19 May 2026 Patricia Hazell · Prevention of Future Deaths report Oxfordshire
View report summary
Concerns raised 3 Failure of wheelchair access door design and operation to prevent opening from the exterior View source Lack of operator ability to mitigate identified residual risks through design or engineering controls View source Dependence on passenger warnings and checks for preventing falls from wheelchair access doors 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
Patricia Hazell · 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
Patricia Hazell fell from a coach at Broadway Rail Station when a wheelchair access door was opened from outside without warning or checks. She sustained serious injuries, reduced mobility and subsequently developed a fatal chest infection. The principal concerns were the design and operation of wheelchair access doors, reliance on warnings and checks that may be ineffective, and the potential for similar incidents involving serious injury or death.
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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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Failure of wheelchair access door design and operation to prevent opening from the exterior
Wider context from the report “• The design and operation of wheelchair access doors on coaches may permit the door to be opened from the exterior
• That risks of falling was dependant solely on giving warnings to passengers inside and checking whether a person is leaning against the door. Such warnings may not always be effective.
• Where operators have identified residual risk, they may have no ability to mitigate that risk through design or engineering controls, as responsibility for such matters lies with the vehicle approval and safety regime overseen by the DVSA.
• In those circumstances, there is a concern that similar incidents could recur involving disabled access doors on coaches, with the potential for serious injury or death.
For these reasons, I consider it appropriate to report this matter to the DVSA so that the safety aspects of disabled access doors on coaches may be reviewed in light of the circumstances of this 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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Lack of operator ability to mitigate identified residual risks through design or engineering controls
Wider context from the report “• The design and operation of wheelchair access doors on coaches may permit the door to be opened from the exterior
• That risks of falling was dependant solely on giving warnings to passengers inside and checking whether a person is leaning against the door. Such warnings may not always be effective.
• Where operators have identified residual risk, they may have no ability to mitigate that risk through design or engineering controls , as responsibility for such matters lies with the vehicle approval and safety regime overseen by the DVSA .
• In those circumstances, there is a concern that similar incidents could recur involving disabled access doors on coaches, with the potential for serious injury or death.
For these reasons, I consider it appropriate to report this matter to the DVSA so that the safety aspects of disabled access doors on coaches may be reviewed in light of the circumstances of this 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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Dependence on passenger warnings and checks for preventing falls from wheelchair access doors
Wider context from the report “• The design and operation of wheelchair access doors on coaches may permit the door to be opened from the exterior
• That risks of falling was dependant solely on giving warnings to passengers inside and checking whether a person is leaning against the door. Such warnings may not always be effective.
• Where operators have identified residual risk, they may have no ability to mitigate that risk through design or engineering controls, as responsibility for such matters lies with the vehicle approval and safety regime overseen by the DVSA.
• In those circumstances, there is a concern that similar incidents could recur involving disabled access doors on coaches, with the potential for serious injury or death.
For these reasons, I consider it appropriate to report this matter to the DVSA so that the safety aspects of disabled access doors on coaches may be reviewed in light of the circumstances of this death.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with the Department for Transport to support its review of technical standards and regulatory requirements for public service vehicles.
Verbatim wording from the response “DVSA is working closely with the Department for Transport to support its review of the relevant technical standards and regulatory requirements for PSVs. DVSA will also ensure that the circumstances identified in the regulation 28 report are reflected in best-practice guidance for operators and will explore further opportunities to raise awareness through trade bodies. These actions are intended to help strengthen safety arrangements and reduce the likelihood of similar tragic incidents occurring in future.” Source location Response from Driver and Vehicle Standards Agency
Open published response
1 Apr 2026 Susan Jane WHITTLES · Prevention of Future Deaths report East Riding and Hull
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Concerns raised 3 Lack of examiner provision to withdraw unsupervised driving after failure to meet required standards View source Ability of non-designated-country nationals who fail GB driving tests to revert to driving on a foreign or international licence View source Lack of equivalent supervision and inexperience-warning restrictions for non-designated-country nationals who fail a GB driving test 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
Susan Jane WHITTLES · 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
Susan Jane WHITTLES died at the scene of a road traffic collision on 24 November 2023 after another vehicle failed to give way and collided with her vehicle. The substantive concerns relate to non-designated-country nationals being able to continue driving in Great Britain on a foreign or international licence after failing GB driving tests, without appropriate supervision, potentially creating a risk of serious injury or harm to other road users.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Lack of examiner provision to withdraw unsupervised driving after failure to meet required standards
Wider context from the report “(4) There appears no provision for an examiner to withdraw the ability to drive without appropriate supervision despite a person’s failure to meet the required standards .
” 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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Ability of non-designated-country nationals who fail GB driving tests to revert to driving on a foreign or international licence
Wider context from the report “(3) If a national of a non-designated country fails any number of driving tests within the 12 month period they are still able to revert and rely on their 12 month limit to drive on their foreign/international licence in the UK , despite not meeting the safety standards set by the DVSA .
” 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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Lack of equivalent supervision and inexperience-warning restrictions for non-designated-country nationals who fail a GB driving test
Wider context from the report “(2) Nationals of non-designated countries who fail a GB driving test are not treated in the same way as a GB resident who fails a GB driving test . A GB resident is not allowed to drive without appropriate supervision and when they are driving they must display L plates to act as a warning to other vehicles of their inexperience .
” Open source report
Concerns raised 4 Inability of batch sample non-destructive testing to guard against rare isolated hidden defects in individual parts View source Proximity of inspectors beneath raised and pressurised air suspension systems during visual pre-delivery inspections View source Lack of sector-wide awareness of inspection-phase proximity risk View source Failure of national guidance to address unexpected component failure during undisturbed visual inspection 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
Richard Gary Hopkins · 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
Richard Gary Hopkins sustained fatal injuries when a defective trailing arm suddenly failed while he was beneath the rear axle of a newly assembled vehicle during a visual pre-delivery inspection. The principal concerns were an unrecognised risk from proximity beneath raised and pressurised air suspension during undisturbed inspection, a lack of guidance addressing that risk, the limitations of batch sample testing, and limited awareness of the risk across the sector.
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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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Inability of batch sample non-destructive testing to guard against rare isolated hidden defects in individual parts
Wider context from the report “c) Limitations of batch sample testing
Batch sample non-destructive testing , although widely accepted for components not designated as safety critical, cannot fully guard against a rare, isolated hidden defect in an individual part . Inspectors may therefore be unknowingly positioned beneath a component capable of unexpected failure under pressure.
” 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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Proximity of inspectors beneath raised and pressurised air suspension systems during visual pre-delivery inspections
Wider context from the report “a) Previously unrecognised proximity risk
The investigation revealed a previously unrecognised proximity risk to inspectors working beneath raised and pressurised air suspension systems during visual pre delivery inspections. Although the defect in this case was exceptionally rare, a sudden and undetectable failure in these circumstances presents a clear risk of fatal injury .
” 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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Lack of sector-wide awareness of inspection-phase proximity risk
Wider context from the report “d) Lack of awareness of this inspection phase risk across the sector
The evidence demonstrated that the inspection phase proximity risk identified in this case was not appreciated by the employer or more widely within the sector . The measures introduced after the incident show that the risk can be effectively eliminated once recognised, but its existence had not been understood before this incident .
” 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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Failure of national guidance to address unexpected component failure during undisturbed visual inspection
Wider context from the report “b) Absence of guidance addressing failure during undisturbed inspection
Existing national guidance recognises the possibility of component failure when work is being carried out on a pressurised suspension system. It does not address the distinct risk demonstrated by this incident: that a component may also fail unexpectedly during an undisturbed visual inspection when the operative is not working on the system.
” 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 Broader workplace safety is predominantly a matter for other agencies, such as the Health and Safety Executive.
Verbatim wording from the response “On the broader point of safety in the workplace, this is predominantly a matter for other agencies such as the HSE. As usual, we will continue to collaborate with HSE to find opportunities to discuss mitigations that employers can implement to address this kind of problem, for example, in any trade communications or guidance.” Source location 2026-0155 - Response from Driver and Vehicle Standards Agency
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 No necessary actions were identified because of the unique nature of the incident.
Verbatim wording from the response “We have not identified any necessary actions given the unique nature of this particular incident. But we continue to support industry efforts (generally through trade associations) to improve safety in commercial vehicle workshops and have supported a number of areas of good practice guidance (such as on wheel chocking and vehicle loading) and will flag this as an area that could be considered.” Source location 2026-0155 - Response from Driver and Vehicle Standards Agency
Open published response
24 Dec 2025 Alan Richard BAKER · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 2 Lack of mandatory requirements for owners to maintain reversing cameras in a fully functioning state View source Lack of mandatory requirements for LGVs to have reversing cameras fitted 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
Alan Richard 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
Alan Richard BAKER died on 25 August 2024 after a reversing LGV ran over his motorcycle on Muck Lane, causing catastrophic injuries. The concerns were that LGVs are not required to have reversing cameras and that there is no mandatory requirement for owners to ensure fitted cameras are fully functioning.
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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory requirements for owners to maintain reversing cameras in a fully functioning state
Wider context from the report “I have concerns that (a) there is no mandatory requirement for LGVs to have reversing cameras fitted to enable drivers to see more thoroughly behind their vehicle before carrying out a reversing manoeuvre and (b) that there is no mandatory requirement for the owners of vehicles which do have such cameras to ensure they are maintained in a fully functioning state.
” 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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory requirements for LGVs to have reversing cameras fitted
Wider context from the report “I have concerns that (a) there is no mandatory requirement for LGVs to have reversing cameras fitted to enable drivers to see more thoroughly behind their vehicle before carrying out a reversing manoeuvre and (b) that there is no mandatory requirement for the owners of vehicles which do have such cameras to ensure they are maintained in a fully functioning state.
” Open source report
Concerns raised 19 Failure to assess new drivers’ understanding of passenger effects on braking, stability and handling View source Failure of licensing arrangements to address combined inexperience, peer presence and full vehicle loading View source Lack of a coordinated cross-sector approach to early indications of unsafe behaviour View source Unequal behavioural oversight of named drivers with similar early-stage risk profiles View source Failure of the standard driving test to require experience on challenging rural roads View source Inconsistent incorporation of safety considerations into young-driver insurance products View source Unclear detection and review of dangerous-driving content uploaded by minors View source Lack of safeguarding processes to identify repeated unsafe conduct among young users View source Uncertainty about wider algorithmic dissemination of dangerous-driving content View source Lack of a consistent method to identify concealed higher-than-expected use by young named drivers View source Insufficient understanding of peer influence, vehicle loading and rural road hazards View source Unclear insurer processes for collecting, interpreting and acting on telematics data View source Difficulty identifying true vehicle use by young named drivers View source Peer sharing of high-risk driving normalising and reinforcing risk-taking View source Failure of test requirements to assess passenger and load-related vehicle dynamics View source Unclear communication of telematics use and safety implications to young drivers and families View source Failure of qualification competencies to cover early independent-driving conditions View source Failure of licensing arrangements to provide structured progression aligned to early post-test risk View source Lack of a uniform approach to applying telematics View source See 16 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Harry Joseph Purcell and Matilda (Tilly) Grace Seccombe · 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
Harry Joseph Purcell and Matilda (Tilly) Grace Seccombe sustained fatal injuries in a single-vehicle collision on 21 April 2023, when a recently qualified 17-year-old driver travelled at excessive speed on a rural road and lost control. The report raised concerns about the combined risks of driver inexperience, peer passengers, vehicle loading and rural-road conditions, as well as issues concerning driver licensing, insurance oversight, unsafe-driving content shared on Snapchat and the lack of coordinated responses to unsafe behaviour.
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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Failure to assess new drivers’ understanding of passenger effects on braking, stability and handling
Wider context from the report “2. New drivers are not required to demonstrate an understanding of how passengers affect braking, stability and handling . The standard driving test does not require experience on rural roads with tight bends, undulations or variable grip. Given that collision risk is highest in the early post-test period, there is a concern as to whether current licensing arrangements adequately reflect the conditions young drivers commonly face or include a structured progression stage aligned to this 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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Failure of licensing arrangements to address combined inexperience, peer presence and full vehicle loading
Wider context from the report “1. The inquest noted that newly qualified drivers may carry multiple peer-age passengers immediately after passing their test. This case suggests that inexperience, peer presence and full vehicle loading can combine to elevate risk , and it is unclear how current licensing arrangements address these combined factors .
” 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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Lack of a coordinated cross-sector approach to early indications of unsafe behaviour
Wider context from the report “10. There does not appear to be a coordinated approach linking driver training bodies, insurers, social media platforms and road-safety organisations in identifying or responding to early indications of unsafe behaviour among newly qualified 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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Unequal behavioural oversight of named drivers with similar early-stage risk profiles
Wider context from the report “4. Evidence was heard about the practice of “fronting.” Although it did not apply in this case, it illustrates difficulties insurers may face in identifying the true pattern of vehicle use when young drivers are insured as named drivers. Named drivers may not be subject to telematics monitoring , which can result in differing levels of behavioural oversight for drivers with similar early-stage risk profiles .
” 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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Failure of the standard driving test to require experience on challenging rural roads
Wider context from the report “2. New drivers are not required to demonstrate an understanding of how passengers affect braking, stability and handling. The standard driving test does not require experience on rural roads with tight bends, undulations or variable grip . Given that collision risk is highest in the early post-test period, there is a concern as to whether current licensing arrangements adequately reflect the conditions young drivers commonly face or include a structured progression stage aligned to this 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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Inconsistent incorporation of safety considerations into young-driver insurance products
Wider context from the report “5. While telematics devices can monitor driving behaviour, it is unclear how insurers collect, interpret or act upon such data, or how consistently safety considerations are incorporated into insurance products designed for 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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Unclear detection and review of dangerous-driving content uploaded by minors
Wider context from the report “7. The inquest heard that unsafe driving behaviour was recorded and shared privately on Snapchat prior to the collision. It received no information on whether Snapchat is able to detect or review content depicting dangerous driving, including where uploaded by minors . It also remains unknown whether any such material was shared via public features, such as Spotlight or Public Stories, or whether algorithmic systems could have disseminated it more widely.
” 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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Lack of safeguarding processes to identify repeated unsafe conduct among young users
Wider context from the report “8. The filming and sharing of high-risk driving among peers, apparently treated as entertainment, raised concern that such use may normalise, encourage or reinforce risk-taking behaviour. There is no publicly available information on whether Snapchat has considered these behavioural risks or has safeguarding processes capable of identifying repeated patterns of unsafe conduct among young users .
” 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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Uncertainty about wider algorithmic dissemination of dangerous-driving content
Wider context from the report “7. The inquest heard that unsafe driving behaviour was recorded and shared privately on Snapchat prior to the collision. It received no information on whether Snapchat is able to detect or review content depicting dangerous driving, including where uploaded by minors. It also remains unknown whether any such material was shared via public features, such as Spotlight or Public Stories, or whether algorithmic systems could have disseminated it more widely .
” 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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Lack of a consistent method to identify concealed higher-than-expected use by young named drivers
Wider context from the report “6. Industry practice does not appear to include a consistent method for identifying when a named driver arrangement may conceal higher-than-expected use by a young driver, with implications for risk assessment and safety. There is also no uniform approach to how telematics is applied or the need for its use communicated to young drivers. The inquest noted uncertainty about how clearly insurers and brokers explain the safety-related aspects of telematics to young drivers or their families, which may influence decisions made when arranging insurance.
” 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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Insufficient understanding of peer influence, vehicle loading and rural road hazards
Wider context from the report “9. The circumstances of this case highlight the continued significance of peer influence, vehicle loading and rural road hazards for young drivers. It is unclear how well these risks are understood by young people, parents (particularly those organising insurance cover), or schools .
” 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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Unclear insurer processes for collecting, interpreting and acting on telematics data
Wider context from the report “5. While telematics devices can monitor driving behaviour, it is unclear how insurers collect, interpret or act upon such data , or how consistently safety considerations are incorporated into insurance products designed for 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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Difficulty identifying true vehicle use by young named drivers
Wider context from the report “4. Evidence was heard about the practice of “fronting.” Although it did not apply in this case, it illustrates difficulties insurers may face in identifying the true pattern of vehicle use when young drivers are insured as named drivers . Named drivers may not be subject to telematics monitoring, which can result in differing levels of behavioural oversight for drivers with similar early-stage risk profiles.
” 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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Peer sharing of high-risk driving normalising and reinforcing risk-taking
Wider context from the report “8. The filming and sharing of high-risk driving among peers, apparently treated as entertainment, raised concern that such use may normalise, encourage or reinforce risk-taking behaviour . There is no publicly available information on whether Snapchat has considered these behavioural risks or has safeguarding processes capable of identifying repeated patterns of unsafe conduct among young users.
” 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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Failure of test requirements to assess passenger and load-related vehicle dynamics
Wider context from the report “3. The inquest heard that newly qualified drivers may have limited experience of rural roads, vehicles under load or situations that significantly affect handling. Test requirements do not involve passengers or load-related vehicle dynamics , raising concern about whether the competencies assessed at qualification correspond to those required during the early stages of independent driving.
” 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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Unclear communication of telematics use and safety implications to young drivers and families
Wider context from the report “6. Industry practice does not appear to include a consistent method for identifying when a named driver arrangement may conceal higher-than-expected use by a young driver, with implications for risk assessment and safety. There is also no uniform approach to how telematics is applied or the need for its use communicated to young drivers . The inquest noted uncertainty about how clearly insurers and brokers explain the safety-related aspects of telematics to young drivers or their families , which may influence decisions made when arranging insurance.
” 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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Failure of qualification competencies to cover early independent-driving conditions
Wider context from the report “3. The inquest heard that newly qualified drivers may have limited experience of rural roads, vehicles under load or situations that significantly affect handling . Test requirements do not involve passengers or load-related vehicle dynamics, raising concern about whether the competencies assessed at qualification correspond to those required during the early stages of independent driving .
” 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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Failure of licensing arrangements to provide structured progression aligned to early post-test risk
Wider context from the report “2. New drivers are not required to demonstrate an understanding of how passengers affect braking, stability and handling. The standard driving test does not require experience on rural roads with tight bends, undulations or variable grip. Given that collision risk is highest in the early post-test period, there is a concern as to whether current licensing arrangements adequately reflect the conditions young drivers commonly face or include a structured progression stage aligned to this 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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Lack of a uniform approach to applying telematics
Wider context from the report “6. Industry practice does not appear to include a consistent method for identifying when a named driver arrangement may conceal higher-than-expected use by a young driver, with implications for risk assessment and safety. There is also no uniform approach to how telematics is applied or the need for its use communicated to young drivers. The inquest noted uncertainty about how clearly insurers and brokers explain the safety-related aspects of telematics to young drivers or their families, which may influence decisions made when arranging insurance.
” Open source report
20 Nov 2025 Lisa Marie Bowen · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 5 Failure of anti-locking braking systems to reliably recognise tyre detachment View source Lack of regulatory requirements for under-run protection device strength View source Lack of industry testing and data collection on braking following tyre detachment View source Insufficient strength of under-run protection devices View source Failure of anti-locking braking regulations to specify requirements for tyre detachment View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Lisa Marie Bowen · 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
Lisa Marie Bowen died instantaneously from fatal injuries after her Toyota Corolla’s tyre detached while she was driving on the M25, and the vehicle failed to stop before colliding with a stationary lorry. The principal concerns were that the anti-locking braking system substantially reduced braking after tyre detachment, and that the lorry’s under-run protection device was insufficiently strong to prevent or reduce the under-run. The report also raised concerns about the adequacy of relevant testing, regulations and protection requirements.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Failure of anti-locking braking systems to reliably recognise tyre detachment
Wider context from the report “Concern 1
As stated above, the brakes on the Deceased’s Toyota Corolla did not work effectively because, when the brake pedal was pressed, the vehicle’s anti-locking braking system was activated, and it operated to reduce the braking effect almost entirely. At the inquest I heard evidence that:
(i) Following the tyre detachment, the speed of the wheel with a detached tyre was much higher than the speed of the three other wheels with undamaged tyres.
(ii) The anti-locking braking system recognised this differential in speed, but perceived that the problem lay with the three slower wheels and assumed that they had locked or were at risk of doing so.
(iii) Consequently, each time the brake was applied, the anti-locking braking system immediately released the braking pressure to the three slower wheels in order to avoid them locking, thereby prioritising the preservation stability and steerability over braking.
(iv) In this way, the anti-locking braking system was working in accordance with its design.
(v) The system was unable to recognise that the problem in fact lay with the fourth wheel which was rotating much more quickly than the other wheels because its tyre had detached.
(vi) The outcome was an unintended effect of the system’s design which arose because the specific scenario, of tyre detachment occurring whilst the vehicle was being driven, which was thought to be a rare occurrence, had not been taken into account in the design process.
(vii) Testing of anti-locking braking systems and braking performance, following a tyre detachment, is not undertaken by the industry as a whole and, therefore, relevant data is not collated.
At the inquest and PFD hearing I was informed that –
(i) A large number Toyota Corolla motor cars continue to be driven on the roads of the UK with the same anti-locking braking system as was in Ms Bowen’s vehicle.
(ii) Anti-locking braking systems are developed by a small number of specialist companies and it may well be that other vehicles currently on the roads of the UK have systems similar to that in Ms Bowen’s car.
(iii) The company which developed the anti-locking braking system used in Ms Bowen’s car (Advics) has since developed and improved its system so that it is better able to recognise if one wheel speed is so different from the others that the data from that wheel should be ignored as unreliable. However, the improvements are not foolproof , not least because acceleration or deceleration of the vehicle affects this function.
(iv) The anti-locking braking system now used in Toyota Corolla motor cars has been developed by a different company (Bosch) and it is not known by Toyota precisely how it would respond following a tyre detachment whilst the vehicle is being driven .
(v) It seems that relevant regulations concerning anti-locking braking systems do not address or specify requirements relating to the scenario faced by Ms Bowen.
Although the detachment of a tyre whilst a vehicle is being driven is thought to be a rare occurrence, I am concerned that that may not be the case and that if it were to happen again, in the same or similar circumstances, the risk of future death continues.
” 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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Lack of regulatory requirements for under-run protection device strength
Wider context from the report “Concern 2
This concern relates to the catastrophic failure of the under-run protection bar (“the Device”) that was in place on the piece of the lorry with which Ms Bowen collided. At the inquest I heard and accepted expert evidence which established that:
(i) The Device was compliant with all relevant regulations and legal requirements, save only that fixing bolts of an incorrect strength had been used to attach it to the lorry’s chassis.
(ii) The strength of the Device was grossly insufficient, either to have prevented any underrun, or even to have reduced the extent of the Toyota’s under-run.
(iii) The Device would not have been strong enough to do so even if the correct fixing bolts had been used.
One expert stated that he was aware that some under-run protection devices are capable of providing protection against much greater forces than is currently required under the law and he expressed disappointment that the relevant legislation and regulations are not more robustly framed, so as to require the use of these much stronger devices.
I am concerned that, in the absence of more stringent requirements in relation to the degree of force that an under-run protection device should be capable of withstanding , a risk of future death arises.
” 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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Lack of industry testing and data collection on braking following tyre detachment
Wider context from the report “Concern 1
As stated above, the brakes on the Deceased’s Toyota Corolla did not work effectively because, when the brake pedal was pressed, the vehicle’s anti-locking braking system was activated, and it operated to reduce the braking effect almost entirely. At the inquest I heard evidence that:
(i) Following the tyre detachment, the speed of the wheel with a detached tyre was much higher than the speed of the three other wheels with undamaged tyres.
(ii) The anti-locking braking system recognised this differential in speed, but perceived that the problem lay with the three slower wheels and assumed that they had locked or were at risk of doing so.
(iii) Consequently, each time the brake was applied, the anti-locking braking system immediately released the braking pressure to the three slower wheels in order to avoid them locking, thereby prioritising the preservation stability and steerability over braking.
(iv) In this way, the anti-locking braking system was working in accordance with its design.
(v) The system was unable to recognise that the problem in fact lay with the fourth wheel which was rotating much more quickly than the other wheels because its tyre had detached.
(vi) The outcome was an unintended effect of the system’s design which arose because the specific scenario, of tyre detachment occurring whilst the vehicle was being driven, which was thought to be a rare occurrence, had not been taken into account in the design process.
(vii) Testing of anti-locking braking systems and braking performance, following a tyre detachment, is not undertaken by the industry as a whole and, therefore, relevant data is not collated .
At the inquest and PFD hearing I was informed that –
(i) A large number Toyota Corolla motor cars continue to be driven on the roads of the UK with the same anti-locking braking system as was in Ms Bowen’s vehicle.
(ii) Anti-locking braking systems are developed by a small number of specialist companies and it may well be that other vehicles currently on the roads of the UK have systems similar to that in Ms Bowen’s car.
(iii) The company which developed the anti-locking braking system used in Ms Bowen’s car (Advics) has since developed and improved its system so that it is better able to recognise if one wheel speed is so different from the others that the data from that wheel should be ignored as unreliable. However, the improvements are not foolproof, not least because acceleration or deceleration of the vehicle affects this function.
(iv) The anti-locking braking system now used in Toyota Corolla motor cars has been developed by a different company (Bosch) and it is not known by Toyota precisely how it would respond following a tyre detachment whilst the vehicle is being driven.
(v) It seems that relevant regulations concerning anti-locking braking systems do not address or specify requirements relating to the scenario faced by Ms Bowen.
Although the detachment of a tyre whilst a vehicle is being driven is thought to be a rare occurrence, I am concerned that that may not be the case and that if it were to happen again, in the same or similar circumstances, the risk of future death continues.
” 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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Insufficient strength of under-run protection devices
Wider context from the report “Concern 2
This concern relates to the catastrophic failure of the under-run protection bar (“the Device”) that was in place on the piece of the lorry with which Ms Bowen collided. At the inquest I heard and accepted expert evidence which established that:
(i) The Device was compliant with all relevant regulations and legal requirements, save only that fixing bolts of an incorrect strength had been used to attach it to the lorry’s chassis.
(ii) The strength of the Device was grossly insufficient, either to have prevented any underrun, or even to have reduced the extent of the Toyota’s under-run.
(iii) The Device would not have been strong enough to do so even if the correct fixing bolts had been used.
One expert stated that he was aware that some under-run protection devices are capable of providing protection against much greater forces than is currently required under the law and he expressed disappointment that the relevant legislation and regulations are not more robustly framed, so as to require the use of these much stronger devices.
I am concerned that, in the absence of more stringent requirements in relation to the degree of force that an under-run protection device should be capable of withstanding, a risk of future death arises.
” 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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Failure of anti-locking braking regulations to specify requirements for tyre detachment
Wider context from the report “Concern 1
As stated above, the brakes on the Deceased’s Toyota Corolla did not work effectively because, when the brake pedal was pressed, the vehicle’s anti-locking braking system was activated, and it operated to reduce the braking effect almost entirely. At the inquest I heard evidence that:
(i) Following the tyre detachment, the speed of the wheel with a detached tyre was much higher than the speed of the three other wheels with undamaged tyres.
(ii) The anti-locking braking system recognised this differential in speed, but perceived that the problem lay with the three slower wheels and assumed that they had locked or were at risk of doing so.
(iii) Consequently, each time the brake was applied, the anti-locking braking system immediately released the braking pressure to the three slower wheels in order to avoid them locking, thereby prioritising the preservation stability and steerability over braking.
(iv) In this way, the anti-locking braking system was working in accordance with its design.
(v) The system was unable to recognise that the problem in fact lay with the fourth wheel which was rotating much more quickly than the other wheels because its tyre had detached.
(vi) The outcome was an unintended effect of the system’s design which arose because the specific scenario, of tyre detachment occurring whilst the vehicle was being driven, which was thought to be a rare occurrence, had not been taken into account in the design process.
(vii) Testing of anti-locking braking systems and braking performance, following a tyre detachment, is not undertaken by the industry as a whole and, therefore, relevant data is not collated.
At the inquest and PFD hearing I was informed that –
(i) A large number Toyota Corolla motor cars continue to be driven on the roads of the UK with the same anti-locking braking system as was in Ms Bowen’s vehicle.
(ii) Anti-locking braking systems are developed by a small number of specialist companies and it may well be that other vehicles currently on the roads of the UK have systems similar to that in Ms Bowen’s car.
(iii) The company which developed the anti-locking braking system used in Ms Bowen’s car (Advics) has since developed and improved its system so that it is better able to recognise if one wheel speed is so different from the others that the data from that wheel should be ignored as unreliable. However, the improvements are not foolproof, not least because acceleration or deceleration of the vehicle affects this function.
(iv) The anti-locking braking system now used in Toyota Corolla motor cars has been developed by a different company (Bosch) and it is not known by Toyota precisely how it would respond following a tyre detachment whilst the vehicle is being driven.
(v) It seems that relevant regulations concerning anti-locking braking systems do not address or specify requirements relating to the scenario faced by Ms Bowen .
Although the detachment of a tyre whilst a vehicle is being driven is thought to be a rare occurrence, I am concerned that that may not be the case and that if it were to happen again, in the same or similar circumstances, the risk of future death continues.
” Open source report
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.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
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.
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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 Driver and Vehicle Standards Agency; 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 Driver and Vehicle Standards Agency; 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 Driver and Vehicle Standards Agency; 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
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.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
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.
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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 Driver and Vehicle Standards Agency; 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
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.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
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.
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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 Driver and Vehicle Standards Agency; 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 Driver and Vehicle Standards Agency; 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 Driver and Vehicle Standards Agency; 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 Driver and Vehicle Standards Agency; 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 Driver and Vehicle Standards Agency; 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
25 May 2021 Christopher Lloyd TAYLOR · Prevention of Future Deaths report Lincolnshire
View report summary
Concerns raised 1 Failure to prevent a fixed monitor from obstructing the driver's field of view during public-highway driving 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
Christopher Lloyd TAYLOR · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Christopher Lloyd TAYLOR died after falling from his bicycle and being run over by an agricultural crop sprayer on a narrow rural road on 15 June 2020. The principal concern was that a screen mounted inside the sprayer’s cab created a blind spot, preventing the driver from seeing the cyclist; the screen had no function while driving on the public highway and did not need to be fixed in place.
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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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent a fixed monitor from obstructing the driver's field of view during public-highway driving
Wider context from the report “(i) The driver of the crop sprayer sat in a cab at the front of his vehicle. It provided an elevated view of the road with full length windows to the front and both sides.
(ii) Directly in front of the driver was a steering wheel and an A pillar at each front corner of the cab.
(III) To the right hand A pillar there was affixed a flat screen monitor. That was for use only when the crop sprayer was being used for agricultural purposes.
(IV) A police reconstruction established that the presence of the screen fixed created a 'blind-spot' in the drivers field of view extending several metres in depth.
(V) The driver of the crop sprayer had not seen the cyclist approach throughout the limited time he would have been in view. On balance that occurred directly as a consequence of the presence of the screen.
(vi) The screen had no function at all whilst the vehicle was being driven on the public highway and did not need to be on a fixed mounting.
” Open source report
12 May 2021 Steven James Oscroft · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 3 Failure to load tipper lorries with loose materials below the level of the sides View source Failure of sheeting systems to fully cover and secure loose materials on tipper lorries View source Failure of mesh sheeting systems to fully cover and secure loose materials on tipper lorries 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
Steven James Oscroft · 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
Steven James Oscroft was killed instantly when a piece of concrete fell from an oncoming lorry and smashed through his windscreen while he was driving on 7 July 2020. The concerns included the practice of mounding loads above the sides of tipper lorries and using sheeting systems that could leave material uncovered and liable to fall or be blown from the vehicle.
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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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Failure to load tipper lorries with loose materials below the level of the sides
Wider context from the report “Paul Wainwright Construction Services Ltd
Evidence was heard regarding the training and practices of loading tipper lorries at Paul Wainwright Construction Services Ltd.
1. Loads are ‘mounded’ such that in the middle of the load area, the height of the load extends above the level of the sides , whilst being below the level of the sides at the point at which the load contacts the side. Part of the load is therefore above the level of the sides, increasing the risk of items on the load falling or blowing off the vehicle.
2. Industry standard sheeting systems are in use which, when the load is ‘mounded’ in this way, causes the sheet to be drawn up. This results in part of the load being uncovered and liable to fall or be blown from the vehicle.
3. Such standard sheeting systems are not designed to be used on loads mounded above the level of the sides and cannot prevent ‘blow off’ from the areas of the load uncovered by the mesh.
4. Evidence was adduced of a number of loads on Wainwrights lorries which, because of the above practice, appeared not to be fully secure.
” 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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Failure of sheeting systems to fully cover and secure loose materials on tipper lorries
Wider context from the report “Paul Wainwright Construction Services Ltd
Evidence was heard regarding the training and practices of loading tipper lorries at Paul Wainwright Construction Services Ltd.
1. Loads are ‘mounded’ such that in the middle of the load area, the height of the load extends above the level of the sides, whilst being below the level of the sides at the point at which the load contacts the side. Part of the load is therefore above the level of the sides, increasing the risk of items on the load falling or blowing off the vehicle.
2. Industry standard sheeting systems are in use which, when the load is ‘mounded’ in this way, causes the sheet to be drawn up. This results in part of the load being uncovered and liable to fall or be blown from the vehicle.
3. Such standard sheeting systems are not designed to be used on loads mounded above the level of the sides and cannot prevent ‘blow off’ from the areas of the load uncovered by the mesh.
4. Evidence was adduced of a number of loads on Wainwrights lorries which, because of the above practice, appeared not to be fully secure.
” 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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Failure of mesh sheeting systems to fully cover and secure loose materials on tipper lorries
Wider context from the report “The Driver and Vehicle Standards Agency
Evidence was heard regarding the manner in which loose materials are loaded and secured onto tipper lorries.
1. The above-mentioned practice of ‘mounding’ loads above the level of the sides is standard practice within the industry.
2. Mesh sheeting systems are commonly deployed in circumstances when the mesh does not cover all of the material being carried.
3. Mesh sheeting systems are typically not secured at the sides and are installed in such a way as to leave a small gap at the sides and a larger gap at the back.
” 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 Produce communications highlighting the revised load-security guidance alongside the targeted roadside checks.
Verbatim wording from the response “• Work with HSE on amending the current load security guidance on GOV.UK to include very specific narrative dealing with bulk loads. This work has already started, and we aim to have the updated guidance prepared by September 2021.” Source location 2021-0162-Response-from-DVSA_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide load-security training covering securing methods, vehicle types and securing equipment to vehicle examiners.
Verbatim wording from the response “DVSA Examiner Training/Awareness
All our vehicle examiners undertake specific training on load security as part of their initial training. The current course was created in partnership with the HSE and designed to cover all aspects of load security, including securing methods, vehicle types and types of securing equipment. Examiners are then supported with their routine daily enforcement activities via the Enforcement Policy Team and Area subject matter experts who had additional training delivered by HSE.” Source location 2021-0162-Response-from-DVSA_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Arrange targeted roadside checks of bulk trailer and skip lorries on strategic and urban roads.
Verbatim wording from the response “Looking ahead, we will start to organise specific roadside checks focussing on bulk tipper and skip operations on the strategic roads network and in more urban areas where these vehicles can be more prevalent. That focus will tackle and act as deterrence towards the type of incident we have seen here.” Source location 2021-0162-Response-from-DVSA_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue prioritising load security during enforcement encounters and scrutinising operators’ load-security compliance systems.
Verbatim wording from the response “Enforcement Activity
We are constantly engaged in a programme of enforcement checks throughout Great Britain. Many of these checks are conducted on the strategic road network on our major check sites, but some are also carried out on minor roads and urban areas. They are designed to ensure that operators and drivers are adhering to their responsibilities towards aspects such as roadworthiness compliance, drivers’ hours, licensing, etc. A routine part of those checks is also devoted to ensuring loads are carried safely, so an emphasis on load securing has been established as one of the constituent parts of a routine vehicle check.” Source location 2021-0162-Response-from-DVSA_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with HSE to develop additional practical load-security material for Driver CPC training providers.
Verbatim wording from the response “Driver Certificate of Professional Competence (CPC)
There are driver CPC modules which cover load security, but currently the content of these is not prepared or dictated by DVSA. We do however monitor the courses to ensure they are fit for purpose, and we are currently working with HSE to look how we can provide additional material on load security, to CPC training companies. The intention is to make” Source location 2021-0162-Response-from-DVSA_Published
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 Amend GOV.UK load-security guidance with specific advice on securing bulk loads.
Verbatim wording from the response “However, we recognise that the detailed nature of both guidance documents does not necessarily equate to helpful advice that can be easily interpreted and understood. Therefore, in conjunction with the Health & Safety Laboratory, we have drafted load security guidance available on GOV.UK which highlights the main elements of DfT and EU guidance in a more easily understood format. This guidance is constantly under review, and, we have already started further work with the Health and Safety Executive (HSE) on drafting more specific GOV.UK content on properly loading and securing bulk loose loads.” Source location 2021-0162-Response-from-DVSA_Published
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation DVSA does not prepare or dictate driver CPC load-security content, although it monitors courses and may provide additional material.
Verbatim wording from the response “Driver Certificate of Professional Competence (CPC)
There are driver CPC modules which cover load security, but currently the content of these is not prepared or dictated by DVSA. We do however monitor the courses to ensure they are fit for purpose, and we are currently working with HSE to look how we can provide additional material on load security, to CPC training companies. The intention is to make” Source location 2021-0162-Response-from-DVSA_Published
Open published response
30 Sep 2020 Mollie Matilda Gifford · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1 Failure of standard class 5 and 6 mirrors to provide adequate close-proximity visibility when the cab is stationary View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mollie Matilda Gifford · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mollie Matilda Gifford was struck by a large goods vehicle while crossing a road and later died in hospital after sustaining severe traumatic injuries and complications. The principal concern was that standard class 5 and 6 lorry mirrors create an avoidable risk that drivers will not see pedestrians and other road users close to the cab when stationary; the cause of death and the role of the collision remained unknown.
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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Failure of standard class 5 and 6 mirrors to provide adequate close-proximity visibility when the cab is stationary
Wider context from the report “The mirrors are convex and therefore even when clean provide a distorted view, but as they are prone to collect road dirt and spray, the distortion is easily amplified, making it difficult for cab drivers to see movement and colour. Some cab drivers will have a false sense of security about the ability of class 5 and 6 mirrors to provide a comprehensive view of other road users and pedestrians around the cab when stationary. Mr ████████ went on to explain that camera units are available on the market to stream live footage of around the cab to the driver on a screen. Camera units offer a clearer view, are not subject to the same distortion as class 5 and 6 mirrors and it is easier to pick out movement and different colours.
My ongoing concern is that standard class 5 and 6 mirrors create an avoidable risk cab drivers will not see other road users and pedestrians in close proximity to the cab when stationary.
” Open source report
25 Mar 2020 Dudley Stanley HOWE · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 2 Failure of HGV training providers to require all drivers to undergo Safe Urban Driving or Vulnerable Road User Awareness training View source Lack of mandated HGV training on the use and positioning of Class VI mirrors 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
Dudley Stanley HOWE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 6 October 2017, Dudley Stanley HOWE was struck by a lorry while crossing Station Road, Attleborough, and died from his injuries. The substantive concerns relate to the lack of mandated HGV training on Class VI mirrors and the inconsistent provision of Safe Urban Driving or Vulnerable Road User Awareness training.
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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Failure of HGV training providers to require all drivers to undergo Safe Urban Driving or Vulnerable Road User Awareness training
Wider context from the report “I understand there is nothing to mandate that specific subjects are covered during HGV training, such as the use and positioning of Class VI (cyclops) mirror which shows the area immediately in front of the lorry, which would otherwise be outside the lorry driver’s view. Some training is provided in respect of use of such mirrors but there are some Industry bodies and Operators who deliver training who do not require all drivers to undergo a Safe Urban Driving or Vulnerable Road User Awareness Course .
” 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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Lack of mandated HGV training on the use and positioning of Class VI mirrors
Wider context from the report “I understand there is nothing to mandate that specific subjects are covered during HGV training, such as the use and positioning of Class VI (cyclops) mirror which shows the area immediately in front of the lorry, which would otherwise be outside the lorry driver’s view. Some training is provided in respect of use of such mirrors but there are some Industry bodies and Operators who deliver training who do not require all drivers to undergo a Safe Urban Driving or Vulnerable Road User Awareness Course.
” 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 Promote safe urban driving and vulnerable road user awareness training with Transport for London and industry stakeholders.
Verbatim wording from the response “Professional lorry drivers must complete 35 hours of periodic training every five years to maintain their driver certificate of professional competence (DCPC). We have worked with Transport for London (TfL) and other industry stakeholders to promote such training (often referred to as safe urban driving or vulnerable road user (VRU) awareness courses. These courses typically highlight the blind spots around a lorry’s cab and advise drivers to be extra vigilant, including how to use the latest mirrors and camera technologies. TfL has delivered its safe urban driving (SUD) course to more than 80,000 professional drivers over the last seven years. Although we cannot mandate which DCPC courses are taken by industry bodies and operators, we can increase our efforts to promote SUD and vulnerable road user awareness courses.” Source location 2020-0079-Response-from-Driver-Vehicle-Standards-Agency-Redacted
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 Recommend that industry bodies and operators include safe urban driving or vulnerable road user training in drivers’ periodic professional training.
Verbatim wording from the response “We will recommend to industry bodies and operators that all drivers take some SUD/VRU training as part of their driver DCPC periodic training.” Source location 2020-0079-Response-from-Driver-Vehicle-Standards-Agency-Redacted
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 Introduce two class VI mirror questions into the large goods vehicle driving theory test question bank.
Verbatim wording from the response “We will introduce two questions to the driving theory test for new drivers of large goods vehicles. These will be on the topic of class VI (cyclopes) mirrors and will increase awareness of the positioning and use of the class VI mirror. We will add these to the theory test question bank for the next reprint in autumn 2020.” Source location 2020-0079-Response-from-Driver-Vehicle-Standards-Agency-Redacted
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 agency cannot mandate which periodic professional driver training courses industry bodies and operators select.
Verbatim wording from the response “Professional lorry drivers must complete 35 hours of periodic training every five years to maintain their driver certificate of professional competence (DCPC). We have worked with Transport for London (TfL) and other industry stakeholders to promote such training (often referred to as safe urban driving or vulnerable road user (VRU) awareness courses. These courses typically highlight the blind spots around a lorry’s cab and advise drivers to be extra vigilant, including how to use the latest mirrors and camera technologies. TfL has delivered its safe urban driving (SUD) course to more than 80,000 professional drivers over the last seven years. Although we cannot mandate which DCPC courses are taken by industry bodies and operators, we can increase our efforts to promote SUD and vulnerable road user awareness courses.” Source location 2020-0079-Response-from-Driver-Vehicle-Standards-Agency-Redacted
Open published response
17 Sep 2019 Dr Jonathan Edward Ball · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 4 Failure of HGV rear hazard warning lights to remain working and sufficiently conspicuous View source Failure to train or instruct HGV drivers to report stranded vehicles to emergency services View source Lack of an HGV warning device for alerting approaching motorists to a stranded vehicle View source Lack of duplicate rear indicator and hazard warning lights on HGVs 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
Dr Jonathan Edward Ball · 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 November 2018, Dr Jonathan Edward Ball died after his Skoda collided with a stationary 32-ton HGV on the A647 Stanningley bypass near Pudsey, Leeds. The substantive concerns related to the absence of advance warning equipment and emergency-service notification for the stranded HGV, and the limited visibility or resilience of its rear hazard warning lights.
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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Failure of HGV rear hazard warning lights to remain working and sufficiently conspicuous
Wider context from the report “(3) The evidence of the other motorists on the A647 at the material time indicated that the rear offside hazard warning light was hard to see (or thought not to be working) thus giving the impression that the HGV was indicating to turn left (and thereby potentially confusing approaching motorists). In such circumstances there was no added resilience to the lights displayed, such as would have been provided by having duplicate indicator/hazard lights on the rear corners of the HGV. Given the arduous work of such vehicles and the propensity for the light to become dirty at the end of a working day , concern was expressed at the Inquest as to the danger which might be created in the event (a) the HGV broke down in a hazardous location and (b) the rear lights were not working or insufficiently conspicuous .
” 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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Failure to train or instruct HGV drivers to report stranded vehicles to emergency services
Wider context from the report “(2) The HGV driver had not been trained or instructed to contact the emergency services to report the foreseeable hazard created by his stranded HGV on a dual carriageway at night. The HGV was there for some 41 minutes before the fatal collision occurred (although the Inquest heard evidence there were several near misses before then). It was likely that when a mechanic did arrive at the scene the HGV would have been there for a further period before it was repaired or could have been towed to a safe location. In consequence, the police had no opportunity to guard the scene, position safety barrier or warning signs to alert approaching motorists of the 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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Lack of an HGV warning device for alerting approaching motorists to a stranded vehicle
Wider context from the report “(1) The HGV was not equipped with a device (such as a warning triangle) which the driver could have positioned some way before his stranded vehicle to warn oncoming motorists of the hazard presented by a stranded 32 ton HGV blocking one lane of a dual carriageway in darkness.
” 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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Lack of duplicate rear indicator and hazard warning lights on HGVs
Wider context from the report “(3) The evidence of the other motorists on the A647 at the material time indicated that the rear offside hazard warning light was hard to see (or thought not to be working) thus giving the impression that the HGV was indicating to turn left (and thereby potentially confusing approaching motorists). In such circumstances there was no added resilience to the lights displayed , such as would have been provided by having duplicate indicator/hazard lights on the rear corners of the HGV . Given the arduous work of such vehicles and the propensity for the light to become dirty at the end of a working day, concern was expressed at the Inquest as to the danger which might be created in the event (a) the HGV broke down in a hazardous location and (b) the rear lights were not working or insufficiently conspicuous.
” Open source report
18 Jul 2019 Miss Rebecca Alice QUALT · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 5 Lack of national guidance on inspections and checks View source Failure to conduct Jockey Wheel tests to indicate coupling-head engagement View source Failure to ensure full engagement of towing mechanisms through full visual inspection View source Foreign objects in tow hitch couplings preventing apparent full engagement View source Failure to ensure that coupler interiors are free from foreign objects View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Miss Rebecca Alice QUALT · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Rebecca was killed when a trailer detached from a van and collided with her car on the A6 near Shap. The trailer coupling was not fully engaged because of a foreign object in the tow hitch, which could appear engaged on visual inspection. The report raised concerns about the absence of national guidance and the possibility that operators may not check couplers for foreign objects or ensure that the coupling is fully engaged.
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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance on inspections and checks
Wider context from the report “1. There is a possibility that a foreign object may enter a tow hitch coupling.
2. This may cause the coupling not to be fully engaged.
3. This may not be apparent on visual inspection.
4. There appears to be no national guidance on inspections and checks.
5. Operators may not always ensure that the inside of a coupler is free from foreign objects.
6. Operators may not always ensure that whatever a towing mechanism is used, that it is fully engaged by way of a full visual inspection.
7. That conducting a Jockey Wheel test is a further indicator that the coupling head may not be engaged and operators may not be doing so.
” 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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct Jockey Wheel tests to indicate coupling-head engagement
Wider context from the report “1. There is a possibility that a foreign object may enter a tow hitch coupling.
2. This may cause the coupling not to be fully engaged.
3. This may not be apparent on visual inspection.
4. There appears to be no national guidance on inspections and checks.
5. Operators may not always ensure that the inside of a coupler is free from foreign objects.
6. Operators may not always ensure that whatever a towing mechanism is used, that it is fully engaged by way of a full visual inspection.
7. That conducting a Jockey Wheel test is a further indicator that the coupling head may not be engaged and operators may not be doing so.
” 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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure full engagement of towing mechanisms through full visual inspection
Wider context from the report “1. There is a possibility that a foreign object may enter a tow hitch coupling.
2. This may cause the coupling not to be fully engaged.
3. This may not be apparent on visual inspection.
4. There appears to be no national guidance on inspections and checks.
5. Operators may not always ensure that the inside of a coupler is free from foreign objects.
6. Operators may not always ensure that whatever a towing mechanism is used, that it is fully engaged by way of a full visual inspection.
7. That conducting a Jockey Wheel test is a further indicator that the coupling head may not be engaged and operators may not be doing so.
” 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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Foreign objects in tow hitch couplings preventing apparent full engagement
Wider context from the report “1. There is a possibility that a foreign object may enter a tow hitch coupling.
2. This may cause the coupling not to be fully engaged.
3. This may not be apparent on visual inspection.
4. There appears to be no national guidance on inspections and checks.
5. Operators may not always ensure that the inside of a coupler is free from foreign objects.
6. Operators may not always ensure that whatever a towing mechanism is used, that it is fully engaged by way of a full visual inspection.
7. That conducting a Jockey Wheel test is a further indicator that the coupling head may not be engaged and operators may not be doing so.
” 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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that coupler interiors are free from foreign objects
Wider context from the report “1. There is a possibility that a foreign object may enter a tow hitch coupling.
2. This may cause the coupling not to be fully engaged.
3. This may not be apparent on visual inspection.
4. There appears to be no national guidance on inspections and checks.
5. Operators may not always ensure that the inside of a coupler is free from foreign objects.
6. Operators may not always ensure that whatever a towing mechanism is used, that it is fully engaged by way of a full visual inspection.
7. That conducting a Jockey Wheel test is a further indicator that the coupling head may not be engaged and operators may not be doing so.
” Open source report
20 May 2019 Christopher George Barnes · Prevention of Future Deaths report Gloucestershire
View report summary
Concerns raised 2 Failure to ensure an appropriate level of safety and maintain sufficient control measures for working at height on vehicles or vehicle trailers View source Lack of sufficient understanding of working-at-height hazards and risks on vehicles or vehicle trailers 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
Christopher George Barnes · 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
Christopher George Barnes, a 69-year-old lorry driver, fell approximately 2.3 metres from the load on his lorry while attempting to untangle securing straps and died from his injuries on 24 April 2018. The principal concern was whether consignors, consignees and their employees sufficiently understood the hazards of working at height on vehicles or trailers and had appropriate safety measures and controls in place.
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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure an appropriate level of safety and maintain sufficient control measures for working at height on vehicles or vehicle trailers
Wider context from the report “Whether consigness and consigners and their employees have sufficient understanding of the hazards and risks associated with working at height on a vehicle or vehicle trailer, and whether they ensure an appropriate level of safety and have in place sufficient control measures to satisfy their legal obligations .
” 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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Lack of sufficient understanding of working-at-height hazards and risks on vehicles or vehicle trailers
Wider context from the report “Whether consigness and consigners and their employees have sufficient understanding of the hazards and risks associated with working at height on a vehicle or vehicle trailer , and whether they ensure an appropriate level of safety and have in place sufficient control measures to satisfy their legal obligations.
” Open source report
7 Apr 2017 Raymond Dathan Berry · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1 Inadequate Supplementary Restraint System activation parameters for collisions away from sensor vicinity 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
Raymond Dathan Berry · 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
Raymond Dathan Berry died at the scene on 26 December 2015 after the Honda Jazz in which he was travelling crashed into a tree; he was not wearing a seatbelt and sustained serious head and chest injuries. The concern was that the parameters for activating the vehicle’s Supplementary Restraint System might need adjustment so that airbags could deploy in collisions occurring away from the sensors, such as at the front centre of the vehicle.
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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Inadequate Supplementary Restraint System activation parameters for collisions away from sensor vicinity
Wider context from the report “- The parameters required to activate the Supplementary Restraint System may require adjusting or amendment to activate airbags in cases where a collision occurs away from the vicinity of the sensors, for example to the front centre of the vehicle
” Open source report
1 Dec 2015 Ricky Craig HUDSON · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Lack of additional driving qualification requirements for quad bike driving View source Lack of a requirement for quad bike riders to wear crash helmets on public roads 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
Ricky Craig HUDSON · 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
Ricky Craig HUDSON died at Queen Elizabeth Hospital Birmingham on 13 August 2015 from injuries sustained when he fell from a quad bike on 11 August 2015. The principal concerns were that quad bike riders are not required to wear crash helmets on public roads and that no additional driving qualifications are required to drive a quad bike.
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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Lack of additional driving qualification requirements for quad bike driving
Wider context from the report “(1) That quad bike riders are not required to wear crash helmets when driving on public roads.
(2) That there are no additional driving qualifications required to drive a quad bike .
” 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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Lack of a requirement for quad bike riders to wear crash helmets on public roads
Wider context from the report “(1) That quad bike riders are not required to wear crash helmets when driving on public roads .
(2) That there are no additional driving qualifications required to drive a quad bike.
” Open source report
8 Jul 2014 Muriel Naylor · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 1 Lack of restraint in priority seating View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Muriel Naylor · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Muriel Naylor died after a bus made an emergency stop on 19 November 2011, causing her to be projected from a designated priority seat into the wheelchair/tip-up bay and sustain fatal spinal injuries. The principal concern was that the priority seat lacked a restraint or other safety measure to restrict passenger movement, despite priority seating being intended to protect vulnerable users.
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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Lack of restraint in priority seating
Wider context from the report “IV. As standing passengers are carried on this vehicle, seat belts are not mandatory although this would not preclude the fitment of a seat belt as an option . However, a seat belt could only be fitted if there was sufficient anchorage and the seat itself would have to undergo a ‘pull’ test. The priority seat in question would not, it is believed, comply with the ‘pull’ test .
V. Notwithstanding the fact that Mrs Naylor was a very fit and active 79 year old. She was propelled across a void of a 184cm before sustaining injuries which crushed her upper spinal cord causing immediate unconsciousness and paralysis.
VI. Given that priority seating is intended to protect the most vulnerable users of the service, it is of significant concern that the risk is accentuated by the lack of any restraint .
” Open source report
17 Apr 2014 Muriel Dawson · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 2 Lack of forward restraint or equivalent impact protection at passenger seats on narrow scheduled service buses View source Type-approval failing to give sufficient weight to the risk of death or serious injury 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
Muriel Dawson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Muriel Dawson, aged 90, died shortly after being thrown forward from her unrestrained aisle seat when a public service bus braked suddenly. She suffered a complete fracture of the lumbar vertebrae and associated trauma. The principal concern was that the vehicle’s design and type-approval gave insufficient weight to the risk of death or serious injury to passengers, particularly because seats lacked restraints and a possible restraining feature was absent.
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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Lack of forward restraint or equivalent impact protection at passenger seats on narrow scheduled service buses
Wider context from the report “(1) My findings were, as summarised in the narrative conclusion, that Muriel Dawson was travelling on an Optare “hopper” type scheduled service bus (narrow model) and the evidence to the Coroner’s court indicated that the profile of passengers on such a vehicle would overwhelmingly be elderly. The evidence given was to the effect that the design of the vehicle provides a compromise between safety and convenience as it allows for standing passengers, seated passengers and provision for a wheelchair. The design is such that the seat in which Mrs. Dawson was seated at the time of the incident has no form of restraint should there be a violent forward motion exerted on passengers, eg. by an emergency stop. The seat position (viewed from the front facing back) is on the right hand side and is in the third row. It is the aisle seat of the first double seats, the two rows in front being single seats on that side.
(2) It is understood that these vehicles are type-approved and the operator has not made modifications to them and thus the original design and approval of the vehicle is universally match which is in regular use. Seat belts are not required to be fitted to any seats.
(3) The evidence to the inquest was that this vehicle had to stop suddenly; the brakes were correctly applied, but there was nothing to prevent Mrs. Dawson being thrown forward and she lost her life as a result of hitting the front panel of the bus having slid the remaining length of the vehicle. Her death was due to the impact with the vehicle fracturing her spine.
(4) It appeared from evidence that, still consistent with convenience, disabled access and gangway width, a floor to ceiling pole with horizontal bar, or some similar restraining construction could have been applied to the area immediately in front of her seat .
(5) It is appreciated that the backs of seats, bars and similar elements of the interior of a vehicle can cause injury in the event of a sudden stop, but I considered, based on the evidence given, that some similar design feature of the vehicle as mentioned in (4) above could, and probably would, have prevented Mrs. Dawson being thrown forward for such distance and with such momentum as to cause her death.
(6) It appears from the evidence, albeit indirectly reported to the Coroner at the inquest, that other operators have expressed concerns with the current design, but feel there is nothing they can do in a type-approved vehicle. I am concerned that the type-approval has given insufficient weight to the risk of death or serious injury.
” 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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Type-approval failing to give sufficient weight to the risk of death or serious injury
Wider context from the report “(1) My findings were, as summarised in the narrative conclusion, that Muriel Dawson was travelling on an Optare “hopper” type scheduled service bus (narrow model) and the evidence to the Coroner’s court indicated that the profile of passengers on such a vehicle would overwhelmingly be elderly. The evidence given was to the effect that the design of the vehicle provides a compromise between safety and convenience as it allows for standing passengers, seated passengers and provision for a wheelchair. The design is such that the seat in which Mrs. Dawson was seated at the time of the incident has no form of restraint should there be a violent forward motion exerted on passengers, eg. by an emergency stop. The seat position (viewed from the front facing back) is on the right hand side and is in the third row. It is the aisle seat of the first double seats, the two rows in front being single seats on that side.
(2) It is understood that these vehicles are type-approved and the operator has not made modifications to them and thus the original design and approval of the vehicle is universally match which is in regular use. Seat belts are not required to be fitted to any seats.
(3) The evidence to the inquest was that this vehicle had to stop suddenly; the brakes were correctly applied, but there was nothing to prevent Mrs. Dawson being thrown forward and she lost her life as a result of hitting the front panel of the bus having slid the remaining length of the vehicle. Her death was due to the impact with the vehicle fracturing her spine.
(4) It appeared from evidence that, still consistent with convenience, disabled access and gangway width, a floor to ceiling pole with horizontal bar, or some similar restraining construction could have been applied to the area immediately in front of her seat.
(5) It is appreciated that the backs of seats, bars and similar elements of the interior of a vehicle can cause injury in the event of a sudden stop, but I considered, based on the evidence given, that some similar design feature of the vehicle as mentioned in (4) above could, and probably would, have prevented Mrs. Dawson being thrown forward for such distance and with such momentum as to cause her death.
(6) It appears from the evidence, albeit indirectly reported to the Coroner at the inquest, that other operators have expressed concerns with the current design, but feel there is nothing they can do in a type-approved vehicle. I am concerned that the type-approval has given insufficient weight to the risk of death or serious injury.
” Open source report
Concerns raised 3 Failure to ensure compliant structural repairs to insurance write-off vehicles View source Uncontrolled sale of insurance write-off vehicles View source Lack of effective independent checks on repaired insurance write-off vehicles before return to the road 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
Sadie Ann Jane McGrady · 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
Sadie Ann Jane McGrady died after the vehicle in which she was travelling was struck on a dual carriageway, causing severe head injuries from intrusion of the vehicle’s rear quarter panel. The report raised concerns about substandard repairs to a previously written-off vehicle, the lack of independent checks before repaired vehicles returned to the road, and whether such repairs could increase injury severity 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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure compliant structural repairs to insurance write-off vehicles
Wider context from the report “(1) Evidence was given by ████████ Advanced Police Vehicle Examiner indicating that the Vauxhall Corsa was the subject of a category D, total loss insurance claim in May 2008, the insurance claim relating to (inter alia) a crumpled rear offside sill member and adjacent quarter panel and a dented driver’s door. Various repairs had been undertaken to the vehicle and the examiner was concerned by the quality of the repair to the rear offside quarter panel . He noted that it did not comply to the recognised industry repair method and was substandard as there had been unnecessary removal of the complete spot weld resulting in the separation of all 3 panels forming part of the laminated “B” pillar structure and inadequate quality and insufficient mig welding to attach the replacement quarter panel compromising the integrity of the “B” pillar structure .
(2) The consequence of this substandard repair undoubtedly resulted in greater intrusion into the passenger cell when the vehicle was subjected to a severe broadside impact, which in turn may have increased the likelihood of the occupants sustaining serious injury.
(3) The evidence of ████████ Home Office Forensic Pathologist, indicated that the head injuries sustained by Sadie were the result of her head impacting against the intruded rear quarter panel and had this not intruded so much as a result of the collision then it is possible that she may not have sustained such severe head injuries and may well have survived the collision.
(4) Forensic Collision Investigator ████████ indicated in his evidence that in circumstances where there had been a category D write off, there were no independent checks undertaken on repaired vehicles before they returned to the road and that the MOT process would be unlikely to establish that the structure/integrity of a damaged vehicle had been compromised by a substandard repair.
(5) The above matters give rise to a concern that there exists the uncontrolled sale and repair of insurance write offs as a result of which future deaths may occur when previously written off vehicles are back on the road and involved in collisions.
” 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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Uncontrolled sale of insurance write-off vehicles
Wider context from the report “(1) Evidence was given by ████████ Advanced Police Vehicle Examiner indicating that the Vauxhall Corsa was the subject of a category D, total loss insurance claim in May 2008, the insurance claim relating to (inter alia) a crumpled rear offside sill member and adjacent quarter panel and a dented driver’s door. Various repairs had been undertaken to the vehicle and the examiner was concerned by the quality of the repair to the rear offside quarter panel. He noted that it did not comply to the recognised industry repair method and was substandard as there had been unnecessary removal of the complete spot weld resulting in the separation of all 3 panels forming part of the laminated “B” pillar structure and inadequate quality and insufficient mig welding to attach the replacement quarter panel compromising the integrity of the “B” pillar structure.
(2) The consequence of this substandard repair undoubtedly resulted in greater intrusion into the passenger cell when the vehicle was subjected to a severe broadside impact, which in turn may have increased the likelihood of the occupants sustaining serious injury.
(3) The evidence of ████████ Home Office Forensic Pathologist, indicated that the head injuries sustained by Sadie were the result of her head impacting against the intruded rear quarter panel and had this not intruded so much as a result of the collision then it is possible that she may not have sustained such severe head injuries and may well have survived the collision.
(4) Forensic Collision Investigator ████████ indicated in his evidence that in circumstances where there had been a category D write off, there were no independent checks undertaken on repaired vehicles before they returned to the road and that the MOT process would be unlikely to establish that the structure/integrity of a damaged vehicle had been compromised by a substandard repair.
(5) The above matters give rise to a concern that there exists the uncontrolled sale and repair of insurance write offs as a result of which future deaths may occur when previously written off vehicles are back on the road and involved in collisions .
” 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 Driver and Vehicle Standards Agency; that does not assign responsibility.
PFD Monitor interpretation Lack of effective independent checks on repaired insurance write-off vehicles before return to the road
Wider context from the report “(1) Evidence was given by ████████ Advanced Police Vehicle Examiner indicating that the Vauxhall Corsa was the subject of a category D, total loss insurance claim in May 2008, the insurance claim relating to (inter alia) a crumpled rear offside sill member and adjacent quarter panel and a dented driver’s door. Various repairs had been undertaken to the vehicle and the examiner was concerned by the quality of the repair to the rear offside quarter panel. He noted that it did not comply to the recognised industry repair method and was substandard as there had been unnecessary removal of the complete spot weld resulting in the separation of all 3 panels forming part of the laminated “B” pillar structure and inadequate quality and insufficient mig welding to attach the replacement quarter panel compromising the integrity of the “B” pillar structure.
(2) The consequence of this substandard repair undoubtedly resulted in greater intrusion into the passenger cell when the vehicle was subjected to a severe broadside impact, which in turn may have increased the likelihood of the occupants sustaining serious injury.
(3) The evidence of ████████ Home Office Forensic Pathologist, indicated that the head injuries sustained by Sadie were the result of her head impacting against the intruded rear quarter panel and had this not intruded so much as a result of the collision then it is possible that she may not have sustained such severe head injuries and may well have survived the collision.
(4) Forensic Collision Investigator ████████ indicated in his evidence that in circumstances where there had been a category D write off, there were no independent checks undertaken on repaired vehicles before they returned to the road and that the MOT process would be unlikely to establish that the structure/integrity of a damaged vehicle had been compromised by a substandard repair .
(5) The above matters give rise to a concern that there exists the uncontrolled sale and repair of insurance write offs as a result of which future deaths may occur when previously written off vehicles are back on the road and involved in collisions.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations