5 Feb 2025 Simon Timothy Harding · Prevention of Future Deaths report Somerset
View report summary
Concerns raised 7 Insufficient and ineffective track steward coverage for immediate assistance View source Absence of safety briefings for riders before track use View source Failure to control track access and maximum rider numbers View source Failure to segregate riders by skill, ability and bike power View source Failure to obtain riders’ next-of-kin and medical information before track access View source Lack of first-aid training for venue staff View source Absence of mandatory minimum safety and risk-management standards for motocross venues 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
Simon Timothy Harding · 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
Simon Timothy Harding died after becoming separated from his motocross bike during a jump at Granfield Moto-Cross Track on 10 September 2022; the bike landed on his head, causing catastrophic and unsurvivable head injuries. Concerns included limited rider registration, no safety briefing, inadequate track regulation and stewarding, lack of rider segregation, and no first-aid training for venue staff. The report also identified a lack of mandatory minimum safety and risk-management standards for motocross venues as a risk of future deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Insufficient and ineffective track steward coverage for immediate assistance
Wider context from the report “(a) There did not appear to be any method meaningful of rider registration before participants could access the Track. The only requirement placed on riders was provide their name and phone number before accessing the track. They were not required to provide details of a Next of Kin and/or medical information to assist paramedics or other professionals in safely and accurately treating them should they be unconscious and unable to communication and give this information for themselves. There appeared to be an assumption that those accompanying the rider on the day would know this information.
(b) There did not appear to be any kind of safety briefing for the riders before using the Track.
(c) The Track itself was largely unregulated. There was one operative ‘Marshall’ at site who was not wearing the high-vis clothing provided and remained confident that he could be clearly identified within the 4 acre site due to carrying a clip-board. At the time of the incident the steward was in the on-site burger van. Despite having a maximum number of riders at any one time, this was not checked or regulated due to the uncontrolled nature of Track access and absence of effective stewards. Adult riders of all skill sets with all speeds of bike could ride together. There was no attempt to segregate riders based on their skill, ability or power of their bike.
(d) Following on from the above point, there was one Marshall to cover the entire Track site which limited the ability to provide immediate and effective assistance in the event of an incident or accident at or on the Track.
(e) Staff at the venue (on the day of the incident, the one Marshall) had no first aid training. By pure chance, two spectators at the Track on the day were medically qualified professionals and coordinated the CPR between themselves until paramedics arrived.
Whilst I am satisfied on the evidence that the layout and organisation of the Track did not, in and of itself, contribute to Simon’s death, the areas of concern highlighted above do, in my opinion, create an enhanced and unmitigated risk that death may occur, over and above the usual risk associated with this type of recreational activity.
It was highlighted during the Inquest that there is an absence of mandatory regulation and implementation of minimum standards that moto-cross venues must confirm to. Whilst various organisations exist that seek to promote and raise minimum standards for such venues, membership of these organisations and compliance to any standards is entirely optional and at the discretion of the venue operator. The owners and operators of the Track appears to be entirely unaware of any such organisations of Minimum Standards documents. I am concerned that without minimum standards for safety and risk management, there is a 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 Absence of safety briefings for riders before track use
Wider context from the report “(a) There did not appear to be any method meaningful of rider registration before participants could access the Track. The only requirement placed on riders was provide their name and phone number before accessing the track. They were not required to provide details of a Next of Kin and/or medical information to assist paramedics or other professionals in safely and accurately treating them should they be unconscious and unable to communication and give this information for themselves. There appeared to be an assumption that those accompanying the rider on the day would know this information.
(b) There did not appear to be any kind of safety briefing for the riders before using the Track.
(c) The Track itself was largely unregulated. There was one operative ‘Marshall’ at site who was not wearing the high-vis clothing provided and remained confident that he could be clearly identified within the 4 acre site due to carrying a clip-board. At the time of the incident the steward was in the on-site burger van. Despite having a maximum number of riders at any one time, this was not checked or regulated due to the uncontrolled nature of Track access and absence of effective stewards. Adult riders of all skill sets with all speeds of bike could ride together. There was no attempt to segregate riders based on their skill, ability or power of their bike.
(d) Following on from the above point, there was one Marshall to cover the entire Track site which limited the ability to provide immediate and effective assistance in the event of an incident or accident at or on the Track.
(e) Staff at the venue (on the day of the incident, the one Marshall) had no first aid training. By pure chance, two spectators at the Track on the day were medically qualified professionals and coordinated the CPR between themselves until paramedics arrived.
Whilst I am satisfied on the evidence that the layout and organisation of the Track did not, in and of itself, contribute to Simon’s death, the areas of concern highlighted above do, in my opinion, create an enhanced and unmitigated risk that death may occur, over and above the usual risk associated with this type of recreational activity.
It was highlighted during the Inquest that there is an absence of mandatory regulation and implementation of minimum standards that moto-cross venues must confirm to. Whilst various organisations exist that seek to promote and raise minimum standards for such venues, membership of these organisations and compliance to any standards is entirely optional and at the discretion of the venue operator. The owners and operators of the Track appears to be entirely unaware of any such organisations of Minimum Standards documents. I am concerned that without minimum standards for safety and risk management, there is a 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 Failure to control track access and maximum rider numbers
Wider context from the report “(a) There did not appear to be any method meaningful of rider registration before participants could access the Track. The only requirement placed on riders was provide their name and phone number before accessing the track. They were not required to provide details of a Next of Kin and/or medical information to assist paramedics or other professionals in safely and accurately treating them should they be unconscious and unable to communication and give this information for themselves. There appeared to be an assumption that those accompanying the rider on the day would know this information.
(b) There did not appear to be any kind of safety briefing for the riders before using the Track.
(c) The Track itself was largely unregulated. There was one operative ‘Marshall’ at site who was not wearing the high-vis clothing provided and remained confident that he could be clearly identified within the 4 acre site due to carrying a clip-board. At the time of the incident the steward was in the on-site burger van. Despite having a maximum number of riders at any one time, this was not checked or regulated due to the uncontrolled nature of Track access and absence of effective stewards. Adult riders of all skill sets with all speeds of bike could ride together. There was no attempt to segregate riders based on their skill, ability or power of their bike.
(d) Following on from the above point, there was one Marshall to cover the entire Track site which limited the ability to provide immediate and effective assistance in the event of an incident or accident at or on the Track.
(e) Staff at the venue (on the day of the incident, the one Marshall) had no first aid training. By pure chance, two spectators at the Track on the day were medically qualified professionals and coordinated the CPR between themselves until paramedics arrived.
Whilst I am satisfied on the evidence that the layout and organisation of the Track did not, in and of itself, contribute to Simon’s death, the areas of concern highlighted above do, in my opinion, create an enhanced and unmitigated risk that death may occur, over and above the usual risk associated with this type of recreational activity.
It was highlighted during the Inquest that there is an absence of mandatory regulation and implementation of minimum standards that moto-cross venues must confirm to. Whilst various organisations exist that seek to promote and raise minimum standards for such venues, membership of these organisations and compliance to any standards is entirely optional and at the discretion of the venue operator. The owners and operators of the Track appears to be entirely unaware of any such organisations of Minimum Standards documents. I am concerned that without minimum standards for safety and risk management, there is a 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 Failure to segregate riders by skill, ability and bike power
Wider context from the report “(a) There did not appear to be any method meaningful of rider registration before participants could access the Track. The only requirement placed on riders was provide their name and phone number before accessing the track. They were not required to provide details of a Next of Kin and/or medical information to assist paramedics or other professionals in safely and accurately treating them should they be unconscious and unable to communication and give this information for themselves. There appeared to be an assumption that those accompanying the rider on the day would know this information.
(b) There did not appear to be any kind of safety briefing for the riders before using the Track.
(c) The Track itself was largely unregulated. There was one operative ‘Marshall’ at site who was not wearing the high-vis clothing provided and remained confident that he could be clearly identified within the 4 acre site due to carrying a clip-board. At the time of the incident the steward was in the on-site burger van. Despite having a maximum number of riders at any one time, this was not checked or regulated due to the uncontrolled nature of Track access and absence of effective stewards. Adult riders of all skill sets with all speeds of bike could ride together. There was no attempt to segregate riders based on their skill, ability or power of their bike.
(d) Following on from the above point, there was one Marshall to cover the entire Track site which limited the ability to provide immediate and effective assistance in the event of an incident or accident at or on the Track.
(e) Staff at the venue (on the day of the incident, the one Marshall) had no first aid training. By pure chance, two spectators at the Track on the day were medically qualified professionals and coordinated the CPR between themselves until paramedics arrived.
Whilst I am satisfied on the evidence that the layout and organisation of the Track did not, in and of itself, contribute to Simon’s death, the areas of concern highlighted above do, in my opinion, create an enhanced and unmitigated risk that death may occur, over and above the usual risk associated with this type of recreational activity.
It was highlighted during the Inquest that there is an absence of mandatory regulation and implementation of minimum standards that moto-cross venues must confirm to. Whilst various organisations exist that seek to promote and raise minimum standards for such venues, membership of these organisations and compliance to any standards is entirely optional and at the discretion of the venue operator. The owners and operators of the Track appears to be entirely unaware of any such organisations of Minimum Standards documents. I am concerned that without minimum standards for safety and risk management, there is a 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 Failure to obtain riders’ next-of-kin and medical information before track access
Wider context from the report “(a) There did not appear to be any method meaningful of rider registration before participants could access the Track. The only requirement placed on riders was provide their name and phone number before accessing the track. They were not required to provide details of a Next of Kin and/or medical information to assist paramedics or other professionals in safely and accurately treating them should they be unconscious and unable to communication and give this information for themselves. There appeared to be an assumption that those accompanying the rider on the day would know this information.
(b) There did not appear to be any kind of safety briefing for the riders before using the Track.
(c) The Track itself was largely unregulated. There was one operative ‘Marshall’ at site who was not wearing the high-vis clothing provided and remained confident that he could be clearly identified within the 4 acre site due to carrying a clip-board. At the time of the incident the steward was in the on-site burger van. Despite having a maximum number of riders at any one time, this was not checked or regulated due to the uncontrolled nature of Track access and absence of effective stewards. Adult riders of all skill sets with all speeds of bike could ride together. There was no attempt to segregate riders based on their skill, ability or power of their bike.
(d) Following on from the above point, there was one Marshall to cover the entire Track site which limited the ability to provide immediate and effective assistance in the event of an incident or accident at or on the Track.
(e) Staff at the venue (on the day of the incident, the one Marshall) had no first aid training. By pure chance, two spectators at the Track on the day were medically qualified professionals and coordinated the CPR between themselves until paramedics arrived.
Whilst I am satisfied on the evidence that the layout and organisation of the Track did not, in and of itself, contribute to Simon’s death, the areas of concern highlighted above do, in my opinion, create an enhanced and unmitigated risk that death may occur, over and above the usual risk associated with this type of recreational activity.
It was highlighted during the Inquest that there is an absence of mandatory regulation and implementation of minimum standards that moto-cross venues must confirm to. Whilst various organisations exist that seek to promote and raise minimum standards for such venues, membership of these organisations and compliance to any standards is entirely optional and at the discretion of the venue operator. The owners and operators of the Track appears to be entirely unaware of any such organisations of Minimum Standards documents. I am concerned that without minimum standards for safety and risk management, there is a 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 first-aid training for venue staff
Wider context from the report “(a) There did not appear to be any method meaningful of rider registration before participants could access the Track. The only requirement placed on riders was provide their name and phone number before accessing the track. They were not required to provide details of a Next of Kin and/or medical information to assist paramedics or other professionals in safely and accurately treating them should they be unconscious and unable to communication and give this information for themselves. There appeared to be an assumption that those accompanying the rider on the day would know this information.
(b) There did not appear to be any kind of safety briefing for the riders before using the Track.
(c) The Track itself was largely unregulated. There was one operative ‘Marshall’ at site who was not wearing the high-vis clothing provided and remained confident that he could be clearly identified within the 4 acre site due to carrying a clip-board. At the time of the incident the steward was in the on-site burger van. Despite having a maximum number of riders at any one time, this was not checked or regulated due to the uncontrolled nature of Track access and absence of effective stewards. Adult riders of all skill sets with all speeds of bike could ride together. There was no attempt to segregate riders based on their skill, ability or power of their bike.
(d) Following on from the above point, there was one Marshall to cover the entire Track site which limited the ability to provide immediate and effective assistance in the event of an incident or accident at or on the Track.
(e) Staff at the venue (on the day of the incident, the one Marshall) had no first aid training. By pure chance, two spectators at the Track on the day were medically qualified professionals and coordinated the CPR between themselves until paramedics arrived.
Whilst I am satisfied on the evidence that the layout and organisation of the Track did not, in and of itself, contribute to Simon’s death, the areas of concern highlighted above do, in my opinion, create an enhanced and unmitigated risk that death may occur, over and above the usual risk associated with this type of recreational activity.
It was highlighted during the Inquest that there is an absence of mandatory regulation and implementation of minimum standards that moto-cross venues must confirm to. Whilst various organisations exist that seek to promote and raise minimum standards for such venues, membership of these organisations and compliance to any standards is entirely optional and at the discretion of the venue operator. The owners and operators of the Track appears to be entirely unaware of any such organisations of Minimum Standards documents. I am concerned that without minimum standards for safety and risk management, there is a 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 Absence of mandatory minimum safety and risk-management standards for motocross venues
Wider context from the report “(a) There did not appear to be any method meaningful of rider registration before participants could access the Track. The only requirement placed on riders was provide their name and phone number before accessing the track. They were not required to provide details of a Next of Kin and/or medical information to assist paramedics or other professionals in safely and accurately treating them should they be unconscious and unable to communication and give this information for themselves. There appeared to be an assumption that those accompanying the rider on the day would know this information.
(b) There did not appear to be any kind of safety briefing for the riders before using the Track.
(c) The Track itself was largely unregulated. There was one operative ‘Marshall’ at site who was not wearing the high-vis clothing provided and remained confident that he could be clearly identified within the 4 acre site due to carrying a clip-board. At the time of the incident the steward was in the on-site burger van. Despite having a maximum number of riders at any one time, this was not checked or regulated due to the uncontrolled nature of Track access and absence of effective stewards. Adult riders of all skill sets with all speeds of bike could ride together. There was no attempt to segregate riders based on their skill, ability or power of their bike.
(d) Following on from the above point, there was one Marshall to cover the entire Track site which limited the ability to provide immediate and effective assistance in the event of an incident or accident at or on the Track.
(e) Staff at the venue (on the day of the incident, the one Marshall) had no first aid training. By pure chance, two spectators at the Track on the day were medically qualified professionals and coordinated the CPR between themselves until paramedics arrived.
Whilst I am satisfied on the evidence that the layout and organisation of the Track did not, in and of itself, contribute to Simon’s death, the areas of concern highlighted above do, in my opinion, create an enhanced and unmitigated risk that death may occur, over and above the usual risk associated with this type of recreational activity.
It was highlighted during the Inquest that there is an absence of mandatory regulation and implementation of minimum standards that moto-cross venues must confirm to. Whilst various organisations exist that seek to promote and raise minimum standards for such venues, membership of these organisations and compliance to any standards is entirely optional and at the discretion of the venue operator. The owners and operators of the Track appears to be entirely unaware of any such organisations of Minimum Standards documents. I am concerned that without minimum standards for safety and risk management, there is a risk of future deaths.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for concerns about a racetrack bike crash lies with DCMS rather than the Department for Transport.
Verbatim wording from the response “Our officials have advised that the matters of concerns raised would not be appropriate for DfT to respond but is for DCMS, as the bike crash happened on a racetrack and not on the public highway.” Source location Response from Department for Transport
Open published response
13 Jan 2025 Angela Stacey Carney · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 2 Lack of an independent secondary braking mechanism in some mobility scooters View source Potential safety hazards from use of older second-hand mobility scooters View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Angela Stacey Carney · 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 26 September 2023, Angela Stacey Carney suffered fatal injuries after her mobility scooter travelled at speed down Westcliffe Road and into the path of a pickup at a junction. The scooter was in freewheel mode, which prevented braking, and the report raised concerns about the absence of an independent fail-safe braking mechanism and the safety of older second-hand mobility scooters.
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 an independent secondary braking mechanism in some mobility scooters
Wider context from the report “Although it is my understanding that more recently designed and manufactured mobility scooters are manufactured with a secondary braking system by way of a fitted hand brake mechanism, I am concerned that other manufacturers may be producing scooters without such an independent braking mechanism .
I also have a concern that there may be many other older second hand models on the second hand market that are being used, which all combined has worrying safety implications for the rider’s and members of the public.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Potential safety hazards from use of older second-hand mobility scooters
Wider context from the report “Although it is my understanding that more recently designed and manufactured mobility scooters are manufactured with a secondary braking system by way of a fitted hand brake mechanism, I am concerned that other manufacturers may be producing scooters without such an independent braking mechanism.
I also have a concern that there may be many other older second hand models on the second hand market that are being used , which all combined has worrying safety implications for the rider’s and members of the public .
” 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 Continue liaising with the MHRA to establish whether further preventive measures are needed.
Verbatim wording from the response “Officials in my Department will continue to liaise with the MHRA to establish whether anything further can be done to prevent such a tragic death happening in future; for example, by providing information to mobility scooter users highlighting the risks of operating in freewheel model and warning users about the absence of a secondary brake on older models of scooter.” Source location Response from Department for Transport
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for mobility scooter construction requirements rests with the MHRA, while the Department regulates their use in the built environment.
Verbatim wording from the response “The regulatory requirements for the construction of mobility scooters is the responsibility of the Medicines and Healthcare products Regulatory Agency (MHRA). The Department for Transport (DfT) has responsibility for the use of these vehicles in the built environment, and the relevant regulations are The Use of Invalid Carriages on Highways Regulations 1988.” Source location Response from Department for Transport
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The mobility scooter was compliant with the 1988 Regulations, including their braking-system requirements.
Verbatim wording from the response “The DfT regulations specify the circumstances where mobility scooters may be used and contain provisions on the performance requirements these vehicles need to meet. Regulation 8 requires braking systems to be maintained, to be able to bring the mobility scooter to rest in all conditions of use, and capable of holding it stationary on a one in five gradient. The regulations permit a transmission brake which operates on the electric motor, and from the information available to us, the mobility scooter was compliant with the 1988 Regulations.” Source location Response from Department for Transport
Open published response
13 Jan 2025 Joseph Samuel Walsh and Tobias Crowther Barraclough · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 3 Increased collision risk for young drivers carrying similarly aged passengers View source Lack of legal restrictions on the licences of young or newly qualified drivers View source Vehicle licensing regime permitting the carrying of young passengers View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Joseph Samuel Walsh and Tobias Crowther Barraclough · 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
Joseph Samuel Walsh was driving a car carrying four passengers after alcohol and cocaine had been consumed when the vehicle collided with a wall on 20 October 2023. Joseph died at the scene, and Tobias Crowther Barraclough later died from his injuries on 12 November 2023; the surviving passengers were injured. The report raises concerns about the absence of legal restrictions on young or newly qualified drivers and the carrying of young passengers in circumstances such as these.
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 Increased collision risk for young drivers carrying similarly aged passengers
Wider context from the report “• Currently there are no legal restrictions upon the licences of young and /or newly qualified drivers and the current vehicle licensing regime permits the carrying of young persons as passengers in circumstances such as these
• Young drivers may be more likely to be involved in a collision with similar aged passengers in the car.
• I would ask you to consider the appropriateness of reviewing the current provisions since I am concerned that there will be further like tragic 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 legal restrictions on the licences of young or newly qualified drivers
Wider context from the report “• Currently there are no legal restrictions upon the licences of young and /or newly qualified drivers and the current vehicle licensing regime permits the carrying of young persons as passengers in circumstances such as these
• Young drivers may be more likely to be involved in a collision with similar aged passengers in the car.
• I would ask you to consider the appropriateness of reviewing the current provisions since I am concerned that there will be further like tragic 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 Vehicle licensing regime permitting the carrying of young passengers
Wider context from the report “• Currently there are no legal restrictions upon the licences of young and /or newly qualified drivers and the current vehicle licensing regime permits the carrying of young persons as passengers in circumstances such as these
• Young drivers may be more likely to be involved in a collision with similar aged passengers in the car.
• I would ask you to consider the appropriateness of reviewing the current provisions since I am concerned that there will be further like tragic deaths.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Graduated driving licences are not being considered as a response to disproportionate risks affecting young drivers.
Verbatim wording from the response “Whilst we are not considering Graduated Driving Licences, we absolutely recognise that young people are disproportionately victims of tragic incidents on our roads. As work progresses on the new road safety strategy, we are exploring options to tackle the root causes of this without unfairly penalising young drivers.” Source location Response from Department of Transport
Open published response
13 Jan 2025 Joseph Samuel WALSH · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 2 Lack of legal licence restrictions for young and/or newly qualified drivers View source Vehicle licensing regime permitting the carrying of young persons as passengers in these circumstances View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Joseph Samuel WALSH · 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
Joseph was driving on Brow Lane on 20 October 2023 when his vehicle collided with a wall, and he was pronounced deceased at the scene. The report raises concerns about the absence of legal restrictions on young or newly qualified drivers and the carrying of young passengers, noting the potential for further similar deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of legal licence restrictions for young and/or newly qualified drivers
Wider context from the report “Joseph was aged 18 at the time of his death following the collision and had passed his driving test in May 2023. This was five months prior to the collision. At the time of the collision, he was legally carrying 5 young friends.
Currently there are no legal restrictions upon the licences of young and /or newly qualified drivers and the current vehicle licensing regime permits the carrying of young persons as passengers in circumstances such as these
Young drivers may be more likely to be involved in a collision with similar aged passengers in the car.
I would ask you to consider the appropriateness of reviewing the current provisions since I am concerned that there will be further like tragic 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 Vehicle licensing regime permitting the carrying of young persons as passengers in these circumstances
Wider context from the report “Joseph was aged 18 at the time of his death following the collision and had passed his driving test in May 2023. This was five months prior to the collision. At the time of the collision, he was legally carrying 5 young friends.
Currently there are no legal restrictions upon the licences of young and /or newly qualified drivers and the current vehicle licensing regime permits the carrying of young persons as passengers in circumstances such as these
Young drivers may be more likely to be involved in a collision with similar aged passengers in the car.
I would ask you to consider the appropriateness of reviewing the current provisions since I am concerned that there will be further like tragic deaths.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Graduated Driving Licences are not currently being considered, although other options to address young-driver risk are being explored.
Verbatim wording from the response “Whilst we are not considering Graduated Driving Licences, we absolutely recognise that young people are disproportionately victims of tragic incidents on our roads. As work progresses on the new road safety strategy, we are exploring options to tackle the root causes of this without unfairly penalising young drivers.” Source location Response from Department of Transport
Open published response
24 Dec 2024 Daniel Isaacs · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 2 Lack of a requirement for electric scooter riders to wear helmets View source Risk of death to electric scooter and bicycle riders not wearing protective headwear in collisions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Daniel Isaacs · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Daniel Isaacs died after losing control of an electric scooter, colliding with the road surface and sustaining a serious head injury. The report raised concern that electric scooter riders and cyclists are not required to wear helmets, creating a risk of death in collisions involving people not wearing protective headwear.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of a requirement for electric scooter riders to wear helmets
Wider context from the report “There is no requirement that riders of electric scooters wear helmets. Due to the expectation of their use on the road, and their vulnerability, there is a risk of death to riders of electric scooters and bicycles not wearing protective headwear who are involved in collisions, even at lower speeds.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Risk of death to electric scooter and bicycle riders not wearing protective headwear in collisions
Wider context from the report “There is no requirement that riders of electric scooters wear helmets. Due to the expectation of their use on the road, and their vulnerability, there is a risk of death to riders of electric scooters and bicycles not wearing protective headwear who are involved in collisions, even at lower speeds.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission a second evaluation of e-scooter trials.
Verbatim wording from the response “However, the purpose of the trials is to inform future regulations on e-scooters and no decisions on this have been made. I have just commissioned a second evaluation of the e-scooter trials, which will look at the impact of helmet provision and uptake amongst e-scooter users and I will ensure we consider a full range of evidence, including international comparisons and a public consultation, before any regulations on the use of e-scooters come into force.” Source location Response from Department for Transport
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete a comprehensive review of cycling and walking safety, including whether cycle helmets should be mandatory.
Verbatim wording from the response “On the matter of helmets for cycles, the question is complex. The Government must carefully balance the safety benefits of mandating helmets against the potential disbenefits. The Department carefully looked at the case for making helmet wearing mandatory in a comprehensive Cycling and Walking Safety Review in 2018 (www.gov.uk/government/speeches/governments-response-to-the-cycling-walking-investment-strategy-safety-review).” Source location Response from Department for Transport
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Evaluate the impact of helmet provision and uptake among e-scooter users.
Verbatim wording from the response “However, the purpose of the trials is to inform future regulations on e-scooters and no decisions on this have been made. I have just commissioned a second evaluation of the e-scooter trials, which will look at the impact of helmet provision and uptake amongst e-scooter users and I will ensure we consider a full range of evidence, including international comparisons and a public consultation, before any regulations on the use of e-scooters come into force.” Source location Response from Department for Transport
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Mandatory cycle helmets are not considered necessary because reduced cycling, health and environmental benefits would outweigh their safety benefits.
Verbatim wording from the response “On the matter of helmets for cycles, the question is complex. The Government must carefully balance the safety benefits of mandating helmets against the potential disbenefits. The Department carefully looked at the case for making helmet wearing mandatory in a comprehensive Cycling and Walking Safety Review in 2018 (www.gov.uk/government/speeches/governments-response-to-the-cycling-walking-investment-strategy-safety-review).” Source location Response from Department for Transport
Open published response
20 Dec 2024 David John Haw · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 8 Lack of required pre-journey safety briefings on pleasure vessels View source Use of support boats as taxis for event-related social transport View source Lack of specific guidance on support-boat responsibilities at sailing events View source Lack of legal requirement to wear lifejackets View source Failure to require carriage of personal flotation devices on all vessels View source Failure of vessel owners and operators to know support-boat use and passenger identity View source Lack of prohibition on helming pleasure vessels under the influence of alcohol or drugs View source Lack of equivalent safety mitigation for pleasure vessels used in commercial-like conditions View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
David John Haw · 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
David John Haw was thrown from a support RHIB after it collided with a buoy in Poole Harbour at approximately 30 knots on 2 May 2022. He was recovered from the water on 14 May 2022, and the inquest recorded drowning and concluded unlawful killing. The concerns include differing safety requirements for pleasure and commercial vessels, alcohol use by pleasure-vessel helms, the absence of requirements for lifejackets on some vessels, and the use and regulation of support boats at sailing events.
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 required pre-journey safety briefings on pleasure vessels
Wider context from the report “Vessels that operate on the water are categorised as either pleasure or commercial vessels under current legislation and the legal requirements governing the design, construction and operation are very different, with commercial vessels being more heavily regulated. The definition of a pleasure vessel is provided under Regulation 2 of The Merchant Shipping (Vessels in Commercial Use for Sport or Pleasure) Regulations 1998 and any vessel that does not meet the definition under regulation 2, is a commercial vessel.
I have concerns that pleasure vessels are being used in a manner, and in conditions, that would be very similar to commercial vessels without the same safety mitigation. For example, there is no requirement to have a safety briefing prior to a journey on a pleasure vessel , whereas there is on a commercial vessel, however the risks may be the same, which can include 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 Use of support boats as taxis for event-related social transport
Wider context from the report “Finally, I have concerns about the use of support boats, often RHIBs, at sailing events or regattas, and particularly when they are used outside of the designated sailing time but in a way linked to the event, for example to transport people to and from the organised social events linked to the regattas, where often there is alcohol available.
I have concerns that there is a culture of using such support boats as a form of taxi particularly at the social events , albeit not for pecuniary gain. This means they could come under the definition of a pleasure vessel and as those helming these vessels may be in drink, they may not take necessary precautions and safety measures given the lack of regulations. Further the owner and operator of the vessel may not be aware, as was the case in David’s death, of the use of the vessel in this way, or of the identity of those on board which may result in the vessel falling under the commercial vessel definition for the purposes of those journeys with the appropriate regulations not being followed.
Under Rules 89 and 90 of the World Sailing Racing Rules of Sailing (RRS20212024Finalwithbookmarks-172255.pdf) (The Rules) there is a requirement for race organisers to issue a “Notice to Race” and “Sailing Instructions” for the race. Under Appendix J to the Rules, at paragraph J2.2, it is stated “Unless included in the notice of race, the sailing instructions shall include those of the following that will apply: …….. (9) restrictions on use of support boats, plastic pools, radios, etc.; on trash disposal; on hauling out; and on outside assistance provided to a boat that is not racing”.
The RYA in their guidance recommend a risk statement is used by race organisers for sailing events, however, the RYA guidance does not contain a specific section to deal with the use of support boats. I am concerned there is a lack of guidance to organisers of race events to ensure that the owners, operators and skippers/helms of vessels are aware of the responsibilities around use of support boats during the period of sailing events, which could lead to a future 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 specific guidance on support-boat responsibilities at sailing events
Wider context from the report “Finally, I have concerns about the use of support boats, often RHIBs, at sailing events or regattas, and particularly when they are used outside of the designated sailing time but in a way linked to the event, for example to transport people to and from the organised social events linked to the regattas, where often there is alcohol available.
I have concerns that there is a culture of using such support boats as a form of taxi particularly at the social events, albeit not for pecuniary gain. This means they could come under the definition of a pleasure vessel and as those helming these vessels may be in drink, they may not take necessary precautions and safety measures given the lack of regulations. Further the owner and operator of the vessel may not be aware, as was the case in David’s death, of the use of the vessel in this way, or of the identity of those on board which may result in the vessel falling under the commercial vessel definition for the purposes of those journeys with the appropriate regulations not being followed.
Under Rules 89 and 90 of the World Sailing Racing Rules of Sailing (RRS20212024Finalwithbookmarks-172255.pdf) (The Rules) there is a requirement for race organisers to issue a “Notice to Race” and “Sailing Instructions” for the race. Under Appendix J to the Rules, at paragraph J2.2, it is stated “Unless included in the notice of race, the sailing instructions shall include those of the following that will apply: …….. (9) restrictions on use of support boats, plastic pools, radios, etc.; on trash disposal; on hauling out; and on outside assistance provided to a boat that is not racing”.
The RYA in their guidance recommend a risk statement is used by race organisers for sailing events, however, the RYA guidance does not contain a specific section to deal with the use of support boats . I am concerned there is a lack of guidance to organisers of race events to ensure that the owners, operators and skippers/helms of vessels are aware of the responsibilities around use of support boats during the period of sailing events , which could lead to a future 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 legal requirement to wear lifejackets
Wider context from the report “Further, I have a concern that personal floatation devices, such as lifejackets or buoyancy aids are not legally required to be carried on all vessels, nor is there any legal requirement to wear lifejackets . The current legislation, The Merchant Shipping (Life-Saving Appliances and Arrangements) Regulations 2020, only requires pleasure vessels of over 13.7 metres in length to carry lifesaving appliances. I have concern that the lack of life saving appliances on all vessels could lead to future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure to require carriage of personal flotation devices on all vessels
Wider context from the report “Further, I have a concern that personal floatation devices, such as lifejackets or buoyancy aids are not legally required to be carried on all vessels , nor is there any legal requirement to wear lifejackets. The current legislation, The Merchant Shipping (Life-Saving Appliances and Arrangements) Regulations 2020, only requires pleasure vessels of over 13.7 metres in length to carry lifesaving appliances . I have concern that the lack of life saving appliances on all vessels could lead to future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure of vessel owners and operators to know support-boat use and passenger identity
Wider context from the report “Finally, I have concerns about the use of support boats, often RHIBs, at sailing events or regattas, and particularly when they are used outside of the designated sailing time but in a way linked to the event, for example to transport people to and from the organised social events linked to the regattas, where often there is alcohol available.
I have concerns that there is a culture of using such support boats as a form of taxi particularly at the social events, albeit not for pecuniary gain. This means they could come under the definition of a pleasure vessel and as those helming these vessels may be in drink, they may not take necessary precautions and safety measures given the lack of regulations. Further the owner and operator of the vessel may not be aware , as was the case in David’s death, of the use of the vessel in this way, or of the identity of those on board which may result in the vessel falling under the commercial vessel definition for the purposes of those journeys with the appropriate regulations not being followed.
Under Rules 89 and 90 of the World Sailing Racing Rules of Sailing (RRS20212024Finalwithbookmarks-172255.pdf) (The Rules) there is a requirement for race organisers to issue a “Notice to Race” and “Sailing Instructions” for the race. Under Appendix J to the Rules, at paragraph J2.2, it is stated “Unless included in the notice of race, the sailing instructions shall include those of the following that will apply: …….. (9) restrictions on use of support boats, plastic pools, radios, etc.; on trash disposal; on hauling out; and on outside assistance provided to a boat that is not racing”.
The RYA in their guidance recommend a risk statement is used by race organisers for sailing events, however, the RYA guidance does not contain a specific section to deal with the use of support boats. I am concerned there is a lack of guidance to organisers of race events to ensure that the owners, operators and skippers/helms of vessels are aware of the responsibilities around use of support boats during the period of sailing events, which could lead to a future 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 prohibition on helming pleasure vessels under the influence of alcohol or drugs
Wider context from the report “Further in relation to pleasure vessels, there is currently no legislation prohibiting the use of alcohol or drugs by those who are helming a vessel for private or pleasure use , whereas for those helming a commercial vessel, there is. The Railways and Transport Safety Act 2003 was enacted on 10th July 2003. Section 78 & 79 of that Act created an offence for professional mariners to perform their duties if impaired by alcohol, with Section 81 setting a prescribed limit for alcohol consumption. This position is very similar to an offence of driving a motor vehicle under the influence of alcohol. Under Section 80(3) there is a specific offence applicable to non-professional mariners of operating a vessel underway whilst under the influence of alcohol or drugs, however it is not currently in force. Accordingly, it is not illegal to helm a pleasure vessel under the influence of alcohol or drugs . Helming a vessel under the influence of alcohol or drugs could lead to a future death given the impact alcohol and drugs has upon perception, control, judgement and decision making.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of equivalent safety mitigation for pleasure vessels used in commercial-like conditions
Wider context from the report “Vessels that operate on the water are categorised as either pleasure or commercial vessels under current legislation and the legal requirements governing the design, construction and operation are very different, with commercial vessels being more heavily regulated. The definition of a pleasure vessel is provided under Regulation 2 of The Merchant Shipping (Vessels in Commercial Use for Sport or Pleasure) Regulations 1998 and any vessel that does not meet the definition under regulation 2, is a commercial vessel.
I have concerns that pleasure vessels are being used in a manner, and in conditions, that would be very similar to commercial vessels without the same safety mitigation . For example, there is no requirement to have a safety briefing prior to a journey on a pleasure vessel, whereas there is on a commercial vessel, however the risks may be the same, which can include death.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue reviewing the evidence base on alcohol limits for recreational mariners.
Verbatim wording from the response “Turning to recreational mariner alcohol limits, the Railways and Transport Safety Act provides alcohol limits and corresponding offences for professional mariners, however no proscribed limits for alcohol have been set for recreational mariners. As noted above, there is already an offence which can be applied in these circumstances under the Merchant Shipping Act 1995. To date, the Department has held three consultations on this issue, the latest a request for evidence to inform a review of the position in 2021. Responses have continued to demonstrate the significant challenges to the introduction of alcohol (and drug) limits for recreational mariners. These noted strong views, both for and against.” Source location Response from Department for Transport
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Bring forward an updated Sport or Pleasure Vessel Code to improve small commercial vessel safety.
Verbatim wording from the response “I would like to take this opportunity to reassure you that my officials within the MCA are working hard to bring forward new legislation and an updated Sport or Pleasure Vessel Code as soon as practical to improve small commercial vessel safety. The MCA will continue to work to ensure that pleasure vessel owners and operators take seriously their responsibilities for ensuring the safety of those onboard their vessels.” Source location Response from Department for Transport
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with sector partners to improve awareness of the risks of drinking and sailing.
Verbatim wording from the response “They also highlighted that the number of serious incidents involving recreational mariners where alcohol was a causal factor is, thankfully, extremely low and that statistics alone do not support the introduction of a national limit. We will continue to keep the evidence base under review and to work with partners in the sector focussing on improving awareness of the risks of drinking and sailing.” Source location Response from Department for Transport
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Mandatory personal flotation device requirements are not introduced because there is insufficient evidence to justify regulatory intervention.
Verbatim wording from the response “Although there is currently no legislation requiring the mandatory wearing of personal flotation devices (PFDs) on any pleasure vessel in the UK, there is not yet sufficient evidence to justify a regulatory intervention to this effect. Some local water authorities, ports and marinas do require this under their by-laws and, of course, voluntary wear is strongly encouraged as publicised by the MCA through Marine Guidance Note (MGN) 599 (M) Amendment 1 “Pleasure vessels – Regulations and Exemptions – Guidance and Best Practice Advice”. This MGN also provides a range of guidance and best practice advice for pleasure vessel owners which includes appropriate training and avoiding consumption of alcohol as well as the wearing of PFDs.” Source location Response from Department for Transport
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A national alcohol limit for recreational mariners is not supported because existing offences apply and evidence does not justify introducing one.
Verbatim wording from the response “Whilst pleasure vessels are not subject to many of the specific regulations that small commercial vessels are, they do remain in scope of the regulatory frameworks set out by Merchant Shipping Act 1995 (MSA), and in particular the Merchant Shipping (Distress Signals and Prevention of Collisions) Regulations 1996 (SI 1996 no. 75). As such, if a pleasure vessel was being operated in such a way that was “dangerously unsafe” there are mechanisms under Section 100 of the MSA to take appropriate action. Likewise, if the consumption of alcohol was a contributing factor and meant the vessel operator was unable to keep a proper lookout, this too would be a prosecutable offence under UK Regulations.” Source location Response from Department for Transport
Open published response
Concerns raised 3 Failure to ascertain relevant manager contact details for hospital helicopter landing sites View source Hazard to people on the ground near hospital helicopter landing sites View source Lack of a real-time database of hospital helicopter landing sites View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jean LANGAN · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 4 March 2022, Jean Langan fell and struck her head when the downwash from a landing helicopter affected her in a public car park at Derriford Hospital; she suffered a serious head injury and died shortly afterwards. The concerns identified included the safe landing of hospital helicopters without endangering people nearby, and the need for a real-time database of hospital helicopter landing sites and contact details for the relevant site managers.
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 ascertain relevant manager contact details for hospital helicopter landing sites
Wider context from the report “Helicopters should land safely at Hospital Helicopter Landing sites without endangering those on the ground in the vicinity of the landing site.
There was identified the need for a real time data base of Hospital Helicopter Landing sites to ensure the safe landing of helicopters.
There was identified a need to ascertain the contact details of the relevant manager of each Helicopter landing site at all Hospital Trusts which receive helicopters .
More particularly set out by the representative for the Air Service Operator by letter of the 6th of December 2024 reciting a request of 22 November 2024.
” 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 Hazard to people on the ground near hospital helicopter landing sites
Wider context from the report “Helicopters should land safely at Hospital Helicopter Landing sites without endangering those on the ground in the vicinity of the landing site .
There was identified the need for a real time data base of Hospital Helicopter Landing sites to ensure the safe landing of helicopters.
There was identified a need to ascertain the contact details of the relevant manager of each Helicopter landing site at all Hospital Trusts which receive helicopters.
More particularly set out by the representative for the Air Service Operator by letter of the 6th of December 2024 reciting a request of 22 November 2024.
” 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 real-time database of hospital helicopter landing sites
Wider context from the report “Helicopters should land safely at Hospital Helicopter Landing sites without endangering those on the ground in the vicinity of the landing site.
There was identified the need for a real time data base of Hospital Helicopter Landing sites to ensure the safe landing of helicopters.
There was identified a need to ascertain the contact details of the relevant manager of each Helicopter landing site at all Hospital Trusts which receive helicopters.
More particularly set out by the representative for the Air Service Operator by letter of the 6th of December 2024 reciting a request of 22 November 2024.
” 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 Develop options for a comprehensive, dynamic database of hospital helicopter landing sites.
Verbatim wording from the response “The DfT has carefully considered your report and its recommendation to develop a database of HHLSs. It is the responsibility of hospitals to procure and maintain any database. We will assist DHSC, hospitals and the NHS by developing options for a database that meet your and the AAIB’s recommendations. We have already started this work. DfT is the co-chair of the Onshore Leadership Group (OnSLG), a forum of rotary operators including air ambulances, Bristol Helicopters and utility operators. This has helped us to investigate how a dynamic and comprehensive database of all HHLSs can be established. We have also spoken to the supplier of the offshore helipad database, and the existing supplier of mapping software to much of the air ambulance and SAR communities.” Source location Response from Department for Transport
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider legislating to strengthen safety oversight of hospital helicopter landing sites.
Verbatim wording from the response “However, we are determined to play our part in reducing the risk at these sites as far as possible. We are also acting on the AAIB’s recommendation to strengthen oversight of HHLSs. In conjunction with the CAA and industry, the DfT is currently considering whether to legislate to ensure safety at all HHLSs. This would be a long-term (2-4 year) project requiring secondary legislation.” Source location Response from Department for Transport
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Oversight of HHLS safety falls outside the remit for unlicensed sites, because the Department oversees only licensed helipads.
Verbatim wording from the response “Hospitals are responsible for the safety of HHLSs located on their grounds. The DfT is responsible for overseeing the safety only of licenced helipads. Currently, all HHLSs are unlicensed. This means they do not have to comply with CAA’s CAP 1264 guidance for hospital helicopter landing areas.” Source location Response from Department for Transport
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation DHSC, working with NHS England and national health authorities, is responsible for ensuring each HHLS has an accountable manager.
Verbatim wording from the response “We understand that the Department of Health and Social Care (DHSC) will respond on your recommendation to ensure each HHLS has an accountable manager. We also understand that DHSC will work with NHS England to implement the demands in Bristol’s letter of 6th December 2024. A named accountable manager is essential to the establishment and maintenance of an HHLS database, and the DHSC is working with national health authorities to ensure that each HHLS has a named and competent accountable manager.” Source location Response from Department for Transport
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hospitals are responsible for procuring and maintaining the HHLS database.
Verbatim wording from the response “The DfT has carefully considered your report and its recommendation to develop a database of HHLSs. It is the responsibility of hospitals to procure and maintain any database. We will assist DHSC, hospitals and the NHS by developing options for a database that meet your and the AAIB’s recommendations. We have already started this work. DfT is the co-chair of the Onshore Leadership Group (OnSLG), a forum of rotary operators including air ambulances, Bristol Helicopters and utility operators. This has helped us to investigate how a dynamic and comprehensive database of all HHLSs can be established. We have also spoken to the supplier of the offshore helipad database, and the existing supplier of mapping software to much of the air ambulance and SAR communities.” Source location Response from Department for Transport
Open published response
26 Nov 2024 Jon-Paul PRIGENT · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 3 Failure of current agricultural tractor and trailer safety arrangements to keep pace with changing road use View source Lack of periodic independent vehicle testing for tractors and trailers used on roads for agricultural purposes View source Failure to require safety features preventing decoupling of tractors and trailers used on public roads View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jon-Paul PRIGENT · 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
Jon-Paul Prigent died on 30 July 2020 when a soil-laden trailer decoupled from its tractor, overturned, and compressed the car in which he was sitting, causing asphyxiation. The principal concerns were the absence of periodic independent testing for agricultural tractors and trailers, the lack of required safety features to prevent decoupling, and the risks posed by worn, overloaded, and unevenly loaded equipment used on public roads.
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 current agricultural tractor and trailer safety arrangements to keep pace with changing road use
Wider context from the report “4. Tractors and trailers are increasingly large and carrying heavier loads due to farm consolidation and are correspondingly traveling further distances on public roads to reach more distant areas on larger farms, and agri-business depots and processing sites. The current safety arrangements have probably failed to keep up to date and relevant and were more suited to an era when agricultural use tractors and trailers might simply have been crossing a road to get form one field to another .
” 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 independent vehicle testing for tractors and trailers used on roads for agricultural purposes
Wider context from the report “1. Tractors and trailers driven on roads for ‘agricultural purposes’ are not subject to periodic independent vehicle testing . This places the responsibility for checking roadworthiness on the user which is clearly dependent on the diligence and competence of the user. It is therefore highly likely that some tractors and trailers are being driven on roads for ‘agricultural purposes’ in unroadworthy and unsafe condition , as was clear in Mr Prigent’s inquest.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure to require safety features preventing decoupling of tractors and trailers used on public roads
Wider context from the report “2. Tractors and trailers driven on roads at below a speed of 25 miles per hour are not required to be fitted with safety features to prevent decoupling (e.g. a safety chain, or dual safe braking system) . Therefore, if decoupling occurs there is nothing to prevent independent and uncontrolled travel of the trailer .
3. Basic hitch hook and ring coupling systems for tractors and trailers are very simple and convenient for ease and speed of coupling and use on farms but present clear risk when used on public roads without safety features to prevent decoupling .
” 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 Instruct officials to examine further measures for ensuring the roadworthiness of tractors, trailers and coupling devices.
Verbatim wording from the response “In view of your report, I will instruct my officials to examine what more could be done to ensure the roadworthiness of tractors, trailers and coupling devices. Additionally, to help promote good maintenance of agricultural vehicles I have asked my officials to investigate how best to raise awareness of the DVSA’s published guidance on maintaining roadworthiness and vehicle loading, as well as the existing voluntary trailer maintenance scheme. My officials will consider how best this information can be communicated to operators of agricultural vehicles.” Source location Response from Department for Transport
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue monitoring the effectiveness of vehicle safety regulations to identify potential amendments.
Verbatim wording from the response “The Department will continue to monitor the effectiveness of vehicle safety regulations to identify any potential amendments.” Source location Response from Department 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 Annual roadworthiness testing was not extended to slower agricultural tractors because their road use was considered too limited to make it proportionate.
Verbatim wording from the response “My Department conducted a consultation in 2016 on introducing roadworthiness testing for fast tractors used for commercial haulage. As a result, agricultural tractors capable of a speed over 40km/h (approximately 25mph) being used for commercial haulage were brought into scope of the Motor Vehicles (Tests) Regulations 1981, therefore requiring them to be subject to annual roadworthiness testing. At the time, it was decided that it would not be proportionate to bring slower speed agricultural tractors in scope of annual roadworthiness testing given their use on roads is limited in comparison with other vehicles.” Source location Response from Department for Transport
Open published response
Concerns raised 1 Lack of medical fitness-to-drive assessment for drivers over 70 View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Dorothy Jennifer Nias · 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
Dorothy Nias was involved in a road traffic collision on the A39 at Devoran, Truro, after confusing the brake and accelerator pedals in her automatic vehicle. She sustained multiple injuries, experienced a gradual deterioration in her condition and died on 6 November 2023; concerns included her continued driving despite prior minor incidents and the absence of a required medical fitness assessment for drivers over 70.
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 medical fitness-to-drive assessment for drivers over 70
Wider context from the report “It was clear from the evidence that there were concerns raised by family members to Miss Nias regarding her ability to continue to drive having had a number of minor incidents prior to this collision. Despite encouragement to use alternative means of transport she was described as independent and chose to continue. The accident was caused by confusion between her brake and accelerator pedals in an automatic transmission vehicle, allowing her speed to increase without restriction and as a result she was unable to negotiate the roundabout leading to the collision. At present there is no upper age limit for drivers. Drivers over 70 are required to apply for a new licence every 3 years and there is no requirement for there to be any form of medical check or assessment to confirm fitness to drive . The applicant must make a self-declaration .
” 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 Analyse call-for-evidence research and evidence to assess whether further research or legislative changes are needed, including self-declaration.
Verbatim wording from the response “In 2023, the DVLA carried out a call for evidence about driver licensing for people with medical conditions. The call for evidence sought views on the current legislative basis for assessing fitness to drive and what changes may be made. This was an important first step in gathering a wide range of views and evidence that may support future changes to the legal framework. The DVLA is considering the research and evidence provided and the need for any further research that may be required to inform potential changes to the legislative framework governing driver licensing for those with medical conditions. This will include the process of self-declaration. There are no plans for changes to the current driver licensing requirements while the analysis of the call for evidence responses continues.” Source location Response from Department for Transport
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conducted a call for evidence on driver licensing for people with medical conditions.
Verbatim wording from the response “In 2023, the DVLA carried out a call for evidence about driver licensing for people with medical conditions. The call for evidence sought views on the current legislative basis for assessing fitness to drive and what changes may be made. This was an important first step in gathering a wide range of views and evidence that may support future changes to the legal framework. The DVLA is considering the research and evidence provided and the need for any further research that may be required to inform potential changes to the legislative framework governing driver licensing for those with medical conditions. This will include the process of self-declaration. There are no plans for changes to the current driver licensing requirements while the analysis of the call for evidence responses continues.” Source location Response from Department for Transport
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No changes to driver licensing requirements are planned while the DVLA analyses call-for-evidence responses and determines whether further research is needed.
Verbatim wording from the response “In 2023, the DVLA carried out a call for evidence about driver licensing for people with medical conditions. The call for evidence sought views on the current legislative basis for assessing fitness to drive and what changes may be made. This was an important first step in gathering a wide range of views and evidence that may support future changes to the legal framework. The DVLA is considering the research and evidence provided and the need for any further research that may be required to inform potential changes to the legislative framework governing driver licensing for those with medical conditions. This will include the process of self-declaration. There are no plans for changes to the current driver licensing requirements while the analysis of the call for evidence responses continues.” Source location Response from Department for Transport
Open published response
Concerns raised 12 Limitations in applying the Small Commercial Vessel and Pilot Boat Code to high-speed passenger craft View source Lack of proper protection for passengers and crew from impact and vibration hazards View source Non-uniform risk management for high-speed rides View source Confusing and inconsistent requirements and guidance for small-craft operators View source Insufficient crewing for lookout and skipper workload control View source Delays in revising codes of practice for high-speed craft View source Loss of situational awareness during RIB operations View source Inadequate seating and collision-impact mitigation in RIBs View source Inadequate forward visibility from passenger-carrying RIBs View source Failure to ensure timely and comprehensive review of MAIB recommendations View source Unavailability of AIS capability for monitoring RIB operations View source Excessive piloting workload during high-speed RIB operations View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Emily Jane 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
Emily Jane Lewis, aged 15, died at Southampton General Hospital on 22 August 2020 after the high-speed RIB on which she was a passenger collided with a buoy, projecting her into a handhold and causing fatal injuries. The principal concerns included the workload and situational awareness of a lone skipper, inadequate forward visibility and passenger protection, shortcomings in seating and handrail design, insufficient risk assessment and safety management, and confusing or inconsistent regulation of high-speed RIB experience rides.
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 Limitations in applying the Small Commercial Vessel and Pilot Boat Code to high-speed passenger craft
Wider context from the report “In the course of the inquest I heard evidence of multiple issues in relation to in particular (a) the high workload of piloting a RIB at high speed, particularly in the vicinity of buoys and vessels (b) loss of situational awareness (c) the improvement in safety of having a second crew member thereby providing an additional lookout and reducing the skipper’s workload (d) forward visibility issues in RIBs complying with existing requisite safety standards when passengers are being carried (e) issues as to safe seating and the need to mitigate the effects of collisions, noting in particular the injuries suffered by Emily Lewis (f) the need for risk assessments and safety management systems to be meaningfully (g) limitations in applying the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280 (M)(Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) to high speed passenger craft operation (h) the potential benefits of an automatic identification system (AIS). There was also evidence concerning the way in which the revision of the codes of practice appears to have slipped back: the Maritime & Coastguard Agency now plan to go to consultation next year, then the RYA will respond. The MAIB describes current requirements and guidance for the operators of small craft as “confusing and inconsistent” and observe that there does not appear to be uniform approach to managing the risks associated with high speed rides.
In the foreword to the MAIB report into the index collision it is stated: “... passengers in small high speed craft are very vulnerable to impact and vibration injuries. In the last 15 years the MAIB has investigated numerous accidents involving high speed craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury and occasionally death.”
My concerns relate to:
a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensive framework for the use of RIB craft on high speed experience rides, including crewing levels, manoeuvres, craft standards and risk assessments
b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides
c. Whether the existing BS EWN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft
d. The need for consideration of seat and handrail design : as well as the injuries sustained by Emily Lewis I note the MAIB’s concerns about handholds for jockey seats
e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified
f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved
” 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 proper protection for passengers and crew from impact and vibration hazards
Wider context from the report “In the course of the inquest I heard evidence of multiple issues in relation to in particular (a) the high workload of piloting a RIB at high speed, particularly in the vicinity of buoys and vessels (b) loss of situational awareness (c) the improvement in safety of having a second crew member thereby providing an additional lookout and reducing the skipper’s workload (d) forward visibility issues in RIBs complying with existing requisite safety standards when passengers are being carried (e) issues as to safe seating and the need to mitigate the effects of collisions, noting in particular the injuries suffered by Emily Lewis (f) the need for risk assessments and safety management systems to be meaningfully (g) limitations in applying the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280 (M)(Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) to high speed passenger craft operation (h) the potential benefits of an automatic identification system (AIS). There was also evidence concerning the way in which the revision of the codes of practice appears to have slipped back: the Maritime & Coastguard Agency now plan to go to consultation next year, then the RYA will respond. The MAIB describes current requirements and guidance for the operators of small craft as “confusing and inconsistent” and observe that there does not appear to be uniform approach to managing the risks associated with high speed rides.
In the foreword to the MAIB report into the index collision it is stated: “... passengers in small high speed craft are very vulnerable to impact and vibration injuries. In the last 15 years the MAIB has investigated numerous accidents involving high speed craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury and occasionally death.”
My concerns relate to:
a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensive framework for the use of RIB craft on high speed experience rides, including crewing levels, manoeuvres, craft standards and risk assessments
b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides
c. Whether the existing BS EWN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft
d. The need for consideration of seat and handrail design : as well as the injuries sustained by Emily Lewis I note the MAIB’s concerns about handholds for jockey seats
e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified
f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Non-uniform risk management for high-speed rides
Wider context from the report “In the course of the inquest I heard evidence of multiple issues in relation to in particular (a) the high workload of piloting a RIB at high speed, particularly in the vicinity of buoys and vessels (b) loss of situational awareness (c) the improvement in safety of having a second crew member thereby providing an additional lookout and reducing the skipper’s workload (d) forward visibility issues in RIBs complying with existing requisite safety standards when passengers are being carried (e) issues as to safe seating and the need to mitigate the effects of collisions, noting in particular the injuries suffered by Emily Lewis (f) the need for risk assessments and safety management systems to be meaningfully (g) limitations in applying the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280 (M)(Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) to high speed passenger craft operation (h) the potential benefits of an automatic identification system (AIS). There was also evidence concerning the way in which the revision of the codes of practice appears to have slipped back: the Maritime & Coastguard Agency now plan to go to consultation next year, then the RYA will respond. The MAIB describes current requirements and guidance for the operators of small craft as “confusing and inconsistent” and observe that there does not appear to be uniform approach to managing the risks associated with high speed rides .
In the foreword to the MAIB report into the index collision it is stated: “... passengers in small high speed craft are very vulnerable to impact and vibration injuries. In the last 15 years the MAIB has investigated numerous accidents involving high speed craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury and occasionally death.”
My concerns relate to:
a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensive framework for the use of RIB craft on high speed experience rides, including crewing levels, manoeuvres, craft standards and risk assessments
b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides
c. Whether the existing BS EWN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft
d. The need for consideration of seat and handrail design : as well as the injuries sustained by Emily Lewis I note the MAIB’s concerns about handholds for jockey seats
e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified
f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved
” 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 Confusing and inconsistent requirements and guidance for small-craft operators
Wider context from the report “In the course of the inquest I heard evidence of multiple issues in relation to in particular (a) the high workload of piloting a RIB at high speed, particularly in the vicinity of buoys and vessels (b) loss of situational awareness (c) the improvement in safety of having a second crew member thereby providing an additional lookout and reducing the skipper’s workload (d) forward visibility issues in RIBs complying with existing requisite safety standards when passengers are being carried (e) issues as to safe seating and the need to mitigate the effects of collisions, noting in particular the injuries suffered by Emily Lewis (f) the need for risk assessments and safety management systems to be meaningfully (g) limitations in applying the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280 (M)(Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) to high speed passenger craft operation (h) the potential benefits of an automatic identification system (AIS). There was also evidence concerning the way in which the revision of the codes of practice appears to have slipped back: the Maritime & Coastguard Agency now plan to go to consultation next year, then the RYA will respond. The MAIB describes current requirements and guidance for the operators of small craft as “confusing and inconsistent” and observe that there does not appear to be uniform approach to managing the risks associated with high speed rides.
In the foreword to the MAIB report into the index collision it is stated: “... passengers in small high speed craft are very vulnerable to impact and vibration injuries. In the last 15 years the MAIB has investigated numerous accidents involving high speed craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury and occasionally death.”
My concerns relate to:
a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensive framework for the use of RIB craft on high speed experience rides, including crewing levels, manoeuvres, craft standards and risk assessments
b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides
c. Whether the existing BS EWN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft
d. The need for consideration of seat and handrail design : as well as the injuries sustained by Emily Lewis I note the MAIB’s concerns about handholds for jockey seats
e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified
f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved
” 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 crewing for lookout and skipper workload control
Wider context from the report “In the course of the inquest I heard evidence of multiple issues in relation to in particular (a) the high workload of piloting a RIB at high speed, particularly in the vicinity of buoys and vessels (b) loss of situational awareness (c) the improvement in safety of having a second crew member thereby providing an additional lookout and reducing the skipper’s workload (d) forward visibility issues in RIBs complying with existing requisite safety standards when passengers are being carried (e) issues as to safe seating and the need to mitigate the effects of collisions, noting in particular the injuries suffered by Emily Lewis (f) the need for risk assessments and safety management systems to be meaningfully (g) limitations in applying the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280 (M)(Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) to high speed passenger craft operation (h) the potential benefits of an automatic identification system (AIS). There was also evidence concerning the way in which the revision of the codes of practice appears to have slipped back: the Maritime & Coastguard Agency now plan to go to consultation next year, then the RYA will respond. The MAIB describes current requirements and guidance for the operators of small craft as “confusing and inconsistent” and observe that there does not appear to be uniform approach to managing the risks associated with high speed rides.
In the foreword to the MAIB report into the index collision it is stated: “... passengers in small high speed craft are very vulnerable to impact and vibration injuries. In the last 15 years the MAIB has investigated numerous accidents involving high speed craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury and occasionally death.”
My concerns relate to:
a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensive framework for the use of RIB craft on high speed experience rides, including crewing levels, manoeuvres, craft standards and risk assessments
b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides
c. Whether the existing BS EWN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft
d. The need for consideration of seat and handrail design : as well as the injuries sustained by Emily Lewis I note the MAIB’s concerns about handholds for jockey seats
e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified
f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved
” 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 Delays in revising codes of practice for high-speed craft
Wider context from the report “In the course of the inquest I heard evidence of multiple issues in relation to in particular (a) the high workload of piloting a RIB at high speed, particularly in the vicinity of buoys and vessels (b) loss of situational awareness (c) the improvement in safety of having a second crew member thereby providing an additional lookout and reducing the skipper’s workload (d) forward visibility issues in RIBs complying with existing requisite safety standards when passengers are being carried (e) issues as to safe seating and the need to mitigate the effects of collisions, noting in particular the injuries suffered by Emily Lewis (f) the need for risk assessments and safety management systems to be meaningfully (g) limitations in applying the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280 (M)(Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) to high speed passenger craft operation (h) the potential benefits of an automatic identification system (AIS). There was also evidence concerning the way in which the revision of the codes of practice appears to have slipped back : the Maritime & Coastguard Agency now plan to go to consultation next year, then the RYA will respond . The MAIB describes current requirements and guidance for the operators of small craft as “confusing and inconsistent” and observe that there does not appear to be uniform approach to managing the risks associated with high speed rides.
In the foreword to the MAIB report into the index collision it is stated: “... passengers in small high speed craft are very vulnerable to impact and vibration injuries. In the last 15 years the MAIB has investigated numerous accidents involving high speed craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury and occasionally death.”
My concerns relate to:
a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensive framework for the use of RIB craft on high speed experience rides, including crewing levels, manoeuvres, craft standards and risk assessments
b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides
c. Whether the existing BS EWN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft
d. The need for consideration of seat and handrail design : as well as the injuries sustained by Emily Lewis I note the MAIB’s concerns about handholds for jockey seats
e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified
f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved
” 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 Loss of situational awareness during RIB operations
Wider context from the report “In the course of the inquest I heard evidence of multiple issues in relation to in particular (a) the high workload of piloting a RIB at high speed, particularly in the vicinity of buoys and vessels (b) loss of situational awareness (c) the improvement in safety of having a second crew member thereby providing an additional lookout and reducing the skipper’s workload (d) forward visibility issues in RIBs complying with existing requisite safety standards when passengers are being carried (e) issues as to safe seating and the need to mitigate the effects of collisions, noting in particular the injuries suffered by Emily Lewis (f) the need for risk assessments and safety management systems to be meaningfully (g) limitations in applying the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280 (M)(Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) to high speed passenger craft operation (h) the potential benefits of an automatic identification system (AIS). There was also evidence concerning the way in which the revision of the codes of practice appears to have slipped back: the Maritime & Coastguard Agency now plan to go to consultation next year, then the RYA will respond. The MAIB describes current requirements and guidance for the operators of small craft as “confusing and inconsistent” and observe that there does not appear to be uniform approach to managing the risks associated with high speed rides.
In the foreword to the MAIB report into the index collision it is stated: “... passengers in small high speed craft are very vulnerable to impact and vibration injuries. In the last 15 years the MAIB has investigated numerous accidents involving high speed craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury and occasionally death.”
My concerns relate to:
a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensive framework for the use of RIB craft on high speed experience rides, including crewing levels, manoeuvres, craft standards and risk assessments
b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides
c. Whether the existing BS EWN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft
d. The need for consideration of seat and handrail design : as well as the injuries sustained by Emily Lewis I note the MAIB’s concerns about handholds for jockey seats
e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified
f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved
” 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 seating and collision-impact mitigation in RIBs
Wider context from the report “In the course of the inquest I heard evidence of multiple issues in relation to in particular (a) the high workload of piloting a RIB at high speed, particularly in the vicinity of buoys and vessels (b) loss of situational awareness (c) the improvement in safety of having a second crew member thereby providing an additional lookout and reducing the skipper’s workload (d) forward visibility issues in RIBs complying with existing requisite safety standards when passengers are being carried (e) issues as to safe seating and the need to mitigate the effects of collisions , noting in particular the injuries suffered by Emily Lewis (f) the need for risk assessments and safety management systems to be meaningfully (g) limitations in applying the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280 (M)(Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) to high speed passenger craft operation (h) the potential benefits of an automatic identification system (AIS). There was also evidence concerning the way in which the revision of the codes of practice appears to have slipped back: the Maritime & Coastguard Agency now plan to go to consultation next year, then the RYA will respond. The MAIB describes current requirements and guidance for the operators of small craft as “confusing and inconsistent” and observe that there does not appear to be uniform approach to managing the risks associated with high speed rides.
In the foreword to the MAIB report into the index collision it is stated: “... passengers in small high speed craft are very vulnerable to impact and vibration injuries. In the last 15 years the MAIB has investigated numerous accidents involving high speed craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury and occasionally death.”
My concerns relate to:
a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensive framework for the use of RIB craft on high speed experience rides, including crewing levels, manoeuvres, craft standards and risk assessments
b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides
c. Whether the existing BS EWN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft
d. The need for consideration of seat and handrail design : as well as the injuries sustained by Emily Lewis I note the MAIB’s concerns about handholds for jockey seats
e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified
f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved
” 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 forward visibility from passenger-carrying RIBs
Wider context from the report “In the course of the inquest I heard evidence of multiple issues in relation to in particular (a) the high workload of piloting a RIB at high speed, particularly in the vicinity of buoys and vessels (b) loss of situational awareness (c) the improvement in safety of having a second crew member thereby providing an additional lookout and reducing the skipper’s workload (d) forward visibility issues in RIBs complying with existing requisite safety standards when passengers are being carried (e) issues as to safe seating and the need to mitigate the effects of collisions, noting in particular the injuries suffered by Emily Lewis (f) the need for risk assessments and safety management systems to be meaningfully (g) limitations in applying the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280 (M)(Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) to high speed passenger craft operation (h) the potential benefits of an automatic identification system (AIS). There was also evidence concerning the way in which the revision of the codes of practice appears to have slipped back: the Maritime & Coastguard Agency now plan to go to consultation next year, then the RYA will respond. The MAIB describes current requirements and guidance for the operators of small craft as “confusing and inconsistent” and observe that there does not appear to be uniform approach to managing the risks associated with high speed rides.
In the foreword to the MAIB report into the index collision it is stated: “... passengers in small high speed craft are very vulnerable to impact and vibration injuries. In the last 15 years the MAIB has investigated numerous accidents involving high speed craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury and occasionally death.”
My concerns relate to:
a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensive framework for the use of RIB craft on high speed experience rides, including crewing levels, manoeuvres, craft standards and risk assessments
b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides
c. Whether the existing BS EWN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft
d. The need for consideration of seat and handrail design : as well as the injuries sustained by Emily Lewis I note the MAIB’s concerns about handholds for jockey seats
e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified
f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved
” 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 timely and comprehensive review of MAIB recommendations
Wider context from the report “In the course of the inquest I heard evidence of multiple issues in relation to in particular (a) the high workload of piloting a RIB at high speed, particularly in the vicinity of buoys and vessels (b) loss of situational awareness (c) the improvement in safety of having a second crew member thereby providing an additional lookout and reducing the skipper’s workload (d) forward visibility issues in RIBs complying with existing requisite safety standards when passengers are being carried (e) issues as to safe seating and the need to mitigate the effects of collisions, noting in particular the injuries suffered by Emily Lewis (f) the need for risk assessments and safety management systems to be meaningfully (g) limitations in applying the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280 (M)(Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) to high speed passenger craft operation (h) the potential benefits of an automatic identification system (AIS). There was also evidence concerning the way in which the revision of the codes of practice appears to have slipped back: the Maritime & Coastguard Agency now plan to go to consultation next year, then the RYA will respond. The MAIB describes current requirements and guidance for the operators of small craft as “confusing and inconsistent” and observe that there does not appear to be uniform approach to managing the risks associated with high speed rides.
In the foreword to the MAIB report into the index collision it is stated: “... passengers in small high speed craft are very vulnerable to impact and vibration injuries. In the last 15 years the MAIB has investigated numerous accidents involving high speed craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury and occasionally death.”
My concerns relate to:
a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensive framework for the use of RIB craft on high speed experience rides, including crewing levels, manoeuvres, craft standards and risk assessments
b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides
c. Whether the existing BS EWN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft
d. The need for consideration of seat and handrail design : as well as the injuries sustained by Emily Lewis I note the MAIB’s concerns about handholds for jockey seats
e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified
f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved
” 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 AIS capability for monitoring RIB operations
Wider context from the report “In the course of the inquest I heard evidence of multiple issues in relation to in particular (a) the high workload of piloting a RIB at high speed, particularly in the vicinity of buoys and vessels (b) loss of situational awareness (c) the improvement in safety of having a second crew member thereby providing an additional lookout and reducing the skipper’s workload (d) forward visibility issues in RIBs complying with existing requisite safety standards when passengers are being carried (e) issues as to safe seating and the need to mitigate the effects of collisions, noting in particular the injuries suffered by Emily Lewis (f) the need for risk assessments and safety management systems to be meaningfully (g) limitations in applying the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280 (M)(Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) to high speed passenger craft operation (h) the potential benefits of an automatic identification system (AIS) . There was also evidence concerning the way in which the revision of the codes of practice appears to have slipped back: the Maritime & Coastguard Agency now plan to go to consultation next year, then the RYA will respond. The MAIB describes current requirements and guidance for the operators of small craft as “confusing and inconsistent” and observe that there does not appear to be uniform approach to managing the risks associated with high speed rides.
In the foreword to the MAIB report into the index collision it is stated: “... passengers in small high speed craft are very vulnerable to impact and vibration injuries. In the last 15 years the MAIB has investigated numerous accidents involving high speed craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury and occasionally death.”
My concerns relate to:
a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensive framework for the use of RIB craft on high speed experience rides, including crewing levels, manoeuvres, craft standards and risk assessments
b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides
c. Whether the existing BS EWN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft
d. The need for consideration of seat and handrail design : as well as the injuries sustained by Emily Lewis I note the MAIB’s concerns about handholds for jockey seats
e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified
f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved
” 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 Excessive piloting workload during high-speed RIB operations
Wider context from the report “In the course of the inquest I heard evidence of multiple issues in relation to in particular (a) the high workload of piloting a RIB at high speed, particularly in the vicinity of buoys and vessels (b) loss of situational awareness (c) the improvement in safety of having a second crew member thereby providing an additional lookout and reducing the skipper’s workload (d) forward visibility issues in RIBs complying with existing requisite safety standards when passengers are being carried (e) issues as to safe seating and the need to mitigate the effects of collisions, noting in particular the injuries suffered by Emily Lewis (f) the need for risk assessments and safety management systems to be meaningfully (g) limitations in applying the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280 (M)(Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) to high speed passenger craft operation (h) the potential benefits of an automatic identification system (AIS). There was also evidence concerning the way in which the revision of the codes of practice appears to have slipped back: the Maritime & Coastguard Agency now plan to go to consultation next year, then the RYA will respond. The MAIB describes current requirements and guidance for the operators of small craft as “confusing and inconsistent” and observe that there does not appear to be uniform approach to managing the risks associated with high speed rides.
In the foreword to the MAIB report into the index collision it is stated: “... passengers in small high speed craft are very vulnerable to impact and vibration injuries. In the last 15 years the MAIB has investigated numerous accidents involving high speed craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury and occasionally death.”
My concerns relate to:
a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensive framework for the use of RIB craft on high speed experience rides, including crewing levels, manoeuvres, craft standards and risk assessments
b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides
c. Whether the existing BS EWN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft
d. The need for consideration of seat and handrail design : as well as the injuries sustained by Emily Lewis I note the MAIB’s concerns about handholds for jockey seats
e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified
f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved
” 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 Commission an anthropometric assessment of safety requirements for small high-speed passenger craft, including seating, restraints, impacts and whole-body vibration.
Verbatim wording from the response “In response to the MAIB recommendations raised, I have tasked the MCA to begin the procurement process to commission an anthropometric assessment of the design and operational requirements for small high-speed passenger craft safety and the protection of passengers and crew provided by the craft with respect to whole-body vibration and sudden decelerations in the event of a horizontal impact.” Source location Response from Department for Transport
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Advance replacement legislation and an updated Sport or Pleasure Vessel Code through consultation and Parliamentary processes.
Verbatim wording from the response “I would like to take this opportunity to reassure you that the work currently being undertaken by the Maritime Coastguard Agency (MCA) to replace the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280(M) (Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) is a priority of mine and we are working hard to bring forward new legislation and an updated Code of Practice for Small Vessels in Commercial Use for Sport or Pleasure (the “Sport or Pleasure Vessel Code”) as soon as practicable, in line with the required consultation and Parliamentary processes.” Source location Response from Department for Transport
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the draft Statutory Instrument and draft Sport or Pleasure Vessel Code for public consultation.
Verbatim wording from the response “To this end, a draft new Statutory Instrument and draft Sport or Pleasure Vessel Code was published for a 12-week public consultation running from 4 December 2024 until 25 February 2025. It should be noted that any interim measures that could be considered to manage risks of high-speed RIB experience rides would not be able to be implemented any sooner than the revised Sport or Pleasure Vessel Code would come into effect.” Source location Response from Department for Transport
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct the 12-week public consultation on the draft Statutory Instrument and Sport or Pleasure Vessel Code.
Verbatim wording from the response “To this end, a draft new Statutory Instrument and draft Sport or Pleasure Vessel Code was published for a 12-week public consultation running from 4 December 2024 until 25 February 2025. It should be noted that any interim measures that could be considered to manage risks of high-speed RIB experience rides would not be able to be implemented any sooner than the revised Sport or Pleasure Vessel Code would come into effect.” Source location Response from Department for Transport
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Interim measures for high-speed RIB experience ride risks cannot be implemented before the revised Sport or Pleasure Vessel Code comes into effect.
Verbatim wording from the response “To this end, a draft new Statutory Instrument and draft Sport or Pleasure Vessel Code was published for a 12-week public consultation running from 4 December 2024 until 25 February 2025. It should be noted that any interim measures that could be considered to manage risks of high-speed RIB experience rides would not be able to be implemented any sooner than the revised Sport or Pleasure Vessel Code would come into effect.” Source location Response from Department for Transport
Open published response
7 Nov 2024 Daniel PINKNEY · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 1 Lack of Highway Code guidance on aquaplaning View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Daniel PINKNEY · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Daniel PINKNEY died after his vehicle aquaplaned on surface water while travelling on the A164 on 19 December 2022, crossed into the opposite carriageway and collided with another vehicle. The principal concern was the need for greater awareness of aquaplaning, reduced speed when surface water is present, and basic knowledge of braking and steering; it was noted that the Highway Code was silent on this matter.
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 Highway Code guidance on aquaplaning
Wider context from the report “I believe that greater awareness of the phenomenon of aquaplaning is important, together with the need to reduce speed when surface water is present, coupled with basic knowledge about braking and steering, should a vehicle experience this phenomenon. I was informed by a forensic collision expert that the Highway Code is at present silent on this matter but road user should be familiar with it.
” 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 Work with stakeholders to amplify road safety messages, including aquaplaning where appropriate.
Verbatim wording from the response “We will continue to work with stakeholders to amplify road safety messages and will encourage them to do this with aquaplaning where appropriate.” Source location Response from Department for Transport
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consult on Highway Code changes and consider adding aquaplaning advice during the next major revision.
Verbatim wording from the response “The Highway Code has historically undergone a major revision approximately every ten years and we currently have no plans to carry out a major revision. When we carry out the next revision to the Code, we will as usual undertake a consultation on proposed changes and this would offer the appropriate opportunity to consider including advice on aquaplaning.” Source location Response from Department for Transport
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing Highway Code rules and DVSA advice provide appropriate guidance on aquaplaning, so no immediate Code update is planned.
Verbatim wording from the response “You recommended updating the Highway Code to raise awareness about aquaplaning. You also mentioned the importance of reducing speed when surface water is present, and basic knowledge about braking and steering.” Source location Response from Department for Transport
Open published response
5 Nov 2024 Terence William Gillard · Prevention of Future Deaths report West London
View report summary
Concerns raised 2 Lack of certainty that the pedestrian crossing safety redesign will be implemented View source Absence of effective pedestrian crossing controls at Jersey Road View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Terence William Gillard · 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 William Gillard was struck by a moving vehicle while crossing the A4 Great West Road at an uncontrolled pedestrian crossing on 11 September 2022. He suffered brain and multiple traumatic injuries and died in hospital on 18 September 2022 from a pulmonary embolism. The concern was that the crossing had no pedestrian traffic lights, demand button or sound signals, and that there was no certainty that proposed safety redesigns would be implemented.
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 certainty that the pedestrian crossing safety redesign will be implemented
Wider context from the report “The A4 Great West Road is a major route for vehicles of all types travelling in and out of west London. The crossing area, where Mr Gillard collided with the moving vehicle on 11 September 2022, is a designated uncontrolled crossing area across Jersey Road. There are no pedestrian traffic lights, no demand button, no sound signals. This pedestrian crossing area spans across a dual carriageway subject to a speed limit of 40mph. It has three lanes in both directions, separated by a raised central kerb. This crossing point also leads pedestrians into the cycling lane.
I understand that at no point during the normal use of the traffic light controlled junction does traffic cease to flow at the marked crossing area, making it difficult for pedestrian to judge when and from where the next vehicle would approach. This means that pedestrians will need to use their own judgment as to when it is safe to cross this road without the aid of pedestrian traffic lights.
I received evidence that there have been other accidents involving pedestrians and moving vehicles at this pedestrian crossing in the past.
I received evidence from the TFL of existing plans to re-design this pedestrian crossing to improve pedestrian safety. However, their implementation may not take place before the end of 2026 and it remains subject to the consent of the DFT and LBH, the outcome of any public consultation as well as funding considerations.
I am concerned that there appears to be no certainty that the redesign plans for the pedestrian crossing in question will be implemented .
I understand that the TFL, LBH and DFT are the organisations with the power to take the necessary actions to improve pedestrian safety at this 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 Absence of effective pedestrian crossing controls at Jersey Road
Wider context from the report “The A4 Great West Road is a major route for vehicles of all types travelling in and out of west London. The crossing area, where Mr Gillard collided with the moving vehicle on 11 September 2022, is a designated uncontrolled crossing area across Jersey Road. There are no pedestrian traffic lights, no demand button, no sound signals. This pedestrian crossing area spans across a dual carriageway subject to a speed limit of 40mph. It has three lanes in both directions, separated by a raised central kerb. This crossing point also leads pedestrians into the cycling lane.
I understand that at no point during the normal use of the traffic light controlled junction does traffic cease to flow at the marked crossing area , making it difficult for pedestrian to judge when and from where the next vehicle would approach. This means that pedestrians will need to use their own judgment as to when it is safe to cross this road without the aid of pedestrian traffic lights .
I received evidence that there have been other accidents involving pedestrians and moving vehicles at this pedestrian crossing in the past.
I received evidence from the TFL of existing plans to re-design this pedestrian crossing to improve pedestrian safety. However, their implementation may not take place before the end of 2026 and it remains subject to the consent of the DFT and LBH, the outcome of any public consultation as well as funding considerations.
I am concerned that there appears to be no certainty that the redesign plans for the pedestrian crossing in question will be implemented.
I understand that the TFL, LBH and DFT are the organisations with the power to take the necessary actions to improve pedestrian safety at this junction.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Department does not oversee or consent to TfL’s traffic schemes, including this pedestrian crossing.
Verbatim wording from the response “The highway authority, in this case Transport for London (TfL), is responsible for how traffic is managed on its roads. This includes the design and maintenance of traffic light junctions and any associated pedestrian crossings. While the Department for Transport issues guidance to highway authorities, the Department does not oversee or consent to traffic schemes of this nature.” Source location Response from Department for Transport
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation TfL and the Mayor of London decide, prioritise and approve investment funding for the pedestrian crossing redesign.
Verbatim wording from the response “On the issue of funding, the Government engages regularly with TfL to understand its investment plans and funding requirements. The Government announced £250 million capital funding in December 2023, and a further £485 million for the coming 2025/26 financial year at the Budget, for TfL’s major capital projects. This is in addition to almost £2.2 billion of business rates for transport retained by TfL in 2024/25. The Mayor of London and TfL consider, prioritise and approve its investment decisions. The re-design of the pedestrian crossing would be funded by TfL from revenue sources outside the Department’s funding.” Source location Response from Department for Transport
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation TfL and the London Borough of Hounslow are responsible for implementing the crossing redesign, subject to funding and public consultation.
Verbatim wording from the response “I am not aware of any consents required from the Department to enable TfL to make changes to this site. I understand my officials have been in contact with TfL and it has confirmed that the new crossing designs are in TfL and the Borough's gift to implement, subject to funding and public consultation, and no DfT involvement is required.” Source location Response from Department for Transport
Open published response
17 Oct 2024 Wilfred John Fitchett and 3 others · Prevention of Future Deaths report North West Wales
View report summary
Concerns raised 4 Lack of legal restrictions on the licences of young and newly qualified drivers View source Lack of roadside barrier or fence preventing vehicles entering the ditch View source Vehicle licensing regime permitting young passengers to be carried by young and newly qualified drivers View source Water-filled ditch below road level beside the carriageway 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
Wilfred John Fitchett and 3 others · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 19 November 2023, a vehicle carrying four young men left the A4085, entered a water-filled drainage ditch and all four died from drowning; the vehicle was found on 21 November 2023. The report raises concerns about the absence of legal restrictions on young or newly qualified drivers carrying young passengers and the risk of further deaths in similar circumstances.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of legal restrictions on the licences of young and newly qualified drivers
Wider context from the report “b. Currently, there are no legal restrictions upon the licences of young and/or newly qualified drivers and the current vehicle licensing regime permits the carrying of young persons as passengers in circumstances such as these.
c. It is noted that young drivers are exponentially more likely to be involved in a collision with each similar aged passengers in the car.
d. I am concerned that deaths will continue to occur or will occur into the future where younger persons are carried in motor vehicles being driven by newly qualified and/or young drivers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of roadside barrier or fence preventing vehicles entering the ditch
Wider context from the report “b. A stock fence had been erected (likely by the private landowner) concerning the lane of the road in question. It is understood that Cyngor Gwynedd had no responsibility for this given that it was on private land. The stock fence had been damaged and had not been replaced prior to the collision on 19 November 2023.
c. Whilst the evidence could not determine whether or not the fence, had it been repaired and in situ at the time of the collision, would have altered the outcome the risk to road users who leave the road accidentally is that they may land in the ditch below the road level .
d. Cyngor Gwynedd has installed a chevron board at the bend but there is no barrier or fence otherwise to prevent motor vehicles leaving the road into the ditch at this bend in the event of leaving the carriageway accidentally .
” 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 Vehicle licensing regime permitting young passengers to be carried by young and newly qualified drivers
Wider context from the report “b. Currently, there are no legal restrictions upon the licences of young and/or newly qualified drivers and the current vehicle licensing regime permits the carrying of young persons as passengers in circumstances such as these .
c. It is noted that young drivers are exponentially more likely to be involved in a collision with each similar aged passengers in the car.
d. I am concerned that deaths will continue to occur or will occur into the future where younger persons are carried in motor vehicles being driven by newly qualified and/or young drivers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Water-filled ditch below road level beside the carriageway
Wider context from the report “a. The specific road area in question along the A4085 Garreg, Llanfrothen had a ditch downward from the road at the nearside of the carriageway . This fills with water during heavy periods of rainfall .
” Open source report
1 Oct 2024 Scott Bradley Davies · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Poor visibility of a locked steel barrier across a legitimate bicycle and emergency-services route View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Scott Bradley Davies · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Scott Bradley Davies collided with a steel barrier while testing a modified motorcycle in Alexandra Park on 2 February 2024. He sustained serious head injuries, never regained consciousness, and died from a traumatic brain injury at Salford Royal Hospital on 8 March 2024. The report raises concern that a matt black locked steel barrier on a legitimate right of way is difficult to see at dusk and in darkness and could cause serious injury or death to users of the thoroughfare.
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 Poor visibility of a locked steel barrier across a legitimate bicycle and emergency-services route
Wider context from the report “The section of road bisecting Alexandra Park, known as Cheadle Old Road Edgeley, is a legitimate right of way for bicycles and emergency services vehicles yet there is a matt black locked steel barrier that is hard to see at dusk and in the dark which could result in serious injury or death if struck by an oncoming legitimate user of that thoroughfare .
” 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 Encourage good practice in highway maintenance through the Well-managed Highway Infrastructure code and related channels.
Verbatim wording from the response “We have provided guidance on traffic management for local authorities in various publications, including the Traffic Signs Manual, as well as a variety of Traffic Advisory Leaflets and Local Transport Notes. These stress the importance of road safety when designing and installing road infrastructure. This guidance is all free to download from the Department’s website. The Department also encourages good practice in highway maintenance through channels such as Well-managed Highway Infrastructure - A Code of Practice, published by the UK Roads Leadership Group. This publication provides advice to local highway authorities on a range of issues, including street lighting.” Source location Response from Department for Transport
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Stockport Metropolitan Borough Council, as highway authority, is responsible for managing traffic and ensuring local road infrastructure is fit for purpose.
Verbatim wording from the response “I note your concerns regarding the risk that the barrier poses to road users. However, I should clarify that this is not a matter for the Department as it is the highway authority, in this case Stockport Metropolitan Borough Council, which is responsible for how traffic is managed on its roads, including rights of way. As with all local roads, it is for the Council to ensure that any infrastructure it installs on its network, including barriers and similar street furniture, is fit for purpose. It is also responsible for maintaining any infrastructure once installed.” Source location Response from Department for Transport
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Managing barrier visibility and lighting on local roads is outside central government’s remit.
Verbatim wording from the response “I note your concerns regarding the risk that the barrier poses to road users. However, I should clarify that this is not a matter for the Department as it is the highway authority, in this case Stockport Metropolitan Borough Council, which is responsible for how traffic is managed on its roads, including rights of way. As with all local roads, it is for the Council to ensure that any infrastructure it installs on its network, including barriers and similar street furniture, is fit for purpose. It is also responsible for maintaining any infrastructure once installed.” Source location Response from Department for Transport
Open published response
Concerns raised 7 Unavailability of a final vehicle-exclusion solution at the waterway View source Delays in risk-reduction action at cluster sites View source Unsafe speed limit for the road design and condition View source Delays in repairing highway degradation View source Failure to take prompt action following road safety representations View source Insufficiently rigorous road inspections View source Failure to audit the quality of road inspections 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
Jennifer BUNYAN and Marion BUNYAN · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jennifer Bunyan and Marion Bunyan died by drowning on 7 June 2020 after their motor car left the carriageway, rolled onto its roof and became partially submerged in Crease Drain. Jennifer was pregnant, and her unborn daughter, later named Erin Marion Chatten, also died in utero. The report raised concerns about the speed limit, road inspections, highway degradation, delays in remedial action and the absence of an effective barrier preventing vehicles entering the waterway.
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 Unavailability of a final vehicle-exclusion solution at the waterway
Wider context from the report “A Barrier to prevent entry to the waterway would be one effective measure that has been deployed in many other places to prevent a vehicle leaving the road and yet, I understand no final solution is in place .
” 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 Delays in risk-reduction action at cluster sites
Wider context from the report “Councils have a number of roads that feature on a cluster site analysis. By their nature, these will carry an obvious and serious risk of death or significant injury. Funding pressures in recent years have delayed prompt action in risk reduction at these sites.
” 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 Unsafe speed limit for the road design and condition
Wider context from the report “The designated speed for this section of road was 60 mph.
The charity BRAKE have stated that the default speed limit on rural roads is 60 mph, a speed at which it is rarely safe to travel.
They stated the approach should be based on the design of roads. This road has an uneven road surface and it was within local knowledge that the designated speed limit was dangerous and could lead to a loss of control whilst driving in the upper speed range.
The need for a reduction in the limit as a safety measure does not appear to have been raised during inspections/debriefs following a series of fatalities that have led to a number of drowning incidents along this section of road. It raises a concern that the speed limit should be reduced significantly as a risk reduction measure – some areas have adopted 20 mph on some sections of 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 Delays in repairing highway degradation
Wider context from the report “This has been an issue and I have a concern about prompt repairs being effected to the road and also the weight of vehicles which is a factor in damage to the verge adjacent to the road itself.
” 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 take prompt action following road safety representations
Wider context from the report “The Fenland Road Safety Campaign (Charlotte's Way) have undertaken outstanding work as a charity in raising awareness of the dangers of Fenland roads given the unique environmental factors involved. It is not clear whether there has been prompt action taken following representations from them on safety matters.
” 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 Insufficiently rigorous road inspections
Wider context from the report “I have a concern that inspections of the road have not been sufficiently rigorous given a recurring issue of highway degradation from ‘rutting’ at the carriageway edge which can be a contributory factor causing loss of control of a vehicle.
It is unclear if the council have carried out audits to review the quality of inspections and whether there have been examples of substandard inspections.
” 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 audit the quality of road inspections
Wider context from the report “I have a concern that inspections of the road have not been sufficiently rigorous given a recurring issue of highway degradation from ‘rutting’ at the carriageway edge which can be a contributory factor causing loss of control of a vehicle.
It is unclear if the council have carried out audits to review the quality of inspections and whether there have been examples of substandard inspections .
” 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 Cluster-site analysis enforcement and any central fund are matters for the relevant local highway authority, so no Department action is intended.
Verbatim wording from the response “The Department allocates highways maintenance capital funding to local highways authorities so they can most effectively invest in maintaining and improving their respective network, based upon their local knowledge, circumstances, and priorities.” Source location Response from Department of Transport
Open published response
25 Jun 2024 Abdul Jabar Oryakhel · Prevention of Future Deaths report Avon
View report summary
Concerns raised 2 Lack of understanding of the dangers of lithium-ion batteries used for e-bikes and e-scooters View source Lack of British or European standards controlling lithium-ion e-bike batteries and chargers sold in the UK View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Abdul Jabar Oryakhel · 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
Abdul Jabar Oryakhel died on 25 September 2022 after falling from the window of his top-floor flat while trying to escape a fire. The fire was caused by overheating and ignition of a lithium-ion battery pack used for an e-bike, and concerns were raised about insufficient understanding of the dangers of such batteries and the absence of a British or European standard controlling the batteries and chargers sold in the UK.
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 understanding of the dangers of lithium-ion batteries used for e-bikes and e-scooters
Wider context from the report “There appears to be a lack of understanding of the dangers with Lithium-ion batteries used for e-bikes and e-scooters .
” 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 British or European standards controlling lithium-ion e-bike batteries and chargers sold in the UK
Wider context from the report “I understand that there is currently no British or European (e.g. BSI or PAS) standard to control what lithium ion e-bike batteries and chargers can be sold in the UK .
” 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 Publish guidance on the safe purchasing, use, charging and storage of e-bike and e-scooter batteries.
Verbatim wording from the response “The Department for Transport, the Home Office and the Office for Product Safety and Standards have worked together to understand the issues with lithium-ion batteries and have all published guidance for users of e-cycles and e-scooters on battery safety. The DfT guidance, published in February this year and concerning the safe purchasing, use, charging and storage of batteries can be viewed on the following link:
www.gov.uk/government/news/new-guidance-to-enhance-e-bike-and-e-scooter-safety” Source location Response from Department of Transport
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct research on developing future e-scooter regulations, including battery safety, and publish its findings.
Verbatim wording from the response “The Office for Product Safety and Standards has commissioned research from Warwick Manufacturing Group to better understand the safety issues associated with the lithium-ion batteries. The outcome of this research, coupled with research from the Department for Transport on how future regulations on e-scooters could be developed (and which contains a section on battery safety) will inform any further action from government. Both pieces of research are scheduled to be published later this year.” Source location Response from Department of 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 Pending publication of relevant research, no additional Department for Transport action is considered appropriate at this stage.
Verbatim wording from the response “The Office for Product Safety and Standards has commissioned research from Warwick Manufacturing Group to better understand the safety issues associated with the lithium-ion batteries. The outcome of this research, coupled with research from the Department for Transport on how future regulations on e-scooters could be developed (and which contains a section on battery safety) will inform any further action from government. Both pieces of research are scheduled to be published later this year.” Source location Response from Department of 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 Office for Product Safety and Standards is best placed to address consumer-product safety, enforcement and standards matters.
Verbatim wording from the response “I am aware you have also written to the Office for Product Safety and Standards. The safety and enforcement of consumer products, and the role of standards, is part of their remit, and I anticipate they will be best placed to respond to you on this point.” Source location Response from Department of Transport
Open published response
14 May 2024 Charlie Hopkins and William Robinson · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 5 Lack of MOT checks that airbag warning lights are functioning View source Risk of road traffic collisions involving young, new drivers View source Lack of MOT diagnostic checks for airbag module faults View source Failure of car services to conduct diagnostic checks of electronic safety systems View source Failure of car services to check airbag warning light functioning View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Charlie Hopkins and William Robinson · 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
Charlie Hopkins, aged 18, died at the scene of a road traffic collision on 26 September 2021, while William Robinson, aged 17, died in hospital on 4 December 2021 from injuries sustained in the same collision. The court found that excessive speed and alcohol contributed to the collision. Concerns were raised about risks involving young, new drivers and passengers, and about airbag faults not being identified during MOTs and vehicle servicing because of gaps in testing and diagnostic practices.
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 MOT checks that airbag warning lights are functioning
Wider context from the report “It is deeply concerning that such a significant safety fault with the VW Polo was not identified during the course of any of the annual MOTs it underwent from 14 March 2014 onwards.
The court heard that the MOT manual itself does not require MOT testers to:
(i) Check whether airbag warning lights are actually working.
The court heard that it is quick and simple to check that a car’s airbag warning light is working . It is done by checking that the light illuminates briefly when the engine is switched on. Further the court heard that the MOT manual requires MOT testers to check that the anti-lock braking system (ABS) warning light is working in this manner .
(ii) Carry out a diagnostic check of the car’s electrical systems to check whether there are any faults with the airbag module.
The court heard that MOT testers rely on the illuminated warning light to assess whether there are any faults with the car’s airbag module. However, this will not identify a fault if the airbag warning light has been concealed. The court heard that there are universal diagnostic tools which can diagnose electrical faults, including airbag module faults, on any type of car, regardless of the manufacturer.
The Coroner considers that there is a gap in the MOT manual which presents a risk of future deaths and you are invited to consider whether any amendments ought to be introduced to the MOT Manual to mitigate against that 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 Risk of road traffic collisions involving young, new drivers
Wider context from the report “As set out above, the court found that it was possible that the fact that Charlie Hopkins had only just passed his driving test contributed to the collision.
During the course of the inquest, the court’s attention was drawn to statistics which suggest that road traffic collisions involving young, new drivers, are a leading cause of death for young people .
As such, you are invited to consider whether any additional measures ought to be introduced to mitigate the ongoing risk in respect of young, new drivers , including by way of the introduction of restrictions on when they can drive and who they can carry as passengers.
” 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 MOT diagnostic checks for airbag module faults
Wider context from the report “It is deeply concerning that such a significant safety fault with the VW Polo was not identified during the course of any of the annual MOTs it underwent from 14 March 2014 onwards.
The court heard that the MOT manual itself does not require MOT testers to:
(i) Check whether airbag warning lights are actually working.
The court heard that it is quick and simple to check that a car’s airbag warning light is working. It is done by checking that the light illuminates briefly when the engine is switched on. Further the court heard that the MOT manual requires MOT testers to check that the anti-lock braking system (ABS) warning light is working in this manner.
(ii) Carry out a diagnostic check of the car’s electrical systems to check whether there are any faults with the airbag module.
The court heard that MOT testers rely on the illuminated warning light to assess whether there are any faults with the car’s airbag module. However, this will not identify a fault if the airbag warning light has been concealed. The court heard that there are universal diagnostic tools which can diagnose electrical faults, including airbag module faults, on any type of car, regardless of the manufacturer .
The Coroner considers that there is a gap in the MOT manual which presents a risk of future deaths and you are invited to consider whether any amendments ought to be introduced to the MOT Manual to mitigate against that risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Failure of car services to conduct diagnostic checks of electronic safety systems
Wider context from the report “It is concerning that such a significant safety fault with the VW Polo was not picked up during many of the regular services that the car underwent during the same time period.
The court heard evidence that it is not standard practice for car services to include a check of whether the airbag warning light is functioning. Further, the court heard that it is not standard practice to carry out a diagnostic check of a car’s electronic safety systems unless a car is being taken to a garage that is associated with the particular car’s manufacturer , despite the availability of universal diagnostic tools .
Given the limitations of the MOT test, as set out above, the Coroner considers that this presents a risk of future deaths and you are invited to consider whether additional standards and/or guidance on these matters ought to be introduced for garages/mechanics involved in the conduct of car 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 Failure of car services to check airbag warning light functioning
Wider context from the report “It is concerning that such a significant safety fault with the VW Polo was not picked up during many of the regular services that the car underwent during the same time period.
The court heard evidence that it is not standard practice for car services to include a check of whether the airbag warning light is functioning . Further, the court heard that it is not standard practice to carry out a diagnostic check of a car’s electronic safety systems unless a car is being taken to a garage that is associated with the particular car’s manufacturer, despite the availability of universal diagnostic tools.
Given the limitations of the MOT test, as set out above, the Coroner considers that this presents a risk of future deaths and you are invited to consider whether additional standards and/or guidance on these matters ought to be introduced for garages/mechanics involved in the conduct of car services.
” 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 Consider policies relating to young and new drivers during development of the Road Safety Strategy.
Verbatim wording from the response “I want to assure you that I am determined that we learn from tragedies like this and that we take action to reduce those killed and injured on our roads. Delivering enduring improvements in road and vehicle safety is a key priority, which is why we have already announced the development of a new Road Safety Strategy – the first in over a decade. We will be considering policies relating to young, new drivers during this development.” Source location 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 Assess MOT consultation results and consider additional measures, including visual inspection of the airbag fault light.
Verbatim wording from the response “The Department and the Driver and Vehicle Standards Agency launched a consultation on updating the MOT to include new technology last year. We are currently considering the results of that consultation and what additional measures could be introduced. We will consider including a visual inspection of the functioning of the airbag fault light when the vehicle is turned on in those measures. Such a consideration will have to take into account whether it can be consistently applied, the amount of time that would be added to the test, and whether changes to the law are required; further exploration of this is needed.” Source location Department for Transport
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider using electronic diagnostic systems in MOT tests to identify airbag-system faults.
Verbatim wording from the response “You also raised the possibility of using electronic diagnostics systems in the MOT to identify faults with the airbag system. We will consider this but expect it to be prohibitively expensive to require every MOT centre to purchase any such piece of equipment, particularly as we believe each car manufacturer has its own diagnostic interface equipment that a garage would be required to have. In the example from your report the service was conducted at a VW franchise which will have had equipment to specifically assess VW vehicles.” Source location 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 Requiring every MOT centre to purchase electronic diagnostic equipment is considered prohibitively expensive.
Verbatim wording from the response “You also raised the possibility of using electronic diagnostics systems in the MOT to identify faults with the airbag system. We will consider this but expect it to be prohibitively expensive to require every MOT centre to purchase any such piece of equipment, particularly as we believe each car manufacturer has its own diagnostic interface equipment that a garage would be required to have. In the example from your report the service was conducted at a VW franchise which will have had equipment to specifically assess VW vehicles.” Source location 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 Vehicle servicing is a matter for individual vehicle owners and mechanics, with drivers responsible for keeping vehicles roadworthy.
Verbatim wording from the response “In relation to servicing I encourage all drivers to get regular services to ensure their vehicle is kept in a roadworthy condition, as legally required. However, servicing is not regulated and is a matter for each vehicle owner and mechanic. There is guidance on what should be covered by a service from road safety organisations such as the RAC and AA, while manufacturers typically provide maintenance manuals. Every driver is responsible for keeping their vehicle in a roadworthy state and it is a tragedy that on this occasion the issue with the airbag system identified during servicing was not followed up.” Source location Department for Transport
Open published response
12 Apr 2024 James Ferris Baxter · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 2 Lack of provision on Form D4 for recent HbA1c and cholesterol results View source Unavailability of cardiac stress testing for asymptomatic individuals View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
James Ferris Baxter · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
James Ferris Baxter, a passenger-carrying coach driver, died at Junction 15 of the M25 while driving a coach with 25 passengers on board after suffering an acute right coronary artery thrombosis. The coach crashed but was brought to a stop by a passenger, causing minor injuries and vehicle damage. Concerns included the renewal and medical assessment process for his Category D licence, and whether risk-based cardiovascular assessment and relevant diabetes and cholesterol information should be incorporated into driver licensing assessments.
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 provision on Form D4 for recent HbA1c and cholesterol results
Wider context from the report “4) I received evidence that DVLA does commission functional cardiac stress testing for those with known cardiovascular disease, or those with symptoms suspected to be related to cardiac disease but this arises only in cases where such conditions are declared. Apparently there is no mechanism in place to diagnose asymptomatic individuals with these tests, but the evidence in the investigation indicated that a risk-based stratification system (for example a Q-Risk score) which takes account of age and comorbidities, rather than just cardiac symptoms, was feasible to reduce the risk of incidents of this type, thereby prompting consideration of stress testing. Alternatively a periodic stress test related to age was suggested as a means of ameliorating risk. Evidence was also provided indicating that on the D4 form there should be a provision to fill in HbA1c and cholesterol results produced within the previous 3 months as obtained by the applicant from a GP.
” 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 cardiac stress testing for asymptomatic individuals
Wider context from the report “4) I received evidence that DVLA does commission functional cardiac stress testing for those with known cardiovascular disease, or those with symptoms suspected to be related to cardiac disease but this arises only in cases where such conditions are declared. Apparently there is no mechanism in place to diagnose asymptomatic individuals with these tests , but the evidence in the investigation indicated that a risk-based stratification system (for example a Q-Risk score) which takes account of age and comorbidities, rather than just cardiac symptoms, was feasible to reduce the risk of incidents of this type, thereby prompting consideration of stress testing. Alternatively a periodic stress test related to age was suggested as a means of ameliorating risk. Evidence was also provided indicating that on the D4 form there should be a provision to fill in HbA1c and cholesterol results produced within the previous 3 months as obtained by the applicant from a GP.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The DVLA can act only on information received from licence holders or healthcare professionals about known medical conditions.
Verbatim wording from the response “I have noted your suggestions regarding the possibility of adding Hbac1 and cholesterol readings as standard to the D4 forms, as a way of screening for risk of heart-related conditions. Currently, the DVLA can only act on information received from licence holders and/or healthcare professionals about known medical conditions.” Source location 2024-0194 Response from Department for Transport
Open published response
20 Mar 2024 Shirley Ann HUNT · Prevention of Future Deaths report York and North Yorkshire
View report summary
Concerns raised 1 Lack of legal requirements for restraint of passengers travelling in the rear areas of motorhomes View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Shirley Ann HUNT · 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 August 2021, Shirley Ann Hunt died instantaneously from multiple injuries after a motorhome tyre deflated and the vehicle collided with a stationary vehicle on the A64 at Barton Hill. The concern was that adults and children over three can travel unrestrained in the rear areas of motorhomes because there is no legal obligation for seat belts to be fitted there, creating a potential risk to life.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of legal requirements for restraint of passengers travelling in the rear areas of motorhomes
Wider context from the report “Evidence given during the inquest indicated that there is no legal obligation for seat belts to be fitted in the rear areas of motorhomes, for passengers to use when the vehicle is in motion . Whilst it was not possible to establish whether Shirley Ann Hunt would have survived the impact if she had been wearing a seatbelt, as a wider point of public safety, I am concerned that adults and children over three years can travel in the rear areas of motorhomes without restraint , and that in doing so, this may create a risk to life .
” 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 Require seat belts for all travelling seats in newly registered motor caravans and identify unsuitable unbelted seats with signage.
Verbatim wording from the response “From 29 April 2012, newly registered motor caravans have required all seats intended for use when the vehicle is travelling, irrespective of whether they are fitted to the accommodation area or elsewhere in the vehicle, to be fitted with seat belts. Seats which are not suitable for use whilst travelling and not fitted with seat belts must be clearly identified to users by means of a pictogram or a sign with appropriate text.” Source location Response from Department for Transport
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish guidance advising motor-caravan passengers to use forward- or rearward-facing seats equipped with three-point seat belts.
Verbatim wording from the response “Although it is not illegal to travel unrestrained in the accommodation area of a motor caravan where no seat belts are fitted, the Department has published guidance at the following link which advises that passengers are safest in a forward or rearward facing seat equipped with a three-point seat belt.
www.gov.uk/government/publications/carriage-of-passengers-in-campervans” Source location Response from Department for Transport
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The existing regulatory framework is considered proportionate and sufficient for the range and age of motor caravans operating on the roads.
Verbatim wording from the response “Overall, I believe the existing regulatory framework is proportionate as it introduced enhanced requirements for new motor caravans from 2012 and provides sufficient in-use provision to cover the broad range and age of motor caravans operating on our roads.” Source location Response from Department for Transport
Open published response
20 Mar 2024 Ellie Louise Frances HUNT · Prevention of Future Deaths report York and North Yorkshire
View report summary
Concerns raised 1 Lack of required rear-area seat-belt restraint in motorhomes View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ellie Louise Frances HUNT · 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
Ellie Louise Frances Hunt was travelling in the rear of a motorhome when a front tyre deflated and the vehicle collided with a stationary vehicle on the A64 on 24 August 2021. She suffered multiple injuries that were not survivable; the principal concern was that rear areas of motorhomes may be used by adults and children over three without restraints, potentially creating a risk to life.
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 required rear-area seat-belt restraint in motorhomes
Wider context from the report “Evidence given during the inquest indicated that there is no legal obligation for seat belts to be fitted in the rear areas of motorhomes, for passengers to use when the vehicle is in motion . Whilst it was not possible to establish whether Ellie Louise Frances Hunt would have survived the impact if she had been wearing a seatbelt, as a wider point of public safety, I am concerned that adults and children over three years can travel in the rear areas of motorhomes without restraint , and that in doing so, this may create a risk to life .
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The existing regulatory framework is considered proportionate and sufficient for the range and age of motor caravans operating on roads.
Verbatim wording from the response “Overall, I believe the existing regulatory framework is proportionate as it introduced enhanced requirements for new motor caravans from 2012 and provides sufficient in-use provision to cover the broad range and age of motor caravans operating on our roads.” Source location Response from Department for Transport
Open published response
Concerns raised 1 Lack of required passenger seatbelts on buses undertaking predominantly rural, high-speed journeys View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Brian CHAPMAN · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Brian Chapman was an upper-deck passenger on a bus that collided with an articulated lorry on the A47 at Wisbech St Mary on 26 June 2018. He suffered significant and unsurvivable traumatic injuries and died at the scene. The principal concern was that buses travelling predominantly rural routes at high speeds were not required to have passenger seatbelts, creating an obvious risk of death in collisions.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Lack of required passenger seatbelts on buses undertaking predominantly rural, high-speed journeys
Wider context from the report “One of the two vehicles involved in the collision was a double decker service bus travelling a scheduled route between Peterborough and Norwich, a distance of approximately 80 miles. The bus was not fitted with passenger seatbelts. I heard evidence that although since 01.01.01 seatbelts are required to be fitted in all new buses(this vehicle was on a ‘63’ plate’) there is an exemption where such vehicles are designed for urban use standing passengers.
Whilst this particular route required the bus to travel from/to and stop off in 5-6 urban centres the majority of the journey took place on a major A route through rural areas. The speed of the bus at the point of collision was approximately 53mph. Both the bus driver and an upper deck passenger were killed in the collision.
Whilst there was no evidence that either death would have been prevented by the wearing of seatbelts a number of other passengers were injured in the collision.
I am concerned where buses are undertaking journeys such as this through predominantly rural locations and subject to the national speed limit without seatbelts being required there is an obvious risk of death to passengers if collisions occur, particularly at high speed.
” 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 Write to the Office of the Traffic Commissioner to raise awareness of appropriate vehicle selection and seat-belt provision.
Verbatim wording from the response “Finally, my officials will write immediately to the CPT, the trade body which represents bus and coach operators, highlighting the importance for their members in selecting appropriate vehicles based on the type of bus service operated, including full consideration of using only vehicles fitted with seat belts. At that same time they will also write to the Office of the Traffic Commissioner to raise awareness of this issue.” Source location Response from Department for Transport
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Write to the Confederation of Passenger Transport highlighting appropriate vehicle selection, including consideration of seat-belt-fitted vehicles.
Verbatim wording from the response “Finally, my officials will write immediately to the CPT, the trade body which represents bus and coach operators, highlighting the importance for their members in selecting appropriate vehicles based on the type of bus service operated, including full consideration of using only vehicles fitted with seat belts. At that same time they will also write to the Office of the Traffic Commissioner to raise awareness of this issue.” Source location Response from Department for Transport
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Traffic commissioners must determine whether their powers can restrict particular buses from particular roads through Traffic Regulation Conditions.
Verbatim wording from the response “Traffic Commissioners are responsible for licensing and regulation of those who operate buses and the registration of most bus services. On the request of a local transport authority, a traffic commissioner can consider the potential use of Traffic Regulation Conditions (TRCs) to prevent danger to road users. It would be for the individual traffic commissioners to determine whether their powers could extend to the use of a TRC to restrict certain buses from particular roads.” Source location Response from Department for Transport
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Standard-service operators are responsible for choosing vehicles appropriate to the intended operation; local authorities may specify vehicle requirements for contracted services.
Verbatim wording from the response “Once a bus is approved for use there are no specific regulations to restrict the type of roads it can use and for standard bus services it is for the operator to choose the type of vehicle used to provide a given service, and this should take account of the type of intended operation. Exceptions to this” Source location Response from Department for Transport
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The existing regulatory framework provides appropriate and proportionate safeguards, so no broader regulatory change is considered necessary.
Verbatim wording from the response “Overall, we believe the existing regulatory framework is appropriate as it harmonises vehicle construction with the wider international community and provides proportionate safeguards whilst ensuring the legislative landscape is sufficiently flexible to meet the needs of the local community. This ensures the economic viability and sustainability of bus services, which in turn supports social inclusion and the local economy, particularly in rural areas.” Source location Response from Department for Transport
Open published response
4 Dec 2023 Fraser William Moore · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 2 Failure to make station CCTV footage immediately available to Route Control Rooms View source Failure to provide CCTV coverage beyond station concourses and platform ends 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
Fraser William Moore · 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 March 2020, Fraser William Moore escaped from custody at London Bridge Station, entered the railway track area, and died after contacting a live rail before power could be severed. The report raised concerns that CCTV coverage ended at the station concourse and that footage was not immediately available to Route Control Rooms, with insufficient coverage beyond the platform ends.
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 make station CCTV footage immediately available to Route Control Rooms
Wider context from the report “The CCTV coverage/ footage ends at the end of the station concourse on both the city and country ends. Station footage does not get sent to Route Control. On a risk-based review, the chances of incidents happening in a busy cosmopolitan station must, by footfall and surrounding populations alone, increase the risk of an event. An event that should then be looked at. In order to look at an event, I accept that current CCTV is in place within the station confines but for these stations, I do not consider that I have received sufficient evidence to persuade me that the footages should not be available immediately to the Route Control Rooms or that the coverage should not extend up or down line beyond the end of the platforms.
” 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 CCTV coverage beyond station concourses and platform ends
Wider context from the report “The CCTV coverage/ footage ends at the end of the station concourse on both the city and country ends. Station footage does not get sent to Route Control. On a risk-based review, the chances of incidents happening in a busy cosmopolitan station must, by footfall and surrounding populations alone, increase the risk of an event. An event that should then be looked at. In order to look at an event, I accept that current CCTV is in place within the station confines but for these stations, I do not consider that I have received sufficient evidence to persuade me that the footages should not be available immediately to the Route Control Rooms or that the coverage should not extend up or down line beyond the end of the platforms .
” Open source report
16 Nov 2023 Terence Charles Scott DUNCAN · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 1 Inadequate sideguard coverage on extended trailers View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Terence Charles Scott DUNCAN · 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 Charles Scott Duncan died on 30 October 2022 after he ducked under the skeleton of an articulated lorry trailer obstructing a pedestrian crossing and was run over by its rear nearside tyres when the lorry moved off. The concern was that an extended trailer, despite being unloaded, had a significant gap between its sideguards and wheels, potentially providing less protection to pedestrians and cyclists than a fixed trailer of the same length.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Transport; that does not assign responsibility.
PFD Monitor interpretation Inadequate sideguard coverage on extended trailers
Wider context from the report “I was informed that the type of trailer involved in this inquest was an extendable trailer and therefore its construction was in compliance with the Regulations as long as the requirements were met when the trailer was in its shortest configuration .
The sideguard on this trailer was only 50cm long whereas the distance between the wheels of the cab unit and trailer wheels was 3 metres when extended . The trailer was extended despite being not being loaded with a shipping container at the time. There was therefore a very significant gap between the end of the sideguards and front of the following wheels .
I am concerned that there is no lesser risk posed to pedestrians or cyclists by an extendable trailer that posed by a fixed trailer of the same length which would have been required to have a more comprehensive sideguard device installed .
” 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 sideguard requirements and propose amendments to require sideguards on extended trailers where possible.
Verbatim wording from the response “In relation to sideguards, both UNECE Regulation 73 and C&U permit extendable trailers to be placed on the market and used respectively, without sideguards in the location of the increase in length when the trailer is extended. These provisions have been in place for many years, and I have asked officials to review the requirements, and to make proposals to amend the international regulation to require sideguards when the trailer is extended, where possible. This would increase the number of vehicles fitted with sideguards while continuing to recognise that this is not possible in all cases.” Source location Response from Department of Transport
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider amending Construction and Use Regulations to keep required sideguards in place throughout a vehicle’s life.
Verbatim wording from the response “In addition, consideration is also being given to amending C&U to ensure that sideguards which are required for the purpose of the original vehicle approval remain in place throughout the life of the vehicle. I trust that these two actions will address your concerns on the absence of sideguards on extendable trailers. The Department will continue to monitor the” Source location Response from Department of 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 Sideguards cannot be required on extendable trailers in all cases because fitting them is not possible in some circumstances.
Verbatim wording from the response “In relation to sideguards, both UNECE Regulation 73 and C&U permit extendable trailers to be placed on the market and used respectively, without sideguards in the location of the increase in length when the trailer is extended. These provisions have been in place for many years, and I have asked officials to review the requirements, and to make proposals to amend the international regulation to require sideguards when the trailer is extended, where possible. This would increase the number of vehicles fitted with sideguards while continuing to recognise that this is not possible in all cases.” Source location Response from Department of Transport
Open published response
5 Oct 2023 Jessica Evie BAKER · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 2 Failure of school commuter coach drivers to wear seatbelts View source Failure of school commuter coach passengers to use fitted seatbelts 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
Jessica Evie BAKER · 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
Jessica Evie Baker, a 15-year-old pupil, died after being partially ejected and trapped beneath a school coach during a motorway collision. The report raises concerns that seatbelts fitted to the coach did not appear to be used and asks about government advice and public information on seatbelt use for school commuter coaches.
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 school commuter coach drivers to wear seatbelts
Wider context from the report “This was a school commuter coach travelling on a motorway. It was constructed after 2001 and will have had seat belts fitted. Review of CCTV does not show the seatbelts were being used.
This coach had secondary school children on board. Some of the pupils those below 14 years of age would be expected to wear seatbelts under driver supervision.
The driver did not appear to be wearing a seat belt.
A distinction should be drawn between school buses in built-up areas and school commuter coaches travelling a distance using A roads and the motorway network – with regard to the availability and use of seatbelts.
I take judicial notice that using seat belts can prevent some injury altogether, make inevitable injury less severe and reduce the risk of fatal injury.
1. What advice does government through the Department of Transport, or the Department of Education give to schools and colleges when contracting for school bus commuter products – about the use of seatbelts?
2. What public information campaigns are being run about the additional road safety provided by the use of seatbelts?
” 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 school commuter coach passengers to use fitted seatbelts
Wider context from the report “This was a school commuter coach travelling on a motorway. It was constructed after 2001 and will have had seat belts fitted. Review of CCTV does not show the seatbelts were being used.
This coach had secondary school children on board. Some of the pupils those below 14 years of age would be expected to wear seatbelts under driver supervision.
The driver did not appear to be wearing a seat belt.
A distinction should be drawn between school buses in built-up areas and school commuter coaches travelling a distance using A roads and the motorway network – with regard to the availability and use of seatbelts.
I take judicial notice that using seat belts can prevent some injury altogether, make inevitable injury less severe and reduce the risk of fatal injury.
1. What advice does government through the Department of Transport, or the Department of Education give to schools and colleges when contracting for school bus commuter products – about the use of seatbelts?
2. What public information campaigns are being run about the additional road safety provided by the use of seatbelts?
” Open source report
Concerns raised 2 Failure to correctly apply the Settlement Policy for a 30mph speed limit View source Lack of independent medical scrutiny of the continued ability of drivers aged over 70 to drive View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Louis Steven James THOROLD · 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
Louis Steven James THOROLD died in hospital after being struck by a van that left the road following a collision on the A10 Ely Road. The report raised concern that drivers over 70 could continue driving through an online self-certification process without independent medical scrutiny, including where undiagnosed dementia may affect their ability to perceive hazards.
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 correctly apply the Settlement Policy for a 30mph speed limit
Wider context from the report “Louis’ father gave evidence at the inquest stating that he understood that this particular location fell within CCC’s ‘Settlement Policy’ for a 30mph speed limit(link included below). The inquest also heard evidence that, unsurprisingly, the risk to life as a result of a road traffic collision reduces with the speed of any impact involving a vehicle.
https://www.cambridgeshire.gov.uk/residents/travel-roads-and-parking/roads-and-pathways/improving-the-local-highway/speeding/alternative-speed-measures
I am therefore concerned that there is a risk of death occurring in similar circumstances if it is correct that CCC’s ‘Settlement Policy’ is not being correctly applied .
” 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 independent medical scrutiny of the continued ability of drivers aged over 70 to drive
Wider context from the report “During the inquest I heard evidence that drivers who reach 70 years of age and are therefore required to reapply for their driving licence at that point(and thereafter every 3 years) do so via an online self-certification process and that there is no need for independent medical scrutiny or input unless there is an issue which is specifically drawn to the attention of a medical practitioner . In this case one of the drivers involved in the road traffic collision was driving with undiagnosed dementia which effected their cognitive ability to perceive hazards on the road.
I am concerned that if drivers beyond the age of 70 continue to drive without independent medical scrutiny of their continued ability to drive then there is a risk of deaths occurring in similar circumstances.
” 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 Conduct a Call for Evidence on driver licensing for people with medical conditions.
Verbatim wording from the response “The DVLA recently published a Call for Evidence (CfE) on driver licensing for people with medical conditions. The CfE ran for 12 weeks and was an early stage request for input into a review of the legislative framework. Evidence has been gathered from members of the public and a range of experts across organisations. The CfE closed on 22 October and the responses are currently being analysed.” Source location Response from Department for Transport
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Analyse responses to the Call for Evidence on driver licensing for people with medical conditions.
Verbatim wording from the response “The DVLA recently published a Call for Evidence (CfE) on driver licensing for people with medical conditions. The CfE ran for 12 weeks and was an early stage request for input into a review of the legislative framework. Evidence has been gathered from members of the public and a range of experts across organisations. The CfE closed on 22 October and the responses are currently being analysed.” Source location Response from Department for Transport
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Current licensing arrangements for drivers renewing at age 70 are considered a proportionate balance of fairness, road safety and individual interests.
Verbatim wording from the response “In regard to older drivers, it is recognised that health can deteriorate in later life and driving licences expire at age 70 and are then renewed at least every three years. Applicants renewing a licence from age 70 must declare that they meet the legal eyesight standards for safe driving and confirm whether they have any relevant medical conditions which may affect safe driving. These regular renewals provide a timely reminder for drivers to consider their health in the context of driving.” Source location Response from Department for Transport
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation There is little evidence that mandatory testing or medical examination for older drivers would improve road safety.
Verbatim wording from the response “We have considered whether any changes to this policy are justified and proportionate. Driver licensing arrangements are designed to be balanced and proportionate for all drivers, and we are of the view that the current process for drivers renewing their licence at 70 strikes the appropriate balance between fairness, road safety and the individual. There is little evidence to suggest that introducing a stricter regime which includes mandatory testing or medical examination would improve road safety. For this reason, we do not propose to change the current approach.” Source location Response from Department for Transport
Open published response
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations