The local highway authority that granted the permit is responsible for deciding enforcement action concerning incorrectly placed signs.
Verbatim wording from the response “You raised a further concern regarding a sign that was placed incorrectly at a junction which obscured visibility but was not a contributing factor to Mr Collingridge’s death. It appears that the placement of the sign was not in accordance with the Safety Code. However, it is for the local highway authority that granted the permit to decide on any enforcement action. It would have been for them to do this at the time of the incident.” Source location Response from Department for Transport
Open published response
7 Feb 2025 Ian Augustus Jones · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 1 Accessibility of electric motors and parts enabling conversion of pedal bicycles into high-powered throttle-controlled scooters 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
Ian Augustus Jones · 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
Ian Augustus Jones died at University Hospital Wales, Cardiff, on 29 October 2022 from a traumatic brain injury sustained after the electrically motorised bicycle he was riding without a helmet collided with a pavement bollard. The report raised concern about the accessibility of electric motors and parts that can convert a pedal bicycle into a high-powered, throttle-controlled scooter capable of high speeds and rapid acceleration, posing a danger to riders and other members of the public.
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 Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Accessibility of electric motors and parts enabling conversion of pedal bicycles into high-powered throttle-controlled scooters
Wider context from the report “(1) The accessibility of electric motors and parts that can be easily used to convert a normal pedal bicycle into a high powered, throttle controlled scooter capable of high speeds with rapid acceleration that can pose a danger to the rider and to other members of the public.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing legal requirements and enforcement powers are considered sufficient, so no additional Department action is appropriate at this stage.
Verbatim wording from the response “On balance and after careful consideration, we have concluded that there is no additional action that would be appropriate for the Department to take at this stage. This is in light of the existing legal framework governing the modification of e-cycles as described above, and the enforcement powers of various bodies, including the police, DVSA, OPSS and local trading standards.” Source location Response from Department for Transport
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations