11 Jul 2023 MUSTAFA NADEEM · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 4 Lack of a regulatory body for hire e-scooter providers View source Inability of hire e-scooter providers to detect use of children’s bank accounts for rides View source Failure to conduct age and identity checks when hire e-scooter accounts are transferred between devices View source Ineffective education and information for preventing children from illegally using hire e-scooters 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
MUSTAFA NADEEM · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 6 December 2022, 12-year-old Mustafa Nadeem was fatally injured after colliding with a pedestrian while riding a hire e-scooter to school and falling into the path of a bus. The principal concern was that children could easily use hire e-scooters illegally, and that existing precautions and education were ineffective in preventing this.
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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 a regulatory body for hire e-scooter providers
Wider context from the report “Hire e-scooters are only available as part of a national pilot scheme. The scheme is implemented locally. Guidance to the providers of hire e-scooters is currently limited to Department for Transport guidance. There is no regulatory body .
” 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 Inability of hire e-scooter providers to detect use of children’s bank accounts for rides
Wider context from the report “I heard evidence that the providers of hire e-scooters have no ability to detect if a child’s bank account is being used to pay for rides . In this case, had the provider been able to detect the use of a child’s bank account it would have alerted them to illegal use on the account and action would have been taken.
” 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 conduct age and identity checks when hire e-scooter accounts are transferred between devices
Wider context from the report “I heard evidence that Department for Transport guidance requires a driving licence, age and identity check when an account is created on a mobile device. However, users can easily transfer the account to another device and no further identity and age check is required . In this case the account was originally created on an adult’s mobile phone, but quickly and easily transferred to a child’s mobile phone and payment switched to an under 16s bank account. Department for Transport guidance did not require the e-scooter provider to undertake any age or identity checks at the point of transfer .
” 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 Ineffective education and information for preventing children from illegally using hire e-scooters
Wider context from the report “I heard evidence from the head teacher of the deceased’s school that from the outset of the hire e-scooter pilot scheme pupils riding e-scooters illegally was instantly problematic. Upon it being known the school would seize e-scooters pupils would simply abandon them at the end of the road. Despite education and the facts of this death being known, children from the same school and other schools continued to use hire e-scooters illegally .
I heard evidence that education is paramount to safe use of hire e-scooters and this requires a collaborative approach .
” 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 Gather and disseminate examples of additional measures with trial operators to raise industry standards against under-age riding.
Verbatim wording from the response “In addition to the minimum standards, officials will work with trial operators to gather and disseminate examples of additional measures that could further discourage under-age riding, with the aim of raising standards across the industry. I understand that these measures could include a selfie to confirm identity, additional selfie checks when a user switches an account to a new device and at random times when the account is in use, and liveness checks to ensure the selfie is not a photograph or recording.” Source location Response from Department for Transport
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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 Issue updated guidance strengthening licence and identity checks, storage and validation requirements, in-app rule messaging, and operator compliance confirmation.
Verbatim wording from the response “procedures and concluded the minimum standards required from operators should be strengthened to further discourage illegal use.” Source location Response from Department for Transport
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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 considering options for future regulation of e-scooters.
Verbatim wording from the response “The trials are designed to assess the safety of e-scooters and their wider impacts, and while they are running, we will keep the guidance under review. The Government continues to consider options for future regulation of e-scooters. Any future regulatory change requires completing an impact assessment, equalities assessment and a public consultation. The latter will provide an opportunity for interested parties to shape the new regime before any regulations are introduced. In the meantime, current regulations for e-scooters still apply, and private e-scooters remain illegal to use on public roads.” Source location Response from Department for Transport
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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 Encourage operators to continue additional measures and good practice deterring under-age riding.
Verbatim wording from the response “I note your comments about the effectiveness of current precautions in preventing children from (illegally) hiring e-scooters, but it is important to acknowledge the steps that e-scooter rental operators have already taken to discourage under-age riding. These vary across the 23 trial areas and include but are not limited to: in-app safety pop-ups and quizzes to ensure awareness of the rules; in-person safety events and training sessions, some held in partnership with the local police; foot patrols by the operator across the trial area; reviews of the location of parking bays; and advertising the rules beyond the app and website, for example in newspapers, on advertising boards, and through the use of stickers on the e-scooter itself.” 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 operators to identify whether more can be done to alert them to suspected under-age riders using children’s bank accounts.
Verbatim wording from the response “You also raised a concern that operators have no ability to detect if a child’s bank account is being used to pay for rides. An initial review by officials suggests there are currently no systems that would allow a bank to share, with an operator, details of the type of account used to make a payment. This is not a system in use when purchasing other age restricted products and services, but I agree it could be useful in preventing under-age access to e-scooters and have asked my officials to work with operators to understand if” Source location Response from Department for Transport
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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 Procurement and management of licence-verification software are outside the Department’s involvement.
Verbatim wording from the response “The Department is not involved in the procurement or management of this software, but whatever system is used must be robust. All operators must also ensure they have in-app messaging that states the rules clearly, including the age limit for the trial, and the rule that the person riding the e-scooter must hold a valid driving licence.” Source location Response from Department for Transport
Open published response
10 Jul 2023 Mr Christian Kwame Tuvi · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 5 Unavailability of training for cleaners to inch and operate travellator controls View source Failure to allocate responsibilities and powers for training and travellator-operation competence in cleaning contracts View source Failure to assess cleaners against an agreed competence standard for inching View source Failure to ensure cleaners understand the full technical method of work View source Failure to provide a movement-communication system that does not rely solely on verbal communication View source See 2 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
Mr Christian Kwame Tuvi · 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
Mr Christian Kwame Tuvi, an escalator cleaner aged 44, died at Waterloo Station after the traveller moved while he was in a gap, causing blunt force trauma to the chest. The jury identified inadequate briefing, failure to complete a site-specific risk assessment, failure to give an audible warning, and failures concerning the inching pendant and compliance with the method statement. The report also raised continuing concerns about unresolved responsibility for training and competence to operate the travellator during cleaning.
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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 Unavailability of training for cleaners to inch and operate travellator controls
Wider context from the report “The ORR informed the coroner that in 2020 an improvement notice was served on Cleshar Cleaners, requiring them to provide a safe system of work for communicating the movement of the conveyor which does not rely solely on verbal communication.
Cleshar has appealed the Improvement Notice and the Employment Tribunal have stayed the notice until 2024. Although the improvement notice is under appeal Cleshar has made some changes to improve their safe system of work. These included a padlock for the operative to place on the nearest isolator switch before entering the gap, pressing the stop button in, KONE discussing with Cleshar where the gap is to be left prior to handing over control of the machine and the risk assessment and method statement now identify the need for a middle person to relay messages.
The improvements that Cleshar made have allowed them to resume the deep clean of Waterloo moving walkway. However, the TfL familiarisation training for working in a plant room no longer provides inching as part of the course . TfL expects their contractors to provide inching training for their operatives. Without the evidence of competence to inch the machine the isolation/inching function remains with KONE as a temporary solution.
It is unclear why this cannot be a permanent solution. I heard from witnesses that it would be safer for engineers, who are present during deep cleans, to operate the movements of the traveller, but I was told that it would lead to a lack of clarity as to who was in charge. This seems not to be insoluble given different contractors with different employees is a norm on building sites working safely under HSE rules across the country. More likely there are undisclosed issues perhaps related to assumption of responsibility for risk or financial considerations which explain the resistance.
The inquest heard that prior to the accident, cleaners would attend a TfL training course with a signed form which TfL observed was a certificate of competence to inch and operate the controls of the traveller. But the issuing manager and cleaners thought that the TfL course provided that training. The withdrawal of that training and the inability to find another training facility, has led to the cleaners not being trained and so not permitted to operate the travellator .
Cleshar Cleaners management have not in the past assessed their cleaners for competence to inch and there is no agreed standard of competence. Concerns were expressed in the inquest that most of the cleaners did not have English as their first language and that the risk assessment method statement was a huge technical document, with which the cleaners were not familiar and they all required training in the whole method of work, and not just the person in charge.
MY CONCERN and reason for reporting this matter to the minister and not just the regulator and contractors, is that nearly four years have passed and there remains an impasse between the organizations as to whom should train whom, and the competence required to operate the travellator whilst it is being cleaned. It seems that TfL has the power to produce a resolution, but is leaving matters to others to resolve. It is hard not to conclude that there is corporate reluctance to assume risk for an important public service. The regulatory bodies and contractors in the supply chain have allowed this matter to remain unresolved for an unacceptable length of time and there may be a system failure in the allocation of responsibilities and powers in the process of contracting for cleaning escalators.
” 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 allocate responsibilities and powers for training and travellator-operation competence in cleaning contracts
Wider context from the report “The ORR informed the coroner that in 2020 an improvement notice was served on Cleshar Cleaners, requiring them to provide a safe system of work for communicating the movement of the conveyor which does not rely solely on verbal communication.
Cleshar has appealed the Improvement Notice and the Employment Tribunal have stayed the notice until 2024. Although the improvement notice is under appeal Cleshar has made some changes to improve their safe system of work. These included a padlock for the operative to place on the nearest isolator switch before entering the gap, pressing the stop button in, KONE discussing with Cleshar where the gap is to be left prior to handing over control of the machine and the risk assessment and method statement now identify the need for a middle person to relay messages.
The improvements that Cleshar made have allowed them to resume the deep clean of Waterloo moving walkway. However, the TfL familiarisation training for working in a plant room no longer provides inching as part of the course. TfL expects their contractors to provide inching training for their operatives. Without the evidence of competence to inch the machine the isolation/inching function remains with KONE as a temporary solution.
It is unclear why this cannot be a permanent solution. I heard from witnesses that it would be safer for engineers, who are present during deep cleans, to operate the movements of the traveller, but I was told that it would lead to a lack of clarity as to who was in charge. This seems not to be insoluble given different contractors with different employees is a norm on building sites working safely under HSE rules across the country. More likely there are undisclosed issues perhaps related to assumption of responsibility for risk or financial considerations which explain the resistance.
The inquest heard that prior to the accident, cleaners would attend a TfL training course with a signed form which TfL observed was a certificate of competence to inch and operate the controls of the traveller. But the issuing manager and cleaners thought that the TfL course provided that training. The withdrawal of that training and the inability to find another training facility, has led to the cleaners not being trained and so not permitted to operate the travellator.
Cleshar Cleaners management have not in the past assessed their cleaners for competence to inch and there is no agreed standard of competence. Concerns were expressed in the inquest that most of the cleaners did not have English as their first language and that the risk assessment method statement was a huge technical document, with which the cleaners were not familiar and they all required training in the whole method of work, and not just the person in charge.
MY CONCERN and reason for reporting this matter to the minister and not just the regulator and contractors, is that nearly four years have passed and there remains an impasse between the organizations as to whom should train whom, and the competence required to operate the travellator whilst it is being cleaned . It seems that TfL has the power to produce a resolution, but is leaving matters to others to resolve. It is hard not to conclude that there is corporate reluctance to assume risk for an important public service. The regulatory bodies and contractors in the supply chain have allowed this matter to remain unresolved for an unacceptable length of time and there may be a system failure in the allocation of responsibilities and powers in the process of contracting for cleaning escalators .
” 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 cleaners against an agreed competence standard for inching
Wider context from the report “The ORR informed the coroner that in 2020 an improvement notice was served on Cleshar Cleaners, requiring them to provide a safe system of work for communicating the movement of the conveyor which does not rely solely on verbal communication.
Cleshar has appealed the Improvement Notice and the Employment Tribunal have stayed the notice until 2024. Although the improvement notice is under appeal Cleshar has made some changes to improve their safe system of work. These included a padlock for the operative to place on the nearest isolator switch before entering the gap, pressing the stop button in, KONE discussing with Cleshar where the gap is to be left prior to handing over control of the machine and the risk assessment and method statement now identify the need for a middle person to relay messages.
The improvements that Cleshar made have allowed them to resume the deep clean of Waterloo moving walkway. However, the TfL familiarisation training for working in a plant room no longer provides inching as part of the course. TfL expects their contractors to provide inching training for their operatives. Without the evidence of competence to inch the machine the isolation/inching function remains with KONE as a temporary solution.
It is unclear why this cannot be a permanent solution. I heard from witnesses that it would be safer for engineers, who are present during deep cleans, to operate the movements of the traveller, but I was told that it would lead to a lack of clarity as to who was in charge. This seems not to be insoluble given different contractors with different employees is a norm on building sites working safely under HSE rules across the country. More likely there are undisclosed issues perhaps related to assumption of responsibility for risk or financial considerations which explain the resistance.
The inquest heard that prior to the accident, cleaners would attend a TfL training course with a signed form which TfL observed was a certificate of competence to inch and operate the controls of the traveller. But the issuing manager and cleaners thought that the TfL course provided that training. The withdrawal of that training and the inability to find another training facility, has led to the cleaners not being trained and so not permitted to operate the travellator.
Cleshar Cleaners management have not in the past assessed their cleaners for competence to inch and there is no agreed standard of competence . Concerns were expressed in the inquest that most of the cleaners did not have English as their first language and that the risk assessment method statement was a huge technical document, with which the cleaners were not familiar and they all required training in the whole method of work, and not just the person in charge.
MY CONCERN and reason for reporting this matter to the minister and not just the regulator and contractors, is that nearly four years have passed and there remains an impasse between the organizations as to whom should train whom, and the competence required to operate the travellator whilst it is being cleaned. It seems that TfL has the power to produce a resolution, but is leaving matters to others to resolve. It is hard not to conclude that there is corporate reluctance to assume risk for an important public service. The regulatory bodies and contractors in the supply chain have allowed this matter to remain unresolved for an unacceptable length of time and there may be a system failure in the allocation of responsibilities and powers in the process of contracting for cleaning escalators.
” 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 cleaners understand the full technical method of work
Wider context from the report “The ORR informed the coroner that in 2020 an improvement notice was served on Cleshar Cleaners, requiring them to provide a safe system of work for communicating the movement of the conveyor which does not rely solely on verbal communication.
Cleshar has appealed the Improvement Notice and the Employment Tribunal have stayed the notice until 2024. Although the improvement notice is under appeal Cleshar has made some changes to improve their safe system of work. These included a padlock for the operative to place on the nearest isolator switch before entering the gap, pressing the stop button in, KONE discussing with Cleshar where the gap is to be left prior to handing over control of the machine and the risk assessment and method statement now identify the need for a middle person to relay messages.
The improvements that Cleshar made have allowed them to resume the deep clean of Waterloo moving walkway. However, the TfL familiarisation training for working in a plant room no longer provides inching as part of the course. TfL expects their contractors to provide inching training for their operatives. Without the evidence of competence to inch the machine the isolation/inching function remains with KONE as a temporary solution.
It is unclear why this cannot be a permanent solution. I heard from witnesses that it would be safer for engineers, who are present during deep cleans, to operate the movements of the traveller, but I was told that it would lead to a lack of clarity as to who was in charge. This seems not to be insoluble given different contractors with different employees is a norm on building sites working safely under HSE rules across the country. More likely there are undisclosed issues perhaps related to assumption of responsibility for risk or financial considerations which explain the resistance.
The inquest heard that prior to the accident, cleaners would attend a TfL training course with a signed form which TfL observed was a certificate of competence to inch and operate the controls of the traveller. But the issuing manager and cleaners thought that the TfL course provided that training. The withdrawal of that training and the inability to find another training facility, has led to the cleaners not being trained and so not permitted to operate the travellator.
Cleshar Cleaners management have not in the past assessed their cleaners for competence to inch and there is no agreed standard of competence. Concerns were expressed in the inquest that most of the cleaners did not have English as their first language and that the risk assessment method statement was a huge technical document, with which the cleaners were not familiar and they all required training in the whole method of work, and not just the person in charge .
MY CONCERN and reason for reporting this matter to the minister and not just the regulator and contractors, is that nearly four years have passed and there remains an impasse between the organizations as to whom should train whom, and the competence required to operate the travellator whilst it is being cleaned. It seems that TfL has the power to produce a resolution, but is leaving matters to others to resolve. It is hard not to conclude that there is corporate reluctance to assume risk for an important public service. The regulatory bodies and contractors in the supply chain have allowed this matter to remain unresolved for an unacceptable length of time and there may be a system failure in the allocation of responsibilities and powers in the process of contracting for cleaning escalators.
” 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 a movement-communication system that does not rely solely on verbal communication
Wider context from the report “The ORR informed the coroner that in 2020 an improvement notice was served on Cleshar Cleaners, requiring them to provide a safe system of work for communicating the movement of the conveyor which does not rely solely on verbal communication .
Cleshar has appealed the Improvement Notice and the Employment Tribunal have stayed the notice until 2024. Although the improvement notice is under appeal Cleshar has made some changes to improve their safe system of work. These included a padlock for the operative to place on the nearest isolator switch before entering the gap, pressing the stop button in, KONE discussing with Cleshar where the gap is to be left prior to handing over control of the machine and the risk assessment and method statement now identify the need for a middle person to relay messages.
The improvements that Cleshar made have allowed them to resume the deep clean of Waterloo moving walkway. However, the TfL familiarisation training for working in a plant room no longer provides inching as part of the course. TfL expects their contractors to provide inching training for their operatives. Without the evidence of competence to inch the machine the isolation/inching function remains with KONE as a temporary solution.
It is unclear why this cannot be a permanent solution. I heard from witnesses that it would be safer for engineers, who are present during deep cleans, to operate the movements of the traveller, but I was told that it would lead to a lack of clarity as to who was in charge. This seems not to be insoluble given different contractors with different employees is a norm on building sites working safely under HSE rules across the country. More likely there are undisclosed issues perhaps related to assumption of responsibility for risk or financial considerations which explain the resistance.
The inquest heard that prior to the accident, cleaners would attend a TfL training course with a signed form which TfL observed was a certificate of competence to inch and operate the controls of the traveller. But the issuing manager and cleaners thought that the TfL course provided that training. The withdrawal of that training and the inability to find another training facility, has led to the cleaners not being trained and so not permitted to operate the travellator.
Cleshar Cleaners management have not in the past assessed their cleaners for competence to inch and there is no agreed standard of competence. Concerns were expressed in the inquest that most of the cleaners did not have English as their first language and that the risk assessment method statement was a huge technical document, with which the cleaners were not familiar and they all required training in the whole method of work, and not just the person in charge.
MY CONCERN and reason for reporting this matter to the minister and not just the regulator and contractors, is that nearly four years have passed and there remains an impasse between the organizations as to whom should train whom, and the competence required to operate the travellator whilst it is being cleaned. It seems that TfL has the power to produce a resolution, but is leaving matters to others to resolve. It is hard not to conclude that there is corporate reluctance to assume risk for an important public service. The regulatory bodies and contractors in the supply chain have allowed this matter to remain unresolved for an unacceptable length of time and there may be a system failure in the allocation of responsibilities and powers in the process of contracting for cleaning escalators.
” 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 Day-to-day London Underground operations and processes fall outside departmental powers and are accountable to the London Mayor through TfL.
Verbatim wording from the response “As you will be aware, my Department has limited powers to intervene formally in transport safety matters, which are the responsibility of the Office of Rail and Road in its capacity as the independent Rail Safety Regulator. Furthermore, my Department does not have powers to intervene in London Underground Limited’s day-to-day operations or processes, for which it is separately accountable to the London Mayor as a subsidiary of TfL.” 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 Formal transport safety intervention is the Office of Rail and Road’s responsibility as the independent rail safety regulator.
Verbatim wording from the response “As you will be aware, my Department has limited powers to intervene formally in transport safety matters, which are the responsibility of the Office of Rail and Road in its capacity as the independent Rail Safety Regulator. Furthermore, my Department does not have powers to intervene in London Underground Limited’s day-to-day operations or processes, for which it is separately accountable to the London Mayor as a subsidiary of TfL.” Source location Response from Department for Transport
Open published response
29 Jun 2023 Peter John WALKER · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 4 Lack of comprehensive medical guidance for pilots making Pilot Medical Declarations View source Lack of guidance for medical professionals on Pilot Medical Declaration standards View source Revalidation of certain aircraft ratings without independent assessment of ability or fitness to fly View source Lack of a system to coordinate licence revocation and licence surrender activities View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Peter John WALKER · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Peter Walker died after the microlight aircraft he was flying alone crashed in a field adjacent to the runway at Beccles Aerodrome on 24 March 2022. The concerns included shortcomings in the Civil Aviation Authority’s guidance and systems for medical self-declarations, licence revalidation, and managing licence revocation or surrender for older pilots and certain microlight licence holders.
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 comprehensive medical guidance for pilots making Pilot Medical Declarations
Wider context from the report “However, unlike the DVLA the CAA provides no comprehensive guidance for the individual pilot making the self-declaration . As such the CAA provides no list of identifiable conditions that would either preclude the pilot flying, or any conditions which suggest the pilot should seeks further medical opinion regarding their fitness to fly .
It was identified that the CAA provided no guidance to any medical professionals to alert them to the medical standards required for an individual making a Pilot Medical Declaration, should that individual approach them for a medical opinion regarding their fitness to fly.
It was identified that the DVLA has an efficient centrally controlled system to manage medically related driving licence decisions and to coordinate licence revocation and licence surrender activities. The CAA has no such system to coordinate their licence revocation and licence surrender activities.
It was identified, that any pilot of the type of aircraft being flown by Peter, who qualified on that type prior to 2008, can revalidate their licence to fly that type of aircraft by providing a self-declaration of evidence of experience of flying that aircraft. As the Pilot Medication Declaration system, and the licence revalidation procedure for this type of aircraft both rely on self-declarations only, it was identified that a pilot over 70 who flies this type of aircraft, can be revalidated to fly it without any independent third-party assessment of their actual ability or fitness to fly.
” 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 guidance for medical professionals on Pilot Medical Declaration standards
Wider context from the report “However, unlike the DVLA the CAA provides no comprehensive guidance for the individual pilot making the self-declaration. As such the CAA provides no list of identifiable conditions that would either preclude the pilot flying, or any conditions which suggest the pilot should seeks further medical opinion regarding their fitness to fly.
It was identified that the CAA provided no guidance to any medical professionals to alert them to the medical standards required for an individual making a Pilot Medical Declaration , should that individual approach them for a medical opinion regarding their fitness to fly.
It was identified that the DVLA has an efficient centrally controlled system to manage medically related driving licence decisions and to coordinate licence revocation and licence surrender activities. The CAA has no such system to coordinate their licence revocation and licence surrender activities.
It was identified, that any pilot of the type of aircraft being flown by Peter, who qualified on that type prior to 2008, can revalidate their licence to fly that type of aircraft by providing a self-declaration of evidence of experience of flying that aircraft. As the Pilot Medication Declaration system, and the licence revalidation procedure for this type of aircraft both rely on self-declarations only, it was identified that a pilot over 70 who flies this type of aircraft, can be revalidated to fly it without any independent third-party assessment of their actual ability or fitness to fly.
” 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 Revalidation of certain aircraft ratings without independent assessment of ability or fitness to fly
Wider context from the report “However, unlike the DVLA the CAA provides no comprehensive guidance for the individual pilot making the self-declaration. As such the CAA provides no list of identifiable conditions that would either preclude the pilot flying, or any conditions which suggest the pilot should seeks further medical opinion regarding their fitness to fly.
It was identified that the CAA provided no guidance to any medical professionals to alert them to the medical standards required for an individual making a Pilot Medical Declaration, should that individual approach them for a medical opinion regarding their fitness to fly.
It was identified that the DVLA has an efficient centrally controlled system to manage medically related driving licence decisions and to coordinate licence revocation and licence surrender activities. The CAA has no such system to coordinate their licence revocation and licence surrender activities.
It was identified, that any pilot of the type of aircraft being flown by Peter, who qualified on that type prior to 2008, can revalidate their licence to fly that type of aircraft by providing a self-declaration of evidence of experience of flying that aircraft . As the Pilot Medication Declaration system, and the licence revalidation procedure for this type of aircraft both rely on self-declarations only , it was identified that a pilot over 70 who flies this type of aircraft, can be revalidated to fly it without any independent third-party assessment of their actual ability or fitness to fly .
” 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 system to coordinate licence revocation and licence surrender activities
Wider context from the report “However, unlike the DVLA the CAA provides no comprehensive guidance for the individual pilot making the self-declaration. As such the CAA provides no list of identifiable conditions that would either preclude the pilot flying, or any conditions which suggest the pilot should seeks further medical opinion regarding their fitness to fly.
It was identified that the CAA provided no guidance to any medical professionals to alert them to the medical standards required for an individual making a Pilot Medical Declaration, should that individual approach them for a medical opinion regarding their fitness to fly.
It was identified that the DVLA has an efficient centrally controlled system to manage medically related driving licence decisions and to coordinate licence revocation and licence surrender activities. The CAA has no such system to coordinate their licence revocation and licence surrender activities .
It was identified, that any pilot of the type of aircraft being flown by Peter, who qualified on that type prior to 2008, can revalidate their licence to fly that type of aircraft by providing a self-declaration of evidence of experience of flying that aircraft. As the Pilot Medication Declaration system, and the licence revalidation procedure for this type of aircraft both rely on self-declarations only, it was identified that a pilot over 70 who flies this type of aircraft, can be revalidated to fly it without any independent third-party assessment of their actual ability or fitness to fly.
” Open source report
22 May 2023 Karl Mitchell · Prevention of Future Deaths report Avon
View report summary
Concerns raised 3 Continued use of unmodified lorry mounted cranes with crush injury risks View source Failure to ensure operators are aware of crush injury risks View source Failure to ensure operators are aware of available safety modifications View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Karl 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
Karl Mitchell, a lorry driver, was crushed by a rotating stabilising leg while retracting a stabiliser beam during the delivery of a container on 23 September 2021. He was taken to hospital and died from his injuries on 25 September 2021. The report raises concerns that many unmodified lorry-mounted cranes remain in use and that operators may be unaware of available safety modifications and the risk of crushing.
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 Continued use of unmodified lorry mounted cranes with crush injury risks
Wider context from the report “(1) There are a large number of these lorry mounted cranes with such stabiliser beams and rotating legs in use by companies of all sizes and for a variety of uses within the industry
(2) Whilst manufacturers have taken steps to modify the design of the stabiliser beams and rotating legs so as to ensure the risk of such crush injuries can be avoided in the future such modifications will only apply to new vehicles and those where the owner / operator of the vehicle becomes aware of possibility of modifications being available.
(3) Vehicles without being modified will continue to be used throughout the industry and thereby such vehicles will continue to pose a risk of crush injuries occurring to the operator.
(4) Action needs to be taken to disseminate the learning from this tragic incident throughout the industry so that operators of such vehicles are aware that safety modifications may be available for their vehicle and in any event operators need to be made aware of the risk of crushing so as to ensure safe operation at all times.
” 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 operators are aware of crush injury risks
Wider context from the report “(1) There are a large number of these lorry mounted cranes with such stabiliser beams and rotating legs in use by companies of all sizes and for a variety of uses within the industry
(2) Whilst manufacturers have taken steps to modify the design of the stabiliser beams and rotating legs so as to ensure the risk of such crush injuries can be avoided in the future such modifications will only apply to new vehicles and those where the owner / operator of the vehicle becomes aware of possibility of modifications being available.
(3) Vehicles without being modified will continue to be used throughout the industry and thereby such vehicles will continue to pose a risk of crush injuries occurring to the operator.
(4) Action needs to be taken to disseminate the learning from this tragic incident throughout the industry so that operators of such vehicles are aware that safety modifications may be available for their vehicle and in any event operators need to be made aware of the risk of crushing so as to ensure safe operation at all times.
” 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 operators are aware of available safety modifications
Wider context from the report “(1) There are a large number of these lorry mounted cranes with such stabiliser beams and rotating legs in use by companies of all sizes and for a variety of uses within the industry
(2) Whilst manufacturers have taken steps to modify the design of the stabiliser beams and rotating legs so as to ensure the risk of such crush injuries can be avoided in the future such modifications will only apply to new vehicles and those where the owner / operator of the vehicle becomes aware of possibility of modifications being available.
(3) Vehicles without being modified will continue to be used throughout the industry and thereby such vehicles will continue to pose a risk of crush injuries occurring to the operator.
(4) Action needs to be taken to disseminate the learning from this tragic incident throughout the industry so that operators of such vehicles are aware that safety modifications may be available for their vehicle and in any event operators need to be made aware of the risk of crushing so as to ensure safe operation at all times.
” 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 Disseminate HSE’s safety notice on swing-up stabilisers to lorry operators once published.
Verbatim wording from the response “The Head of Traffic Commissioner Policy has been in contact with the Health and Safety Executive (HSE), who has informed them that the underlying harmonised standard has been reviewed and is being updated. HSE intends to publish a safety notice relating to swing-up stabilisers on their website. Once informed of HSE’s publication of the safety notice, the Office of the Traffic Commissioner will assist in providing this notice to lorry operators.” 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 HSE is responsible for publishing the safety notice on swing-up stabilisers; the Office of the Traffic Commissioner will help distribute it.
Verbatim wording from the response “The Head of Traffic Commissioner Policy has been in contact with the Health and Safety Executive (HSE), who has informed them that the underlying harmonised standard has been reviewed and is being updated. HSE intends to publish a safety notice relating to swing-up stabilisers on their website. Once informed of HSE’s publication of the safety notice, the Office of the Traffic Commissioner will assist in providing this notice to lorry operators.” 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 The Department does not set requirements for stationary-use machinery, except where it may interfere with the vehicle’s safe operation.
Verbatim wording from the response “The Department sets the requirements that vehicles must meet to ensure they can be driven safely on the roads. However, the Department does not set requirements for machinery which is primarily intended for use when the vehicle is stationary, other than to ensure it doesn’t interfere with the safe operation of the vehicle itself.” Source location Response from Department for Transport
Open published response
29 Mar 2023 Rebecca Lisa KIRBY · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 3 Failure to adequately restrict through traffic during Friday and Saturday nights View source Failure to safely manage the taxi rank and taxi manoeuvres on Lowgate View source Inadequate provision of suitable pedestrian crossing facilities on Lowgate 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
Rebecca Lisa KIRBY · 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
Rebecca Lisa KIRBY died after being struck by a vehicle while crossing Lowgate, Hull, on the evening of 27 August 2021. The report raised concerns about the road remaining open to traffic in a busy area where pedestrians, including people who had been drinking, had to cross among vehicles, taxis and limited crossing facilities. It also expressed concern that the danger in the area had been underestimated and that further incidents could occur without appropriate action.
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 adequately restrict through traffic during Friday and Saturday nights
Wider context from the report “(1) On a Friday and Saturday night the Lowgate area of Hull city is exceptionally busy with people enjoying the night time economy. As such many are in drink. The area of Lowgate is open to traffic, it is also the location of a taxi rank. There is only one crossing facility (aside from at either end of the road), the road narrows significantly at one end.
(2) Police raised concerns as follows:
- The road remaining open during a Friday and Saturday night.
- The number of pedestrians using the area.
- Many people in drink in the area having to cross the road.
- The road is a 30 mph.
- Lights of vehicles are distracting.
- The location of the taxi rank, pedestrians having to navigate around the parked taxis, some with lights on, to enter the road. Taxis do 3 point turns in the road and any vehicle doing this is a danger to pedestrians.
(3) Evidence was heard one doorman working in the area who stated “Having worked at the same location for some time, the area where the bars are on Lowgate is an accident waiting to happen. Members of the public are leaving the bars in a drunken state and they just wander into the road to cross, many of them not even looking for traffic on the road. Some vehicles travel down Lowgate far too fast given the evening activity” and another doorman stated “the road and both the footpaths at the location of the collision occurred on Lowgate are both very narrow. There is also a taxi rank outside O’Leary’s which doesn’t help as taxis were parked there at the time of the collision. I have seen numerous near misses over the years I have worked in the area. It is no exaggeration to say that there are between six to twelve incidents each night between cars and pedestrians, one thing which does not help and is also dangerous are taxis which do U turns in the road once they have collected their fare”.
(4) The police had previously made recommendations and further felt that closing Lowgate to all through traffic on a Friday and Saturday evening, making Lowgate a total no stopping zone on an evening between certain hours, moving the location of a taxi rank onto nearby Alfred Gelder Street.
(5) I note the statement from the local authority listed
- They have erected 2 speed signs since the incident. Bearing in mind that this incident occurred with a vehicle travelling well within the limits, traffic is the concern not limited to the speed of vehicles.
- The council was looking at developing a document that reviewed speed limits for the whole of the city centre. Lowgate has a special reason for being an area of concern and should be looked at as a priority and not in conjunction with all other city centre streets.
- That engagement with the councils public transport department has commenced with the intention to relocate the taxi rank to Alfred Gelder street “but this requires consultation with the Hackney Carriage Association”. No indication was given regarding what was being done to facilitate this.
- The council say that there are no resources to manage the road closure, despite acknowledging it is their responsibility. The fact the road is open at this time is a danger and I am concerned given the comments of the doormen that the danger is being underestimated.
- Crossing facilities had been looked at but could not be positioned within a suitable distance.
(6) I am concerned that inappropriate weight has been given to the danger arising in this area and that without appropriate action further incidents will 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 Failure to safely manage the taxi rank and taxi manoeuvres on Lowgate
Wider context from the report “(1) On a Friday and Saturday night the Lowgate area of Hull city is exceptionally busy with people enjoying the night time economy. As such many are in drink. The area of Lowgate is open to traffic, it is also the location of a taxi rank. There is only one crossing facility (aside from at either end of the road), the road narrows significantly at one end.
(2) Police raised concerns as follows:
- The road remaining open during a Friday and Saturday night.
- The number of pedestrians using the area.
- Many people in drink in the area having to cross the road.
- The road is a 30 mph.
- Lights of vehicles are distracting.
- The location of the taxi rank, pedestrians having to navigate around the parked taxis, some with lights on, to enter the road. Taxis do 3 point turns in the road and any vehicle doing this is a danger to pedestrians.
(3) Evidence was heard one doorman working in the area who stated “Having worked at the same location for some time, the area where the bars are on Lowgate is an accident waiting to happen. Members of the public are leaving the bars in a drunken state and they just wander into the road to cross, many of them not even looking for traffic on the road. Some vehicles travel down Lowgate far too fast given the evening activity” and another doorman stated “the road and both the footpaths at the location of the collision occurred on Lowgate are both very narrow. There is also a taxi rank outside O’Leary’s which doesn’t help as taxis were parked there at the time of the collision. I have seen numerous near misses over the years I have worked in the area. It is no exaggeration to say that there are between six to twelve incidents each night between cars and pedestrians, one thing which does not help and is also dangerous are taxis which do U turns in the road once they have collected their fare ”.
(4) The police had previously made recommendations and further felt that closing Lowgate to all through traffic on a Friday and Saturday evening, making Lowgate a total no stopping zone on an evening between certain hours, moving the location of a taxi rank onto nearby Alfred Gelder Street.
(5) I note the statement from the local authority listed
- They have erected 2 speed signs since the incident. Bearing in mind that this incident occurred with a vehicle travelling well within the limits, traffic is the concern not limited to the speed of vehicles.
- The council was looking at developing a document that reviewed speed limits for the whole of the city centre. Lowgate has a special reason for being an area of concern and should be looked at as a priority and not in conjunction with all other city centre streets.
- That engagement with the councils public transport department has commenced with the intention to relocate the taxi rank to Alfred Gelder street “but this requires consultation with the Hackney Carriage Association”. No indication was given regarding what was being done to facilitate this.
- The council say that there are no resources to manage the road closure, despite acknowledging it is their responsibility. The fact the road is open at this time is a danger and I am concerned given the comments of the doormen that the danger is being underestimated.
- Crossing facilities had been looked at but could not be positioned within a suitable distance.
(6) I am concerned that inappropriate weight has been given to the danger arising in this area and that without appropriate action further incidents will 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 Inadequate provision of suitable pedestrian crossing facilities on Lowgate
Wider context from the report “(1) On a Friday and Saturday night the Lowgate area of Hull city is exceptionally busy with people enjoying the night time economy. As such many are in drink. The area of Lowgate is open to traffic, it is also the location of a taxi rank. There is only one crossing facility (aside from at either end of the road) , the road narrows significantly at one end.
(2) Police raised concerns as follows:
- The road remaining open during a Friday and Saturday night.
- The number of pedestrians using the area.
- Many people in drink in the area having to cross the road.
- The road is a 30 mph.
- Lights of vehicles are distracting.
- The location of the taxi rank, pedestrians having to navigate around the parked taxis, some with lights on, to enter the road. Taxis do 3 point turns in the road and any vehicle doing this is a danger to pedestrians.
(3) Evidence was heard one doorman working in the area who stated “Having worked at the same location for some time, the area where the bars are on Lowgate is an accident waiting to happen. Members of the public are leaving the bars in a drunken state and they just wander into the road to cross, many of them not even looking for traffic on the road. Some vehicles travel down Lowgate far too fast given the evening activity” and another doorman stated “the road and both the footpaths at the location of the collision occurred on Lowgate are both very narrow. There is also a taxi rank outside O’Leary’s which doesn’t help as taxis were parked there at the time of the collision. I have seen numerous near misses over the years I have worked in the area. It is no exaggeration to say that there are between six to twelve incidents each night between cars and pedestrians, one thing which does not help and is also dangerous are taxis which do U turns in the road once they have collected their fare”.
(4) The police had previously made recommendations and further felt that closing Lowgate to all through traffic on a Friday and Saturday evening, making Lowgate a total no stopping zone on an evening between certain hours, moving the location of a taxi rank onto nearby Alfred Gelder Street.
(5) I note the statement from the local authority listed
- They have erected 2 speed signs since the incident. Bearing in mind that this incident occurred with a vehicle travelling well within the limits, traffic is the concern not limited to the speed of vehicles.
- The council was looking at developing a document that reviewed speed limits for the whole of the city centre. Lowgate has a special reason for being an area of concern and should be looked at as a priority and not in conjunction with all other city centre streets.
- That engagement with the councils public transport department has commenced with the intention to relocate the taxi rank to Alfred Gelder street “but this requires consultation with the Hackney Carriage Association”. No indication was given regarding what was being done to facilitate this.
- The council say that there are no resources to manage the road closure, despite acknowledging it is their responsibility. The fact the road is open at this time is a danger and I am concerned given the comments of the doormen that the danger is being underestimated.
- Crossing facilities had been looked at but could not be positioned within a suitable distance.
(6) I am concerned that inappropriate weight has been given to the danger arising in this area and that without appropriate action further incidents will occur.
” Open source report
2 Mar 2023 Kathleen Grace Fancourt · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 2 Failure to require medical fitness checks for drivers over 70 View source Lack of an upper legal age limit for drivers View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kathleen Grace Fancourt · 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
Kathleen Fancourt was killed when a Peugeot car struck her mobility scooter as she crossed Broyle Road at a pedestrian crossing on 16 September 2021. The report raises concern that drivers over 70 must renew their licences every three years but are not required to undergo medical checks, leaving potential medical conditions to self-declaration and potentially posing risks 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 Failure to require medical fitness checks for drivers over 70
Wider context from the report “This accident was caused by a driver who was 95 years old. At present there is no upper legal limit for drivers. Whilst drivers over 70 are required to apply for a new licence every 3 years there is no requirement for there to be any form of medical check to confirm their fitness to drive . It is left to a self declaration of any medical condition by the driver . There is a concern that if no checks are carried out a driver may be oblivious to their enduring medical condition and this may pose a serious risk to other road users.
In 2020 (the last figures publicly available) there were 174 fatal accidents cause by drivers over the age of 70 years old. The Government’s own statistics confirm that “driver illness or disability (mental or physical)” was the 4th most common contributory factor to these 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 Lack of an upper legal age limit for drivers
Wider context from the report “This accident was caused by a driver who was 95 years old. At present there is no upper legal limit for drivers. Whilst drivers over 70 are required to apply for a new licence every 3 years there is no requirement for there to be any form of medical check to confirm their fitness to drive. It is left to a self declaration of any medical condition by the driver. There is a concern that if no checks are carried out a driver may be oblivious to their enduring medical condition and this may pose a serious risk to other road users.
In 2020 (the last figures publicly available) there were 174 fatal accidents cause by drivers over the age of 70 years old. The Government’s own statistics confirm that “driver illness or disability (mental or physical)” was the 4th most common contributory factor to these deaths.
” 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 Existing medical declaration, notification, investigation and age-70 renewal arrangements are considered balanced and proportionate without additional medical checks.
Verbatim wording from the response “The current driver licensing arrangements are underpinned by a legal requirement that all drivers, of any age, must inform the DVLA if at any time they develop a medical condition that may affect safe driving. All drivers must meet the appropriate health standards for driving and a licence will only be issued to those who meet those standards.” Source location Response from Department for Transport
Open published response
15 Feb 2023 Natalie Ann Young · Prevention of Future Deaths report Somerset
View report summary
Concerns raised 3 Lack of legal registration requirements for mobility scooters View source Lack of fitness and competence requirements for mobility scooter operators View source Lack of mobility scooter ownership records View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Natalie Ann Young · 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
Natalie Ann Young, a 92-year-old woman, was knocked over by a mobility scooter in a supermarket on 9 March 2022 and suffered a humeral fracture. Following immobility and a subsequent lower respiratory tract infection, she died at Musgrove Park Hospital on 13 April 2022. The principal concern was the lack of regulation governing who may operate mobility scooters and the absence of legal registration or ownership records, which was considered capable of contributing to further 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 Lack of legal registration requirements for mobility scooters
Wider context from the report “During the course of the Inquest the evidence revealed that in relation to mobility scooters there are:
1. No restrictions on those who are able to operate them; i.e. there are no requirements on the drivers to have vision to a certain standard; to evidence cognitive ability and competence to a standard to be able to understand the controls of the vehicle and how to operate them safely; to be within the acceptable drink drive limit of 80mg/100ml and/or not under the influence of any other substance.
2. No requirements for legal registration and/or record of ownership of the mobility scooter.
There are many laws and regulations into the safe ownership and operation of a car or motorbike; i.e. there are vision tests, cognitive ability requirements, drink-drive laws etc, all of which are in place to ensure that the person in charge of a car or motorcycle is safe and competent and does not place those around him/her at risk of harm or death because of a failing below the acceptable standard applicable when in control of a mechanically (or electrically, in the case of PHEV or hybrid) propelled vehicle.
It was, however, apparent on the evidence at Natalie’s Inquest that no similar laws or protections are in place for those who operate mobility scooters meaning that someone who is legally prevented from driving due to age, infirmity or other inability is freely able to own, use and operate a mobility scooter without any restriction whatsoever. The Inquest heard that the current legislation appears to distinguish between vehicles based on power and speed. However, as was evident in Natalie’s case, mobility scooters can reach a fast enough speed to pose a significant risk to the entire community and population but specifically, small children, pregnant mothers and the elderly who are all particularly vulnerable to being impacted at speed by a blunt-force object and dying as a result of the injuries that they sustain.
I am concerned that the lack of regulation around mobility scooters will continue to result in further deaths, especially when there continues to be no regulation around those who are deemed fit to operate and use them.
” 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 fitness and competence requirements for mobility scooter operators
Wider context from the report “During the course of the Inquest the evidence revealed that in relation to mobility scooters there are:
1. No restrictions on those who are able to operate them ; i.e. there are no requirements on the drivers to have vision to a certain standard; to evidence cognitive ability and competence to a standard to be able to understand the controls of the vehicle and how to operate them safely; to be within the acceptable drink drive limit of 80mg/100ml and/or not under the influence of any other substance .
2. No requirements for legal registration and/or record of ownership of the mobility scooter.
There are many laws and regulations into the safe ownership and operation of a car or motorbike; i.e. there are vision tests, cognitive ability requirements, drink-drive laws etc, all of which are in place to ensure that the person in charge of a car or motorcycle is safe and competent and does not place those around him/her at risk of harm or death because of a failing below the acceptable standard applicable when in control of a mechanically (or electrically, in the case of PHEV or hybrid) propelled vehicle.
It was, however, apparent on the evidence at Natalie’s Inquest that no similar laws or protections are in place for those who operate mobility scooters meaning that someone who is legally prevented from driving due to age, infirmity or other inability is freely able to own, use and operate a mobility scooter without any restriction whatsoever . The Inquest heard that the current legislation appears to distinguish between vehicles based on power and speed. However, as was evident in Natalie’s case, mobility scooters can reach a fast enough speed to pose a significant risk to the entire community and population but specifically, small children, pregnant mothers and the elderly who are all particularly vulnerable to being impacted at speed by a blunt-force object and dying as a result of the injuries that they sustain.
I am concerned that the lack of regulation around mobility scooters will continue to result in further deaths, especially when there continues to be no regulation around those who are deemed fit to operate and use them .
” 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 mobility scooter ownership records
Wider context from the report “During the course of the Inquest the evidence revealed that in relation to mobility scooters there are:
1. No restrictions on those who are able to operate them; i.e. there are no requirements on the drivers to have vision to a certain standard; to evidence cognitive ability and competence to a standard to be able to understand the controls of the vehicle and how to operate them safely; to be within the acceptable drink drive limit of 80mg/100ml and/or not under the influence of any other substance.
2. No requirements for legal registration and/or record of ownership of the mobility scooter .
There are many laws and regulations into the safe ownership and operation of a car or motorbike; i.e. there are vision tests, cognitive ability requirements, drink-drive laws etc, all of which are in place to ensure that the person in charge of a car or motorcycle is safe and competent and does not place those around him/her at risk of harm or death because of a failing below the acceptable standard applicable when in control of a mechanically (or electrically, in the case of PHEV or hybrid) propelled vehicle.
It was, however, apparent on the evidence at Natalie’s Inquest that no similar laws or protections are in place for those who operate mobility scooters meaning that someone who is legally prevented from driving due to age, infirmity or other inability is freely able to own, use and operate a mobility scooter without any restriction whatsoever. The Inquest heard that the current legislation appears to distinguish between vehicles based on power and speed. However, as was evident in Natalie’s case, mobility scooters can reach a fast enough speed to pose a significant risk to the entire community and population but specifically, small children, pregnant mothers and the elderly who are all particularly vulnerable to being impacted at speed by a blunt-force object and dying as a result of the injuries that they sustain.
I am concerned that the lack of regulation around mobility scooters will continue to result in further deaths, especially when there continues to be no regulation around those who are deemed fit to operate and use them.
” 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 Support rollout of a nationwide certified powered wheelchair and mobility scooter assessment and training scheme through funding and collaboration with Driving Mobility.
Verbatim wording from the response “We are also supporting the roll-out of a nationwide certified powered wheelchair and mobility scooter assessment and training scheme. Through our DfT Road Safety Research programme, we have provided funding to” Source location Response from Department for Transport
Open published response
8 Feb 2023 Stephen Robert Wood · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 1 Lack of knowledge and/or understanding of when to report road obstructions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Stephen Robert Wood · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 30 May 2021, Stephen Robert Wood was riding his motorcycle when it entered a 60-metre stretch of grass covering the carriageway, causing him to fall into the path of an oncoming car. He sustained numerous significant and unsurvivable injuries and died. The principal concern was a lack of knowledge about when road obstructions should be reported, meaning hazards may not be removed or warnings provided 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 knowledge and/or understanding of when to report road obstructions
Wider context from the report “2. I have concerns with regard to the following:
i. That there is a lack of knowledge and/or understanding as to when people should report an obstruction in the road. I would request that consideration is given to making all road users aware of the dangers of obstructions in the road and to encourage them to report any hazards to the local Police force or Local Authority so that it can be removed as soon as possible, or at least other road users be warned of the hazard to prevent a future death.
” 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 Regularly promote The Highway Code’s safety guidance to road users.
Verbatim wording from the response “Finally, the Department regularly updates and promotes The Highway Code. Under Rule 280 of The Highway Code, if anything falls from a vehicle on to a motorway or other high-speed road, road users are advised to stop in a place of relative safety and call the emergency services on 999. On other roads, road users are advised to only remove obstructions if it is safe to do so. The Highway Code was last updated in September 2021, and under The Highway Code rules 277, 279, and 283 now advises the use of ‘eCall’ to contact the police and to provide a specific location directly to a 999 operator.” 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 Update The Highway Code with guidance on responding to road obstructions and using eCall to contact emergency services.
Verbatim wording from the response “Finally, the Department regularly updates and promotes The Highway Code. Under Rule 280 of The Highway Code, if anything falls from a vehicle on to a motorway or other high-speed road, road users are advised to stop in a place of relative safety and call the emergency services on 999. On other roads, road users are advised to only remove obstructions if it is safe to do so. The Highway Code was last updated in September 2021, and under The Highway Code rules 277, 279, and 283 now advises the use of ‘eCall’ to contact the police and to provide a specific location directly to a 999 operator.” 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 No further action by the Department is considered appropriate at this stage.
Verbatim wording from the response “Based on this, we have concluded that there is no further action that would be appropriate for the Department to take at this stage.” Source location Response from Department for Transport
Open published response
30 Dec 2022 Jordan Kevin Pry · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 2 Failure to implement an informed and comprehensive plan for risk management at the location View source Persistent road-surface flat spot and associated aquaplaning hazard 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
Jordan Kevin Pry · 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
Jordan Kevin Pry died after his car aquaplaned on surface water while travelling on the M25 on 2 April 2018, left the carriageway and collided with a tree. The principal concern was an ongoing risk of further deaths at the location, where aquaplaning incidents had continued and a flat spot remained while investigations and decisions about risk management were ongoing.
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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 implement an informed and comprehensive plan for risk management at the location
Wider context from the report “As stated in my Conclusion (above), Jordan Pry died on the M25 motorway at marker post B4348, when he drove his vehicle through an area of surface water and the car began to aquaplane and rotate, causing it to leave the carriageway and collide with a tree. There is a long and significant history of aquaplaning incidents at the location, including a previous similar fatality following which, in 2010, a Prevention of Future Deaths Report was issued by the then Senior Coroner for Surrey. That report drew attention to the presence of surface water from rain and the effects of a blocked drain, and the presence of a flat spot on the road. Subsequently, changes were made to the drainage system at the location, first in 2011 by means of a small scale improvement scheme and secondly, as part of works completed in 2015, by means of the introduction of a slot drain. However, the flat spot still remains and aquaplaning incidents have continued.
I was told in evidence that there are ongoing investigations concerning the risk arising at the location, that a decision as to whether or not the flat spot should be addressed is still to be taken , and that a comprehensive plan for the management of the risk at the location cannot be made until that decision is taken .
The concern arising, therefore, is that there is an ongoing risk of further death at this location pending the implementation of an informed and comprehensive plan for risk management .
” 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 Persistent road-surface flat spot and associated aquaplaning hazard
Wider context from the report “As stated in my Conclusion (above), Jordan Pry died on the M25 motorway at marker post B4348, when he drove his vehicle through an area of surface water and the car began to aquaplane and rotate, causing it to leave the carriageway and collide with a tree. There is a long and significant history of aquaplaning incidents at the location , including a previous similar fatality following which, in 2010, a Prevention of Future Deaths Report was issued by the then Senior Coroner for Surrey. That report drew attention to the presence of surface water from rain and the effects of a blocked drain, and the presence of a flat spot on the road. Subsequently, changes were made to the drainage system at the location, first in 2011 by means of a small scale improvement scheme and secondly, as part of works completed in 2015, by means of the introduction of a slot drain. However, the flat spot still remains and aquaplaning incidents have continued.
I was told in evidence that there are ongoing investigations concerning the risk arising at the location, that a decision as to whether or not the flat spot should be addressed is still to be taken, and that a comprehensive plan for the management of the risk at the location cannot be made until that decision is taken.
The concern arising, therefore, is that there is an ongoing risk of further death at this location pending the implementation of an informed and comprehensive plan for risk management.
” 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 National Highways is responsible for safely managing the Strategic Road Network, including the accident location.
Verbatim wording from the response “Responsibility for the safe management of the Strategic Road Network, which includes the location of this accident, falls to National Highways and I am aware that work has already been undertaken at this site since the accident, including the installation of a vehicle restraint system.” Source location Response from Department for Transport
Open published response
21 Dec 2022 Donald Frederick HOOKER · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 4 Failure to ensure correct motorcycle helmet sizing and fitting View source Motorcycle helmets coming off or rotating during collisions View source Lack of appropriate education for motorcycle riders View source Lack of research and knowledge about motorcycle helmet displacement during collisions 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
Donald Frederick HOOKER · 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
Donald Frederick HOOKER died on 28 August 2021 after his motorcycle’s drive chain broke while he was travelling on the Humber Bridge, causing a collision and fall. His crash helmet came off during the incident, and he sustained severe head and facial injuries. The principal concerns were the lack of understanding of why motorcycle helmets come off or rotate during collisions and the absence of clear checks or education concerning helmet sizing and fitting.
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 ensure correct motorcycle helmet sizing and fitting
Wider context from the report “(1) This is the second matter that has been referred to my jurisdiction in recent months where a motorcyclist has lost his helmet during a collision. During evidence it was adduced that, although it is not a common occurrence, it is certainly not unusual for a motorcyclist’s helmet to come off or to rotate during a collision.
(2) The Forensic Collision Investigator was unable to explain the reason for Dr Hooker’s crash helmet coming off. The chin strap was in place.
(3) The Forensic Collision Investigator indicated that she had been unable to find any research or scientific data on why such incidents occur.
(4) It was adduced in evidence that a kit safety mark may be checked by an instructor during motor cycle courses/tests but there did not appear to be a known check for ensuring a person has the correct size motorcycle helmet .
(5) It was acknowledged that many people may now purchase motorcycle helmets over the internet and the sizing and fitting may not be appropriate .
(6) I am concerned that without knowledge of why such incidents are occurring, or appropriate education of the riders, that more deaths may 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 Motorcycle helmets coming off or rotating during collisions
Wider context from the report “(1) This is the second matter that has been referred to my jurisdiction in recent months where a motorcyclist has lost his helmet during a collision. During evidence it was adduced that, although it is not a common occurrence, it is certainly not unusual for a motorcyclist’s helmet to come off or to rotate during a collision .
(2) The Forensic Collision Investigator was unable to explain the reason for Dr Hooker’s crash helmet coming off. The chin strap was in place.
(3) The Forensic Collision Investigator indicated that she had been unable to find any research or scientific data on why such incidents occur.
(4) It was adduced in evidence that a kit safety mark may be checked by an instructor during motor cycle courses/tests but there did not appear to be a known check for ensuring a person has the correct size motorcycle helmet.
(5) It was acknowledged that many people may now purchase motorcycle helmets over the internet and the sizing and fitting may not be appropriate.
(6) I am concerned that without knowledge of why such incidents are occurring, or appropriate education of the riders, that more deaths may 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 Lack of appropriate education for motorcycle riders
Wider context from the report “(1) This is the second matter that has been referred to my jurisdiction in recent months where a motorcyclist has lost his helmet during a collision. During evidence it was adduced that, although it is not a common occurrence, it is certainly not unusual for a motorcyclist’s helmet to come off or to rotate during a collision.
(2) The Forensic Collision Investigator was unable to explain the reason for Dr Hooker’s crash helmet coming off. The chin strap was in place.
(3) The Forensic Collision Investigator indicated that she had been unable to find any research or scientific data on why such incidents occur.
(4) It was adduced in evidence that a kit safety mark may be checked by an instructor during motor cycle courses/tests but there did not appear to be a known check for ensuring a person has the correct size motorcycle helmet.
(5) It was acknowledged that many people may now purchase motorcycle helmets over the internet and the sizing and fitting may not be appropriate.
(6) I am concerned that without knowledge of why such incidents are occurring, or appropriate education of the riders , that more deaths may 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 Lack of research and knowledge about motorcycle helmet displacement during collisions
Wider context from the report “(1) This is the second matter that has been referred to my jurisdiction in recent months where a motorcyclist has lost his helmet during a collision. During evidence it was adduced that, although it is not a common occurrence, it is certainly not unusual for a motorcyclist’s helmet to come off or to rotate during a collision.
(2) The Forensic Collision Investigator was unable to explain the reason for Dr Hooker’s crash helmet coming off. The chin strap was in place.
(3) The Forensic Collision Investigator indicated that she had been unable to find any research or scientific data on why such incidents occur .
(4) It was adduced in evidence that a kit safety mark may be checked by an instructor during motor cycle courses/tests but there did not appear to be a known check for ensuring a person has the correct size motorcycle helmet.
(5) It was acknowledged that many people may now purchase motorcycle helmets over the internet and the sizing and fitting may not be appropriate.
(6) I am concerned that without knowledge of why such incidents are occurring , or appropriate education of the riders, that more deaths may occur.
” 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 Produce and publish SHARP guidance on motorcycle helmet selection and fitting.
Verbatim wording from the response “The Department recognises the importance of a good fitting and performing helmet and has for many years been providing advice and guidance to motorcyclists through its Safety Helmet Assessment and Rating Programme (SHARP). Working with the motorcycle helmet supply industry, SHARP has established the best practice and produced a guidance that offers advice on helmet selection and appropriate fitting. This is available on the SHARP website at the following link: https://sharp.dft.gov.uk/get-the-right-fit/.” Source location Response from the 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 Continue promoting and raising awareness through SHARP of correct motorcycle helmet fitting and usage.
Verbatim wording from the response “The Department is committed to improving safety for all motorcyclists and will continue to review the technical standards for new helmets under the UNECE to ensure they reflect new and emerging technology and offer increasing levels of safety, while at the same time promoting and raising awareness of” Source location Response from the Department for Transport
Open published response
14 Dec 2022 Fatima Abukar · Prevention of Future Deaths report East London
View report summary
Concerns raised 3 Reduced legal enforcement of unlawful e-scooter use View source Failure to provide prominent written warnings about the illegal use of e-scooters View source Failure to require head protection for riders of legally authorised 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
Fatima Abukar · 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
Fatima Abukar, a 14-year-old girl, died from catastrophic head injuries after the privately owned e-scooter she was riding entered the carriageway and struck a mini-bus. The concerns included e-scooter fatalities and enforcement, the absence of a requirement for riders of legally authorised scooters to wear head protection, and inconsistent or insufficiently prominent warnings about illegal e-scooter use.
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 Reduced legal enforcement of unlawful e-scooter use
Wider context from the report “1. Evidence in this inquest confirmed that since 2019 here have been 8 recorded fatalities involving e-scooters in London and 31 in the country at large. At the time of her death Ms Abukar was riding a privately owned e-scooter on a public highway. Despite the ubiquity of such devices on London’s streets, riding them on public roads is unlawful.
Whereas approximately 4000 unlawfully used scooters were seized by the Metropolitan Police Service in 2021, only 1100 were confiscated in 2022 . The reduction is attributable to a change in policy introduced in November 2021.
An inverse correlation exists between the rate of legal enforcement and the rate of deaths caused by e-scooters. The number of deaths in Q1 & 2 of 2022 is more than double that of Q1 & 2 of 2021.
” 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 prominent written warnings about the illegal use of e-scooters
Wider context from the report “3. Some manufacturers and retailers of e-scooters in England and Wales provide consumers with written warnings about the illegal use of e-scooters, others do not. Where such warnings are present, often they are not prominent.
” 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 require head protection for riders of legally authorised scooters
Wider context from the report “2. Ms Abukar died due to traumatic head injuries. Riders of legally authorised scooters (those hired from licenced operators) are not required to wear head protection.
” 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 helmet wearing as part of developing future e-scooter regulation.
Verbatim wording from the response “The e-scooter trials were launched in July 2020 and are currently live in 25 areas across England. These trials are designed to assess the safety of e-scooters, their potential benefits and their impact on public space to help us consider options for future regulation of e-scooters. Cycle helmets are recommended for the trials but are not a requirement, as is the case for bicycles and electrically-assisted pedal cycles. In February 2022 we issued updated guidance to all local authorities and e-scooter operators that further encouraged them to provide helmets and incentivise their use. Whilst this tragic incident did not happen within the trials, I recognise this is an important consideration as the Government plans to bring forward legislation that will allow e-scooters to be regulated. As part of this, we will consult on a range of topics, including helmet wearing.” 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 Issue updated guidance encouraging trial operators and local authorities to provide helmets and incentivise their use.
Verbatim wording from the response “The e-scooter trials were launched in July 2020 and are currently live in 25 areas across England. These trials are designed to assess the safety of e-scooters, their potential benefits and their impact on public space to help us consider options for future regulation of e-scooters. Cycle helmets are recommended for the trials but are not a requirement, as is the case for bicycles and electrically-assisted pedal cycles. In February 2022 we issued updated guidance to all local authorities and e-scooter operators that further encouraged them to provide helmets and incentivise their use. Whilst this tragic incident did not happen within the trials, I recognise this is an important consideration as the Government plans to bring forward legislation that will allow e-scooters to be regulated. As part of this, we will consult on a range of topics, including helmet wearing.” 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 Enforcement and seizure of privately owned e-scooters used illegally on public land is addressed by the Home Secretary.
Verbatim wording from the response “I am writing to address your concerns about the marketing practices of e-scooter retailers and riders of hired scooters not being required to wear helmets. My Rt Hon colleague, the Secretary of State for the Home Department will write to you with regards to your concerns about the enforcement and seizure of privately owned e-scooters being used illegally on public land.” Source location Response from Department for Transport
Open published response
2 Sep 2022 Jennifer Wong · Prevention of Future Deaths report Oxfordshire
View report summary
Concerns raised 4 Inadequate near-side and forward visibility safeguards for mobile cranes View source Unclear and inconsistent classification and application of regulations for mobile cranes View source Insufficient cycle-lane width View source Cycle lane layout failing to provide clear and safe positioning for cyclists crossing the junction View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jennifer Wong · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jennifer Wong died at the scene of a road traffic accident on Headington Road, Oxford, on 26 September 2021, after a mobile crane turning left knocked her from her cycle and ran over her. The report identifies concerns about the crane driver's significant nearside blind spots and the lack of close-proximity mirrors or other visibility measures. It also raises concerns about the layout and width of the cycle lane, which may bring cyclists into conflict with vehicles turning left.
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 near-side and forward visibility safeguards for mobile cranes
Wider context from the report “It was apparent at inquest that the regulations concerning vehicles of this type are difficult to understand and to determine which regulations apply. The mobile crane in question was a Kato City Crane with a capacity of 22 tonnes, registration number P477 YHT. The odometer recorded 65,917 kilometres. According to the police Vehicle Examiner, it is classed as a mobile crane and operates outside of the Construction and Use regulations which governs HGV’s. It is said that it is governed by the Road Vehicles (Authorisation of Special Types) (General) Order 2003, otherwise known as STGO. I am further advised that under STGO it is likely to be classed a Cat B mobile crane. I understand it can also be regarded as a motor tractor/light locomotive/heavy locomotive under some regulations but at the same time it can also be classed as a road vehicle as it is intended for use on the road to get to site for example. Despite this, if I understand the position correctly, it is subject to reg 33 of the Construction and Use Regs and, for a vehicle first used after 1978 as this one was, it only requires a single offside mirror to be fitted.
According to paragraph 9.8 of the Collision Investigator’s report, it is categorised as ‘Engineering Plant’ (Department of Transport 2010) and does not fall within the requirements for close proximity mirrors (EU 2007, UN 2013).
1. It is immediately striking that the driver has virtually no view of the nearside of his vehicle or immediately in front of it . The crane is designed in such a way so that the boom/jib extends along the near side of the cab obliterating most of the view. It had one side mirror on each side but there were very significant blind spots . These appear to be worse than what one might have with a HGV or bus for example which, very often, have more mirrors and perhaps camera’s and audible warnings. It is also noteworthy that the crane did not have indicators which could be seen by someone alongside the crane as opposed to being behind or in front of it.
I refer you to the photographs in the report of the police collision investigator, ████████ ████████ and particularly from paragraph 9.10 and the figures which give a representation of the driver’s view.
Notwithstanding the above, it appears that the vehicle is only required by regulations to have one offside mirror and no close proximity mirrors which are designed to reduce the driver’s blind spots. The regulations are confusing but regardless of whether the vehicle is classed as engineering plant or some form of locomotive, the reality is that such vehicles are permitted to drive on the roads through towns and cities with next to no near side view . It is the second such case I have dealt with this year in Oxford. I understand there may be some separate and safer regulations that apply in London called the Transport for London Direct Vision Standard which would classify this vehicle with a star rating of zero and require the fitting of safe system measures.
” 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 and inconsistent classification and application of regulations for mobile cranes
Wider context from the report “It was apparent at inquest that the regulations concerning vehicles of this type are difficult to understand and to determine which regulations apply . The mobile crane in question was a Kato City Crane with a capacity of 22 tonnes, registration number P477 YHT. The odometer recorded 65,917 kilometres. According to the police Vehicle Examiner, it is classed as a mobile crane and operates outside of the Construction and Use regulations which governs HGV’s. It is said that it is governed by the Road Vehicles (Authorisation of Special Types) (General) Order 2003, otherwise known as STGO. I am further advised that under STGO it is likely to be classed a Cat B mobile crane. I understand it can also be regarded as a motor tractor/light locomotive/heavy locomotive under some regulations but at the same time it can also be classed as a road vehicle as it is intended for use on the road to get to site for example. Despite this, if I understand the position correctly, it is subject to reg 33 of the Construction and Use Regs and, for a vehicle first used after 1978 as this one was, it only requires a single offside mirror to be fitted.
According to paragraph 9.8 of the Collision Investigator’s report, it is categorised as ‘Engineering Plant’ (Department of Transport 2010) and does not fall within the requirements for close proximity mirrors (EU 2007, UN 2013).
1. It is immediately striking that the driver has virtually no view of the nearside of his vehicle or immediately in front of it. The crane is designed in such a way so that the boom/jib extends along the near side of the cab obliterating most of the view. It had one side mirror on each side but there were very significant blind spots. These appear to be worse than what one might have with a HGV or bus for example which, very often, have more mirrors and perhaps camera’s and audible warnings. It is also noteworthy that the crane did not have indicators which could be seen by someone alongside the crane as opposed to being behind or in front of it.
I refer you to the photographs in the report of the police collision investigator, ████████ ████████ and particularly from paragraph 9.10 and the figures which give a representation of the driver’s view.
Notwithstanding the above, it appears that the vehicle is only required by regulations to have one offside mirror and no close proximity mirrors which are designed to reduce the driver’s blind spots. The regulations are confusing but regardless of whether the vehicle is classed as engineering plant or some form of locomotive, the reality is that such vehicles are permitted to drive on the roads through towns and cities with next to no near side view. It is the second such case I have dealt with this year in Oxford. I understand there may be some separate and safer regulations that apply in London called the Transport for London Direct Vision Standard which would classify this vehicle with a star rating of zero and require the fitting of safe system measures.
” 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 cycle-lane width
Wider context from the report “The second concern relates to the width of the cycle lane . It is believed to be 0.95 metres wide at this location but the recommended width is 1.2m or perhaps 1.5m . I understand this is an issue which has already been raised following a site meeting. There may be valid reasons why the lane is the width it is but I would be grateful if this could be considered.
” 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 Cycle lane layout failing to provide clear and safe positioning for cyclists crossing the junction
Wider context from the report “The first and main concern is in relation to the nearside cycle lane and what appeared to be an element of confusion or perhaps a dilemma for cyclists at this location intending to cycle straight across the junction. The cycle lane puts cyclists on the nearside of a lane that is specifically for vehicles turning right into Headley Way . There is the box/advanced stop line in front of the line of traffic in the lane but this requires the cyclist to decide to use it and, importantly, to have time to make it pass the nearside of the vehicles and into the box before the vehicles in the lane commence their right turn .
If there was no cycle lane, it appears more likely that a cyclist heading straight across would position themselves in lane 2 for vehicles also heading straight on. I believe that further consideration should be given to this issue and if improved signage has a part to play to mitigate the risks.
I appreciate of course that it is not possible to remove risk completely and cyclists will make different choices about where to position themselves at a junction such as this one. I anticipate that the junction is not dissimilar to many others in Oxford. The issue of cyclists in nearside blind spots, particularly involving large commercial vehicles with limited visibility, therefore presents a significant and ongoing risk .
” 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 Write to the Construction Plant-hire Association raising mobile crane compliance and encouraging members to consider additional driver-vision devices or technology.
Verbatim wording from the response “Irrespective of these measures, the vehicle appears to have been used in a condition which was not compliant with regulations. Whilst it is impossible to determine with any certainty whether full compliance with the regulations would have prevented this collision, I shall be writing to the CPA in the next month to raise the issue of compliance and encouraging its members to consider additional devices or technology to help improve mobile crane driver vision.” 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 construction and use regulations set the minimum standards considered necessary for vehicle vision and mirrors.
Verbatim wording from the response “Regulation 30 of C&U covers view to the front and requires every motor vehicle to be so designed and constructed that the driver has a full view of the road and traffic ahead. As you have noted, for the purposes of Regulation 33 of C&U, the subject vehicle is classified as a locomotive and requires as a minimum one exterior mirror fitted to the offside. From the evidence provided, the vehicle appears compliant with regards to the C&U requirements. However, these regulations set the minimum standards considered necessary and there is flexibility for manufacturers/operators to install additional devices for indirect vision, including additional mirrors, cameras, and sensors should they wish to do so, and I note from the evidence that this vehicle is fitted with an additional mirror to the nearside.” Source location Response from Department for Transport
Open published response
30 Aug 2022 Jennifer Lilian Davies · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 3 Pedestrian exposure to delivery vans in hugely populated areas View source Exclusion of delivery van drivers from Working Time Regulations limiting working hours View source Lack of a legal requirement for delivery van drivers to take a 30-minute break View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jennifer Lilian Davies · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jennifer Lilian Davies was struck by a parcel delivery vehicle while crossing the road in Brighton on 21 May 2020, sustaining a serious head injury. She died in hospital on 23 May 2020; the report raised concerns that delivery van drivers may work long hours without a legal requirement to take a break, potentially placing pedestrians at risk.
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 Pedestrian exposure to delivery vans in hugely populated areas
Wider context from the report “Delivery van drivers (of vehicles under 3.5 Tonnes) are not subject to the current Working Time Regulations. However, as in this case, a driver could be required to work up to 11 hours a day. Whilst employers can stipulate that their drivers should take a 30-minute break there is no legal requirement upon them to do so.
With the growth in home parcel delivery this is putting lives at risk. Delivery van drivers, by the very nature of the work that they do, are being driven in hugely populated areas where pedestrians are particularly at 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 Exclusion of delivery van drivers from Working Time Regulations limiting working hours
Wider context from the report “Delivery van drivers (of vehicles under 3.5 Tonnes) are not subject to the current Working Time Regulations. However, as in this case, a driver could be required to work up to 11 hours a day . Whilst employers can stipulate that their drivers should take a 30-minute break there is no legal requirement upon them to do so.
With the growth in home parcel delivery this is putting lives at risk. Delivery van drivers, by the very nature of the work that they do, are being driven in hugely populated areas where pedestrians are particularly at 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 legal requirement for delivery van drivers to take a 30-minute break
Wider context from the report “Delivery van drivers (of vehicles under 3.5 Tonnes) are not subject to the current Working Time Regulations. However, as in this case, a driver could be required to work up to 11 hours a day. Whilst employers can stipulate that their drivers should take a 30-minute break there is no legal requirement upon them to do so .
With the growth in home parcel delivery this is putting lives at risk. Delivery van drivers, by the very nature of the work that they do, are being driven in hugely populated areas where pedestrians are particularly at risk.
” 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 drivers’ hours, working-time and fatigue-management requirements are considered an appropriate response to risks involving light goods vehicle drivers.
Verbatim wording from the response “Drivers of commercial goods vehicles weighing 3.5 tonnes or less fall in-scope of the GB domestic drivers’ hours rules (contained in the Transport Act 1968). According to these domestic rules, in any 24-hour period the maximum driving time is 10 hours and the maximum duty time is 11 hours. Duty includes all periods of work and standby but does not include rest or breaks. If someone is self-employed, duty time is only time spent driving the vehicle or its load. There are no specific break or rest requirements for goods vehicles under these rules.” 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 provide a definitive interpretation of legislation because its meaning and scope are ultimately matters for the courts.
Verbatim wording from the response “As I hope you will appreciate, I must point out that the Department is unable to give a definitive interpretation of the meaning and scope of any legislation as this is ultimately a matter for the courts to determine. We can, however, provide the Department's view.” 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 DVSA is responsible for enforcing drivers’ hours rules, while employers and the Health and Safety Executive address workplace fatigue risks.
Verbatim wording from the response “The current drivers’ hours and working time rules are vital in ensuring the safety of drivers and others on the road and it is important that those rules are adhered to by delivery companies. Any perceived breaches of the rules can be reported to Driver and Vehicle Standards Agency (DVSA), who are responsible for enforcement, via DVSA’s confidential hotline on 0300 123 9000 or by email to the DVSA intelligence team at intelligenceunit@dvsa.gov.uk. All calls/emails will be treated in confidence.” Source location Response from Department for Transport
Open published response
Concerns raised 1 Failure to provide bus and coach drivers with safe emergency braking training View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Stanley HARDY · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 16 June 2019, Stanley HARDY, a pedestrian, was struck by a coach after crossing Peel Street against a red light and died the following day from serious head injuries. Concerns included the coach driver not applying emergency braking despite seeing him in the carriageway, and emergency braking procedures not forming part of required training for new bus and coach 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 Failure to provide bus and coach drivers with safe emergency braking training
Wider context from the report “(1) The coach driver’s evidence was that although he saw the pedestrian in the carriageway he did not forcefully apply his brakes as he had been trained not to do so to protect the welfare of the passengers traveling in his vehicle .
(2) Evidence from the Forensic Collision Investigator was that:
i. If emergency braking had been applied the coach could have stopped prior to hitting the pedestrian or the collision would have occurred at a significantly reduced speed;
and
ii. Emergency braking procedures do not form part of the required training for new bus
and coach drivers .
” 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 all learning materials covering emergency braking and consider whether they need additional or stronger information.
Verbatim wording from the response “We therefore do not propose to amend that framework, but given the importance of this matter, the DVSA will ensure that all learning materials where emergency braking skills are covered are reviewed at the next opportunity; and consider whether these sections could benefit from additional or stronger information.” 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 Existing driver training standards and learning materials are considered sufficient, so the framework will not be amended.
Verbatim wording from the response “You are correct that there is, in a strict reading of the terms, no “required training” for a bus or coach driver (that is, there is no legally mandated training course). I am however satisfied that there is an appropriate framework in place to promote and support safe braking skills; DVSA’s National Standards set out what is expected of bus and coach drivers and the official learning materials support the knowledge and skills that drivers are expected to understand and demonstrate.” Source location Response from Department for Transport
Open published response
Concerns raised 1 Failure of the vehicle ownership system to prevent purchase and retention of cars by unlicensed drivers View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Charles William WHEATLEY · 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
Charles William Wheatley died at the scene of a head-on road traffic collision on the A66 on 14 December 2021. The report identified concerns that he had no valid driving licence, had epilepsy and was not taking his anti-epileptic medication regularly, and that the system allows a person to own a car without a driving licence.
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 the vehicle ownership system to prevent purchase and retention of cars by unlicensed drivers
Wider context from the report “While it may not have prevented Amy’s death, it seems illogical and indeed incomprehensible to me that the system allows a person to buy a car without having a licence to drive it . In this case there was no evidence that Mr Wheatley had ever held a driving licence.
I recognise that currently, the DVLA are responsible for the statutory instrument 1999/2864 which covers matters around driving entitlements and that vehicle ownership/registered keepers are catered for under an Act of Parliament (the Vehicle Excise and Registration Act 1994) and therefore significant change in the law would be needed. However, I suspect that the public would find it difficult to understand how someone can buy and keep a car without having a licence to drive the vehicle .
” 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 The law does not require a driving licence to register or keep a vehicle, including where the keeper will not drive it.
Verbatim wording from the response “I note that following the inquest, you have asked why an individual is able to purchase a vehicle when they do not hold a driving licence. It may help to explain that the purpose of the vehicle register held by the Driver and Vehicle Licensing Agency (DVLA), is to record details of vehicles and their registered keepers. While the DVLA requests proof of the applicant’s name and address when a vehicle is first registered, and for the driving licence number of a new keeper at subsequent keeper changes, there is no requirement in law to hold a driving licence to register a vehicle, or to become the keeper of an already registered vehicle.” Source location Response from Department for Transport
Open published response
19 May 2022 Sangeerth GIRIRATHAN · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 2 Lack of regulations governing van driver working hours View source Failure to keep monitoring alarms operational View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sangeerth GIRIRATHAN · 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
Sangeerth GIRIRATHAN, aged 23, was involved in a road traffic collision on the M1 motorway and suffered a traumatic brain injury. While receiving intensive care, he suffered a cardiorespiratory arrest after a tracheostomy blockage was not recognised because the monitor alarm was switched off, and he died on 12 December 2021. The concerns included disengaged monitoring alarms and the absence of regulations governing the hours worked by van 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 Lack of regulations governing van driver working hours
Wider context from the report “During the course of the inquest it became apparent that the deceased, who was employed as a delivery van driver, had been working for long hours prior to the original collision. It is likely that he may have fallen asleep and collided with the back of a stationary lorry on the M1 motorway. I am told that there are currently no regulations regarding the hours that can be worked by a van driver as opposed to the regulations that operate for heavy goods vehicles . I believe that this is a matter that should be reviewed by the department in order to prevent similar deaths in similar 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 Failure to keep monitoring alarms operational
Wider context from the report “During the inquest it became apparent that the alarms that are operating on the monitors had been disengaged . This resulted in the staff not being alerted when the patient’s saturations fell below an acceptable level and he went into cardiac arrest. My understanding is that if a patient is being monitored at all then it is essential that the alarms remain operational . I believe that all staff should be reminded of the need for the alarms to be active so that future deaths in similar circumstances do not arise.
” 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 The Driver and Vehicle Standards Agency is responsible for enforcing the GB Drivers’ Hours rules.
Verbatim wording from the response “The Driver and Vehicle Standards Agency (DVSA) is responsible for the enforcement of the GB Drivers’ Hours rules and last year made 15,464 traffic checks on light goods vehicles and 67 different people were fined for Drivers’ Hours related offences.” Source location Response from Department for Transport
Open published response
18 Mar 2022 Emiliano Raul Sala · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 4 Risk of future deaths from illegal flights View source Failure of relevant organisations to communicate illegal-flight risks to their members View source Insufficient CAA powers for investigating and enforcing aviation regulation breaches View source Lack of effective public guidance about illegal flights and their risks 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
Emiliano Raul Sala · 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
Emiliano Raul Sala was a passenger on a flight from Nantes to Cardiff on 21 January 2019 when the aircraft crashed into the sea. He died from fatal head and trunk injuries; the flight was an unauthorised commercial operation. The report raised concerns about illegal flights, their safety risks, and limitations on the Civil Aviation Authority’s investigative and enforcement powers.
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 future deaths from illegal flights
Wider context from the report “2. I have concerns with regard to the following:
i. There could be future deaths as a result of these illegal flights , and I request that the Secretary of State for Transport conducts a review of the powers available to the CAA in investigating breaches of aviation regulations. I request that the Secretary of State for Transport consider meeting with the CAA to establish what powers they would find of assistance in their investigative and enforcement role.
ii. I further request that a review is undertaken by the Secretary of State for Digital, Culture, Media and Sport of the guidance given to the general public, especially all those involved in the sporting and music worlds, about the illegality of these flights and the risks associated with them. I would again request that consideration be given to meeting with the CAA who can properly advise on the risks associated with these flights, especially of future deaths that can occur and what support may assist them in deterring people from using these flights.
iii. I would request that all the organisations identified at numbers 3-20 in the list at the beginning of this report, consider cascading to all their members, and anyone else they consider will benefit from the information, the illegality of these flights and the risks associated with them, especially of a future death, in order to discourage the use of these flights. I would again request that consideration be given to liaising with the CAA who can properly advise on the risks and what support would be of benefit to reduce the use of these flights and prevent future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure of relevant organisations to communicate illegal-flight risks to their members
Wider context from the report “2. I have concerns with regard to the following:
i. There could be future deaths as a result of these illegal flights, and I request that the Secretary of State for Transport conducts a review of the powers available to the CAA in investigating breaches of aviation regulations. I request that the Secretary of State for Transport consider meeting with the CAA to establish what powers they would find of assistance in their investigative and enforcement role.
ii. I further request that a review is undertaken by the Secretary of State for Digital, Culture, Media and Sport of the guidance given to the general public, especially all those involved in the sporting and music worlds, about the illegality of these flights and the risks associated with them. I would again request that consideration be given to meeting with the CAA who can properly advise on the risks associated with these flights, especially of future deaths that can occur and what support may assist them in deterring people from using these flights.
iii. I would request that all the organisations identified at numbers 3-20 in the list at the beginning of this report, consider cascading to all their members , and anyone else they consider will benefit from the information, the illegality of these flights and the risks associated with them, especially of a future death, in order to discourage the use of these flights. I would again request that consideration be given to liaising with the CAA who can properly advise on the risks and what support would be of benefit to reduce the use of these flights and prevent future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Insufficient CAA powers for investigating and enforcing aviation regulation breaches
Wider context from the report “2. I have concerns with regard to the following:
i. There could be future deaths as a result of these illegal flights, and I request that the Secretary of State for Transport conducts a review of the powers available to the CAA in investigating breaches of aviation regulations . I request that the Secretary of State for Transport consider meeting with the CAA to establish what powers they would find of assistance in their investigative and enforcement role .
ii. I further request that a review is undertaken by the Secretary of State for Digital, Culture, Media and Sport of the guidance given to the general public, especially all those involved in the sporting and music worlds, about the illegality of these flights and the risks associated with them. I would again request that consideration be given to meeting with the CAA who can properly advise on the risks associated with these flights, especially of future deaths that can occur and what support may assist them in deterring people from using these flights.
iii. I would request that all the organisations identified at numbers 3-20 in the list at the beginning of this report, consider cascading to all their members, and anyone else they consider will benefit from the information, the illegality of these flights and the risks associated with them, especially of a future death, in order to discourage the use of these flights. I would again request that consideration be given to liaising with the CAA who can properly advise on the risks and what support would be of benefit to reduce the use of these flights and prevent future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of effective public guidance about illegal flights and their risks
Wider context from the report “2. I have concerns with regard to the following:
i. There could be future deaths as a result of these illegal flights, and I request that the Secretary of State for Transport conducts a review of the powers available to the CAA in investigating breaches of aviation regulations. I request that the Secretary of State for Transport consider meeting with the CAA to establish what powers they would find of assistance in their investigative and enforcement role.
ii. I further request that a review is undertaken by the Secretary of State for Digital, Culture, Media and Sport of the guidance given to the general public , especially all those involved in the sporting and music worlds, about the illegality of these flights and the risks associated with them . I would again request that consideration be given to meeting with the CAA who can properly advise on the risks associated with these flights, especially of future deaths that can occur and what support may assist them in deterring people from using these flights.
iii. I would request that all the organisations identified at numbers 3-20 in the list at the beginning of this report, consider cascading to all their members, and anyone else they consider will benefit from the information, the illegality of these flights and the risks associated with them, especially of a future death, in order to discourage the use of these flights. I would again request that consideration be given to liaising with the CAA who can properly advise on the risks and what support would be of benefit to reduce the use of these flights and prevent future deaths.
” 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 Provide a further update on the Department’s work addressing illegal flight activity.
Verbatim wording from the response “(iii) The Department will continue to work closely with the CAA, who also recognise that no single measure or type of action is likely to provide a complete solution to this particular problem, and like them the Department intends to provide you with a further update in due course.” 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 Complete a review with the CAA of powers available for investigating breaches of aviation regulations.
Verbatim wording from the response “1. In relation to your request that the Secretary of State conduct a review of the powers available to the CAA in investigating breaches of aviation regulations, I can confirm that such a review has now been carried out together with the CAA.” 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 Continue working closely with the CAA on measures addressing illegal flight activity.
Verbatim wording from the response “(iii) The Department will continue to work closely with the CAA, who also recognise that no single measure or type of action is likely to provide a complete solution to this particular problem, and like them the Department intends to provide you with a further update in due course.” 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 consultation responses on cost-sharing regulations for private pilots as part of the aviation safety rule-making programme.
Verbatim wording from the response “(i) As part of its ongoing work to deter and prevent illegal flight activity and to ensure the safety of consumers and other members of the public, the Department (and CAA) are currently considering responses received to the consultation on cost” 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 Continue considering policy and legal changes that could improve the CAA’s investigation of suspected illegal flight activity.
Verbatim wording from the response “(ii) In parallel with the ongoing work on cost sharing arrangements, the Department is continuing to consider in detail what meaningful changes might be able to be made, in both policy and legal terms and, perhaps, in other respects, in order that the CAA is able to investigate suspected illegal flight activity more effectively. As you will appreciate the aviation regulatory framework is extensive and any changes to the law require careful consideration and justification. This or any other form of action may well require discussions with and the cooperation of other government departments and the police, in addition to further public consultation.” 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 Meet with the CAA to establish which powers would assist its investigative and enforcement role.
Verbatim wording from the response “2. In relation to your request that the Secretary of State consider meeting with the CAA to establish what powers they would find of assistance in their investigative and enforcement role, I can confirm that such a meeting has taken place between officials in the course of conducting a review of the powers available to the CAA in investigating breaches of aviation regulations.” 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 Further action and its timetable cannot yet be specified because potential legal changes require careful consideration, justification, consultation and interdepartmental cooperation.
Verbatim wording from the response “(ii) In parallel with the ongoing work on cost sharing arrangements, the Department is continuing to consider in detail what meaningful changes might be able to be made, in both policy and legal terms and, perhaps, in other respects, in order that the CAA is able to investigate suspected illegal flight activity more effectively. As you will appreciate the aviation regulatory framework is extensive and any changes to the law require careful consideration and justification. This or any other form of action may well require discussions with and the cooperation of other government departments and the police, in addition to further public consultation.” Source location Response from Department for Transport
Open published response
9 Dec 2021 James McKeough · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 1 Failure to ensure that rear flashing warning lights are distinguishable from directional indicator lights 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
James McKeough · 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 McKeough died after his motorcycle collided with a tractor towing a slurry tanker on 3 February 2020. The report raised concerns that the positioning, brightness and colour of the tanker’s rear flashing LED lights may have masked or confused the tractor’s right indicator, contributing to the collision.
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 ensure that rear flashing warning lights are distinguishable from directional indicator lights
Wider context from the report “1. The positioning and size of the rear mounted flashing LED lights on the SlurryKat and other types of similar trailers.
2. The fact that these lights emitted a brighter light than the right or left turn indicator light therefore masking the indicator lights.
3. These rear flashing lights are the same colour as the indicator lights.
4. The indicator light seems to get lost amongst the other flashing lights or can be misinterpreted as an additional non directional warning lamp.
5. On this particular trailer (SlurryKat) the indicator lights are at the same height as the indicators.
It was found that this issue may have been a contributing factor in Mr McKeough's death as it appears he did not see the right indicator flashing.
” Open source report
28 Sep 2021 Dane CHINNERY and 6 others · Prevention of Future Deaths report South London
View report summary
Concerns raised 1 Risk of under-reporting of incidents 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
Dane CHINNERY and 6 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
On 9 November 2016, a tram travelling between Lloyd Park Station and Sandilands station derailed and overturned after the driver became disorientated and failed to brake before a tight curve; seven passengers were killed. The substantive concerns included inadequate risk assessment and mitigation, a lack of a just culture discouraging reporting of health and safety concerns, and the risk of under-reporting incidents.
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 under-reporting of incidents
Wider context from the report “The risk of under-reporting of incidents
” Open source report
17 Sep 2021 Heike MOJAY-SINCLARE · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 4 Failure to include river fords and depth gauges in mandatory highways inspection requirements View source Lack of mandatory requirements for water depth gauges at river ford crossings View source Lack of a prescribed design and standard for water depth gauges View source Failure to notify relevant local authorities of serious river ford incidents 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
Heike MOJAY-SINCLARE · 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
Heike Mojay-Sinclare drowned after her car became stuck in high and rising flood water at a ford on Doles Lane, Derbyshire, in late December 2018. The report raised concerns about the lack of mandatory standards, inspection and maintenance requirements for ford depth gauges, and insufficient sharing of information about previous serious incidents.
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 include river fords and depth gauges in mandatory highways inspection requirements
Wider context from the report “2. The inquest heard that river fords and depth gauges do not currently lie within mandatory highways inspection requirements and therefore there is no guarantee of their maintenance and review , and therefore no guarantee that they continue to provide on-going usability and safety .
” 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 mandatory requirements for water depth gauges at river ford crossings
Wider context from the report “1. The inquest heard that with regard to water depth gauges, specifically for river fords, the Traffic Signs and General Directions 2016 removed prescription of the type of signs to be used and the requirement for their use at river ford crossings . Those requirements were in the previous 2002 Directions. There s relevant guidance (Ch.4 Traffic Signs Manual) but this is not mandatory and leaves enactment to the discretion of the relevant local authority . As water depth gauges are outside of the regulatory regime there may be fords without gauges , or where they are installed they may be sub-optimal and deficient. There is also lack of clarity for local authorities and the lack of a prescribed design and standard means that manufacturers do not have an approved design to work to and provide to local authorities.
” 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 prescribed design and standard for water depth gauges
Wider context from the report “1. The inquest heard that with regard to water depth gauges, specifically for river fords, the Traffic Signs and General Directions 2016 removed prescription of the type of signs to be used and the requirement for their use at river ford crossings. Those requirements were in the previous 2002 Directions. There s relevant guidance (Ch.4 Traffic Signs Manual) but this is not mandatory and leaves enactment to the discretion of the relevant local authority. As water depth gauges are outside of the regulatory regime there may be fords without gauges, or where they are installed they may be sub-optimal and deficient. There is also lack of clarity for local authorities and the lack of a prescribed design and standard means that manufacturers do not have an approved design to work to and provide to local authorities .
” 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 notify relevant local authorities of serious river ford incidents
Wider context from the report “3. The inquest heard that there were a number of previous serious incidents which it appears were not notified to the relevant local authority , and that if they had been there would likely have been a review of measures relating to the river ford. A mandatory requirement for inter-agency information sharing in these circumstances is indicated .
” 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 The Government has no power to override local highway maintenance decisions or intervene in local inspection arrangements.
Verbatim wording from the response “3. With regards to highways inspection requirements, local highway authorities have a duty, under section 41 of the Highways Act 1980, to maintain the highway network in their area. The Act does not set out specific standards of maintenance, as it is for each individual local highway authority to assess which parts of its network are in need of repair and what standards should be applied, based upon their local knowledge and circumstances. The Government has no powers to override local decisions in these matters or intervene in these kinds of local issues.” 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 authorities decide whether to install water-depth gauges; their use is not mandated by the Department.
Verbatim wording from the response “2. The water depth gauge was prescribed in the Traffic Signs Regulations and General Directions 2002, but the decision to place them at any site would have still been at the discretion of the local authority. Their use was not mandated by this Department.” 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 agencies are responsible for sharing information about incidents; no requirement requires police and local authorities to do so.
Verbatim wording from the response “4. I appreciate that there were a number of previous incidents at this ford that the local highway authority was not made aware of, but I am afraid I cannot comment on the why this might have happened. While service agreements are often in place between forces and local authorities there are no existing requirements for this to take place. The sharing of information locally is a matter for local agencies. You may wish to consider bringing this matter to the attention of your Local Resilience Forum.” 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 No Departmental action is considered necessary because the relevant decisions rest with local authorities and tools are already available.
Verbatim wording from the response “I hope this response has explained my thinking on why I do not believe there are any actions necessary from the Department. I am afraid the concerns that you have raised are issues where the decision to act rests with the local authority, and there are tools available to them already to enable them to do so.” Source location Response from Department for Transport
Open published response
10 Sep 2021 Billy Martyn WARWICK-JONES · Prevention of Future Deaths report West London
View report summary
Concerns raised 4 Absence of specific driving guidance for sudden-onset confusion or delirium in physically unwell older people View source Failure to advise drivers and families that confusion, agitation or delirium may render driving unfit View source Insufficient road-safety instruction for older drivers View source Insufficient road-safety testing of older drivers 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
Billy Martyn WARWICK-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
Billy was killed while riding his motorbike when he was struck head-on by a car travelling on the wrong side of the A3. The driver was elderly, unwell with a urinary tract infection, delirious and had driven for 16 hours. The concerns included insufficient advice about delirium-related unfitness to drive and inadequate testing and guidance on road safety for older 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 Absence of specific driving guidance for sudden-onset confusion or delirium in physically unwell older people
Wider context from the report “The driver of the vehicle that caused this death was unwell with a urine tract infection. He had previously been treated for a urine tract infection. There is no evidence to suggest that he or his family were advised that he may demonstrate symptoms of confusion, agitation or delirium as a consequence of this and they would render him unfit to drive.
There appears to be insufficient testing and instruction of the older population with regards to road safety, which led to this tragic outcome. While there are guidelines for driving for dementia or mild cognitive impairment produced by the General Medical Council, there appears to be nothing specific to other sudden onset confusion or delirium which is a well recognised and common symptom in the elderly when physically unwell.
It is recognised that our population are growing older and that an increasing number of this cohort will have a driving licence. It is of concern that a situation can arise that leads to the loss of another drivers life, and additional lives could very easily have been lost as a consequence of this incident. Consideration should be given to more frequent, rigorous testing and to consider the duties that should be placed on the driver, their medical practitioners and also family members/carers to report changes in presentation or health to the Driver and Vehicle Licensing Agency.
” 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 advise drivers and families that confusion, agitation or delirium may render driving unfit
Wider context from the report “The driver of the vehicle that caused this death was unwell with a urine tract infection. He had previously been treated for a urine tract infection. There is no evidence to suggest that he or his family were advised that he may demonstrate symptoms of confusion, agitation or delirium as a consequence of this and they would render him unfit to drive.
There appears to be insufficient testing and instruction of the older population with regards to road safety, which led to this tragic outcome. While there are guidelines for driving for dementia or mild cognitive impairment produced by the General Medical Council, there appears to be nothing specific to other sudden onset confusion or delirium which is a well recognised and common symptom in the elderly when physically unwell.
It is recognised that our population are growing older and that an increasing number of this cohort will have a driving licence. It is of concern that a situation can arise that leads to the loss of another drivers life, and additional lives could very easily have been lost as a consequence of this incident. Consideration should be given to more frequent, rigorous testing and to consider the duties that should be placed on the driver, their medical practitioners and also family members/carers to report changes in presentation or health to the Driver and Vehicle Licensing Agency.
” 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 road-safety instruction for older drivers
Wider context from the report “The driver of the vehicle that caused this death was unwell with a urine tract infection. He had previously been treated for a urine tract infection. There is no evidence to suggest that he or his family were advised that he may demonstrate symptoms of confusion, agitation or delirium as a consequence of this and they would render him unfit to drive.
There appears to be insufficient testing and instruction of the older population with regards to road safety , which led to this tragic outcome. While there are guidelines for driving for dementia or mild cognitive impairment produced by the General Medical Council, there appears to be nothing specific to other sudden onset confusion or delirium which is a well recognised and common symptom in the elderly when physically unwell.
It is recognised that our population are growing older and that an increasing number of this cohort will have a driving licence. It is of concern that a situation can arise that leads to the loss of another drivers life, and additional lives could very easily have been lost as a consequence of this incident. Consideration should be given to more frequent, rigorous testing and to consider the duties that should be placed on the driver, their medical practitioners and also family members/carers to report changes in presentation or health to the Driver and Vehicle Licensing Agency.
” 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 road-safety testing of older drivers
Wider context from the report “The driver of the vehicle that caused this death was unwell with a urine tract infection. He had previously been treated for a urine tract infection. There is no evidence to suggest that he or his family were advised that he may demonstrate symptoms of confusion, agitation or delirium as a consequence of this and they would render him unfit to drive.
There appears to be insufficient testing and instruction of the older population with regards to road safety, which led to this tragic outcome. While there are guidelines for driving for dementia or mild cognitive impairment produced by the General Medical Council, there appears to be nothing specific to other sudden onset confusion or delirium which is a well recognised and common symptom in the elderly when physically unwell.
It is recognised that our population are growing older and that an increasing number of this cohort will have a driving licence. It is of concern that a situation can arise that leads to the loss of another drivers life, and additional lives could very easily have been lost as a consequence of this incident. Consideration should be given to more frequent, rigorous testing and to consider the duties that should be placed on the driver, their medical practitioners and also family members/carers to report changes in presentation or health to the Driver and Vehicle Licensing Agency.
” 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 Fund and develop an older-driver website providing safety advice, assessment information and refresher-training details.
Verbatim wording from the response “The Royal Society for the Prevention of Accidents, with funding from the Department, has developed an older driver website which can be accessed at: www.olderdrivers.org.uk. The website contains information to help older people to continue to drive for as long as they are safe to do so. It includes general advice, as well as details on driving assessments and refresher training.” 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 The current driver licensing process at age 70 or over is considered to balance road safety and individual needs.
Verbatim wording from the response “A driver’s age is, in itself, not an automatic barrier to driving. But the likelihood of having a medical condition that can affect safe driving does increase with age. The current process for drivers renewing their licences at age 70 or over is designed to balance road safety and the needs of the individual. There is little evidence to suggest that introducing a stricter regime which included mandatory testing or medical examinations would improve road safety. Drivers are encouraged to discuss any concerns about their driving fitness with their own medical professionals.” 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 There is little evidence that mandatory testing or medical examinations for older drivers would improve road safety.
Verbatim wording from the response “A driver’s age is, in itself, not an automatic barrier to driving. But the likelihood of having a medical condition that can affect safe driving does increase with age. The current process for drivers renewing their licences at age 70 or over is designed to balance road safety and the needs of the individual. There is little evidence to suggest that introducing a stricter regime which included mandatory testing or medical examinations would improve road safety. Drivers are encouraged to discuss any concerns about their driving fitness with their own medical professionals.” Source location Response from Department for Transport
Open published response
19 Jul 2021 Sarah Lewis · Prevention of Future Deaths report County of Dorset
View report summary
Concerns raised 2 Failure to provide banksman assistance for reversing Large Goods Vehicles View source Lack of mandatory rear-camera fitting for Large Goods Vehicles View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sarah Lewis · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 16 November 2020, Sarah Lewis was fatally struck by a reversing large goods vehicle while crossing behind it in Weymouth. The principal concern was the blind spot behind large goods vehicles and the absence of a legal requirement for rear cameras, particularly where no banksman is present. The report also noted uncertainty about the possible effect of fluoxetine levels above the therapeutic range.
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 provide banksman assistance for reversing Large Goods Vehicles
Wider context from the report “(1) A Large Goods Vehicle was being driven which had reverse warning lights and a reversing alarm. The driver was assisted by 7 mirrors. A pedestrian was stood on the pavement and she was not seen by the driver. It is likely that the driver was checking his nearside mirror or the road around him when the pedestrian stepped out behind the reversing lorry which resulted in a complete blind spot once she was behind the vehicle.
(2) The evidence I heard is that it is not mandatory for Large Goods Vehicles to be fitted with a camera at the rear of the vehicle to assist drivers and prevent this blind spot. A lot of drivers complete journeys alone without a banksman to assist them in safely reversing .
(3) There is no legal requirement for vehicles to have a rear camera and yet this may prevent future deaths. At the very least it would prevent a large number of accidents.
” 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 mandatory rear-camera fitting for Large Goods Vehicles
Wider context from the report “(1) A Large Goods Vehicle was being driven which had reverse warning lights and a reversing alarm. The driver was assisted by 7 mirrors. A pedestrian was stood on the pavement and she was not seen by the driver. It is likely that the driver was checking his nearside mirror or the road around him when the pedestrian stepped out behind the reversing lorry which resulted in a complete blind spot once she was behind the vehicle.
(2) The evidence I heard is that it is not mandatory for Large Goods Vehicles to be fitted with a camera at the rear of the vehicle to assist drivers and prevent this blind spot . A lot of drivers complete journeys alone without a banksman to assist them in safely reversing.
(3) There is no legal requirement for vehicles to have a rear camera and yet this may prevent future deaths. At the very least it would prevent a large number of accidents.
” 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 Finalize international technical requirements for reversing detection systems using cameras, sensors, or both on LGVs.
Verbatim wording from the response “The DfT has been working at international level to develop appropriate requirements to improve vision for drivers around LGVs. This work includes a reversing detection system using cameras, sensors or a combination of these to enable the driver to be aware of an obstacle or person directly behind their vehicle. The technical requirements for the system have been finalised and were formally agreed earlier this year.” Source location 2021-0251-Response-from-Department-for-Transport_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop the new approval system for vehicles registered for use in Great Britain.
Verbatim wording from the response “Following the UK leaving the European Union, a new approval system for vehicles being registered for use in Great Britain is being developed. A call for evidence is planned later this year to gather views on the inclusion of a wide range of technologies that are becoming available, including reversing detection systems. The outcome will inform decisions on future legislation to require these technologies to be fitted to new vehicles. We will hold and record your observations on the use of reversing camera systems within the responses to the call for evidence.” Source location 2021-0251-Response-from-Department-for-Transport_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct a call for evidence on available technologies, including reversing detection systems, and record the coroner’s observations in the responses.
Verbatim wording from the response “Following the UK leaving the European Union, a new approval system for vehicles being registered for use in Great Britain is being developed. A call for evidence is planned later this year to gather views on the inclusion of a wide range of technologies that are becoming available, including reversing detection systems. The outcome will inform decisions on future legislation to require these technologies to be fitted to new vehicles. We will hold and record your observations on the use of reversing camera systems within the responses to the call for evidence.” Source location 2021-0251-Response-from-Department-for-Transport_Published
Open published response
20 Apr 2021 Ella Adoo-Kissi-Debrah · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 6 Insufficient undergraduate teaching on the health effects of air pollution View source Insufficient postgraduate education on the health effects of air pollution View source Insufficient detail and monitoring capacity for air quality information View source Insufficient professional guidance on communicating the health effects of air pollution View source Low public awareness of sources of national and local pollution information View source National Particulate Matter limits exceeding WHO guideline levels View source See 3 more concerns
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
Ella Adoo-Kissi-Debrah · 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
Ella Adoo-Kissi-Debrah died aged 9 after an asthmatic episode led to cardiac arrest on 15 February 2013. The report states that air pollution, including exposure to nitrogen dioxide and particulate matter from traffic emissions, significantly contributed to her asthma and death. It also identifies concerns about pollution limits, public access to pollution information, and communication of air-pollution health risks by healthcare professionals.
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 Insufficient undergraduate teaching on the health effects of air pollution
Wider context from the report “(3) The adverse effects of air pollution on health are not being sufficiently communicated to patients and their carers by medical and nursing professionals. The evidence at the inquest was that this needs to be addressed at three levels:
a. Undergraduate. I am informed that undergraduate teaching is the responsibility of the GMC, Health Education England and the NMC.
b. Postgraduate. I am informed that postgraduate education is the responsibility of the Royal Colleges, in this case the Royal College of Physicians, the Royal College of Paediatrics and Child Health, the Royal College of General Practitioners, and the NMC.
c. Professional guidance. In this case relevant organisations are NICE and the British Thoracic Society.
” 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 postgraduate education on the health effects of air pollution
Wider context from the report “(3) The adverse effects of air pollution on health are not being sufficiently communicated to patients and their carers by medical and nursing professionals. The evidence at the inquest was that this needs to be addressed at three levels:
a. Undergraduate. I am informed that undergraduate teaching is the responsibility of the GMC, Health Education England and the NMC.
b. Postgraduate. I am informed that postgraduate education is the responsibility of the Royal Colleges, in this case the Royal College of Physicians, the Royal College of Paediatrics and Child Health, the Royal College of General Practitioners, and the NMC.
c. Professional guidance. In this case relevant organisations are NICE and the British Thoracic Society.
” 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 detail and monitoring capacity for air quality information
Wider context from the report “(2) There is a low public awareness of the sources of information (such as UK-Air website) about national and local pollution levels. Greater awareness would help individuals reduce their personal exposure to air pollution. It was clear from the evidence at the inquest that publicising this information is an issue that needs to be addressed by national as well as local government. The information must be sufficiently detailed and this is likely to require enlargement of the capacity to monitor air quality, for example by increasing the number of air quality sensors .
” 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 professional guidance on communicating the health effects of air pollution
Wider context from the report “(3) The adverse effects of air pollution on health are not being sufficiently communicated to patients and their carers by medical and nursing professionals. The evidence at the inquest was that this needs to be addressed at three levels:
a. Undergraduate. I am informed that undergraduate teaching is the responsibility of the GMC, Health Education England and the NMC.
b. Postgraduate. I am informed that postgraduate education is the responsibility of the Royal Colleges, in this case the Royal College of Physicians, the Royal College of Paediatrics and Child Health, the Royal College of General Practitioners, and the NMC.
c. Professional guidance. In this case relevant organisations are NICE and the British Thoracic Society.
” 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 Low public awareness of sources of national and local pollution information
Wider context from the report “(2) There is a low public awareness of the sources of information (such as UK-Air website) about national and local pollution levels. Greater awareness would help individuals reduce their personal exposure to air pollution. It was clear from the evidence at the inquest that publicising this information is an issue that needs to be addressed by national as well as local government . The information must be sufficiently detailed and this is likely to require enlargement of the capacity to monitor air quality, for example by increasing the number of air quality sensors.
” 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 National Particulate Matter limits exceeding WHO guideline levels
Wider context from the report “(1) The national limits for Particulate Matter are set at a level far higher than the WHO guidelines. The evidence at the inquest was that there is no safe level for Particulate Matter and that the WHO guidelines should be seen as minimum requirements. Legally binding targets based on WHO guidelines would reduce the number of deaths from air pollution in the UK.
” Open source report
Concerns raised 6 Motorist confusion caused by mixed smart and traditional motorways View source Lack of effective and consistent overview of smart motorways across England and Wales View source Lack of driver awareness of smart motorway use View source Risk posed by the absence of a hard shoulder on smart motorways View source Lack of driver awareness of the need to get over the crash barrier where possible View source Failure to identify stationary vehicles promptly View source See 3 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
JASON LEE MERCER and ALEXANDRU MURGEANU · 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 7 June 2019, Jason Lee Mercer and Alexandru Murgeanu were involved in a minor collision on the M1 Northbound and stopped in an active lane. About six minutes later, both were struck by a Mercedes goods vehicle and died at the scene. The report identifies concerns about the absence of a hard shoulder on smart motorways, driver awareness, detection of stationary vehicles, and the need for a wider review of smart 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 Motorist confusion caused by mixed smart and traditional motorways
Wider context from the report “• The confusion caused to motorists posed by a mixture of smart motorways and traditional motorways
” 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 effective and consistent overview of smart motorways across England and Wales
Wider context from the report “• The need for a wider review / inquiry into Smart Motorways for the following reasons:
○ Coroners only conduct inquests for deaths that occur in their coronial area ( unless there is a body transfer ) and given smart motorways exist across England and Wales, coroners do not and cannot have an effective and consistent overview of the whole of England and Wales
○ An inquest is confined to consider the facts insofar as they relate to the death(s) before him or her in order to answer the four statutory questions. It must not consider wider issues.
○ An inquest cannot say what government policy should be
○ A wider review would not be constrained by the above and could consider all issues relevant to its remit and has the opportunity thereby of saving lives.
” 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 driver awareness of smart motorway use
Wider context from the report “• The need for better driver awareness on the use of smart motorways
” 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 posed by the absence of a hard shoulder on smart motorways
Wider context from the report “• The obvious and foreseeable risk posed by the absence of a hard shoulder on smart motorways ;
” 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 driver awareness of the need to get over the crash barrier where possible
Wider context from the report “• The need for better driver awareness of the need, where possible, to get over the crash barrier on all motorways, not just smart motorways
” 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 identify stationary vehicles promptly
Wider context from the report “• The need to for Highways England to be better able to identify stationary vehicles
” 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 Commission and complete a review of Smart Motorway safety, resulting in the 2020 Safety Evidence Stocktake and Action Plan.
Verbatim wording from the response “Smart Motorways were originally introduced under former Secretary of State John Prescott in 2001. Although per hundred million miles driven there appear to be fewer deaths on Smart Motorways than conventional ones², I have shared the public’s unease about whether Smart Motorways could be made safer still. As a result, one of my earliest actions as Secretary of State for Transport in Autumn 2019 was to commission a review into Smart Motorways.” Source location 2021-0013-Response-from-DFT-Redacted
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 Abolish dynamic hard shoulder motorways.
Verbatim wording from the response “Moreover, I believe that a lack of consistency on different types of smart motorways might cause confusion and we have already committed to abolishing the "dynamic hard shoulder" (DHS) motorways, where the hard shoulder operates only part-time and is a live running lane the rest of the time. Highways England is converting all DHS smart motorways into all lane running to provide a less confusing environment for motorists.” Source location 2021-0013-Response-from-DFT-Redacted
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 Press Highways England to accelerate implementation of safety measures recommended in the 2020 Action Plan.
Verbatim wording from the response “The Smart Motorway Safety Evidence Stocktake and Action Plan report (‘2020 Action Plan’), which was published in March 2020. One year on, I have received a progress report on existing actions and I am pressing Highways England to accelerate safety measures recommended in the 2020 Action Plan where possible to ensure that all lane running (ALR) motorways are the safest roads in the country. Highways England will publish this report shortly.” Source location 2021-0013-Response-from-DFT-Redacted
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 Highways England is responsible for addressing the points raised about smart motorway safety.
Verbatim wording from the response “I understand that Highways England is addressing the points you raise in further detail.” Source location 2021-0013-Response-from-DFT-Redacted
Open published response
Concerns raised 1 Potential inadequacy of driving-licence surrender time frames for seizure risk 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
William Edward TURNER · 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 Edward TURNER, aged 74, died at the scene after a multi-vehicle collision on 8 October 2019, when a vehicle travelling in the opposite direction went out of control and caused a head-on collision. The report raised concern about whether the driving-licence surrender periods for people with epilepsy should be revisited or reviewed in light of the circumstances.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Potential inadequacy of driving-licence surrender time frames for seizure risk
Wider context from the report “(3) The time frames of 6 months and 12 months for surrender of the drivers licence were provided in the Regulations, which are framed and from time to time amended pursuant to recommendations of the Secretary of State for Transport’s Honorary Medical Advisory Panel on Driving and Disorders of the Nervous System, which you chair.
(4) Is there scope for re-visiting these time frames in the light of the facts of this case, or at least reviewing them in the light of this case?
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations