30 Sep 2020 Mollie Matilda Gifford · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1 Failure of standard class 5 and 6 mirrors to provide adequate close-proximity visibility when the cab is stationary 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
Mollie Matilda Gifford · 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
Mollie Matilda Gifford was struck by a large goods vehicle while crossing a road and later died in hospital after sustaining severe traumatic injuries and complications. The principal concern was that standard class 5 and 6 lorry mirrors create an avoidable risk that drivers will not see pedestrians and other road users close to the cab when stationary; the cause of death and the role of the collision remained unknown.
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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 standard class 5 and 6 mirrors to provide adequate close-proximity visibility when the cab is stationary
Wider context from the report “The mirrors are convex and therefore even when clean provide a distorted view, but as they are prone to collect road dirt and spray, the distortion is easily amplified, making it difficult for cab drivers to see movement and colour. Some cab drivers will have a false sense of security about the ability of class 5 and 6 mirrors to provide a comprehensive view of other road users and pedestrians around the cab when stationary. Mr ████████ went on to explain that camera units are available on the market to stream live footage of around the cab to the driver on a screen. Camera units offer a clearer view, are not subject to the same distortion as class 5 and 6 mirrors and it is easier to pick out movement and different colours.
My ongoing concern is that standard class 5 and 6 mirrors create an avoidable risk cab drivers will not see other road users and pedestrians in close proximity to the cab when stationary.
” 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 Develop international requirements for blind-spot information systems detecting cyclists alongside large goods vehicles and warning drivers.
Verbatim wording from the response “You will be interested to know that the DfT is working at international level to develop appropriate requirements to improve vision for drivers around large goods vehicles. This work includes improved direct vision for the driver through vehicle windows and the windscreen, a moving-off information system to provide a warning to the driver if a vulnerable road user is in front of a vehicle, a blind spot information system to detect cyclists alongside vehicles and provide a warning to the driver, and reversing detection using cameras or sensors.” Source location 2020-0211-Response-from-DFT-Redacted.pdf
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 international requirements for moving-off information systems warning drivers about vulnerable road users ahead.
Verbatim wording from the response “You will be interested to know that the DfT is working at international level to develop appropriate requirements to improve vision for drivers around large goods vehicles. This work includes improved direct vision for the driver through vehicle windows and the windscreen, a moving-off information system to provide a warning to the driver if a vulnerable road user is in front of a vehicle, a blind spot information system to detect cyclists alongside vehicles and provide a warning to the driver, and reversing detection using cameras or sensors.” Source location 2020-0211-Response-from-DFT-Redacted.pdf
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 international requirements for reversing detection using cameras or sensors on large goods vehicles.
Verbatim wording from the response “You will be interested to know that the DfT is working at international level to develop appropriate requirements to improve vision for drivers around large goods vehicles. This work includes improved direct vision for the driver through vehicle windows and the windscreen, a moving-off information system to provide a warning to the driver if a vulnerable road user is in front of a vehicle, a blind spot information system to detect cyclists alongside vehicles and provide a warning to the driver, and reversing detection using cameras or sensors.” Source location 2020-0211-Response-from-DFT-Redacted.pdf
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 international requirements for improved direct vision through large goods vehicle windows and windscreens.
Verbatim wording from the response “You will be interested to know that the DfT is working at international level to develop appropriate requirements to improve vision for drivers around large goods vehicles. This work includes improved direct vision for the driver through vehicle windows and the windscreen, a moving-off information system to provide a warning to the driver if a vulnerable road user is in front of a vehicle, a blind spot information system to detect cyclists alongside vehicles and provide a warning to the driver, and reversing detection using cameras or sensors.” Source location 2020-0211-Response-from-DFT-Redacted.pdf
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 Vehicle operators are responsible for selecting mirrors or camera-monitor systems according to their operating environment.
Verbatim wording from the response “The CMS and mirrors permitted under C & U each has benefits in different circumstances. The selection of which system to use is one for the operator to consider, taking account of the nature of their operating environment.” Source location 2020-0211-Response-from-DFT-Redacted.pdf
Open published response
16 Jun 2020 JOAN WILLIAMS · Prevention of Future Deaths report Bedfordshire and Luton
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Concerns raised 1 Failure to require direct referral of Alzheimer’s dementia diagnoses to the DVLA/DVA 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
JOAN WILLIAMS · 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
JOAN WILLIAMS was driving on the A5120 on 19 August 2019 when her car collided head-on with a heavy goods vehicle. She sustained multiple injuries and died in hospital on 3 September 2019. The concerns included that, despite her Alzheimer’s dementia diagnosis and advice to notify the DVLA and stop driving, she continued to drive and the DVLA was not informed; the report also raised whether diagnoses should be referred directly to the DVLA or DVA.
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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 require direct referral of Alzheimer’s dementia diagnoses to the DVLA/DVA
Wider context from the report “(3) Current legislation makes the driver legally responsible for telling the DVLA or DVA about Alzheimer’s dementia. Doctors are only required to alert patients to such a condition that can affect their ability to drive and to remind them of their duty to tell the appropriate agency. Doctors are only told that they should disclose this information directly to the DVA or DVLA without consent IF they are aware that the patient is continuing to drive and they consider it to be in the public interest to do so ;
(4) The Alzheimer’s Society reports that, in 2013, there were 815,827 people with dementia in the UK (including 1 in every 14 of the population aged 65 years and over) and that, if current trends continue, the number of people with dementia in the UK is forecast to increase to 1,142,677 by 2025 and 2,092,945 by 2051, which will be an increase of 40% over the next 12 years and of 156% over the next 38 years.
(5) GPs are extremely busy professionals and may not always be made aware of a patient’s day to day activities. It was discussed at the Inquest that this tragedy, which involved not only the death of the deceased but also the death of her husband, might suggest that the public interest could be better served by the introduction of legislation to require ALL such diagnoses to be referred directly to the DVA/DVLA from the Memory Assessment Clinic and/or GP.
” 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 Mandatory doctor notification of dementia diagnoses is not planned because current notification arrangements are considered effective and sufficient.
Verbatim wording from the response “There are no plans to place a legal obligation on doctors to notify a diagnosis of dementia. The current arrangements work well by respecting the rights of those diagnosed with dementia who retain insight, to be trusted to notify the DVLA. Where a doctor assesses that insight has been lost, a notification to the DVLA by the doctor is already allowed in the public interest.” Source location Department for Transport Response
Open published response
Concerns raised 2 Lack of publicly available information on planned lifeguard patrol locations and timing View source Unavailability of professional lifeguard cover on Cornwall beaches 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
Gillian Louisa DAVEY and Michael PENDER · 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 25 May 2020, Gillian Louisa Davey died after a pleasure craft capsized off the north Cornish coast, trapping her underneath, and Michael Pender died after being rescued from the sea off Treyarnon Bay, apparently having been caught in a rip current. The principal concern was that there was no lifeguard cover on any Cornish beach that day, with uncertainty about when professional lifeguard services would resume and concern about further loss of life.
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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 publicly available information on planned lifeguard patrol locations and timing
Wider context from the report “On the day of these incidents, there was no lifeguard cover on any Cornish beach.
How this state of affairs arose will be a matter for the future.
My immediate concern is that the beaches in Cornwall remain unguarded. There have been numerous reports on social media and in the general press of volunteers from surf lifesaving clubs and elsewhere performing rescues or intervening to prevent an incident from developing.
I have seen mention that the RNLI hopes to provide some lifeguard cover at 70 beaches but I have not seen a plan confirming which beaches will be patrolled and by when . This information needs to be put in the public domain at the first opportunity .
Unless and until there is a professional lifeguard service back on the beaches in Cornwall, I fear it will be inevitable that there will be further loss of life.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Unavailability of professional lifeguard cover on Cornwall beaches
Wider context from the report “On the day of these incidents, there was no lifeguard cover on any Cornish beach .
How this state of affairs arose will be a matter for the future.
My immediate concern is that the beaches in Cornwall remain unguarded . There have been numerous reports on social media and in the general press of volunteers from surf lifesaving clubs and elsewhere performing rescues or intervening to prevent an incident from developing.
I have seen mention that the RNLI hopes to provide some lifeguard cover at 70 beaches but I have not seen a plan confirming which beaches will be patrolled and by when. This information needs to be put in the public domain at the first opportunity.
Unless and until there is a professional lifeguard service back on the beaches in Cornwall , I fear it will be inevitable that there will be further loss of life.
” 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 Beach safety and lifeguarding provision fall outside the respondent’s remit, which is limited to coordinating coastal and sea search-and-rescue responses.
Verbatim wording from the response “In your report, under Section 6, you say that the Department for Transport, the RNLI and the Maritime and Coastguard Agency (MCA) have the powers to take action in respect to providing a lifeguard service on beaches in Cornwall, to help prevent the future loss of life. The MCA, which includes Her Majesty’s Coastguard, is an executive Agency of the Department for Transport. I am therefore replying on my own behalf, and also on behalf of the Secretary of State for Transport, the Right Honourable Grant Shapps MP. The MCA has a responsibility to respond to calls for assistance as the emergency responder with the remit for search and rescue at the coast and at sea. Our role is to coordinate the emergency response drawing from the matrix of search and rescue resources that are available and appropriate. However, we have no remit for beach safety or the provision of lifeguarding.” Source location 2020-0121-Response-from-Maritime-and-Coastguard-Agency_Redacted.pdf
Open published response
Concerns raised 2 Unavailability of public information on planned beach patrol locations and timing View source Lack of professional lifeguard cover on Cornwall’s beaches View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Gillian Louisa DAVEY and Michael PENDER · 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 25 May 2020, Gillian Davey, aged 17, was trapped under a capsized pleasure craft near Padstow and could not be resuscitated. On the same day, Michael Pender, aged 63, was rescued after apparently being caught in a rip current while swimming off Treyarnon Bay, but could not be resuscitated. The principal concern was that no Cornish beach had lifeguard cover that day and that beaches remained unguarded, with a fear of further loss of life until professional lifeguard services returned.
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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 public information on planned beach patrol locations and timing
Wider context from the report “These incidents both occurred on Bank Holiday Monday. Ordinarily, I understand the RNLI is responsible for the provision of lifeguard cover (during peak season) at something in the order of 240 beaches. On the day of these incidents, there was no lifeguard cover on any Cornish beach.
How this state of affairs arose will be a matter for the future.
My immediate concern is that the beaches in Cornwall remain unguarded. There have been numerous reports on social media and in the general press of volunteers from surf lifesaving clubs and elsewhere performing rescues or intervening to prevent an incident from developing.
I have seen mention that the RNLI hopes to provide some lifeguard cover at 70 beaches but I have not seen a plan confirming which beaches will be patrolled and by when . This information needs to be put in the public domain at the first opportunity .
Unless and until there is a professional lifeguard service back on the beaches in Cornwall, I fear it will be inevitable that there will be further loss of life.
” 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 professional lifeguard cover on Cornwall’s beaches
Wider context from the report “These incidents both occurred on Bank Holiday Monday. Ordinarily, I understand the RNLI is responsible for the provision of lifeguard cover (during peak season) at something in the order of 240 beaches. On the day of these incidents, there was no lifeguard cover on any Cornish beach .
How this state of affairs arose will be a matter for the future.
My immediate concern is that the beaches in Cornwall remain unguarded . There have been numerous reports on social media and in the general press of volunteers from surf lifesaving clubs and elsewhere performing rescues or intervening to prevent an incident from developing.
I have seen mention that the RNLI hopes to provide some lifeguard cover at 70 beaches but I have not seen a plan confirming which beaches will be patrolled and by when. This information needs to be put in the public domain at the first opportunity.
Unless and until there is a professional lifeguard service back on the beaches in Cornwall , I fear it will be inevitable that there will be further loss of life.
” Open source report
Concerns raised 4 Lack of defined and auditable determination of emergency status for courier services View source Lack of statutory basic, ongoing or refresher training requirements for high-powered motorcycle use and emergency exemptions View source Lack of traceable NHS ambulance trust control-centre coordination of vehicle allocation or dispatch View source Lack of ongoing review of urgency and need to apply emergency exemptions or permissions 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
Russell Curwen · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Russell Curwen, a volunteer with the North West Blood Bikes, was fatally injured after riding through a traffic light against the lights while transporting blood samples and colliding with another vehicle on 5 May 2018. The concerns included the lack of traceable NHS ambulance service coordination in dispatching blood-bike vehicles, no clear or auditable determination or review of whether courier journeys constituted emergencies, and no statutory training requirements for riders using high-powered motorcycles with emergency lights and sirens.
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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 defined and auditable determination of emergency status for courier services
Wider context from the report “2) That there is no definition of what constitutes an emergency and in the cases of courier services no apparent auditable or co-ordinated determination of what is classified as an emergency in these cases : - In this instance it was identified that Mr Curwen was transporting blood samples for 5 patients from one hospital to another who provided for weekend cover. There does not appear to be any determination by an NHS Ambulance Trust co-ordinator or control room supervisor, or even a recorded clinical decision as to ████████ whether the situation truly requires an “emergency” response. It is not suggested at present that the samples were required for life saving treatment, or that delays could significantly reduce the life expectancy of the patients.
” 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 statutory basic, ongoing or refresher training requirements for high-powered motorcycle use and emergency exemptions
Wider context from the report “4) That there is no statutory requirement for training: - There appears to be no statutory requirement for even a basic level of training before using high powered motorcycles and applying the exemptions or permissions , nor does there appear to be any requirement for ongoing or refresher training .
” 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 traceable NHS ambulance trust control-centre coordination of vehicle allocation or dispatch
Wider context from the report “1) That the exemptions all relate to actions requiring an emergency response at the request of an NHS ambulance service: - There appears to be no traceable or auditable co-ordination or control of the allocation or dispatch of vehicles by a NHS ambulance trust control centre. Allocation or dispatch appears to be actioned at the request of the four NHS trusts contracted to with North West Blood Bikes under contracts for courier services ;
” 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 ongoing review of urgency and need to apply emergency exemptions or permissions
Wider context from the report “3) That there is no auditable or co-ordinated review of the appropriateness of the urgency or emergency nature of the situation: - There does not appear to be any review of the urgency of the situation by control personnel , or continued assessment of the need to apply the exemptions or permissions referred to above .
” 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 Progress commencement of section 19 and develop regulations establishing minimum driver training standards and clarifying exemptions, warning equipment rules and related best practice.
Verbatim wording from the response “Work is in hand to commence section 19 Road Safety Act 2006 (which will substitute section 87 Road Traffic Regulation Act 1984) to introduce a regulation-making power to mandate a minimum driver training standard before any speed exemption may be claimed. It is intended that associated regulations will also create new narrowly-defined speed limit exemption purposes and further clarify and update existing traffic sign, blue light and siren regulations.” 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 Ensure the report and inquest findings are considered in developing relevant legislation and incorporated where appropriate into associated regulations and the code of best practice.
Verbatim wording from the response “I will ensure that this regulation 28 report, and findings from the ongoing inquest, will be considered by officials working on the relevant legislation, and where appropriate incorporated into the ongoing development of the High Speed Driver Training Regulations, Speed Limits Exemptions Regulations and Code of Best Practice under the amended Road Traffic Regulation Act 1984.” 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 NHS ambulance services have appropriate processes to determine emergencies and supervise lawful urgent responses, so additional measures are conditional on contrary inquest findings.
Verbatim wording from the response “2) NHS Ambulance Services have the appropriate training, experience, command and control processes, and policies, to determine whether an incident is both an emergency and requiring an urgent response. Should the inquest determine any basis for suggesting that Mr. Curwen was providing a lawful response to an emergency at the request of an NHS Ambulance Service, further consideration will be given to additional guidance and amending regulations.” 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 The incident indicates unlawful use of existing laws, rather than inadequacy of the current road traffic regulations.
Verbatim wording from the response “On the information provided, this incident would appear to be one where existing laws were contravened, rather than where the existing regulations are inadequate. The fitment and use of blue lights and sirens, and the contravention of the red traffic light, all appear to be unlawful on the information provided, and neither part of providing a response to an emergency at the request of an NHS Ambulance Service nor enabled by other legislation. Established governance and oversight procedures were therefore circumvented or non-existent.” Source location Response from Department for Transport
Open published response
17 Apr 2020 Ashley Mark Holden · Prevention of Future Deaths report Lincolnshire
View report summary
Concerns raised 3 Inconsistent and uncoordinated guidance on bale safety View source Lack of definitive guidance on loading and strapping loaded trailers for differing bale and trailer configurations View source Lack of definitive guidance on stacking or unstacking bales 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
Ashley Mark Holden · 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 10 November 2018, HGV driver Ashley Holden was struck by a falling straw bale while collecting bales from a farm and sustained a fatal head injury. The report identified inconsistent guidance and a lack of definitive guidance on stacking, unstacking, loading and strapping bales, creating a risk of unsafe practices and future deaths.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Inconsistent and uncoordinated guidance on bale safety
Wider context from the report “3. The two pieces of guidance are not consistent in the approaches that they suggest and indeed the later guidance does not reference the earlier guidance .
4. There is no definitive guidance provided to the industry in relation to the stacking or unstacking of bales, or in relation to the loading and strapping of loaded trailers in a manner which takes account of the different sizes and composition of bales, and/or different trailer sizes and configurations.
5. The absence of specific guidance on this issue creates a risk of the development of unapproved and potentially unsafe individual practices, with the consequential risk of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of definitive guidance on loading and strapping loaded trailers for differing bale and trailer configurations
Wider context from the report “3. The two pieces of guidance are not consistent in the approaches that they suggest and indeed the later guidance does not reference the earlier guidance.
4. There is no definitive guidance provided to the industry in relation to the stacking or unstacking of bales, or in relation to the loading and strapping of loaded trailers in a manner which takes account of the different sizes and composition of bales, and/or different trailer sizes and configurations.
5. The absence of specific guidance on this issue creates a risk of the development of unapproved and potentially unsafe individual practices, with the consequential risk of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of definitive guidance on stacking or unstacking bales
Wider context from the report “3. The two pieces of guidance are not consistent in the approaches that they suggest and indeed the later guidance does not reference the earlier guidance.
4. There is no definitive guidance provided to the industry in relation to the stacking or unstacking of bales , or in relation to the loading and strapping of loaded trailers in a manner which takes account of the different sizes and composition of bales, and/or different trailer sizes and configurations.
5. The absence of specific guidance on this issue creates a risk of the development of unapproved and potentially unsafe individual practices, with the consequential risk of future deaths.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with relevant organisations, including DVSA and HSE where appropriate, to promote safe loading and unloading practices.
Verbatim wording from the response “• DfT will work with other organisations including, where appropriate, the DVSA and HSE to promote safe working practices during loading and unloading operations. We note that HSE does and will continue to engage with the agricultural industry to promote safe practice over a variety of topics, including safe working with bales.” Source location 2020-0096-Response-from-Department-for-Transport_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 Amend the DfT Code of Practice, “Safety Loads on Vehicles”, to cross-reference relevant guidance effectively.
Verbatim wording from the response “• To amend the DfT Code of Practice, ‘Safety Loads on Vehicles’ (2002) to ensure both are cross referenced effectively. Whilst HSE leaflet INDG125 already references the DfT guidance on page 10 titled Find out more - https://www.hse.gov.uk/pubns/indg125.pdf, we note that HSE intends to consider whether improvements can be made to INDG125 when it is next under periodic re-evaluation.” Source location 2020-0096-Response-from-Department-for-Transport_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 A comprehensive table covering every bale and trailer permutation is considered impractical because it would be overly complex and potentially confusing.
Verbatim wording from the response “• That DVSA updates the ‘Load Securing - Vehicle Operators Guidance’ which was last reviewed with HSE in 2015. HSE has agreed in principle to assist DVSA in updating this guidance which was already proposed at the start of this year. Having considered the approaches that could be taken, we have identified that a generic approach to safe loading principles, rather than very specific information covering each size of bale and trailer, is considered to be most practical. A comprehensive table seeking to cover every permutation of trailer and bale would be overly complex and may confuse. However, the updated guidance will look at the key principles for the safe loading and transport of bales.” Source location 2020-0096-Response-from-Department-for-Transport_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 DVSA is assigned responsibility for updating the Load Securing—Vehicle Operators Guidance, with HSE assistance.
Verbatim wording from the response “• That DVSA updates the ‘Load Securing - Vehicle Operators Guidance’ which was last reviewed with HSE in 2015. HSE has agreed in principle to assist DVSA in updating this guidance which was already proposed at the start of this year. Having considered the approaches that could be taken, we have identified that a generic approach to safe loading principles, rather than very specific information covering each size of bale and trailer, is considered to be most practical. A comprehensive table seeking to cover every permutation of trailer and bale would be overly complex and may confuse. However, the updated guidance will look at the key principles for the safe loading and transport of bales.” Source location 2020-0096-Response-from-Department-for-Transport_Redacted
Open published response
17 Feb 2020 Lorraine Anne Molyneaux and James Anthony Lewis · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 3 Lack of a suitable pedestrian crossing near the bus stops and entrance to Turbary Retail Park View source Insufficient street lighting between Mountbatten Roundabout and Clock Garage Roundabout View source Failure to ensure street lighting is working between Mountbatten Roundabout and Clock Garage Roundabout View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Lorraine Anne Molyneaux and James Anthony 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 October 2019, Lorraine Molyneaux was struck by a motorcycle while crossing Ringwood Road near Turbary Retail Park and died at the scene. The motorcyclist, James Anthony Lewis, had consumed alcohol, suffered significant traumatic head injuries and died on 22 October 2019. Concerns related to repeated pedestrian collisions at the location, the distance of crossings from nearby bus stops and the adequacy and operation of street lighting.
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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 suitable pedestrian crossing near the bus stops and entrance to Turbary Retail Park
Wider context from the report “i. The deaths of Lorraine and James now bring the total fatalities to 3 in the same location and in similar circumstances since September 2018. I have concerns that there could be future deaths at this location if action is not taken.
ii. I therefore request that a review is undertaken of the pedestrian crossings and the layout of Ringwood Road outside of Turbary Retail Park . I request that consideration is given to the placing of a pedestrian crossing closer to the bus stops and the entrance to Turbary Retail Park as soon as possible to avoid 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 street lighting between Mountbatten Roundabout and Clock Garage Roundabout
Wider context from the report “iii. I further request that the street lighting between Mountbatten roundabout and Clock Garage Roundabout is reviewed in relation to the amount of lighting and to ensure that the current lighting is working.
” 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 street lighting is working between Mountbatten Roundabout and Clock Garage Roundabout
Wider context from the report “iii. I further request that the street lighting between Mountbatten roundabout and Clock Garage Roundabout is reviewed in relation to the amount of lighting and to ensure that the current lighting is working .
” Open source report
29 Nov 2019 Suzanna Jayne Bull · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Lack of warnings on dashboard trays against fitting them in moving vehicles View source Lack of general warnings to lorry manufacturers and haulage firms against using such trays in moving vehicles 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
Suzanna Jayne Bull · 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
Dr Suzanna Bull died after being struck and dragged beneath a 32-tonne lorry while cycling in a designated bus/cycle lane on 9 October 2017. The lorry driver's aftermarket dashboard tray and items placed on it obscured the front and nearside view, creating a blind spot. The substantive concerns were the absence of warnings that such trays can create blind spots and should not be fitted while a vehicle is moving.
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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 warnings on dashboard trays against fitting them in moving vehicles
Wider context from the report “1. The fact that the tray creates a blind spot may not be apparent to users. There is no warning on the tray to say that it can create a blind spot when fixed in place whilst the vehicle is moving. Consideration should be given to placing a clear warning on the tray that it should not be fitted.
2. There is no general warning to lorry manufacturers and haulage firms to advise against the use of such trays in a moving vehicle due to the blind spot it creates. Consideration should be given to sending out a warning to all manufacturers and users to highlight the concern.
3. There is no warning on the dashboard tray to say that it should only be fitted when the vehicle is parked up and stationary.
” 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 general warnings to lorry manufacturers and haulage firms against using such trays in moving vehicles
Wider context from the report “1. The fact that the tray creates a blind spot may not be apparent to users. There is no warning on the tray to say that it can create a blind spot when fixed in place whilst the vehicle is moving. Consideration should be given to placing a clear warning on the tray that it should not be fitted.
2. There is no general warning to lorry manufacturers and haulage firms to advise against the use of such trays in a moving vehicle due to the blind spot it creates. Consideration should be given to sending out a warning to all manufacturers and users to highlight the concern.
3. There is no warning on the dashboard tray to say that it should only be fitted when the vehicle is parked up and stationary.
” 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 Inform additional haulage umbrella bodies about the concerns and seek transmission of the information to their members.
Verbatim wording from the response “• the Department for Transport will make umbrella bodies (in addition to the Road Haulage Association to whom you sent your letter) such as the Society of Motor Manufacturers and Trades and the Freight Transport Association aware of the areas of concern in your report and seek they also transmit information to their members.” Source location 2019-0404-Response-from-the-Department-for-Transport-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 The Department lacks authority to require warning messages on aftermarket dashboard trays about visibility risks during driving.
Verbatim wording from the response “Further to the Regulation 28 Report you listed some matters of concerns and your opinion that action should be taken. Several actions are planned, although the Department does not have a locus to require warning messages to be placed on aftermarket dashboard trays to indicate they may block visibility during driving (particularly if substantial objects are put on them).” Source location 2019-0404-Response-from-the-Department-for-Transport-Redacted
Open published response
1 Nov 2019 Xavier Thomas and 10 others · Prevention of Future Deaths report London Inner (South)
View report summary
Concerns raised 7 Counter-terrorism investigation concerns View source Emergency response concerns for terrorist attacks View source Concerns about rental vehicles used in terrorist attacks View source Communications concerns View source Protective security concerns View source Concerns about locating casualties View source Medical equipment and training concerns View source See 4 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.
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AI-generated summary
Xavier Thomas and 10 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 3 June 2017, three attackers carried out vehicle and knife attacks at London Bridge and Borough Market, killing eight victims: Xavier Thomas, Christine Archibald, Sara Zelenak, James McMullan, Sébastien Bélanger, Alexandre Pigeard, Kirsty Boden and Ignacio Echeverría Miralles de Imperial. The report identifies substantive concerns relating to protective security, counter-terrorism investigations, emergency response, communications, locating casualties, medical equipment and training, and rental vehicles used in terrorist attacks.
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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 Counter-terrorism investigation concerns
Wider context from the report “The substantive matters of concern are set out throughout the remainder of the Report, including MC1 to MC18, addressed to the relevant public authorities and industry body, concerning protective security, counter-terrorism investigations , emergency response to terrorist attacks, communications, locating casualties, medical equipment and training, and rental vehicles used in terrorist attacks.
” 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 Emergency response concerns for terrorist attacks
Wider context from the report “The substantive matters of concern are set out throughout the remainder of the Report, including MC1 to MC18, addressed to the relevant public authorities and industry body, concerning protective security, counter-terrorism investigations, emergency response to terrorist attacks , communications, locating casualties, medical equipment and training, and rental vehicles used in terrorist attacks.
” 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 Concerns about rental vehicles used in terrorist attacks
Wider context from the report “The substantive matters of concern are set out throughout the remainder of the Report, including MC1 to MC18, addressed to the relevant public authorities and industry body, concerning protective security, counter-terrorism investigations, emergency response to terrorist attacks, communications, locating casualties, medical equipment and training, and rental vehicles used in terrorist attacks .
” 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 Communications concerns
Wider context from the report “The substantive matters of concern are set out throughout the remainder of the Report, including MC1 to MC18, addressed to the relevant public authorities and industry body, concerning protective security, counter-terrorism investigations, emergency response to terrorist attacks, communications , locating casualties, medical equipment and training, and rental vehicles used in terrorist attacks.
” 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 Protective security concerns
Wider context from the report “The substantive matters of concern are set out throughout the remainder of the Report, including MC1 to MC18, addressed to the relevant public authorities and industry body, concerning protective security , counter-terrorism investigations, emergency response to terrorist attacks, communications, locating casualties, medical equipment and training, and rental vehicles used in terrorist attacks.
” 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 Concerns about locating casualties
Wider context from the report “The substantive matters of concern are set out throughout the remainder of the Report, including MC1 to MC18, addressed to the relevant public authorities and industry body, concerning protective security, counter-terrorism investigations, emergency response to terrorist attacks, communications, locating casualties , medical equipment and training, and rental vehicles used in terrorist attacks.
” 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 Medical equipment and training concerns
Wider context from the report “The substantive matters of concern are set out throughout the remainder of the Report, including MC1 to MC18, addressed to the relevant public authorities and industry body, concerning protective security, counter-terrorism investigations, emergency response to terrorist attacks, communications, locating casualties, medical equipment and training , and rental vehicles used in terrorist attacks.
” Open source report
24 Jun 2019 Priscilla Tropp · Prevention of Future Deaths report North London
View report summary
Concerns raised 3 Lack of a station-specific plan for responding to illness or injury in station areas View source Lack of a station-specific plan for responding to illness or injury in station areas View source Lack of a station-specific plan for responding to illness or injury in station areas 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
Priscilla Tropp · 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 27 November 2018, Priscilla Tropp fell down steps at Mill Hill Broadway Station and was taken to hospital, where she died from injuries sustained in the fall. The principal concern was the absence of a station flow chart or plan for managing people who become ill or injured, including steps to mitigate potential injury to them and others using the station.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of a station-specific plan for responding to illness or injury in station areas
Wider context from the report “That there is no flow chart or plan for this station , taking into account its design and available public spaces, to cover the situations where a person is taken ill on the station, or in any of the area that are involved in moving around the station , that sets out a sensible series of steps that need to be taken by staff to mitigate any potential injury to the person who may themselves have been injured or to any one else using the station.
” 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 station-specific plan for responding to illness or injury in station areas
Wider context from the report “That there is no flow chart or plan for this station , taking into account its design and available public spaces , to cover the situations where a person is taken ill on the station, or in any of the area that are involved in moving around the station , that sets out a sensible series of steps that need to be taken by staff to mitigate
any potential injury to the person who may themselves have been injured or to any one else using the station.
” 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 station-specific plan for responding to illness or injury in station areas
Wider context from the report “That there is no flow chart or plan for this station , taking into account its design and available public spaces , to cover the situations where a person is taken ill on the station, or in any of the area that are involved in moving around the station , that sets out a sensible series of steps that need to be taken by staff to mitigate any potential injury to the person who may themselves have been injured or to any one else using the station .
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Govia Thameslink Railway is responsible for managing and operating Mill Hill Broadway station as its station facility owner.
Verbatim wording from the response “Govia Thameslink Railway (GTR), as a franchisee of the Department for Transport, is the train operating company that is responsible, as station facility owner, for managing and operating Mill Hill Broadway station.” Source location 2019-0213-Response-by-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 considers GTR’s measures sufficient to resolve the identified matters of concern.
Verbatim wording from the response “Jerome Pacatte, Head of Customer Service at Thameslink / Great Northern (a part of GTR) wrote to you on 2 August 2019, to set out the measures that GTR is undertaking in response to your stated ‘Matters of Concern’. These measures are:” Source location 2019-0213-Response-by-Department-for-Transport
Open published response
Concerns raised 1 Failure to ensure a reliable Search and Rescue information technology network 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
Clive Anthony 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
Clive Anthony Jones drowned after his fishing vessel capsized when an excessive weight in the net caused it to become unstable while he was trapped in the wheelhouse. The concerns included the need for an independent review of UK Search and Rescue operational capability and Coastguard functionality, and a thorough review of Search and Rescue information technology systems.
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 a reliable Search and Rescue information technology network
Wider context from the report “(2) To conduct a thorough review of Search and Rescue information technology systems to ensure a reliable network .
” 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 Complete a thorough review of search and rescue information technology systems.
Verbatim wording from the response “The second concern recommendation, relating to conducting a thorough review of SAR information technology systems, has been completed, and the MCA confirmed this in a letter sent to the MAIB on 31 May. I am aware that a full review was conducted, and the improvements identified in the network have resulted in greater reliability and resilience throughout the UK. I trust this addresses the concerns raised in your letter.” Source location 2019-0217_Response-by-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 Implement network improvements identified through the search and rescue information technology review to increase reliability and resilience.
Verbatim wording from the response “The second concern recommendation, relating to conducting a thorough review of SAR information technology systems, has been completed, and the MCA confirmed this in a letter sent to the MAIB on 31 May. I am aware that a full review was conducted, and the improvements identified in the network have resulted in greater reliability and resilience throughout the UK. I trust this addresses the concerns raised in your letter.” Source location 2019-0217_Response-by-Department-for-Transport
Open published response
4 Apr 2019 Julia Luxmore Peto · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 2 Lack of louvres preventing pedestrian see-through at two-stage pedestrian crossings View source Lack of road markings warning pedestrians of traffic direction at two-stage pedestrian crossings View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Julia Luxmore Peto · 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 September 2018, Julia Luxmore Peto was struck by a bus while crossing Deptford Broadway and suffered a catastrophic head injury; she died in hospital the following day. The principal concern was that pedestrians might be distracted or confused by green pedestrian signals visible across the other carriageway at two-stage crossings, with wider concern about similar crossings lacking louvres and road markings to indicate traffic direction.
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 louvres preventing pedestrian see-through at two-stage pedestrian crossings
Wider context from the report “TfL informed me, at the inquest, that they are putting in place “Look Left” and “Look Right” markings on the road to inform pedestrians on the direction of approaching traffic (A copy of the TfL report to me is appended for ease of reference. This contains a useful plan and photographs). From the evidence I heard I am satisfied that these particular changes would not have a wider impact on traffic flow but would improve the safety of pedestrians.
I was pleased to hear that TfL had taken proactive practical measures to reduce the risk at this particular junction but I remain concerned that there are likely be other “two stage” pedestrian crossings throughout England and Wales which also do not currently have louvres to prevent pedestrian ‘see-through’ and road markings to warn pedestrians of traffic direction.
I am therefore of the view that I am under a duty to report this wider concern to the Department of Transport to take appropriate action to reduce the risk of fatalities and serious injuries at two stage crossings throughout England and Wales.
” 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 road markings warning pedestrians of traffic direction at two-stage pedestrian crossings
Wider context from the report “TfL informed me, at the inquest, that they are putting in place “Look Left” and “Look Right” markings on the road to inform pedestrians on the direction of approaching traffic (A copy of the TfL report to me is appended for ease of reference. This contains a useful plan and photographs). From the evidence I heard I am satisfied that these particular changes would not have a wider impact on traffic flow but would improve the safety of pedestrians.
I was pleased to hear that TfL had taken proactive practical measures to reduce the risk at this particular junction but I remain concerned that there are likely be other “two stage” pedestrian crossings throughout England and Wales which also do not currently have louvres to prevent pedestrian ‘see-through’ and road markings to warn pedestrians of traffic direction .
I am therefore of the view that I am under a duty to report this wider concern to the Department of Transport to take appropriate action to reduce the risk of fatalities and serious injuries at two stage crossings throughout England and Wales.
” 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 pedestrian-crossing guidance, soon to be updated in Traffic Signs Manual Chapter 6, makes further action unnecessary.
Verbatim wording from the response “Guidance on pedestrian crossings is currently provided in two documents: Traffic Advisory Leaflet 5/05: Pedestrian Facilities at Signal-Controlled Junctions, and Local Transport Note 2/95: The Design of Pedestrian Crossings. These provide advice on the phasing and staging of pedestrian movements as well pedestrian crossing display sequencing.” Source location 2019-0119-Response-from-the-Department-for-Transport_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 Local traffic management responsibility rests with Transport for London as the relevant highways authority, rather than the Department.
Verbatim wording from the response “The responsibility for traffic management on local roads rests with the relevant local highways authority; in this case Transport for London, as they are best placed to consider how to use a range of traffic management measures so that local needs can be effectively met. My Department’s role is to provide the overarching strategy and policy context, as well as guidance to help them in managing their roads.” Source location 2019-0119-Response-from-the-Department-for-Transport_Redacted
Open published response
7 Mar 2019 Matthew Bilby · Prevention of Future Deaths report Lincolnshire
View report summary
Concerns raised 1 Dangerous and confusing layout of the A16/B1166 junction 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
Matthew Bilby · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Matthew Bilby died after his motorcycle collided with a DAF Tipper Heavy Goods Vehicle at the A16/B1166 junction in Spalding, Lincolnshire, on 6 September 2018. He sustained extensive internal injuries and was pronounced dead at the scene. Concerns included evidence that the junction was dangerous and confusing, was an accident blackspot, had been the site of four fatalities, and posed an ongoing risk to road users.
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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 Dangerous and confusing layout of the A16/B1166 junction
Wider context from the report “1. The court heard evidence from a number of current regular road users describing the layout of the A16/B1166 junction as "dangerous", "horrendous", "confusing" and "difficult" ;
2. In evidence the Lincolnshire Police confirmed that this was the fourth fatality at this junction ;
3. The junction was created as a "staggered" junction in August 2010. Following one of the previous fatalities at the junction further work had been undertaken with red thermoplastic laid in hatched areas;
4. Expert evidence received from the East Midlands Operational Support Service Serious Collision Investigation Unit confirmed the junction to be an "accident blackspot" and that the staggered junction created an on-going risk to future road users in that:
a. This junction should be reconfigured as a roundabout;
b. Alternatively there should be the deployment of considered traffic calming measures (cameras, traffic lights, speed restrictions).
” 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 Local highway authorities, not the Department, are responsible for deciding and implementing site-specific traffic management measures.
Verbatim wording from the response “The responsibility for traffic management on local roads rests with the relevant local highway authority, as they are best placed to consider how to use traffic management measures so that local needs can be effectively met. My Department’s role is to provide the overarching strategy and policy context, as well as guidance to help them in managing their roads.” Source location 2019-0112-Response-by-Department-for-Transport
Open published response
19 Dec 2018 Kurt Cochran and 5 others · Prevention of Future Deaths report London Inner (West)
View report summary
Concerns raised 18 Lack of consistent and up-to-date national protective security advice View source Failure of supervisory systems to audit ADAM System use View source Failure to record reasons for closing a Subject of Interest View source Lack of clear required intervals for officers to access the ADAM System View source Inadequate training for lone-actor and multi-actor marauding attacks View source Failure to provide revised Post Instructions directly to relevant officers View source Insufficient time for officers to access the ADAM System and review Post Instructions View source Failure to brief officers on the rationale for changes to Post Instructions View source Failure of Post Instructions to be clear and readily interpretable View source Inadequate coordinated training of AFOs, unarmed officers and security officers View source Lack of consistent pre-rental vehicle checks and enquiries View source Lack of regular supervisory audits of policing at the Palace of Westminster View source Lack of armed police protection at a vulnerable public entrance to the Parliamentary Estate View source Lack of periodic audit of Tactical Firearms Reviews View source Failure of Post Instructions to be consistent with tactical plans, orders and practices View source Lack of guidance on removing unconscious persons or bodies from navigable water View source Failure of officers to register for and access the ADAM System View source Insufficient facilities for officers to access the ADAM System View source See 15 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
Kurt Cochran and 5 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 22 March 2017, Khalid Masood drove a vehicle across Westminster Bridge, fatally injuring Kurt Cochran, Leslie Rhodes, Aysha Frade and Andreea Cristea, before fatally stabbing PC Keith Palmer at the Palace of Westminster. The report raised concerns about the protection of public entrances, officers’ access to and understanding of Post Instructions, use of the ADAM System, supervision and training, and wider protective security measures.
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 consistent and up-to-date national protective security advice
Wider context from the report “MC14: I suggest that the Secretary of State for the Home Department asks the authorities responsible for preparing and delivering advice on protective security to consider whether any further work can usefully be done on this subject, particularly in preparing and delivering consistent and up-to-date national advice . I also suggest that TfL considers whether there is any further work it can do to improve protective security on major roadways and bridges in the capital, in response to national advice and known threats.
” 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 supervisory systems to audit ADAM System use
Wider context from the report “MC6: It was a matter of concern that officers were unaware of their Post Instructions and that supervisory systems had not identified limited usage of the ADAM System . I therefore suggest that the MPS considers auditing use of the ADAM System periodically , by checks to confirm use at sufficiently regular intervals over the period.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure to record reasons for closing a Subject of Interest
Wider context from the report “MC16: I suggest that the Security Service considers whether it would be practicable and beneficial to introduce a procedure whereby any decision to close a person as a Subject of Interest is recorded with brief reasons .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of clear required intervals for officers to access the ADAM System
Wider context from the report “MC2: I suggest that the MPS considers making it mandatory for officers on the Command to register for ADAM and to access it at specified intervals (perhaps supplemented by an instruction to confirm review of material on the system). I was concerned that a proportion of officers on the Command had not registered for the ADAM System despite it having been in use for six years. Furthermore, I heard evidence that officers were under instructions to access the system “regularly” but no definition of that term could be given . Given that the ADAM System is the repository for the authorised versions of Post Instructions, these were troubling features of the evidence. In short, a proportion of the officers had no means of accessing their instructions and officers generally had no clear guidance on how regularly they should be checking the system . Although the MPS has provided submissions referring to improvements in the ADAM System and improved systems of supervision, these would be relatively simple rules which would be readily enforceable through the disciplinary process.
” 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 training for lone-actor and multi-actor marauding attacks
Wider context from the report “MC9: I suggest that the MPS reviews the adequacy of training of officers stationed in the Parliamentary Estate to ensure it includes lone actor and multi-actor marauding attacks .
” 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 revised Post Instructions directly to relevant officers
Wider context from the report “MC1: I suggest that the MPS gives consideration to providing revised Post Instructions to relevant groups by direct emails, in hard copy and/or via electronic devices (as well as their being accessible through ADAM) and to providing them in a way that requires the recipient to respond indicating safe receipt. I was concerned that, when Post Instructions were updated, they were apparently not emailed or provided in hard copy to relevant officers directly . The system relied upon officers’ use of the ADAM System, which was sporadic . I am aware from the submissions of the MPS that, since the attack, an update is sent to all relevant officers advising them of a revision of Post Instructions and telling them to view the new version on ADAM. The MPS has provided a copy of an example email, which was sent on 11 October 2018. However, it may be valuable for the MPS to go further than this by supplying revised instructions directly to the officers and in requiring an acknowledgement of safe receipt is sent back by the officers.
” 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 time for officers to access the ADAM System and review Post Instructions
Wider context from the report “MC3: Given the figures for usage of the ADAM System, it is a matter of concern whether officers have (a) adequate time to access the System regularly and review their Post Instructions and (b) adequate facilities to do so (e.g. ready access to computer terminals). I therefore suggest that the MPS considers the time and facilities available for officers to access the ADAM System and review their instructions.
” 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 brief officers on the rationale for changes to Post Instructions
Wider context from the report “MC10: I suggest that the MPS considers the possibility of the firearms assessor / adviser briefing officers as to the rationale for any changes to their Post Instructions .
” 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 Post Instructions to be clear and readily interpretable
Wider context from the report “MC4: I suggest that the MPS considers a periodic audit of all extant Post Instructions for the Parliamentary Estate to ensure their consistency and fitness for purpose. This might be part of the supervisory audit discussed at MC7 below, or separate from it. On the evidence I heard, Post Instructions are prepared after careful work by relevant experts within the MPS (firearms tactical assessors, in the case of AFO Post Instructions). Nevertheless, there were deficiencies in the expression of some Post Instructions , and some officers when presented with them found it difficult to interpret parts . It is important that each Post Instruction should be clear and internally consistent, and should be consistent with the broader tactical plan for the Estate. It was clear from the evidence of Commander Usher that Post Instructions should be followed precisely. They should not be subject to personal interpretation, since that would introduce inconsistent practice and would undermine the tactical rationale behind the instructions. Where the content of Post Instructions is ambiguous or not consistent with other orders or practices, security can be undermined.
” 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 coordinated training of AFOs, unarmed officers and security officers
Wider context from the report “MC8: I suggest that the MPS, with the Parliamentary Authorities, reviews the adequacy of training to ensure that it involves AFOs, unarmed officers and security officers and their co-ordination .
” 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 consistent pre-rental vehicle checks and enquiries
Wider context from the report “MC18: I recommend that the Department for Transport and the British Vehicle Rental & Leasing Association consider introducing a Code of Practice (or at least guidance) on checks to be carried out and/or enquiries made before vehicles are rented .
” 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 regular supervisory audits of policing at the Palace of Westminster
Wider context from the report “MC7: I suggest that the MPS considers instituting regular supervisory audits of policing at the Palace of Westminster (and perhaps other parts of the Parliamentary Estate), preferably by officers outside the PaDP Command.
” 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 armed police protection at a vulnerable public entrance to the Parliamentary Estate
Wider context from the report “MC5: It was a matter of concern that, at the time of the attack, one of the most vulnerable and public entrances to the Parliamentary Estate was not protected by armed police . In my view, the MPS should consider (a) imposing a standing order that there should be armed officers stationed at all open public entry points to the Palace of Westminster (and possibly to some other buildings on the Parliamentary Estate) and (b) introducing a provision that this standing order may only be varied with the written approval of an officer of very senior rank.
” 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 periodic audit of Tactical Firearms Reviews
Wider context from the report “MC11: I suggest that the MPS considers a periodic audit of Tactical Firearms Reviews .
” 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 Post Instructions to be consistent with tactical plans, orders and practices
Wider context from the report “MC4: I suggest that the MPS considers a periodic audit of all extant Post Instructions for the Parliamentary Estate to ensure their consistency and fitness for purpose. This might be part of the supervisory audit discussed at MC7 below, or separate from it. On the evidence I heard, Post Instructions are prepared after careful work by relevant experts within the MPS (firearms tactical assessors, in the case of AFO Post Instructions). Nevertheless, there were deficiencies in the expression of some Post Instructions, and some officers when presented with them found it difficult to interpret parts. It is important that each Post Instruction should be clear and internally consistent, and should be consistent with the broader tactical plan for the Estate . It was clear from the evidence of Commander Usher that Post Instructions should be followed precisely. They should not be subject to personal interpretation, since that would introduce inconsistent practice and would undermine the tactical rationale behind the instructions. Where the content of Post Instructions is ambiguous or not consistent with other orders or practices , security can be undermined.
” 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 on removing unconscious persons or bodies from navigable water
Wider context from the report “MC17: I suggest that the Maritime and Coastguard Agency considers whether it or some other body could provide guidance on the removal of unconscious persons or bodies from the water close to those operating on navigable rivers and canals .
” 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 officers to register for and access the ADAM System
Wider context from the report “MC2: I suggest that the MPS considers making it mandatory for officers on the Command to register for ADAM and to access it at specified intervals (perhaps supplemented by an instruction to confirm review of material on the system). I was concerned that a proportion of officers on the Command had not registered for the ADAM System despite it having been in use for six years. Furthermore, I heard evidence that officers were under instructions to access the system “regularly” but no definition of that term could be given. Given that the ADAM System is the repository for the authorised versions of Post Instructions, these were troubling features of the evidence. In short, a proportion of the officers had no means of accessing their instructions and officers generally had no clear guidance on how regularly they should be checking the system. Although the MPS has provided submissions referring to improvements in the ADAM System and improved systems of supervision, these would be relatively simple rules which would be readily enforceable through the disciplinary process.
” 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 facilities for officers to access the ADAM System
Wider context from the report “MC3: Given the figures for usage of the ADAM System, it is a matter of concern whether officers have (a) adequate time to access the System regularly and review their Post Instructions and (b) adequate facilities to do so (e.g. ready access to computer terminals) . I therefore suggest that the MPS considers the time and facilities available for officers to access the ADAM System and review their instructions.
” Open source report
25 Sep 2018 Caitlin Lydia Huddleston and Skye Olivia Mitchell · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 2 Hazard of driving by inexperienced drivers View source Increased risk of death or injury from carrying passengers in a car View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Caitlin Lydia Huddleston and Skye Olivia 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
On 14 July 2017, Caitlin Lydia Huddleston and Skye Olivia Mitchell died at the scene after the car in which they were travelling lost control on a wet bend and collided with an oncoming van. The principal concerns were Skye’s limited driving experience, the presence of two passengers of a similar age, possible distraction, and the increased risk associated with carrying passengers.
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 Hazard of driving by inexperienced drivers
Wider context from the report “(1) That Skye was a driver with only 4 months driving experience after passing her driving test ;
(2) That she was accompanied by 2 friends of similar age in the car;
(3) The circumstances of the loss of control are likely to be a direct result of the inexperience of the driver ;
(4) Whilst we do not know this is the case it is likely that Skye Catlin and ████████ would be having discussions in the car at the time, and these may have distracted Skye when driving;
(5) The carrying of passengers in the car increases the likelihood of death or injury not only to the driver but also to the passengers being carried, therefore multiplies the 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 Increased risk of death or injury from carrying passengers in a car
Wider context from the report “(1) That Skye was a driver with only 4 months driving experience after passing her driving test;
(2) That she was accompanied by 2 friends of similar age in the car;
(3) The circumstances of the loss of control are likely to be a direct result of the inexperience of the driver;
(4) Whilst we do not know this is the case it is likely that Skye Catlin and ████████ would be having discussions in the car at the time, and these may have distracted Skye when driving;
(5) The carrying of passengers in the car increases the likelihood of death or injury not only to the driver but also to the passengers being carried, therefore multiplies the risk .
” 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 Implement practical driving-test changes incorporating independent driving and assessment on higher-risk roads and traffic situations.
Verbatim wording from the response “• Changes were made to the practical driving test in December 2017. The independent driving section, where the candidate must drive for 20 minutes without detailed guidance by the examiner, provides more relevant ‘real world’ situations for the assessment of a candidate’s ability to manage the vehicle, route and traffic simultaneously. The new test means that they spend less time on minor roads for manoeuvres enabling test routes to focus on high risk areas, such as busier roundabouts, rural and higher speed roads, where collisions occur.” Source location Response from Department for Transport - July 2021
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the refreshed Road Safety Statement and two-year action plan addressing young-adult road safety risks.
Verbatim wording from the response “Since your letter with ████████ MP in 2018, the Department has continued to improve road safety in the United Kingdom. In 2019 the Department published its refreshed Road Safety Statement – ‘A Lifetime of Road Safety’ and two-year action plan. 15 of the 74 actions in the plan addressed road safety risks faced by young adults learning to drive.” Source location Response from Department for Transport - July 2021
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Fund development of a modular learning approach for driver training, including e-learning and competence assessment.
Verbatim wording from the response “• In March 2020, we funded the Driving Instructors Association (DIA) to develop a modular approach to learning. The vision of modular learning is to potentially reduce young driver collision risks without posing greater restrictions on young people, or increasing the costs or time taken to learn to drive. Whilst the Driver 2020 project includes interventions designed to increase the amount and variety of pre-test practice (the logbook), this intervention is distinct as it also uses e-learning and includes assessment of learners’ competence during the training period.” Source location Response from Department for Transport - July 2021
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 Evaluate interventions designed to improve the safety of young novice drivers through the Driver 2020 project.
Verbatim wording from the response “In the 2018 letter to ████████ MP there is reference to the Driver 2020 project. The Driver 2020 project (an evaluation of interventions to improve the safety of young novice drivers) commenced in January 2019 and over 28,000 learner and novice drivers have been recruited. We expect the project to report in early 2023.” Source location Response from Department for Transport - July 2021
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 Run the THINK! “Road Whisperer” campaign targeting young and inexperienced drivers with safer-driving messages.
Verbatim wording from the response “• In March 2019, DfT’s THINK! team ran a campaign directly targeting new drivers “The Road Whisperer” campaign. As 1 in 5 drivers crash within the first year after their test, this campaign is aimed at young drivers who feel vulnerable on the road and may take risks on the road to overcompensate for their inexperience. Through the character of the Road Whisperer, who shared wisdom with young drivers about challenging situations like driving at night or on country roads, the campaign communicated the message that it takes time to learn the ways of the road. This campaign was viewed on social media by an estimated 13.8 million times within the young people community.” Source location Response from Department for Transport - July 2021
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 Run a £2 million research programme testing five technological and educational measures intended to improve young and novice driver safety.
Verbatim wording from the response “In April 2017, the Department commissioned a £2 million research programme to explore the effectiveness of five technological and educational measures to improve the safety of young and novice drivers, both before they take their test and after they have passed. The aim of the study is to provide thorough evidence as to whether any of the interventions produce clear road safety benefits and reduce collision risk. The measures being tested are:” Source location Response from Department for Transport - November 2018
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 Use Northern Ireland’s graduated driving licensing introduction as a pilot to gather evidence for applying graduated licensing in Great Britain.
Verbatim wording from the response “For this reason, the Department has decided to use the introduction of GDL in Northern Ireland as a pilot, to gather evidence on the potential for GDL in Great Britain. The Northern Irish Government has consulted on secondary legislation to bring a number of provisions into force, including passenger carrying restrictions and a six month mandatory minimum learning period.” Source location Response from Department for Transport - November 2018
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 Investigate whether emerging technology, including virtual reality, can improve learner drivers’ hazard perception skills.
Verbatim wording from the response “Better hazard perception skills are crucial to improving road safety and we have used our ‘Innovation Challenge Fund’ to investigate how new technology, including virtual reality, can help learner drivers hone their hazard perception skills before taking their tests.” Source location Response from Department for Transport - November 2018
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 restrictions on young and novice drivers will be enforced during the COVID-19 recovery because of potential educational, employment and wellbeing harms.
Verbatim wording from the response “Due to the ongoing COVID-19 pandemic, this Government has no current plans to enforce any further restrictions which could be detrimental to the younger generation. We are also conscious that any move to place any form of restrictions on young and novice drivers would be detrimental to their education and employment prospects, as well as the potential to negatively affect their social and mental health during the national recovery from COVID. These effects would also be felt more severely in rural or socio-economically challenged areas in the United Kingdom.” Source location Response from Department for Transport - July 2021
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 research will be commissioned into the social and economic consequences of Graduated Driver Licensing.
Verbatim wording from the response “Whilst the Department for Transport acknowledges the recommendation on continuing research into Graduated Driver Licensing, the Department will not be commissioning any research into the social and economic consequences of GDL.” Source location Response from Department for Transport - July 2021
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 Foreign licensing-restriction statistics are considered neither comparable nor evidence that Graduated Driver Licensing is necessary in the United Kingdom.
Verbatim wording from the response “We remain of the opinion that statistics from other countries who use a form of licensing restrictions show that it is not comparable nor necessary in the United Kingdom at this time for young and novice drivers.” Source location Response from Department for Transport - July 2021
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 will not introduce GDL nationally until evidence establishes that its safety benefits outweigh restrictions’ potential risks and costs.
Verbatim wording from the response “However, the Department needs to be sure that the benefits of introducing GDL to the UK are balanced against the potential risks and costs of the restrictions on the young drivers themselves, as many (especially in rural areas) use their cars to get to work or college.” Source location Response from Department for Transport - November 2018
Open published response
Concerns raised 5 Absence of a westbound left-turn filter lane from the A40 onto Redstone Road View source Insufficient length and width of both filter lanes on the A40 View source Insufficient speed control or warning at the upcoming bend and junction View source Inadequate positioning of national speed limit signs near the junction mouth View source Lack of road markings and early warning signs on the approach to the main A40 from Redstone Road View source See 2 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
Herbert John Bernard Francis · 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
Herbert John Bernard Francis was driving towards the A40 when he failed to stop at the junction and collided with an articulated heavy goods vehicle, dying at the scene from injuries sustained in the collision. The concerns identified related to road safety measures, including improved markings and warning signs, changes to filter lanes, and consideration of lower or advisory speed limits.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Absence of a westbound left-turn filter lane from the A40 onto Redstone Road
Wider context from the report “(4) That filter lanes should also be introduced on the A40 for vehicles heading westbound and intending to turn left onto Redstone Road .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Insufficient length and width of both filter lanes on the A40
Wider context from the report “(2) That both filter lanes on the A40 at this location should be made longer and wider .
” 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 speed control or warning at the upcoming bend and junction
Wider context from the report “(3) That consideration should be given to lowering the speed limit along this stretch of road, or by placing advisory speed limit signs at the location to warn motorists of the upcoming bend and junction .
” 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 positioning of national speed limit signs near the junction mouth
Wider context from the report “(1) The approach to the main A40 from Redstone Road could be further enhanced with the introduction of road markings and early warning signs. That consideration should be given to the re-positioning of the national speed limit signs from their current location to closer to the mouth of the junction .
” 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 road markings and early warning signs on the approach to the main A40 from Redstone Road
Wider context from the report “(1) The approach to the main A40 from Redstone Road could be further enhanced with the introduction of road markings and early warning signs . That consideration should be given to the re-positioning of the national speed limit signs from their current location to closer to the mouth of the junction.
” Open source report
16 Jul 2018 Tyrone Declan EVANS · Prevention of Future Deaths report Coventry
View report summary
Concerns raised 1 Absence of a legal requirement for road-using quad bike drivers to wear crash helmets 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
Tyrone Declan EVANS · 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 15 September 2017, Tyrone Declan EVANS was thrown from a quad bike after it collided with a crash barrier and another vehicle, suffering fatal injuries. The principal concern was that quad bike riders were not legally required to wear crash helmets, despite the pathologist’s view that helmet use may have altered the head injury pattern and potentially reduced its severity. The report identified this absence of a legal requirement as a continuing and potentially avoidable risk of deaths on the roads.
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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 Absence of a legal requirement for road-using quad bike drivers to wear crash helmets
Wider context from the report “(1) The medical cause of death was 1a Blunt Head Injury and the conclusion of the pathologist included the following: "I note the suggestion that he was not wearing a helmet and in my opinion the head injury pattern would support this. As a pathologist I am not in a position to provide expert evidence on the issue of whether or not a helmet would have prevented the death but clearly when a death is caused by an isolated head injury, one has to suggest that wearing a helmet may well have altered the injury pattern and potentially severity, at least from basic principles".
(2) I was informed at the inquest that the quad bike the deceased was driving was an off-road vehicle that had been adapted to use on the road. Yamaha UK confirmed to police that the vehicle had undertaken an Individual Vehicle Approval test by the Vehicle Operator Services Agency (VOSA) and had been issued with a registration number.
(3) I was also informed at the inquest by the Collision Investigator that quad bike riders or passengers in England, Scotland and Wales are not required to wear crash helmets .
(4) In light of the pathologist’s comments and I am concerned that the absence of any legal requirement for quad bike drivers to wear crash helmets even where such bikes have been legally adapted for road use presents a continuing and potentially avoidable risk of deaths on our roads .
” Open source report
19 Jun 2018 Jacob Elliot Brown · Prevention of Future Deaths report Staffordshire South
View report summary
Concerns raised 1 Lack of compulsory black-box monitoring for young drivers View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jacob Elliot Brown · 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
Jacob Elliot Brown died at Royal Stoke University Hospital on 7 December 2017 from injuries sustained in a road traffic collision on 11 November 2017. The principal concern was whether compulsory ‘black boxes’ for young drivers could help monitor driving and reduce future deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of compulsory black-box monitoring for young drivers
Wider context from the report “For many young drivers now insurance companies will reduce the premium payable significantly if relevant vehicle has a ‘black box’ in it monitoring the actions of the driver . During the inquest Jacob’s family made the interesting suggestion that it should be compulsory for all young drivers (say between 17 and 25) to have black boxes fitted in any vehicles they drive . I was also assured that practically this can be done. If this was the situation then it would be likely to save a number of lives in the future and I would appreciate your views on this.
” 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 Investigate whether telematics can reduce young-driver collision risk through the Driver 2020 research programme.
Verbatim wording from the response “We do not propose to take any action at this time to make telematics compulsory, as we do not have sufficient data to demonstrate that it would be effective. To understand how telematics in a non-insurance context could reduce young driver collision risk, it needs to be tested and evaluated. As such we are investigating its use as part of our £2 million research programme called ‘Driver 2020’.” Source location 2018-0187-Response-by-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 Trial five Driver 2020 interventions with learner and novice drivers, including telematics, hazard-perception training, practice logging, mentor agreements and classroom education.
Verbatim wording from the response “In Driver 2020, which commenced in April 2017, five interventions are about to be trialled with over 14,000 learner and novice drivers aged between 17 and 24 years old. The aim of the study is to provide thorough evidence as to whether any of the five interventions produce clear road safety benefits and reduce collision risk. Once the research is completed at the end of 2020, we will consider the way forward. The specific interventions being considered are:” Source location 2018-0187-Response-by-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 Compulsory telematics will not be introduced because there is insufficient evidence that it would reduce young-driver collision risk.
Verbatim wording from the response “We do not propose to take any action at this time to make telematics compulsory, as we do not have sufficient data to demonstrate that it would be effective. To understand how telematics in a non-insurance context could reduce young driver collision risk, it needs to be tested and evaluated. As such we are investigating its use as part of our £2 million research programme called ‘Driver 2020’.” Source location 2018-0187-Response-by-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 decision to adopt telematics currently rests with the motor insurance policyholder.
Verbatim wording from the response “As you are aware, there is currently no legal requirement for telematics to be used by young drivers. The decision to take up telematics is made in the context of motor insurance – a driver may accept telematics in order to reduce his or her premiums – and so the decision rests with the policy holder.” Source location 2018-0187-Response-by-Department-for-Transport
Open published response
18 Jun 2018 Mr Bryan Allsop · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 1 Lack of mandatory instruction and testing in partial loss of engine power scenarios for light aircraft pilot licences 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
Mr Bryan Allsop · 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 Bryan Allsop died very soon after a light aircraft he was piloting crashed shortly after take-off on 28 May 2017. The inquest found that the aircraft’s fuel vapour return line, use of unauthorised E5 Mogas, warm conditions and the engine’s failure to reach full power were contributory factors. The principal concern was that light-aircraft pilot licences did not mandatorily require instruction and testing for partial loss of engine power scenarios.
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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 mandatory instruction and testing in partial loss of engine power scenarios for light aircraft pilot licences
Wider context from the report “The court heard evidence that neither the pilot training leading to issue of a pilot’s license (for light aircraft) nor the biennial pilot license revalidation have mandatory requirements for instruction and testing in partial loss of engine power scenarios . This is the case for both EASA and non-EASA licences . The court also heard evidence that a significant number of aircraft crashes and near crashes occur in the context of partial loss of engine power scenarios. Reference was made to Australian research and also awareness of the issue at the AAIB and the LAA. The court was informed that pilot licenses require instruction and testing in full loss of engine power scenarios but that a partial loss of engine power, particularly at low altitude, presents distinct and very difficult challenges to pilots.
My specific concern relates to there being no mandatory requirement for instruction and testing in partial loss of engine power scenarios in relation to light aircraft pilot’s licences . If this is also the case for more powerful classes of aircraft for license purposes this would also be a concern.
” Open source report
Concerns raised 2 Reliance on driver self-reporting and recognition of unfitness to drive View source Lack of mandatory objective fitness testing before automatic licence renewal for older drivers 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
Evelyn Fisher · 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
Evelyn Fisher, aged 61, was struck by a vehicle that mounted the kerb while she was walking along a pavement in Paignton. She sustained a catastrophic head injury, never regained consciousness, and died from head injury. Concerns included the driver’s dementia and the reliance on self-reporting when renewing driving licences for older drivers, with no statutory requirement for objective testing before automatic renewal.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Reliance on driver self-reporting and recognition of unfitness to drive
Wider context from the report “(2) It was probable that ████████ had started to develop dementia before this incident but had not recognised it
(3) Despite ████████ renewing his licence in March 2015, as an over 70-year-old, this failed to prevent this incident as this scheme relies almost entirely on self reporting and further on a driver recognising that they may be unfit to drive .
” 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 objective fitness testing before automatic licence renewal for older drivers
Wider context from the report “(4) ████████ was 88 at the time of the incident and there is no statutory scheme to make it mandatory for drivers over 70 or 80 to be objectively tested before they have licenses automatically renewed .
” Open source report
Concerns raised 3 Failure of the driver and treating clinicians reporting pathway to obtain relevant medical fitness information View source Lack of mechanisms for formal medical review of drivers with deteriorating or fluctuating health View source Lack of mechanisms for ensuring required vehicle modifications remain relevant, in place and used View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Henry Prow · 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
Henry Prow died at the scene after his car collided with a roundabout while he was returning from a medical appointment. A medical event before the collision could not be excluded. Concerns were raised about mechanisms for medical review of drivers with deteriorating or fluctuating health, the potential impact of licence surrender, and whether required vehicle modifications remained appropriate and were being used.
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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 of the driver and treating clinicians reporting pathway to obtain relevant medical fitness information
Wider context from the report “At the inquest concerns were raised by the police and a friend as to the criteria required by the DVLA and Department of Transport for the issuing and surrendering of driving licences and the terms and conditions for ensuring appropriate modification of driver’s vehicles.
Mr Prow had been a very fit and active man and worked as a training instructor in the Army for 3 years. As a result of his deteriorating poor health he lost his mobility and he was keen not to lose his driving license which would reduce his independence. At inquest it was considered that the collision was possibly preceded by Mr Prow having a medical issue/event.
The DVLA appears to have limited mechanisms for drivers to be formally medically reviewed for the purpose of being medically fit to drive. In particular in cases where drivers have deteriorating health or fluctuating health (of which they may not have insight) as in the case of Mr Prow.
It is understood that at present the treating GP/doctors or the driver themselves have a duty to advise the DVLA of medical issues which can affect a person’s ability to drive . A driver’s voluntary surrender of a driving licence (especially in a rural area with little public transport) may have a serious detrimental effect on their health and social/employment situation making it unrealistic expectation on the driver in many cases. There was concern, that the driver's GP/doctors could have a conflict of interests in such situations as they would have a duty to inform the DVLA of medical issues which could result in the surrender of the driving licence which could/would result in deterioration of the patient/doctor relationship e.g. such as patients withholding significant medical information with their doctors for fear of losing their licence .
There were also concerns that there appeared to be no mechanism for ensuring the required modification to the vehicles were still relevant to the vehicle that they were driving at the time (he had changed cars since requirement made and his health had deteriorated) and were appropriately in place and used .
” 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 mechanisms for formal medical review of drivers with deteriorating or fluctuating health
Wider context from the report “At the inquest concerns were raised by the police and a friend as to the criteria required by the DVLA and Department of Transport for the issuing and surrendering of driving licences and the terms and conditions for ensuring appropriate modification of driver’s vehicles.
Mr Prow had been a very fit and active man and worked as a training instructor in the Army for 3 years. As a result of his deteriorating poor health he lost his mobility and he was keen not to lose his driving license which would reduce his independence. At inquest it was considered that the collision was possibly preceded by Mr Prow having a medical issue/event.
The DVLA appears to have limited mechanisms for drivers to be formally medically reviewed for the purpose of being medically fit to drive. In particular in cases where drivers have deteriorating health or fluctuating health (of which they may not have insight) as in the case of Mr Prow.
It is understood that at present the treating GP/doctors or the driver themselves have a duty to advise the DVLA of medical issues which can affect a person’s ability to drive. A driver’s voluntary surrender of a driving licence (especially in a rural area with little public transport) may have a serious detrimental effect on their health and social/employment situation making it unrealistic expectation on the driver in many cases. There was concern, that the driver's GP/doctors could have a conflict of interests in such situations as they would have a duty to inform the DVLA of medical issues which could result in the surrender of the driving licence which could/would result in deterioration of the patient/doctor relationship e.g. such as patients withholding significant medical information with their doctors for fear of losing their licence.
There were also concerns that there appeared to be no mechanism for ensuring the required modification to the vehicles were still relevant to the vehicle that they were driving at the time (he had changed cars since requirement made and his health had deteriorated) and were appropriately in place and used .
” 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 mechanisms for ensuring required vehicle modifications remain relevant, in place and used
Wider context from the report “At the inquest concerns were raised by the police and a friend as to the criteria required by the DVLA and Department of Transport for the issuing and surrendering of driving licences and the terms and conditions for ensuring appropriate modification of driver’s vehicles.
Mr Prow had been a very fit and active man and worked as a training instructor in the Army for 3 years. As a result of his deteriorating poor health he lost his mobility and he was keen not to lose his driving license which would reduce his independence. At inquest it was considered that the collision was possibly preceded by Mr Prow having a medical issue/event.
The DVLA appears to have limited mechanisms for drivers to be formally medically reviewed for the purpose of being medically fit to drive. In particular in cases where drivers have deteriorating health or fluctuating health (of which they may not have insight) as in the case of Mr Prow.
It is understood that at present the treating GP/doctors or the driver themselves have a duty to advise the DVLA of medical issues which can affect a person’s ability to drive. A driver’s voluntary surrender of a driving licence (especially in a rural area with little public transport) may have a serious detrimental effect on their health and social/employment situation making it unrealistic expectation on the driver in many cases. There was concern, that the driver's GP/doctors could have a conflict of interests in such situations as they would have a duty to inform the DVLA of medical issues which could result in the surrender of the driving licence which could/would result in deterioration of the patient/doctor relationship e.g. such as patients withholding significant medical information with their doctors for fear of losing their licence.
There were also concerns that there appeared to be no mechanism for ensuring the required modification to the vehicles were still relevant to the vehicle that they were driving at the time (he had changed cars since requirement made and his health had deteriorated) and were appropriately in place and used .
” 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 how medical-condition and disability driving-licence restrictions are communicated, particularly when drivers change cars.
Verbatim wording from the response “Every time a driver renews their entitlement they are asked to confirm whether they require special controls to be able to safely control a vehicle and what these are. These would be checked and recorded on any subsequent driving licences issued. However, I can confirm that the DVLA is currently reviewing how restrictions imposed on driving licences as a result of a medical condition or disability are communicated to drivers, particularly when they change their cars.” Source location 2017-0227-Response-by-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 legal duties require drivers to use specified vehicle adaptations, providing the mechanism for ensuring adaptations are fitted and used appropriately.
Verbatim wording from the response “You have also suggested that there should be mechanisms in place to ensure that any required modifications to a vehicle are still relevant and are fitted and used appropriately. By law, drivers must ensure that they are able to control a vehicle safely and be able to meet any conditions or restrictions on their licence. Drivers who require adaptations to their vehicle and whose licence is noted with the appropriate code can only legally drive a vehicle fitted with the specified adaptations. The police are responsible for enforcing compliance with the requirements of any restricted driving licence.” Source location 2017-0227-Response-by-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 Independent medical or driving assessments are already used in complex cases, so broader mandatory assessment is not adopted.
Verbatim wording from the response “Your report suggests that when deciding whether someone is medically fit to drive, consideration should be given to using independent medical assessment. I can confirm that in more complex cases, the DVLA already uses independent medical or driving assessments before deciding whether to issue a driving licence.” Source location 2017-0227-Response-by-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 police, rather than the respondent, are responsible for enforcing restricted driving licence requirements concerning vehicle adaptations.
Verbatim wording from the response “You have also suggested that there should be mechanisms in place to ensure that any required modifications to a vehicle are still relevant and are fitted and used appropriately. By law, drivers must ensure that they are able to control a vehicle safely and be able to meet any conditions or restrictions on their licence. Drivers who require adaptations to their vehicle and whose licence is noted with the appropriate code can only legally drive a vehicle fitted with the specified adaptations. The police are responsible for enforcing compliance with the requirements of any restricted driving licence.” Source location 2017-0227-Response-by-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 Mandatory medical or practical assessments would not be introduced without evidence of improved road safety because they could be costly and overly bureaucratic.
Verbatim wording from the response “The current process focuses on those drivers who have a medical condition. It is designed to be fair and proportionate without penalising those drivers with disabilities who continue to drive safely. There is little evidence to suggest that introducing a stricter regime which includes mandatory medical or practical driving assessments would improve road safety. To impose such a requirement without the appropriate evidence would be overly bureaucratic and potentially very costly. Britain’s roads are some of the safest in the world and our road safety record compares favourably with other countries with stricter and more intrusive driver licensing regimes.” Source location 2017-0227-Response-by-Department-for-Transport
Open published response
Concerns raised 4 Failure of elderly drivers to recognise and disclose health conditions affecting driving View source Failure of drivers to surrender licences when medically necessary View source Unclear criteria for issuing and surrendering driving licences View source Conflict of interests affecting GPs’ reporting of driving-related medical issues 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
Geoffrey Frank Taylor · 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
Geoffrey Frank Taylor, aged 75, died from fatal injuries sustained in a road traffic collision while driving in Cornwall on 8 August 2016. Concerns were raised about the criteria and processes for issuing and surrendering driving licences after medical events, including potential conflicts for GPs and difficulties faced by elderly drivers who may be reluctant to report health problems or surrender their licences.
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 elderly drivers to recognise and disclose health conditions affecting driving
Wider context from the report “At the inquest concerns were raised by the police and family members as to the criteria required by the DVLA and Department of Transport for the issuing and surrendering of driving licences. In this case Mr Taylor had voluntarily given up his licence after medical events on a number of occasions. It was considered that a good number of drivers may not have given up their licence for fear or losing their independence putting their own health and other at risk. There was further concern that the driver’s GP could have a conflict of interests in such situations as they would have a duty to inform the DVLA of medical issues which can affect a person’s ability to drive, which could result in deterioration of the GP relationship with the patient.
This was thought to be of particular concern in the elderly who may or may not have insight into their failing health (e.g. eye sight, immobility) and who would be reluctant to voluntarily surrender their licence or inform their GP of significant medical events which would result in the surrendering of their licence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure of drivers to surrender licences when medically necessary
Wider context from the report “At the inquest concerns were raised by the police and family members as to the criteria required by the DVLA and Department of Transport for the issuing and surrendering of driving licences. In this case Mr Taylor had voluntarily given up his licence after medical events on a number of occasions. It was considered that a good number of drivers may not have given up their licence for fear or losing their independence putting their own health and other at risk . There was further concern that the driver’s GP could have a conflict of interests in such situations as they would have a duty to inform the DVLA of medical issues which can affect a person’s ability to drive, which could result in deterioration of the GP relationship with the patient.
This was thought to be of particular concern in the elderly who may or may not have insight into their failing health (e.g. eye sight, immobility) and who would be reluctant to voluntarily surrender their licence or inform their GP of significant medical events which would result in the surrendering of their licence.
” 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 criteria for issuing and surrendering driving licences
Wider context from the report “At the inquest concerns were raised by the police and family members as to the criteria required by the DVLA and Department of Transport for the issuing and surrendering of driving licences . In this case Mr Taylor had voluntarily given up his licence after medical events on a number of occasions. It was considered that a good number of drivers may not have given up their licence for fear or losing their independence putting their own health and other at risk. There was further concern that the driver’s GP could have a conflict of interests in such situations as they would have a duty to inform the DVLA of medical issues which can affect a person’s ability to drive, which could result in deterioration of the GP relationship with the patient.
This was thought to be of particular concern in the elderly who may or may not have insight into their failing health (e.g. eye sight, immobility) and who would be reluctant to voluntarily surrender their licence or inform their GP of significant medical events which would result in the surrendering of their licence.
” 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 Conflict of interests affecting GPs’ reporting of driving-related medical issues
Wider context from the report “At the inquest concerns were raised by the police and family members as to the criteria required by the DVLA and Department of Transport for the issuing and surrendering of driving licences. In this case Mr Taylor had voluntarily given up his licence after medical events on a number of occasions. It was considered that a good number of drivers may not have given up their licence for fear or losing their independence putting their own health and other at risk. There was further concern that the driver’s GP could have a conflict of interests in such situations as they would have a duty to inform the DVLA of medical issues which can affect a person’s ability to drive , which could result in deterioration of the GP relationship with the patient .
This was thought to be of particular concern in the elderly who may or may not have insight into their failing health (e.g. eye sight, immobility) and who would be reluctant to voluntarily surrender their licence or inform their GP of significant medical events which would result in the surrendering of their licence.
” 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 Developed straightforward processes for licence renewal, health investigations and voluntary licence surrender.
Verbatim wording from the response “The DVLA has developed its processes to renew a licence, investigate health, or facilitate the surrender of a licence so as to be as straightforward as possible. Last year, it launched an online service allowing car and motorcycle drivers to notify the DVLA of a medical condition (the existing paper channel is still available). A key message of the campaign that launched the service was the importance of drivers speaking to their GPs about their health and driving.” Source location 2017-0226-Response-by-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 Published and publicised revised fitness-to-drive guidance for medical professionals through medical publications and professional organisations.
Verbatim wording from the response “I recognise your concern that GPs could have a conflict of interest in notifying the DVLA of their patient’s medical condition. GPs play an important role in the driver licensing process by advising their patients of the implications of their condition on driving, the effect of any treatment or medication and whether they should notify the DVLA. The DVLA published “Assessing Fitness to Drive: a Guide for Medical Professionals”, in 2016.” Source location 2017-0226-Response-by-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 Launched an online service for car and motorcycle drivers to notify the DVLA of medical conditions.
Verbatim wording from the response “The DVLA has developed its processes to renew a licence, investigate health, or facilitate the surrender of a licence so as to be as straightforward as possible. Last year, it launched an online service allowing car and motorcycle drivers to notify the DVLA of a medical condition (the existing paper channel is still available). A key message of the campaign that launched the service was the importance of drivers speaking to their GPs about their health and driving.” Source location 2017-0226-Response-by-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 licensing, medical assessment, notification and professional guidance arrangements address health-related driving fitness and GP reporting concerns.
Verbatim wording from the response “You asked that the Department look at the process for issuing driving licences to those with health conditions. By law, all drivers must meet the appropriate health standards for driving and a licence will only be issued to those who meet those standards. When applying for, or renewing a driving licence, applicants must declare whether they have any medical conditions. All drivers of any age also have a legal responsibility to notify the DVLA at any time of a health condition that affects safe driving. In this context, the DVLA will also investigate notifications from third parties, including concerned relatives, neighbours, police and health professionals. This recognises that there may be occasions where drivers do not notify the DVLA appropriately as they fear losing their licence or because a health condition affects their insight into their driving safety.” Source location 2017-0226-Response-by-Department-for-Transport
Open published response
21 Aug 2017 Mr Roger Hamer · Prevention of Future Deaths report Manchester (North)
View report summary
Concerns raised 7 Failure to document carriageway defect condition during inspections View source Lack of a duty-of-candour procedure for significant incidents View source Unmarked potholes lacking paint markings View source Failure to investigate carriageway defects below the 40mm threshold View source Inconsistent application of the current highway-management procedure View source Lack of an effective significant-incident investigation and learning procedure View source Failure to repair carriageway defects at or above the 40mm threshold View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Roger Hamer · 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 Roger Hamer fell from his bicycle on Bury New Road, suffering a traumatic brain injury and multiple fractures, and died in hospital from those injuries on 2 April 2016. The inquest jury found that a pothole probably caused his fall. Concerns included inadequate recording and monitoring of carriageway deterioration, a lack of paint markings around potholes, the absence of a duty-of-candour procedure for investigating significant incidents, and proposed highway-management thresholds that might increase risks to cyclists.
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 document carriageway defect condition during inspections
Wider context from the report “(1) When he inspected the carriageway in January 2016 and February 2016 the highway inspector did not photograph, measure and/or record any details as to the condition of the carriageway where the Pothole developed despite it having started to deteriorate, wear and crack by October 2015.
This prevented the Highway Authority from effectively assessing the rate of deterioration of this part of the carriageway which may have helped to inform it as to the need for earlier repair.
Also, the lack of images and/or measurements of the Pothole as at the date of the inspections restricted the Highway Authority’s ability to effectively supervise and monitor the highway inspector and it hindered the jury’s ability to make more detailed findings as to the circumstances of Mr Hamer’s death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of a duty-of-candour procedure for significant incidents
Wider context from the report “(3) The Highway Authority does not have a procedure with a duty of candour for the effective investigation of, and learning lessons from, significant incidents comparable to those adopted by other public bodies (for example within the National Health Service).
” 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 Unmarked potholes lacking paint markings
Wider context from the report “(2) The jury recorded its concern as to the lack of paint markings around the potholes which may have highlighted their presence to Mr Hamer thereby enabling him to avoid 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 Failure to investigate carriageway defects below the 40mm threshold
Wider context from the report “(4) The Highway Authority is in the process of adopting a new procedure for highway management (“the New Procedure”), apparently based upon Well-Managed Highway Infrastructure: a Code of Practice published by the Department for Transport in October 2016.
With regards to defects in the carriageway, the Highway Authority’s current procedure for highway management has an intervention level of 40mm so that any defect which is found to be 40mm or greater is repaired.
Under the New Procedure 40mm will be redefined as the “investigation level”, so that once a carriageway defect is greater than 40mm a highway inspector will investigate it and consider whether a repair is needed.
If 40mm is specified in the New Procedure as the minimum threshold for investigation then defects which measure less than 40mm may not be investigated and defects of 40mm or above may not be repaired.
Whilst I was informed that highway inspectors have a discretion under both the current and new procedures to repair defects which do not meet the intervention or investigation criteria the jury noted inconsistencies in the application of the current procedure and I consider that the New Procedure will increase the risk of future deaths, in particular to cyclists.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Inconsistent application of the current highway-management procedure
Wider context from the report “(4) The Highway Authority is in the process of adopting a new procedure for highway management (“the New Procedure”), apparently based upon Well-Managed Highway Infrastructure: a Code of Practice published by the Department for Transport in October 2016.
With regards to defects in the carriageway, the Highway Authority’s current procedure for highway management has an intervention level of 40mm so that any defect which is found to be 40mm or greater is repaired.
Under the New Procedure 40mm will be redefined as the “investigation level”, so that once a carriageway defect is greater than 40mm a highway inspector will investigate it and consider whether a repair is needed.
If 40mm is specified in the New Procedure as the minimum threshold for investigation then defects which measure less than 40mm may not be investigated and defects of 40mm or above may not be repaired.
Whilst I was informed that highway inspectors have a discretion under both the current and new procedures to repair defects which do not meet the intervention or investigation criteria the jury noted inconsistencies in the application of the current procedure and I consider that the New Procedure will increase the risk of future deaths, in particular to cyclists.
” 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 effective significant-incident investigation and learning procedure
Wider context from the report “(3) The Highway Authority does not have a procedure with a duty of candour for the effective investigation of, and learning lessons from, significant incidents comparable to those adopted by other public bodies (for example within the National Health Service).
” 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 repair carriageway defects at or above the 40mm threshold
Wider context from the report “(4) The Highway Authority is in the process of adopting a new procedure for highway management (“the New Procedure”), apparently based upon Well-Managed Highway Infrastructure: a Code of Practice published by the Department for Transport in October 2016.
With regards to defects in the carriageway, the Highway Authority’s current procedure for highway management has an intervention level of 40mm so that any defect which is found to be 40mm or greater is repaired.
Under the New Procedure 40mm will be redefined as the “investigation level”, so that once a carriageway defect is greater than 40mm a highway inspector will investigate it and consider whether a repair is needed.
If 40mm is specified in the New Procedure as the minimum threshold for investigation then defects which measure less than 40mm may not be investigated and defects of 40mm or above may not be repaired .
Whilst I was informed that highway inspectors have a discretion under both the current and new procedures to repair defects which do not meet the intervention or investigation criteria the jury noted inconsistencies in the application of the current procedure and I consider that the New Procedure will increase the risk of future deaths, in particular to cyclists.
” 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 Provide nearly £6 billion to local highway authorities in England outside London to improve local road condition.
Verbatim wording from the response “I was very saddened to hear of the circumstances leading to Mr Hamer’s death. The Department for Transport considers the safety of all road users, including cyclists, a priority. The Government is providing just under £6 billion from 2015 to 2021 to allow local highway authorities in England, outside of London, to improve the condition of local roads across they are responsible for. In addition, we have topped this funding up with an extra £250 million specifically to tackle the blight of potholes.” Source location 2017-0259-Response-by-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 Endorse the UK Roads Liaison Group code of practice for highway maintenance and management.
Verbatim wording from the response “That said, the Department endorses a code of practice, issued by the UK Roads Liaison Group of which we are a member. This code of practice provides guidance to highway authorities on how to maintain and manage their highways: http://www.ukroadsliaisongroup.org/en/utilities/document-summary.cfm?docid=4F93BA10-D3B0-4222-827A8C48401B26AC” Source location 2017-0259-Response-by-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 Provide an additional £250 million specifically to address potholes on local roads.
Verbatim wording from the response “I was very saddened to hear of the circumstances leading to Mr Hamer’s death. The Department for Transport considers the safety of all road users, including cyclists, a priority. The Government is providing just under £6 billion from 2015 to 2021 to allow local highway authorities in England, outside of London, to improve the condition of local roads across they are responsible for. In addition, we have topped this funding up with an extra £250 million specifically to tackle the blight of potholes.” Source location 2017-0259-Response-by-Department-for-Transport
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local highway authorities are responsible for deciding highway repairs, maintenance standards and pothole dimensions based on local circumstances.
Verbatim wording from the response “However, as you will be aware, local highway authorities, in this case Bury Council, have a duty under Section 41 of the Highways Act 1980 to maintain the highways network in their area. The Act does not set out specific standards of maintenance, as it is for each individual local highway authority to assess which parts of their network are in need of repair and what standards should be applied, based upon their local knowledge and circumstances. Central Government has no powers to override local decisions in these matters.” Source location 2017-0259-Response-by-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 Central Government cannot override local highway authorities’ decisions about highway maintenance, repair priorities or applicable standards.
Verbatim wording from the response “However, as you will be aware, local highway authorities, in this case Bury Council, have a duty under Section 41 of the Highways Act 1980 to maintain the highways network in their area. The Act does not set out specific standards of maintenance, as it is for each individual local highway authority to assess which parts of their network are in need of repair and what standards should be applied, based upon their local knowledge and circumstances. Central Government has no powers to override local decisions in these matters.” Source location 2017-0259-Response-by-Department-for-Transport
Open published response
31 Jul 2017 Philip James Clayton · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Failure to impose graduated licensing restrictions for drivers of modified or powerful vehicles View source Failure to subject vehicles passing Individual Vehicle Approval to regular rigorous testing View source Lack of mandatory driving-course provision for purchasers of high-powered kit vehicles View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Philip James Clayton · 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
Philip James Clayton was a passenger in a Zcar Mini that collided with another vehicle on 24 April 2016, and he died at the scene. The report raises concerns that sellers of high-powered kit-built vehicles are not required to provide a driving course, that such vehicles may not undergo rigorous regular testing after initial approval, and that current legislation permits people with a normal driving licence to drive modified or powerful vehicles regardless of experience.
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 impose graduated licensing restrictions for drivers of modified or powerful vehicles
Wider context from the report “The vehicle in question was a Z car which is a type of vehicle built using a kit and to which a high powered engine is fitted. There are a number of sellers of such vehicles in the country. None of these sellers have to provide any form of driving course in the use of such vehicles before they are sold. These vehicles once built have to undergo a rigorous test to comply with Driver & Vehicle Standards Agency under the Individual Vehicle Approval (IVA). This test is more a lot more involved than a normal MOT and checks things from the conformity of switches to the actual construction of the vehicle body and everything in between. Each item fitted to the vehicle is checked to ensure it conforms to the current legislation, if the vehicle passed the IVA then it is assigned a registration number more often than not a “Q” plate. However once this designation has been given it appears that the vehicles do not undergo such rigorous testing on a regular basis.
In addition, the driver of the vehicle was relatively inexperienced and had very limited experience of driving vehicles such as the one involved in this case. The current legislation allows a person to drive any modified or powerful vehicle once they have passed a normal driving test within the UK. This contrasts with the position where a person passes a motorcycle test. In that case then they are restricted by age to ride a reduced power machine for a period of time
” 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 subject vehicles passing Individual Vehicle Approval to regular rigorous testing
Wider context from the report “The vehicle in question was a Z car which is a type of vehicle built using a kit and to which a high powered engine is fitted. There are a number of sellers of such vehicles in the country. None of these sellers have to provide any form of driving course in the use of such vehicles before they are sold. These vehicles once built have to undergo a rigorous test to comply with Driver & Vehicle Standards Agency under the Individual Vehicle Approval (IVA). This test is more a lot more involved than a normal MOT and checks things from the conformity of switches to the actual construction of the vehicle body and everything in between. Each item fitted to the vehicle is checked to ensure it conforms to the current legislation, if the vehicle passed the IVA then it is assigned a registration number more often than not a “Q” plate. However once this designation has been given it appears that the vehicles do not undergo such rigorous testing on a regular basis.
In addition, the driver of the vehicle was relatively inexperienced and had very limited experience of driving vehicles such as the one involved in this case. The current legislation allows a person to drive any modified or powerful vehicle once they have passed a normal driving test within the UK. This contrasts with the position where a person passes a motorcycle test. In that case then they are restricted by age to ride a reduced power machine for a period of time
” 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 driving-course provision for purchasers of high-powered kit vehicles
Wider context from the report “The vehicle in question was a Z car which is a type of vehicle built using a kit and to which a high powered engine is fitted. There are a number of sellers of such vehicles in the country. None of these sellers have to provide any form of driving course in the use of such vehicles before they are sold. These vehicles once built have to undergo a rigorous test to comply with Driver & Vehicle Standards Agency under the Individual Vehicle Approval (IVA). This test is more a lot more involved than a normal MOT and checks things from the conformity of switches to the actual construction of the vehicle body and everything in between. Each item fitted to the vehicle is checked to ensure it conforms to the current legislation, if the vehicle passed the IVA then it is assigned a registration number more often than not a “Q” plate. However once this designation has been given it appears that the vehicles do not undergo such rigorous testing on a regular basis.
In addition, the driver of the vehicle was relatively inexperienced and had very limited experience of driving vehicles such as the one involved in this case. The current legislation allows a person to drive any modified or powerful vehicle once they have passed a normal driving test within the UK. This contrasts with the position where a person passes a motorcycle test. In that case then they are restricted by age to ride a reduced power machine for a period of time
” 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 Ongoing regular IVA-standard testing is inappropriate because IVA applies only to unregistered vehicles and assesses new-vehicle design, not subsequent wear and tear.
Verbatim wording from the response “The purposes of MOT and Individual Vehicle Approval (IVA) testing differ greatly, and the Department does not think it would be appropriate to mandate ongoing, regular IVA-standard testing for specific types of vehicles in the way suggested. This is because IVA looks at the vehicle for its projected life and ensures that it can meet specified safety, security and environmental standards before it is used on the road. IVA only applies to unregistered vehicles; IT is a one off test that takes into account its design and construction, and takes no account of wear and tear (it’s treated as a new vehicle).” Source location 2017-0323-Response
Open published response
24 Jul 2017 GUSTAVO SILVA DA CRUZ and 6 others · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 4 Visitors’ language difficulties and lack of experience with the sea View source Failure to maintain effective public communication about coastal safety View source Lack of formal governance and control of coastal risk management View source Insufficient education and awareness of coastal dangers 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
GUSTAVO SILVA DA CRUZ 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 24 June 2016, Gustavo Silva da Cruz and Mohit Dupar entered the sea at Camber Sands; Da Cruz's body was later washed ashore, and Dupar was brought unconscious to the beach and died at Ashford Hospital on 28 July 2016. On 24 August 2016, five young Sri Lankan men entered the sea as the tide came in and all died, with their bodies recovered that day or after the tide receded. The report raises concerns about the lack of formal governance and risk management for beach safety, including lifeguard provision, public education, communication, resources, and whether restrictions on beach use should be considered.
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 Visitors’ language difficulties and lack of experience with the sea
Wider context from the report “(b) There appears to be no formal governance or control of risk management requirements. Should the present, virtually voluntarily, structure be examined? Could perhaps the Marine and Coastguard Agency, who have enforcement powers akin to those of the Police, be given more resources and take a bigger role than they currently have? The problem is an increasing one. The evidence suggested that on a pleasant hot summer’s day 25,000 to 30,000 people visit Camber Sands, many of whom have language difficulties and do not speak much English, and many others of whom have no experience of going into the sea . The question is whether leaving matters to a charity is really the best basis of a structure intended to spearhead a possibly overdue attempt to modernise, harmonise, and improve the safety regime, given so many changes at Camber.
(c) Changes include:-
(i) possible climate change effects,
(ii) differences in ethnic origins and language spoken by current visitors,
(iii) constant and fast changes in means of communication with the public, which everybody at these inquests agreed to be crucial to the necessary educative process,
(iv) improvement, considered vital, of education and awareness of coastal dangers amongst children and those who live far from the sea.
(d) Inevitably resource and monetary considerations affect decision making by those charged with safeguarding people like the seven who died here. Perhaps that is another reason why a review of the current system may well be needed.
” 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 maintain effective public communication about coastal safety
Wider context from the report “(b) There appears to be no formal governance or control of risk management requirements. Should the present, virtually voluntarily, structure be examined? Could perhaps the Marine and Coastguard Agency, who have enforcement powers akin to those of the Police, be given more resources and take a bigger role than they currently have? The problem is an increasing one. The evidence suggested that on a pleasant hot summer’s day 25,000 to 30,000 people visit Camber Sands, many of whom have language difficulties and do not speak much English, and many others of whom have no experience of going into the sea. The question is whether leaving matters to a charity is really the best basis of a structure intended to spearhead a possibly overdue attempt to modernise, harmonise, and improve the safety regime, given so many changes at Camber.
(c) Changes include:-
(i) possible climate change effects,
(ii) differences in ethnic origins and language spoken by current visitors,
(iii) constant and fast changes in means of communication with the public, which everybody at these inquests agreed to be crucial to the necessary educative process ,
(iv) improvement, considered vital, of education and awareness of coastal dangers amongst children and those who live far from the sea.
(d) Inevitably resource and monetary considerations affect decision making by those charged with safeguarding people like the seven who died here. Perhaps that is another reason why a review of the current system may well be needed.
” 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 formal governance and control of coastal risk management
Wider context from the report “(b) There appears to be no formal governance or control of risk management requirements . Should the present, virtually voluntarily, structure be examined? Could perhaps the Marine and Coastguard Agency, who have enforcement powers akin to those of the Police, be given more resources and take a bigger role than they currently have? The problem is an increasing one. The evidence suggested that on a pleasant hot summer’s day 25,000 to 30,000 people visit Camber Sands, many of whom have language difficulties and do not speak much English, and many others of whom have no experience of going into the sea. The question is whether leaving matters to a charity is really the best basis of a structure intended to spearhead a possibly overdue attempt to modernise, harmonise, and improve the safety regime , given so many changes at Camber.
(c) Changes include:-
(i) possible climate change effects,
(ii) differences in ethnic origins and language spoken by current visitors,
(iii) constant and fast changes in means of communication with the public, which everybody at these inquests agreed to be crucial to the necessary educative process,
(iv) improvement, considered vital, of education and awareness of coastal dangers amongst children and those who live far from the sea.
(d) Inevitably resource and monetary considerations affect decision making by those charged with safeguarding people like the seven who died here. Perhaps that is another reason why a review of the current system may well be needed.
” 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 education and awareness of coastal dangers
Wider context from the report “(b) There appears to be no formal governance or control of risk management requirements. Should the present, virtually voluntarily, structure be examined? Could perhaps the Marine and Coastguard Agency, who have enforcement powers akin to those of the Police, be given more resources and take a bigger role than they currently have? The problem is an increasing one. The evidence suggested that on a pleasant hot summer’s day 25,000 to 30,000 people visit Camber Sands, many of whom have language difficulties and do not speak much English, and many others of whom have no experience of going into the sea. The question is whether leaving matters to a charity is really the best basis of a structure intended to spearhead a possibly overdue attempt to modernise, harmonise, and improve the safety regime, given so many changes at Camber.
(c) Changes include:-
(i) possible climate change effects,
(ii) differences in ethnic origins and language spoken by current visitors,
(iii) constant and fast changes in means of communication with the public, which everybody at these inquests agreed to be crucial to the necessary educative process,
(iv) improvement, considered vital, of education and awareness of coastal dangers amongst children and those who live far from the sea .
(d) Inevitably resource and monetary considerations affect decision making by those charged with safeguarding people like the seven who died here. Perhaps that is another reason why a review of the current system may well be needed.
” 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