6 Aug 2014 Lee Michael FRIEND · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 7 Lack of operative guidance or training on placing traffic lights near blind bends View source Lack of a clear route for locating the person responsible for placing road works View source Failure to pass public calls about serious road-network safety issues directly to those responsible for action View source Failure to carry out effective risk assessments for road works View source Insufficient visibility distance between approaching drivers and temporary traffic light heads View source Inadequate staff training in the safe setting up of road works View source Lack of a clear police policy or protocol for responding to public risks created by road works 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
Lee Michael FRIEND · 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
Lee Michael Friend died on 21 February 2013 after his motorcycle collided with stationary traffic near temporary road works on a blind bend. The report raised concerns about the positioning and visibility of temporary traffic lights, the adequacy of risk assessments and training for road works, the response to public safety concerns, and Surrey Police’s procedures for identifying and reporting risks created by road works.
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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 operative guidance or training on placing traffic lights near blind bends
Wider context from the report “1. Action is required to ensure that when temporary traffic lights are placed there is a minimum distance of visibility (line of sight) between approaching drivers and the temporary traffic light heads. Further, guidance or training should be provided to operatives as to placing traffic lights near to blind bends or where waiting traffic will encroach upon blind bends .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear route for locating the person responsible for placing road works
Wider context from the report “2. Action is required by Surrey Police to formulate a clear policy/protocol for all Officers to follow when they identify a risk created to the public by road works which should include a clear route allow them to locate who is responsible for the placing of the road works if not apologies board is seen/present .
” 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 pass public calls about serious road-network safety issues directly to those responsible for action
Wider context from the report “3. Action is required by Reigate and Banstead Council to ensure that any calls from members of the public to the Council about serious safety issues relating to the road network are passed directly to those with responsibility to take action .
” 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 carry out effective risk assessments for road works
Wider context from the report “4. Action is required by Sutton and East Surrey Water to take steps to ensure all members of staff are fully and properly trained in the safe setting up of road works and the carrying out of effective risk assessments .
” 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 visibility distance between approaching drivers and temporary traffic light heads
Wider context from the report “1. Action is required to ensure that when temporary traffic lights are placed there is a minimum distance of visibility (line of sight) between approaching drivers and the temporary traffic light heads . Further, guidance or training should be provided to operatives as to placing traffic lights near to blind bends or where waiting traffic will encroach upon blind bends.
” 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 staff training in the safe setting up of road works
Wider context from the report “4. Action is required by Sutton and East Surrey Water to take steps to ensure all members of staff are fully and properly trained in the safe setting up of road works and the carrying out of effective risk assessments.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear police policy or protocol for responding to public risks created by road works
Wider context from the report “2. Action is required by Surrey Police to formulate a clear policy/protocol for all Officers to follow when they identify a risk created to the public by road works which should include a clear route allow them to locate who is responsible for the placing of the road works if not apologies board is seen/present.
” Open source report
23 Jul 2014 Kenneth John PAUL · Prevention of Future Deaths report South Lincolnshire
View report summary
Concerns raised 2 Lack of legislative requirement for automatically operated audible reverse warning devices on light commercial vehicles View source Failure to fit light commercial vehicles with automatically operated audible reverse warning devices 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
Kenneth John PAUL · 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
Kenneth John Paul sustained fatal injuries after being run over by a reversing delivery vehicle on 29 November 2013. The vehicle had no automatically operating audible warning device when reverse gear was engaged, and there was no legislative requirement for such a device on light commercial vehicles of that type.
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 legislative requirement for automatically operated audible reverse warning devices on light commercial vehicles
Wider context from the report “The delivery vehicle, a Mercedes Sprinter that collided with Mr Paul, a vehicle with no windows behind the driver's position, was not fitted with an audible warning device that operated automatically when reverse gear was engaged and there is no legislative requirement for such a device to be fitted to light commercial vehicles of this type .
” 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 fit light commercial vehicles with automatically operated audible reverse warning devices
Wider context from the report “The delivery vehicle, a Mercedes Sprinter that collided with Mr Paul, a vehicle with no windows behind the driver's position, was not fitted with an audible warning device that operated automatically when reverse gear was engaged and there is no legislative requirement for such a device to be fitted to light commercial vehicles of this type.
” Open source report
9 Jul 2014 Georgina Lauren Taylor · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 2 Lack of inspection of developing soft estate to assess vehicle restraint protection requirements View source Failure to protect or remove trees within 4.5m of the paved carriageway 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
Georgina Lauren 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
Georgina Lauren Taylor died following a road traffic collision on the A627(M), in which a vehicle lost control at excessive speed, struck a tree and rolled. The report raised concerns about trees and other roadside features near the carriageway, including whether they were adequately protected or should have been removed, and about the lack of requirements to reassess protection as roadside vegetation developed.
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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 inspection of developing soft estate to assess vehicle restraint protection requirements
Wider context from the report “2. The introduction of the interim requirements for road restraint systems in 2002 identified that all trees with a girth exceeding 500mm (or several closely spaced trees) located within a distance of 4.5m from the paved carriageway require protection. The re-issued requirements in 2004 identified that trees above 300mm in girth should be protected by a suitable vehicle restraint system.
3. Current design standard TD19/06 includes a site specific risk process where topographical features, together with adjacent sources of risk are reviewed in order to identify the most appropriate restraint facility and containment levels and that in relation to the presence of trees adjacent to the nearside verge and protection requirements, it is unclear as to when these regimented and it is likely that they are all ‘self-seeded’ with the larger specimens being over 10 years old. Whilst the vehicle restraint systems in place comply with identified requirements at the time of the construction of the route, there are no current requirements to inspect soft estate as it develops in terms of assessing protection requirements . The application of more recent design standards would have required some of the trees at this location to be protected (as well as the lighting columns) or removed within the 4.5m threshold.
” 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 protect or remove trees within 4.5m of the paved carriageway
Wider context from the report “2. The introduction of the interim requirements for road restraint systems in 2002 identified that all trees with a girth exceeding 500mm (or several closely spaced trees) located within a distance of 4.5m from the paved carriageway require protection . The re-issued requirements in 2004 identified that trees above 300mm in girth should be protected by a suitable vehicle restraint system .
3. Current design standard TD19/06 includes a site specific risk process where topographical features, together with adjacent sources of risk are reviewed in order to identify the most appropriate restraint facility and containment levels and that in relation to the presence of trees adjacent to the nearside verge and protection requirements, it is unclear as to when these regimented and it is likely that they are all ‘self-seeded’ with the larger specimens being over 10 years old. Whilst the vehicle restraint systems in place comply with identified requirements at the time of the construction of the route, there are no current requirements to inspect soft estate as it develops in terms of assessing protection requirements. The application of more recent design standards would have required some of the trees at this location to be protected (as well as the lighting columns) or removed within the 4.5m threshold .
” Open source report
8 Jul 2014 Muriel Naylor · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 1 Lack of restraint in priority seating View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Muriel Naylor · 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
Muriel Naylor died after a bus made an emergency stop on 19 November 2011, causing her to be projected from a designated priority seat into the wheelchair/tip-up bay and sustain fatal spinal injuries. The principal concern was that the priority seat lacked a restraint or other safety measure to restrict passenger movement, despite priority seating being intended to protect vulnerable 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 Lack of restraint in priority seating
Wider context from the report “IV. As standing passengers are carried on this vehicle, seat belts are not mandatory although this would not preclude the fitment of a seat belt as an option . However, a seat belt could only be fitted if there was sufficient anchorage and the seat itself would have to undergo a ‘pull’ test. The priority seat in question would not, it is believed, comply with the ‘pull’ test .
V. Notwithstanding the fact that Mrs Naylor was a very fit and active 79 year old. She was propelled across a void of a 184cm before sustaining injuries which crushed her upper spinal cord causing immediate unconsciousness and paralysis.
VI. Given that priority seating is intended to protect the most vulnerable users of the service, it is of significant concern that the risk is accentuated by the lack of any restraint .
” 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 Bring the seating-safety issue to bus manufacturers and industry representatives.
Verbatim wording from the response “I have already brought this issue to the attention of the bus manufacturers through the Society of Motor Manufacturers and Traders (SMMT), and the Confederation of Passenger Transport (CPT) who represent the bus & coach operating industry. We have a tripartite meeting scheduled this month, at which we will be encouraging them to adopt additional safety features for these seating positions where it is possible.” Source location 2014-0329-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 Raise the seating-safety issue with the international technical group to explore amending minimum specifications and assess international support.
Verbatim wording from the response “I also intend to raise this issue within the international technical group responsible for the pan-European construction requirements to explore whether it is appropriate to amend the minimum specification for new vehicles to reduce the risk of similar incidents in future, and to determine whether there is international support for such a move.” Source location 2014-0329-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 Encourage manufacturers and operators to adopt additional safety features for the affected seating positions where feasible.
Verbatim wording from the response “I have already brought this issue to the attention of the bus manufacturers through the Society of Motor Manufacturers and Traders (SMMT), and the Confederation of Passenger Transport (CPT) who represent the bus & coach operating industry. We have a tripartite meeting scheduled this month, at which we will be encouraging them to adopt additional safety features for these seating positions where it is possible.” Source location 2014-0329-Response-by-Department-for-Transport
Open published response
19 Jun 2014 Names not published · Prevention of Future Deaths report West Somerset
View report summary
Concerns raised 9 Failure to position lookouts for smoke or fog approaching nearby highways or railway lines View source Lack of immediate communication access to emergency services during firework displays View source Failure to assess humidity and wind conditions immediately before firework displays View source Lack of firework-firer training on recognising risks arising from high humidity View source Failure to prepare a comprehensive firework-display risk assessment View source Failure of road-safety-equipment deployment criteria to provide special consideration below six personal injury collisions in three years View source Lack of fog detection devices to identify reduced visibility before an initial incident View source Insufficient use of overhead gantries displaying reduced-visibility warnings View source Failure to ensure immediate stopping of firework displays when emergencies arise View source See 6 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
Names not published · 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
Seven people died when 34 vehicles collided in thick fog on the M5 motorway near Taunton on 4 November 2011; 51 others were injured. The concerns related to preventing vehicles entering areas of severely reduced visibility, detecting and warning of fog, and managing risks from firework displays that may increase fog or smoke near highways.
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 position lookouts for smoke or fog approaching nearby highways or railway lines
Wider context from the report ““B”
To consider whether or not risks arising from firework displays being held in periods of very high humidity can be greatly reduced if the City and Guild’s courses for Firers and Senior Firers (being the only persons able to conduct a firework display using class IV fireworks) had instruction in realising when such risks arose.
AND before operating any display Firers had prepared :-
(i) a risk assessment which took account of the topography of the area, nearby watercourses, prevailing wind conditions, identifying highways and all other matters relevant for the safety of the users thereof onlookers and nearby residents.
(ii) Assessed the humidity, wind direction and speed immediately before the display,
(iii) Positioned lookouts to see if any smoke or fog was approaching a highway or railway line in the immediate vicinity .
(iv) Had immediate access to a communication link to the emergency services and
(v) Be able to stop the display immediately if an emergency arises
AND to consider whether Firers and Senior Firers should be licensed by law for periods of five year
AND whether Local Licensing Authorities shall advise persons holding firework displays of the risks referred to herein.
” 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 immediate communication access to emergency services during firework displays
Wider context from the report ““B”
To consider whether or not risks arising from firework displays being held in periods of very high humidity can be greatly reduced if the City and Guild’s courses for Firers and Senior Firers (being the only persons able to conduct a firework display using class IV fireworks) had instruction in realising when such risks arose.
AND before operating any display Firers had prepared :-
(i) a risk assessment which took account of the topography of the area, nearby watercourses, prevailing wind conditions, identifying highways and all other matters relevant for the safety of the users thereof onlookers and nearby residents.
(ii) Assessed the humidity, wind direction and speed immediately before the display,
(iii) Positioned lookouts to see if any smoke or fog was approaching a highway or railway line in the immediate vicinity.
(iv) Had immediate access to a communication link to the emergency services and
(v) Be able to stop the display immediately if an emergency arises
AND to consider whether Firers and Senior Firers should be licensed by law for periods of five year
AND whether Local Licensing Authorities shall advise persons holding firework displays of the risks referred to herein.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure to assess humidity and wind conditions immediately before firework displays
Wider context from the report ““B”
To consider whether or not risks arising from firework displays being held in periods of very high humidity can be greatly reduced if the City and Guild’s courses for Firers and Senior Firers (being the only persons able to conduct a firework display using class IV fireworks) had instruction in realising when such risks arose.
AND before operating any display Firers had prepared :-
(i) a risk assessment which took account of the topography of the area, nearby watercourses, prevailing wind conditions, identifying highways and all other matters relevant for the safety of the users thereof onlookers and nearby residents.
(ii) Assessed the humidity, wind direction and speed immediately before the display ,
(iii) Positioned lookouts to see if any smoke or fog was approaching a highway or railway line in the immediate vicinity.
(iv) Had immediate access to a communication link to the emergency services and
(v) Be able to stop the display immediately if an emergency arises
AND to consider whether Firers and Senior Firers should be licensed by law for periods of five year
AND whether Local Licensing Authorities shall advise persons holding firework displays of the risks referred to herein.
” 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 firework-firer training on recognising risks arising from high humidity
Wider context from the report ““B”
To consider whether or not risks arising from firework displays being held in periods of very high humidity can be greatly reduced if the City and Guild’s courses for Firers and Senior Firers (being the only persons able to conduct a firework display using class IV fireworks) had instruction in realising when such risks arose .
AND before operating any display Firers had prepared :-
(i) a risk assessment which took account of the topography of the area, nearby watercourses, prevailing wind conditions, identifying highways and all other matters relevant for the safety of the users thereof onlookers and nearby residents.
(ii) Assessed the humidity, wind direction and speed immediately before the display,
(iii) Positioned lookouts to see if any smoke or fog was approaching a highway or railway line in the immediate vicinity.
(iv) Had immediate access to a communication link to the emergency services and
(v) Be able to stop the display immediately if an emergency arises
AND to consider whether Firers and Senior Firers should be licensed by law for periods of five year
AND whether Local Licensing Authorities shall advise persons holding firework displays of the risks referred to herein.
” 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 prepare a comprehensive firework-display risk assessment
Wider context from the report ““B”
To consider whether or not risks arising from firework displays being held in periods of very high humidity can be greatly reduced if the City and Guild’s courses for Firers and Senior Firers (being the only persons able to conduct a firework display using class IV fireworks) had instruction in realising when such risks arose.
AND before operating any display Firers had prepared :-
(i) a risk assessment which took account of the topography of the area, nearby watercourses, prevailing wind conditions, identifying highways and all other matters relevant for the safety of the users thereof onlookers and nearby residents .
(ii) Assessed the humidity, wind direction and speed immediately before the display,
(iii) Positioned lookouts to see if any smoke or fog was approaching a highway or railway line in the immediate vicinity.
(iv) Had immediate access to a communication link to the emergency services and
(v) Be able to stop the display immediately if an emergency arises
AND to consider whether Firers and Senior Firers should be licensed by law for periods of five year
AND whether Local Licensing Authorities shall advise persons holding firework displays of the risks referred to herein.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure of road-safety-equipment deployment criteria to provide special consideration below six personal injury collisions in three years
Wider context from the report ““A”
I am concerned that the Highway Agency's proposals whilst possibly preventing further vehicles entering an accident scene or a large area of reduced visibility would not prevent the initial incident and that this can only be achieved by the erection of fog detection devises and greater use of overhead gantries displaying signs warning of events that may cause reduced visibility.
AND as the criterion for deploying road safety equipment is six personal injury collisions in three years the present incident would not qualify for special consideration .
” 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 fog detection devices to identify reduced visibility before an initial incident
Wider context from the report ““A”
I am concerned that the Highway Agency's proposals whilst possibly preventing further vehicles entering an accident scene or a large area of reduced visibility would not prevent the initial incident and that this can only be achieved by the erection of fog detection devises and greater use of overhead gantries displaying signs warning of events that may cause reduced visibility.
AND as the criterion for deploying road safety equipment is six personal injury collisions in three years the present incident would not qualify for special consideration.
” 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 use of overhead gantries displaying reduced-visibility warnings
Wider context from the report ““A”
I am concerned that the Highway Agency's proposals whilst possibly preventing further vehicles entering an accident scene or a large area of reduced visibility would not prevent the initial incident and that this can only be achieved by the erection of fog detection devises and greater use of overhead gantries displaying signs warning of events that may cause reduced visibility .
AND as the criterion for deploying road safety equipment is six personal injury collisions in three years the present incident would not qualify for special consideration.
” 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 immediate stopping of firework displays when emergencies arise
Wider context from the report ““B”
To consider whether or not risks arising from firework displays being held in periods of very high humidity can be greatly reduced if the City and Guild’s courses for Firers and Senior Firers (being the only persons able to conduct a firework display using class IV fireworks) had instruction in realising when such risks arose.
AND before operating any display Firers had prepared :-
(i) a risk assessment which took account of the topography of the area, nearby watercourses, prevailing wind conditions, identifying highways and all other matters relevant for the safety of the users thereof onlookers and nearby residents.
(ii) Assessed the humidity, wind direction and speed immediately before the display,
(iii) Positioned lookouts to see if any smoke or fog was approaching a highway or railway line in the immediate vicinity.
(iv) Had immediate access to a communication link to the emergency services and
(v) Be able to stop the display immediately if an emergency arises
AND to consider whether Firers and Senior Firers should be licensed by law for periods of five year
AND whether Local Licensing Authorities shall advise persons holding firework displays of the risks referred to herein.
” Open source report
28 May 2014 Arnold SOULSBY · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 1 Failure to apply forward-facing mirror requirements retrospectively to lorries View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Arnold SOULSBY · 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
Arnold SOULSBY was killed when a lorry moved off at traffic lights and knocked him down while he was crossing the road. The concern was that forward-facing mirror requirements for lorries were not retrospective, leaving many older lorries without this facility and potentially limiting drivers’ visibility of pedestrians.
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 apply forward-facing mirror requirements retrospectively to lorries
Wider context from the report “I am concerned that the regulations that have been introduced requiring lorries to have forward facing mirrors are not retrospective , hence there are a large number of lorries on the road which do not have this facility . I have conducted a number of inquests where the circumstances are similar and I have previously drawn the attention of the department to this problem on (I believe) two occasions, one prior to the 2007 Regulations providing for forward facing mirrors and one thereafter.
” 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 Prepare a consultation on retrofitting forward-facing Class VI mirrors to older heavy goods vehicles, assessing benefits, costs and engineering issues.
Verbatim wording from the response “Driver vision is an important factor in minimising collisions of large vehicles with vulnerable road users and I have recently asked officials to prepare a consultation which is specifically about retro-fitting forward facing (Class VI) mirrors above the windscreen of heavy goods vehicles that were first registered prior to 26 January 2007. These mirrors were required as standard fitment on heavy goods vehicles first used after that date.” Source location 2014-0241-Response-by-Department-of-Transport
Open published response
27 May 2014 Gerardo Abadilla Tongobanua · Prevention of Future Deaths report Avon
View report summary
Concerns raised 2 Failure of the LSA Code and ISO 15516 to specify the number, definition and performance of davit safety devices View source Lack of requirements to assess rescue boat lifting davits, winches and fall wires as a system 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
Gerardo Abadilla Tongobanua · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 7 February 2011, Gerardo Abadilla Tongobanua fell 29 metres during a fast rescue boat drill onboard the MV Tombarra while it was docked at Royal Portbury Dock, Bristol, after the fall wire snapped. The concerns identified were that the winch motor could overstress the fall wire and that the failed electronic switch did not stop the motor, while the relevant code and standard did not adequately specify system design or safety-device requirements.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure of the LSA Code and ISO 15516 to specify the number, definition and performance of davit safety devices
Wider context from the report “2. An electronic switch, fitted to the rescue boat davit onboard Tombarra, failed to operate and stop the winch motor. The LSA Code refers to ‘safety devices’ fitted to the davits which will automatically cut off the winch power to prevent overstressing of components. This is reflected in the international standard ISO 15516 “Ships and marine technology—launching appliances for davit-launched lifeboats”. However, neither the Code nor the standard specify the number, definition or performance of the ‘safety devices’ fitted. Consequently, manufacturers have little guidance in these areas compared to manufacturers of industrial machinery
” 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 requirements to assess rescue boat lifting davits, winches and fall wires as a system
Wider context from the report “1. The fall wire of MV Tombarra’s rescue boat failed because the winch electric motor was capable of easily overstressing the fall wire to the point of failure. There is currently no requirement within the Life-Saving Appliances (LSA) Code to consider design of the rescue boat lifting davit, winch and fall wire, as a ‘system’ when assessing the suitability of the forces and loads applied. The Code infers that ‘overstressing’ of the falls or davits could occur.
” Open source report
Concerns raised 1 Failure to assess mental fitness to drive during driving-licence renewals for people over 70 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
Arthur Clifford Shaw · 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
Arthur Clifford Shaw was struck by a car while crossing Privett Road, Gosport, on 31 December 2012 and died in hospital on 1 January 2013 from injuries sustained. The report raised concern that assessment of older drivers' fitness to drive did not specifically consider mental fitness, including dementia, beyond sight and hearing tests.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure to assess mental fitness to drive during driving-licence renewals for people over 70
Wider context from the report “The driver of the vehicle that struck Mr Shaw was herself 87 years old and was suffering from dementia at the time of the collision. This was confirmed by her GP whose evidence was that she had been diagnosed as suffering from dementia in November 2012 and the doctor believed the dementia had been present prior to that diagnosis. Her condition was such that the GP did not think she would be capable of giving reliable evidence at the Inquest and, accordingly, she was not called as a witness.
I was told by police witnesses that when persons over the age of 70 renew their driving licences, they have to be certified by their doctor as being fit to drive . However, whilst doctors check hearing and vision, there is no specific need for the doctor to consider mental fitness to drive . I believe that the circumstances of Mr Shaw's death demonstrate the need for more careful examination of an elderly person's fitness to drive beyond simple sight and hearing tests.
” Open source report
13 May 2014 Mitchell Harvey Clifton · Prevention of Future Deaths report Staffordshire South
View report summary
Concerns raised 2 Failure of the access-way layout to adequately accommodate regular pedestrian and vehicle use View source Reduction in off-side visibility from vehicle adaptations 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
Mitchell Harvey Clifton · 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
Mitchell Clifton died at the scene of a road traffic collision after being struck by a van while travelling on a footpath on a scooter. The report raised concern about the layout of the access way to the car park, which was regularly used by pedestrians and vehicles, and suggested that it might be improved.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure of the access-way layout to adequately accommodate regular pedestrian and vehicle use
Wider context from the report “The access way is a wide one to the Co-operative car park. It is likely that pedestrians and vehicles use this access way on a regular basis. I wonder if you could give consideration as to if the lay-out of this access way might be improved . Possibilities might include tactile or coloured paving, extension of the double yellow lines (or other road markings), or the insertion of a central island.
” 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 Reduction in off-side visibility from vehicle adaptations
Wider context from the report “The van in question was a Mercedes Sprinter being used as a security van. As part of the adaptations for it to be a security van the size of the driver's door window had been reduced . The off-side wing mirror was standard . A reduction in the available view to the off-side may have been a factor why the van driver did not spot Mitchell. Perhaps you can kindly confirm that the design of this vehicle has been duly approved and consider if any further adaptations regarding either the window or mirror are appropriate.
” 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 Changes to existing window or mirror requirements are not proposed because their effectiveness in preventing similar incidents is unproven.
Verbatim wording from the response “You have asked me to consider whether adaptations to the window or the mirror requirements are appropriate. As I have indicated, I take the matter of vehicle safety seriously and have considered the national road safety data for light commercial vehicles to understand better the contribution of a reduced view of the road to collisions, compared to other factors such as driver error or inattention, and the potential for making regulation to improve the situation. The circumstances of this case are tragic but I am not convinced that making changes to the existing requirements would necessarily prevent such an incident from happening again. On this basis I do not propose adaptations to the current requirements.” Source location 2014-0227-Response-by-Department-for-Transport
Open published response
12 May 2014 Terence Vincent Anthony FERNANDES · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 1 Lack of basic first aid training for personnel responding to unwell passengers 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
Terence Vincent Anthony FERNANDES · 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
Terence Vincent Anthony FERNANDES collapsed on a train on 23 January 2013 after drinking alcohol, suffered cardiac arrest associated with airway occlusion, and died in hospital on 25 January 2013. The report raised concern that the train and station personnel who assisted him had no basic first-aid training and may not have recognised that his airway was partially occluded.
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 basic first aid training for personnel responding to unwell passengers
Wider context from the report “(1) Terence Fernandes had become seriously unwell during the journey from Blackfriars to St. Albans whilst a passenger on a train. He was taken off the train by the driver, security staff and staff in attendance at the station and yet none of the personnel had even basic first aid training . If someone had had even limited first aid knowledge they may have been able to recognise that Terence’s airway had become partially occluded .
” Open source report
Concerns raised 3 Failure to consider potential risks and dangers of pedal cycle cleats and shoes View source Lack of warnings supplied at the time of purchase of pedal cycle cleats and shoes View source Lack of oversight, control or legislation governing the supply of pedal cycle cleats and shoes 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
Neil Andrew Blood · 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
Neil Andrew Blood died shortly after falling from his bicycle under a passing van and its rear wheel while cycling in St Helier, Jersey, on 31 July 2013. The report raised concerns about the oversight, control, legislation, risks and warnings associated with the supply of pedal cycle cleats and shoes.
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 consider potential risks and dangers of pedal cycle cleats and shoes
Wider context from the report “2. To Department of Transport (UK): What oversight, control or legislation governs the supply of pedal cycle cleats and shoes, and what consideration has been given to the potential risks and dangers involved and what warnings should be supplied at the time of purchase?
” 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 warnings supplied at the time of purchase of pedal cycle cleats and shoes
Wider context from the report “2. To Department of Transport (UK): What oversight, control or legislation governs the supply of pedal cycle cleats and shoes, and what consideration has been given to the potential risks and dangers involved and what warnings should be supplied at the time of purchase ?
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of oversight, control or legislation governing the supply of pedal cycle cleats and shoes
Wider context from the report “2. To Department of Transport (UK): What oversight, control or legislation governs the supply of pedal cycle cleats and shoes , and what consideration has been given to the potential risks and dangers involved and what warnings should be supplied at the time of purchase?
” Open source report
5 May 2014 Donald Spooner · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 1 Lack of compulsory suitable protective helmet use on motorised bicycles capable of exceeding 15 MPH 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
Donald Spooner · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Donald Spooner died after being thrown from a motorised bicycle when it caught the edge of a parked vehicle. He was not wearing a protective helmet, and the report raised concerns that helmet use was not compulsory for motorised bicycles capable of speeds over 15 MPH and that protective headgear might have reduced his injuries.
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 suitable protective helmet use on motorised bicycles capable of exceeding 15 MPH
Wider context from the report “1. That it is not compulsory to wear a suitable protective helmet whilst travelling on a motorised bicycle which can reach speeds in excess of 15 MPH
” Open source report
13 Jan 2014 Mustafa Cicek · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 4 Lack of a SLOW carriageway marking on the approach to the bend View source Failure of chevron signs to have yellow backgrounds View source Collision black spot at the bend View source Potential carriageway hazard from a maturing eucalyptus sapling 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.
×
AI-generated summary
Mustafa Cicek · 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
Mustafa Cicek died following a road traffic collision on the A21 when his Ford Fiesta left the carriageway on a bend and struck a fixed structure. The concerns identified included the bend being a collision black spot, inadequate chevron-sign visibility, a potentially hazardous sapling, and the need for a “SLOW” road marking.
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 SLOW carriageway marking on the approach to the bend
Wider context from the report “(4) Consideration should be given to painting “SLOW” in the carriageway on the approach to the bend .
” 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 chevron signs to have yellow backgrounds
Wider context from the report “(2) The apparatus along the carriageway, particularly two of the chevron signs, could be improved. There are three chevron signs but only one has a yellow background . If the two chevron signs without a yellow background could have a yellow background added it would further enhance their presence on this bend.
” 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 Collision black spot at the bend
Wider context from the report “(1) The bend at this particular location is a collision black spot as there have been several road traffic collisions at the location of Mr Cicek’s collision .
” 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 Potential carriageway hazard from a maturing eucalyptus sapling
Wider context from the report “(3) A Eucalyptus sapling has been planted on Highways Agency land between the front fence at ████████ and the edge of the carriageway. This will mature into a potential hazard and consideration should be given to its removal.
” Open source report
8 Oct 2013 Kuldeep Singh Dhillon · Prevention of Future Deaths report East London
View report summary
Concerns raised 2 Insufficient enforcement and auditing of road-goods loading and transport requirements View source Lack of restraint for palletised loads during loading, unloading and road transport 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
Kuldeep Singh Dhillon · 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
Kuldeep Singh Dhillon was driving a lorry on the M25 on 25 May 2012 when it collided with a stationary vehicle during a rolling road block. He was trapped when the vehicle exploded and died at the scene from extensive full-thickness burns. The report raised concerns that palletised loads were commonly carried without restraint, putting drivers at risk, and that enforcement and auditing of relevant guidance and codes of practice were insufficient.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Insufficient enforcement and auditing of road-goods loading and transport requirements
Wider context from the report “5. Evidence was given at the inquest that it is the Department of Transport that is responsible for enforcing and auditing compliance with the pieces of legislation (supported by specific guidance and codes of practice) that govern the loading and transport of goods by road in the UK .
6. Evidence was given that there, clearly, is insufficient enforcing and auditing of the guidance and codes of practice .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of restraint for palletised loads during loading, unloading and road transport
Wider context from the report “1. Evidence was given at the inquest that the load which the deceased was carrying was sitting on the vehicle’s load bed without any restraint at all .
2. This, according to the evidence given, was ‘common practice nationwide with palletised loads’ . You note that this evidence was given by a senior engineer from the Engineering Safety Unit of the Health and Safety Laboratory.
3. This type of lack of restraint not only puts a driver at risk whilst driving but also at risk during loading and unloading .
4. Evidence was given at the inquest by the senior engineer that similar evidence has been given be her at inquests nationwide over a number of years without any apparent change in industry practice .
” 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