31 Oct 2023 Eric Sebastian Huber · Prevention of Future Deaths report Exeter and Greater Devon
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Concerns raised 2 Failure to conduct multi-agency and multi-disciplinary discussions about concerns and risks View source Failure to engage with and fully assess an individual's risk and needs View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Eric Sebastian Huber · 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
Eric Sebastian Huber had a history of drug and alcohol use, depression and anxiety, and was considered vulnerable to exploitation and harm. He was discovered deceased on 1 April 2021 after self-inflicted suspension; the report identifies missed opportunities to engage with him, assess his risks and needs, and conduct multi-agency discussions.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Devon County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct multi-agency and multi-disciplinary discussions about concerns and risks
Wider context from the report “The evidence shows that there were opportunities to engage with Mr Huber and fully assess his risk and needs, these were not taken; in addition, multi-agency and multi-disciplinary discussions to consider Mr Huber’s situation and how organisations could work together to address the concerns and risks were not conducted .
” 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 Devon County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to engage with and fully assess an individual's risk and needs
Wider context from the report “The evidence shows that there were opportunities to engage with Mr Huber and fully assess his risk and needs, these were not taken ; in addition, multi-agency and multi-disciplinary discussions to consider Mr Huber’s situation and how organisations could work together to address the concerns and risks were not conducted.
” Open source report
Concerns raised 1 Failure to consider safeguarding during welfare visits View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Joan Mary PRESCOTT · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Joan Mary PRESCOTT lived alone, was probably not compliant with her medication and neglected herself, deteriorated, and died in hospital on 9 May 2020. A concern was that safeguarding was not recorded as having been considered during a welfare visit, despite social workers identifying a need for GP involvement and possible admission.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Devon County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to consider safeguarding during welfare visits
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
Safeguarding Consideration at the time of the visit – There was no reference in the recordings to a discussion on safeguarding being considered. Again, on interviewing the social workers they felt there was a need for GP involvement and for an admission, not safeguarding at that stage (missed opportunity). The social workers formed an opinion that the initial focus was not on the state of the property, which was a known situation, but on the immediate presenting potential physical and mental health needs, hence their plan to recommend to re-contact GP for involvement. There is a clear recording of this reflection and decision in notes following visit. Following the welfare visit the GP was made aware (24/04/2020) of findings via the Duty Worker.
” Open source report
Concerns raised 2 Lack of improved communication with Children’s Services during child protection investigations or care proceedings planning View source Failure to provide appropriate support to parents open to DPT services with mental health problems 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
Marc David Bennett · 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
Marc David Bennett was distressed by his children being taken into foster care and took his own life at home on 24 May 2020, having fashioned a ligature. The report identified concerns about communication between Devon Partnership Trust staff and Children’s Services during child protection investigations or care proceedings, and about ensuring appropriate support for parents receiving mental health services.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Devon County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of improved communication with Children’s Services during child protection investigations or care proceedings planning
Wider context from the report “Lessons learned and submitted in the report by Devon Partnership Trust were, there is a need to ensure improved communication by DPT staff with Children’s Services when children are undergoing S47 Child Protection investigations, and/or planning is taking place for care proceedings , to ensure appropriate support to parents open to DPT services with mental health problems
” 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 Devon County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide appropriate support to parents open to DPT services with mental health problems
Wider context from the report “Lessons learned and submitted in the report by Devon Partnership Trust were, there is a need to ensure improved communication by DPT staff with Children’s Services when children are undergoing S47 Child Protection investigations, and/or planning is taking place for care proceedings, to ensure appropriate support to parents open to DPT services with mental health problems
” Open source report
21 Sep 2017 Margaret Olive PINE (Mrs Pine) · Prevention of Future Deaths report Exeter and Greater Devon
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Concerns raised 1 Lack of warning signage for the no-through road and road closure View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Margaret Olive PINE (Mrs Pine) · 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
Margaret Olive Pine was the front-seat passenger in a car returning from an evening out when, in poor visibility, the driver took a wrong turn and the car collided with a wall closing off a road. The inquest concluded that Mrs Pine died from injuries received in the road traffic collision. The substantive concern was that there were no signs indicating the road was a dead end and no reflective warning on the wall.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Devon County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of warning signage for the no-through road and road closure
Wider context from the report “To avoid the potential for a similar incident in the future I would ask Devon Highways to consider the erection of signs at the start of the aforementioned road advising drivers that this was a no through road and at the end of the road which is closed off with a wall, affixing to that wall some form of reflective signage warning drivers they have reached the end of the road .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Install a reflective bollard in front of the wall at Site 1.
Verbatim wording from the response “In section 5 of the Report you asked for two particular actions to be considered. I have attached a sketch which was issued to our contractor ordering works to be carried out in the suggested locations. Also attached are the two photographs from their works system showing completion.” Source location Response from Devon County Council
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Install an additional No Through Road sign on the first lighting column after the Site 2 roundabout.
Verbatim wording from the response “In section 5 of the Report you asked for two particular actions to be considered. I have attached a sketch which was issued to our contractor ordering works to be carried out in the suggested locations. Also attached are the two photographs from their works system showing completion.” Source location Response from Devon County Council
Open published response
Concerns raised 4 Inability of a person with the relevant disability to take evasive action during a fire View source Failure to recognise that carers were not obliged to facilitate smoking despite the fire risk View source Lack of carer training to assess household and appliance fire hazards View source Failure of smoke detectors to alert a fire station View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Kenneth Arthur Brincombe · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Kenneth Arthur Brincombe, an 81-year-old man with severe mobility and visual impairments, accidentally set fire to himself while smoking on 31 October 2016 and died from his burns. Concerns included carers facilitating smoking without supervision, insufficient training to assess fire hazards, and smoke detectors that would not alert a fire station or enable him to take evasive action.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Devon County Council; that does not assign responsibility.
PFD Monitor interpretation Inability of a person with the relevant disability to take evasive action during a fire
Wider context from the report “(3) Mr Brincombe had received advice and had three smoke detectors fitted, however these would only alert Mr Brincombe to the fire. The smoke detectors would not alert a fire station, and in Mr Brincombe’s level of disability he would be unable to take evasive action .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Devon County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise that carers were not obliged to facilitate smoking despite the fire risk
Wider context from the report “(1) There was an assumption that because Mr Brincombe wanted to smoke that the carers had no choice but to facilitate this despite putting Mr Brincombe and his neighbours at risk of death by fire .
” 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 Devon County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of carer training to assess household and appliance fire hazards
Wider context from the report “(2) In evidence the carer confirmed that the carers were responsible for maintaining a safe environment, but had no training in how to assess whether the house and the appliances were safe or whether they posed a fire hazard .
” 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 Devon County Council; that does not assign responsibility.
PFD Monitor interpretation Failure of smoke detectors to alert a fire station
Wider context from the report “(3) Mr Brincombe had received advice and had three smoke detectors fitted, however these would only alert Mr Brincombe to the fire. The smoke detectors would not alert a fire station , and in Mr Brincombe’s level of disability he would be unable to take evasive action.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Inform NHS and DCC staff using the community equipment service about incident learning and available assistive-technology alerting solutions.
Verbatim wording from the response “b) The new NHS and DCC community equipment service contract has assistive technology solutions available for alerting in these situations. We will ensure that all 2000 plus NHS and DCC staff who access this service are informed of the learning from this incident and directed to the solutions available within the service. Community equipment service Prescriber Newsletter and Newsflash to be issued by April 2018.” Source location Kenneth-BRINICOMBE-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Raise incident learning and alternative alerting options through local and countywide management forums.
Verbatim wording from the response “c) Learning from this incident to be raised via local and countywide management fora, to include reminders regarding options for alerting. By end April 2018” Source location Kenneth-BRINICOMBE-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share incident learning and alerting options with the Provider Engagement Network, including reminders about robust risk assessment and escalation of concerns.
Verbatim wording from the response “d) Learning from the incident, options and solutions will be shared with the Provider Engagement Network (for independent service providers) to include a reminder for the need to undertake robust risk assessments and alert the relevant social care team should ongoing concerns arise. By end April 2018” Source location Kenneth-BRINICOMBE-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use Care Act assessments, risk-based analysis and care planning to identify and address fire risks through support or assistive technology.
Verbatim wording from the response “6. The care management processes and documentation that support the assessment and support responsibilities under the Care Act, include risk based analysis against the Care Act eligibility outcomes as set out in Regulation 2(2) of the Care and Support (Eligibility Criteria) Regulations 2014:” Source location Kenneth-BRINICOMBE-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Inform DCC care management staff about incident learning and remind them to consider alternative alerting options in similar circumstances.
Verbatim wording from the response “a) All DCC care management staff to be informed of the learning from this incident and reminded of the need to consider alternative alerting options in any similar circumstances. Next monthly DCC staff newsletter due mid April 2018.” Source location Kenneth-BRINICOMBE-Response
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The provider should determine measures for carers facilitating dangerous activities under its internal policies, practices and CQC requirements.
Verbatim wording from the response “Describe what measures should be taken when carers are being asked to facilitate an activity which will endanger the lives of the individual concerned and others.” Source location Kenneth-BRINICOMBE-Response
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Fire Service does not have facilities to monitor individual properties or respond directly to smoke-detector alerts.
Verbatim wording from the response “Confirm whether in future, where a vulnerable adult is at high risk of accidental starting a fire, putting himself and others lives in danger, and being unable to take any action if this occurs, that smoke detectors would be fitted that have a direct link to a fire station.” Source location Kenneth-BRINICOMBE-Response
Open published response
Concerns raised 1 Failure to prevent people from easily crossing the walkway barrier 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
Charles Edward Pitcher · 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 5 July 2016, Charles Edward Pitcher jumped over the walkway barrier of the Tamar Bridge and landed in Wolseley Road, Plymouth, suffering fatal injuries. The report raised concerns that the barrier was too easy to cross, that people in Wolseley Road were at risk, and that further procedures and measures should be reviewed to reduce the likelihood of suicide from the bridge.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Devon County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent people from easily crossing the walkway barrier
Wider context from the report “At the Inquest I received information from Detective Constable ████████ who informed me there have been 11 persons who had jumped from the bridge in the last 10 years. He formed the view that it was all too easy to jump the barrier . He also made the observation there was a risk to persons in Wolseley Road arising from people crossing the walkway barrier at that point . He made the observation that on other significant bridges and he gave as an example the Humber Bridge, the operators have established precautions and set up appropriate notices.
” Open source report
27 May 2016 Keenan John WALSH · Prevention of Future Deaths report Exeter and Greater Devon
View report summary
Concerns raised 5 Lack of enforceable swimming-pool supervision requirements View source Insufficient swimming-pool safety signage View source Lack of regulatory oversight of private holiday lets with swimming pools View source Insufficient ratio of competent adults to children around swimming pools View source Swimming-pool profile failing to meet accepted safety standards View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Keenan John 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
Keenan John WALSH, a non-swimmer aged 4, drowned in the deep end of a heated swimming pool during a large family party on 23 August 2013. The concerns included the lack of regulation of private holiday lets with swimming pools, the pool’s hazardous profile and limited signage, and inadequate supervision ratios, with adults responsible for supervision being unable to rescue him.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Devon County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of enforceable swimming-pool supervision requirements
Wider context from the report “(3) The ratio of competent adults to children was one adult to anything up to 12 children at the time of this incident. This ratio was against the advice of the proprietors but unenforceable . Responsibility lay with adult family members.
” 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 Devon County Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient swimming-pool safety signage
Wider context from the report “(2) Although there was a limited amount of signage the profile of the swimming pool fell outside accepted standards and presented a significant hazard to non-swimmers approaching a sharp slope to the deep end.
” 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 Devon County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of regulatory oversight of private holiday lets with swimming pools
Wider context from the report “(1) At the time of the incident private holiday lets with swimming pools were not regulated by the Health and Safety Department of Local Authority Environmental Health , despite tourism being a significant part of local economy. See recording of evidence of ████████ Environmental Health Officer (North Devon Council).
” 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 Devon County Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient ratio of competent adults to children around swimming pools
Wider context from the report “(3) The ratio of competent adults to children was one adult to anything up to 12 children at the time of this incident. This ratio was against the advice of the proprietors but unenforceable. Responsibility lay with adult family members.
” 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 Devon County Council; that does not assign responsibility.
PFD Monitor interpretation Swimming-pool profile failing to meet accepted safety standards
Wider context from the report “(2) Although there was a limited amount of signage the profile of the swimming pool fell outside accepted standards and presented a significant hazard to non-swimmers approaching a sharp slope to the deep end .
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for health and safety in holiday lets rests with Devon’s district councils, which hold the power to make relevant practice changes.
Verbatim wording from the response “We note the content of North Devon Council’s response and agree with them that the responsibility for ensuring health and safety in holiday lets sits with District Councils across Devon. In light of this Devon County Council has no power to make changes to improve practice as that power is in the hands of the District Councils.” Source location 2016-0202-Response-by-Devon-County-Council
Open published response
31 Mar 2016 David Alan CURTIS · Prevention of Future Deaths report Exeter and Greater Devon
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Concerns raised 1 Lack of warning signage for a concealed left-hand bend View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
David Alan CURTIS · 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 Alan CURTIS died after his motorcycle collided with a tractor on the A3079 Holsworthy Road near Okehampton, Devon. The inquest conclusion was “Road Traffic Collision”, and the stated medical cause was moving blunt force trauma to the head and chest. The substantive concern was that there was no warning sign for the left-hand bend for motorists approaching from the direction in which the motorcycle was travelling, despite the bend not being visible until the hill crest.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Devon County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of warning signage for a concealed left-hand bend
Wider context from the report “When approaching from the Okehampton direction (the direction in which the motorcycle was travelling), there is a warning triangle sign advising motorists that they are approaching a 12% decrease in the gradient. There is no warning triangle indicating a left hand bend ahead. Conversely, when travelling from the opposite direction (Halwill towards Okehampton) there is a warning triangle indicating a right hand bend ahead and immediately below that there is another warning traffic sign indicating a slippery road. There was no prior signage warning vehicle users approaching the Halwill direction ; the apparent course of the road ahead is denoted by the convergence of hedge lines towards the right.
Photographs taken of the road from Halwill towards Okehampton (the direction the motorcycle was travelling) show the crest of the hill but does not indicate that there is a left hand bend immediately beyond that crest until the driver or rider arrives at that crest . If it was deemed necessary to warn drivers travelling from Halwill towards Okehampton that there is a right hand bend ahead, which can be seen from some distance away in that particular carriageway, it would seem appropriate to consider that drivers travelling from Okehampton towards Halwill should have the benefit of a warning triangle sign indicating the left hand bend ahead, particularly where that bend cannot be seen until the hill is crested .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Erect a left-hand bend warning sign before the crest of the hill on the A3079.
Verbatim wording from the response “I can confirm that we are arranging for a left hand bend warning sign to be erected in advance of the crest of the hill on the A3079 as recommended. It is anticipated that this work will be completed by 31st July 2016, or earlier if possible.” Source location 2016-0144-Response-by-Devon-County-Council
Open published response
Concerns raised 1 Failure to ensure clear information sharing for vulnerable adults at risk of self-neglect when their primary carer is outside the Clinical Commissioning Group View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Andrew John Nickolls · 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
Andrew John Nickolls was discharged from Torbay Hospital on 12 September 2013 and was later found by police officers in his flat after concerns were raised. The report identified concerns about information sharing and continuity of primary care for a vulnerable adult who may have been neglecting himself; the medical cause of death was unascertained and the inquest conclusion was open.
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 Devon County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure clear information sharing for vulnerable adults at risk of self-neglect when their primary carer is outside the Clinical Commissioning Group
Wider context from the report “The principal learning point is to be that there is an advantage in a patient being looked after by a primary carer (i.e. a GP) within the Clinical Commissioning Group. If this is not the case, then it is imperative that there is clear information sharing, particularly where there is a vulnerable adult and there is a possibility they are neglecting themselves.
” Open source report
17 Sep 2013 Luke James LYONS · Prevention of Future Deaths report Exeter & Greater Devon
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Concerns raised 1 Inadequate drainage to prevent water crossing the road and washing away road gritting View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Luke James LYONS · 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
Luke James Lyons died at the scene of a road accident on 25 January 2013 after his vehicle hit overnight black ice on the A396. The area was affected by water flowing across the road, which washed away salt, and information indicated that a subsequently installed drain may have been inadequate.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Devon County Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate drainage to prevent water crossing the road and washing away road gritting
Wider context from the report “I received evidence that the area in question was subject to water egress from the land at the side of the road which flowed from the higher ground across the road, thereby washing away any salt gritting put down by the Highway Department in anticipation of bad weather .
It was clear that procedures were followed, gritting undertaken which it was anticipated would have satisfied the need for gritting in the area in question in the absence of the localised water problem.
I received evidence that a number of vehicles going through this area also lost control despite the gritting but had managed to counteract the loss of control.
I understand that the Highways Department have since placed a drain at the location in order to combat the problem but it appears that it is inadequate (from information received from ████████ of Devon and Cornwall Constabulary). Clearly a repetition of Luke’s death in the forthcoming winter would be a disaster if it could be avoided by further action.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use drainage features and best-practice measures within the 2013/14 winter maintenance approach.
Verbatim wording from the response “Our plans for the 2013/14 winter period therefore include the use of the drainage features and best practice and we will continue to use our inspection process and intelligence gathering to inform our approach. We will also use the media to communicate this information to travellers.” Source location 2013-0203-Response-by-Devon-County-Council
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Communicate the commitment to fit-for-purpose winter maintenance work and improve communication and management of drainage features among relevant staff.
Verbatim wording from the response “The commitment to ensuring that the work has been fit for purpose and helps to prepare us for a level of inspection for this location, following our winter maintenance routes and procedures, has been communicated to all relevant staff. This will include improved communication and management of the drainage features.” Source location 2013-0203-Response-by-Devon-County-Council
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undertake further weather-response treatments on the A396 in support of precautionary winter gritting routes.
Verbatim wording from the response “In tandem with the special treatments taken on the A396 last winter and in support of the treatments undertaken throughout our precautionary gritting routes, Devon County Council will undertake further treatments in support of the response to the weather conditions.” Source location 2013-0203-Response-by-Devon-County-Council
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue inspections, intelligence gathering and risk assessment to inform responses to severe weather and drainage conditions.
Verbatim wording from the response “As you noted within the letter, the flooding on the A396, with water practically spilling onto the road, was a result of the conditions and would be difficult to predict. Our staff seeing this road and were thought to be proportionate to the predicted conditions. Our configuration of the road, together with the conditions at the time, meant that, for the most part, water was not going over the centre of the carriageway. The issues on sight lines, public, and our inspections have not noted recurring drainage issues. This further suggests that any water on the carriageway will be picked up and removed from the carriageway, before the saturated water flows above the carriageway. We accept the types of weather events to repeat in future and our inspections and risk assessment will continue to respond to this.” Source location 2013-0203-Response-by-Devon-County-Council
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete works at the A396 junction and review drainage management at that location.
Verbatim wording from the response “Since the incident involving Mr Lyons, we have undertaken work at the junction of the A396 and have reviewed the way in which drainage is managed at this location. We have also reviewed the winter service arrangements over the winter period, and these support measures will continue throughout the coming winter.” Source location 2013-0203-Response-by-Devon-County-Council
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Flooding at the A396 was difficult to predict, and inspections had not identified recurring drainage issues at the location.
Verbatim wording from the response “As you noted within the letter, the flooding on the A396, with water practically spilling onto the road, was a result of the conditions and would be difficult to predict. Our staff seeing this road and were thought to be proportionate to the predicted conditions. Our configuration of the road, together with the conditions at the time, meant that, for the most part, water was not going over the centre of the carriageway. The issues on sight lines, public, and our inspections have not noted recurring drainage issues. This further suggests that any water on the carriageway will be picked up and removed from the carriageway, before the saturated water flows above the carriageway. We accept the types of weather events to repeat in future and our inspections and risk assessment will continue to respond to this.” Source location 2013-0203-Response-by-Devon-County-Council
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations