Concerns raised 1 Failure to prevent unrestricted and unguarded public access to a vertical drop View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kay Wilson · 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
Kay Wilson drowned shortly after 23:30 on 6 December 2025 after accidentally passing through a gap in a protective stone wall near County Bridge in Barnard Castle, falling approximately 9 metres onto rocks and then into the River Tees. The principal concern was that the breach provided unrestricted and unguarded access from a public area to the vertical drop and river below.
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 Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent unrestricted and unguarded public access to a vertical drop
Wider context from the report “A breach in the stone wall running north above the riverside from the east side of “County Bridge", Barnard Castle, provides unrestricted and unguarded access from a public area to a vertical drop of approximately 9 metres onto rocks and the River Tees below . ████████
” 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 Install a steel fence section to close the riverside wall gap and prevent unrestricted access to the drop.
Verbatim wording from the response “• In relation to the breach in the stone wall running north above the riverside from the east side of "County Bridge" it has been agreed that the most appropriate permanent control measure is the installation of a steel fencing section to fully close the gap in the existing stone wall and prevent unrestricted public access to the drop below.” Source location 2026-0132 - Response from Durham County Council
Open published response
Concerns raised 4 Failure to put recommended falls prevention equipment in place View source Reluctance to provide adequate resources for falls prevention equipment View source Failure to apply for DoLS assessments for residents lacking mental capacity View source Failure to pass on Community Falls Service recommendations to family and social services View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Patricia Heaviside · 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 Heaviside, a resident of Howlish Hall Care Home, suffered an unwitnessed fall on 4 October 2024, fractured her left hip, and died on 26 December 2024 as a consequence of the fracture. Concerns included the failure to implement recommended falls-prevention equipment, failures to share relevant information with family and social services, and apparent reluctance to provide adequate resources for falls prevention. The report also raised concerns that no DoLS assessment application appeared to have been made despite her lack of mental capacity and inability to keep herself safe.
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 Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to put recommended falls prevention equipment in place
Wider context from the report “(1) Despite recommendations for falls prevention equipment being made by the Community Falls Service in August 2023, no falls prevention equipment was put in place by the time of the Deceased’s fall in fall October 2024
(2) Despite the social worker expressing concern about the lack of falls prevention equipment on 27 September 2024, no falls equipment was put in place prior to the Deceased’s fall on 4 October 2024.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Reluctance to provide adequate resources for falls prevention equipment
Wider context from the report “(4) On 5 August 2024 (following a fall, but before the more significant fall on 4 October 2024), the Deceased’s family were told by the Deputy Manager of Howlish Hall that the owner of Howlish Hall “probably wouldn’t want to pay for a sensor mat” .
(5) I received evidence that, subsequent to the Deceased’s death, there had been a reluctance on the part of ████████ (who was believed to be the owner of Howlish Hall Care Home) to provide adequate resources for falls prevention equipment .
” 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 Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to apply for DoLS assessments for residents lacking mental capacity
Wider context from the report “(6) Despite it being recognised that the Deceased lacked mental capacity to make decisions about where she lived and was unable to keep herself safe, it appears that the home did not make any application for a DoLS assessment for the Deceased . Indeed I received evidence that when a new home manager was appointed at Howlish Hall in January 2025 none of the residents were subject to a DoLS, despite a large number of the residents lacking mental capacity .
” 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 Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to pass on Community Falls Service recommendations to family and social services
Wider context from the report “(3) Information about the Community Falls Service recommendations was not passed on to the family, or to social services.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reinforce the importance of DoLS during upcoming Care Home Strategic Provider Forum sessions.
Verbatim wording from the response “Deprivation of Liberty Safeguards is a regular agenda item and discussion point at our Care Home Strategic Provider Forum meetings, and we will continue to reinforce its importance in upcoming forum sessions. To strengthen oversight, commissioning and safeguarding teams will work with the DoLS team to explore ways of identifying care homes that currently have no active DoLS authorisations in place or where renewals may be overdue. This will help us highlight potential gaps and ensure timely action is taken to proactively address any issues with the care home.” Source location Response from Durham County Council
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 Work with the new care-home manager to submit required DoLS applications and renew expired authorisations.
Verbatim wording from the response “(6) Despite it being recognised that the Deceased lacked mental capacity to make decisions about where she lived and was unable to keep herself safe, it appears that the home did not make any application for a DoLS assessment for the Deceased. Indeed I received evidence that when a new home manager was appointed at Howlish Hall in January 2025 none of the residents were subject to a DoLS, despite a large number of residents lacking mental capacity.” Source location Response from Durham County Council
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 Apply DoLS considerations to all residents moved during the care-home closure.
Verbatim wording from the response “DoLS considerations have been applied to all residents who have transitioned to a new care home placement as part of the care home closure work for Howlish Hall.” Source location Response from Durham County Council
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 Work with Community Falls Teams to explore strengthening communication of falls-prevention recommendations to families and social services.
Verbatim wording from the response “We have reviewed this matter and can confirm that we are unable to identify any Council records indicating that the recommendations made by the CDDFT Community Falls Service on 16 August 2023, and again during June 2024, were shared with either Durham County Council or the family by CDDFT Community Falls Team or the Care Home.” Source location Response from Durham County Council
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 Work with commissioning and safeguarding teams to explore identifying care homes without active DoLS authorisations or with overdue renewals.
Verbatim wording from the response “Deprivation of Liberty Safeguards is a regular agenda item and discussion point at our Care Home Strategic Provider Forum meetings, and we will continue to reinforce its importance in upcoming forum sessions. To strengthen oversight, commissioning and safeguarding teams will work with the DoLS team to explore ways of identifying care homes that currently have no active DoLS authorisations in place or where renewals may be overdue. This will help us highlight potential gaps and ensure timely action is taken to proactively address any issues with the care home.” Source location Response from Durham County Council
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 Council was not aware of evidence that the owner specifically refused resources for falls prevention equipment, and observed equipment installed in several bedrooms.
Verbatim wording from the response “(5) I received evidence that, subsequent to the Deceased’s death, there had been a reluctance on the part of ████████ (who was believed to be the owner of Howlish Hall Care Home) to provide adequate resources for falls prevention equipment.” Source location Response from Durham County Council
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for sourcing and implementing recommended falls prevention equipment rests with care home management, not the Council.
Verbatim wording from the response “It is important to clarify that Durham County Council was not directly informed of the recommendations made by the County Durham and Darlington NHS Foundation Trust (CDDFT) Community Falls Service. In accordance with standard protocol, such recommendations are communicated solely to the care home, which retains full responsibility for reviewing, actioning, and implementing the advised measures.” Source location Response from Durham County Council
Open published response
Concerns raised 6 Lack of clear and timely internal and external fall reporting View source Failure to clearly document medical advice obtained after resident falls View source Failure to promptly re-evaluate and amend care plans after significant events View source Failure to provide effective, individually tailored monitoring measures for residents at high risk of falls View source Failure to obtain timely medical advice after a resident fall View source Failure to maintain accessible and retained resident records View source See 3 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
Sylvia Margaret Louisa SAVAGE · 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
Sylvia Margaret Louisa Savage died on 25 April 2023 at the University Hospital of North Durham from bronchopneumonia, following a fall from her bed at Redwell Hills Care Home on 18 March 2023 and subsequent injuries and decline in health. The concerns included unclear fall-reporting arrangements, ineffective monitoring of her mobilisation, inadequate post-fall medical assessment, missing or insufficient care records, and failure to promptly reassess her care plan after falls.
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 Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of clear and timely internal and external fall reporting
Wider context from the report “1. There was I heard no clear definition of when to report falls externally & internally - this to me is perhaps the reason why the fall Mrs Savage suffered on 1/2/23 was not recorded internally, all be it CQC were notified on this occasion. The fall on 18/3/23 was not reported to CQC and whilst I understand staff at the care home did not know the outcome of Mrs Savage's treatment in hospital - she left the home by ambulance and did not return. This seems an occurrence worthy of reporting – It strikes me some clearer reporting structure is necessary - timely and accurate reporting both internally and to regulators allows for those concerned to assess the care home and decide on whether there are risks/issues that need addressing and protect residents. I would suggest over reporting is preferable to under reporting.
” 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 Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly document medical advice obtained after resident falls
Wider context from the report “3. Mrs Savage's fall in February 2023 was it appears reported to her GP by her daughter and that led to a nurse attending the home to examine her. Staff at the home do not appear to have done so themselves. It is of concern that after a fall the staff within the home should have a mechanism to ensure medical advice is obtained in a timely fashion and that it is documented clearly and not be reliant on family members summoning help for residents themselves when they have become aware of an 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 Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to promptly re-evaluate and amend care plans after significant events
Wider context from the report “5. The evidence I have heard is after Mrs Savage's fall on 1/2/23 and when it became clear the sensor mat was not working as intended - this should have prompted staff to return to the care plans and re-evaluate them - it did not . Indeed one care home witness stated as Mrs Savage had not had 3 falls in 3 months no change to her plan was needed. Given the second fall Mrs Savage had some weeks later gave her injuries that led to her death this approach appears flawed. Whilst I acknowledge work is ongoing in this area it appears that prompt re-evaluation of the care plans after events such as a fall are necessary to prevent injury and death - I would ask for some reassurance that significant events are captured by staff and in turn their significance is carefully considered and if necessary changes made to care .
” 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 Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide effective, individually tailored monitoring measures for residents at high risk of falls
Wider context from the report “2. The evidence is clear that the provided sensor mat was not an efficient way of monitoring Mrs Savage when she attempted to mobilise . It was well known in the home that Mrs Savage defeated it's purpose by moving or unplugging it. There seems to have been a lack of thought as to an alternative measure . The wall mounted sensor, for example was seen by the expert as a reasonable measure - the home manager said he could consider them and the regional manager indicated they were used in the company, but not at the care home where Mrs Savage was residing. It seems to me the council should have an armoury of measures to pick from to tailor to the needs of the individual resident not just limited to one particular measure . The risk of death is obvious to others if persons at high risk of falls are not known to be moving by those charged with looking after them.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain timely medical advice after a resident fall
Wider context from the report “3. Mrs Savage's fall in February 2023 was it appears reported to her GP by her daughter and that led to a nurse attending the home to examine her. Staff at the home do not appear to have done so themselves. It is of concern that after a fall the staff within the home should have a mechanism to ensure medical advice is obtained in a timely fashion and that it is documented clearly and not be reliant on family members summoning help for residents themselves when they have become aware of an 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 Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accessible and retained resident records
Wider context from the report “4. The absence of records has hindered my investigation into Mrs Savage's death. The expert in her evidence made it clear - good recording keeping allows staff to monitor changes in condition, allows new staff or those returning from time off to reacquaint themselves with residents condition and allows clinicians to make diagnosis - without access to good records I can see a clear risk to the care of residents . It is also surprising to me the complete reliance on paper records which in Mrs Savage’s case have been lost . I would have expected to see electronic recording of information and electronic storage of it. I note the roll out of this in the company has been paused whilst the company is awaiting sale and my concern is whether the electronic recording and storage will be implemented - to me immediate access to records of a resident or the absence of them creates a concern .
” Open source report
Concerns raised 1 Hazard to vehicular traffic on the steep, sharply bending stretch of Butsfield Lane in slippery conditions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sonny James FARRIER · 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
Sonny James FARRIER died after being struck by a car while outside a van that had collided with a tree on an icy stretch of Butsfield Lane. The report identified that, in slippery conditions and without effective mitigation, this section of road presents a risk of death to 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 Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Hazard to vehicular traffic on the steep, sharply bending stretch of Butsfield Lane in slippery conditions
Wider context from the report “The Road called Butsfield Lane in Consett (locally known as “Bogle Hole Lane”), approximately 1 km north-east of its junction with Delves Lane, includes a hill of between 19 and 21% gradient, with a bend immediately beyond its lower portion.
In slippery conditions, and in the absence of effective mitigation, passage of vehicular traffic along this stretch of Butsfield Lane presents a hazard and risk of death to road users.
” 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 Check the road gradient between known points and assess whether updated gradient signage is required.
Verbatim wording from the response “• Check accuracy of gradient and if required change the existing sign with the “new” gradient – The gradient was checked between 2 known points 120m apart. It is accepted there are some isolated locations between the 2 points where the gradient exceeds 13% but the average gradient is 13%. No further action required/taken;” Source location Response from Durham County Council
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 Investigate potential additional safety features, including signage, and assess their suitability for Busfield Lane.
Verbatim wording from the response “Signage
Following receipt of the council’s fatal accident report and the concerns highlighted in your report we have also investigated other potential safety features we could facilitate to improve safety on Busfield Lane for example the introduction of additional signage. However, having reviewed and considered the advice provided in The Traffic Signs Regulations and General Directions 2016 there is not a sign, or combination of signs which would be suitable for this location.” Source location Response from Durham County Council
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide an additional salt bin.
Verbatim wording from the response “• Consider the provision of an additional salt bin – New additional salt bin provided;” Source location Response from Durham County Council
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No further action was planned because, after reviewing all options, practical improvements to the network were not considered achievable.
Verbatim wording from the response “The council takes its responsibility to ensure the highway network is maintained in a safe and serviceable condition all year round and especially during the winter period. This can be evidenced by the importance it places on its winter service. However, on this particular road, having reviewed all options we don’t consider improvements to the network can be achieved practically and therefore whilst we accept the death of an individual as a result of weather conditions is a very emotive subject we have come to the very difficult conclusion that no further action is required on Busfield Lane.” Source location Response from Durham County Council
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 After checking the gradient, no further action was considered necessary because the average gradient between two known points was 13%.
Verbatim wording from the response “• Check accuracy of gradient and if required change the existing sign with the “new” gradient – The gradient was checked between 2 known points 120m apart. It is accepted there are some isolated locations between the 2 points where the gradient exceeds 13% but the average gradient is 13%. No further action required/taken;” Source location Response from Durham County Council
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No additional signage was proposed because traffic-sign regulations provided no suitable sign or combination of signs for this location.
Verbatim wording from the response “Signage
Following receipt of the council’s fatal accident report and the concerns highlighted in your report we have also investigated other potential safety features we could facilitate to improve safety on Busfield Lane for example the introduction of additional signage. However, having reviewed and considered the advice provided in The Traffic Signs Regulations and General Directions 2016 there is not a sign, or combination of signs which would be suitable for this location.” Source location Response from Durham County Council
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 Busfield Lane was excluded from routine gritting because the existing winter-service policy prioritises strategic roads and resources are limited.
Verbatim wording from the response “Gritting Routes
The Council precautionary salts 45% of our highway network as part of our Priority 1 network, with a further 10% being treated in prolonged severe weather as part of our Priority 2 network. This is much higher than many other similar Highway Authorities and shows the Council’s commitment to provide the best winter maintenance service we can in line with available resources.” Source location Response from Durham County Council
Open published response
Concerns raised 7 Failure to provide adequate speed control within the junction series View source Inadequate junction capacity for traffic volume View source Failure to account for increased traffic from planned area development View source Failure to assess junction improvements across the junction series View source Delays in implementing junction safety improvements View source Insufficient junction safety improvements View source Failure to safely manage complex traffic movements at junctions View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kelly Nadine DUNNE · 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
Kelly Nadine DUNNE died at the Royal Victoria Infirmary in Newcastle on 4 July 2022 from fatal head injuries sustained in a road traffic collision on 2 July 2022. Concerns were raised about the adequacy and layout of the junction and other junctions on the A690, including traffic volume, traffic complexity, speed limits, and the timing and sufficiency of proposed safety improvements in light of planned development.
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 Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequate speed control within the junction series
Wider context from the report “During the course of the Inquest evidence was heard from the lead road traffic collision investigator in the case that there are significant concerns in relation to the adequacy and layout of this particular junction and the five other junctions on this stretch of road (A690). Evidence was given that since this fatality, there has been another fatal road traffic collision on the 22/12/22, at the junction directly opposite. Further that between 11/01/00 and 31/12/22 there have been 21 collisions at this junction (including this fatality and 3 other serious collisions) and that there have been 29 collisions at the other junctions on this stretch of road (including one further fatality and 6 other serious collisions).
The concerns in relation to this junction, and the other junctions relate to:-
1. The volume of traffic that the junctions must manage.
2. The complexity of traffic movement at the junctions.
3. The speed limit in the vicinity of the junctions.
Concerns were also raised in relation to the planned extensive expansion/development of the area in the vicinity of the junction, including increased housing development, a proposed retail park, football site, as well as developments occurring more widely in the area which will lead to increased traffic, and that any proposed improvements to the junction are not required until prior to the occupation of the 39th dwelling on the site. The concern is that the proposals to improve the safety of the junction are not sufficient nor timely, and that consideration does not appear to have been given to reducing the speed limit within the junction series. A further concern was raised that the proposed improvements to the junction considered this junction in isolation, and did not consider the series of junctions on this stretch of road.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate junction capacity for traffic volume
Wider context from the report “During the course of the Inquest evidence was heard from the lead road traffic collision investigator in the case that there are significant concerns in relation to the adequacy and layout of this particular junction and the five other junctions on this stretch of road (A690). Evidence was given that since this fatality, there has been another fatal road traffic collision on the 22/12/22, at the junction directly opposite. Further that between 11/01/00 and 31/12/22 there have been 21 collisions at this junction (including this fatality and 3 other serious collisions) and that there have been 29 collisions at the other junctions on this stretch of road (including one further fatality and 6 other serious collisions).
The concerns in relation to this junction, and the other junctions relate to:-
1. The volume of traffic that the junctions must manage.
2. The complexity of traffic movement at the junctions.
3. The speed limit in the vicinity of the junctions.
Concerns were also raised in relation to the planned extensive expansion/development of the area in the vicinity of the junction, including increased housing development, a proposed retail park, football site, as well as developments occurring more widely in the area which will lead to increased traffic, and that any proposed improvements to the junction are not required until prior to the occupation of the 39th dwelling on the site. The concern is that the proposals to improve the safety of the junction are not sufficient nor timely, and that consideration does not appear to have been given to reducing the speed limit within the junction series. A further concern was raised that the proposed improvements to the junction considered this junction in isolation, and did not consider the series of junctions on this stretch of road.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to account for increased traffic from planned area development
Wider context from the report “During the course of the Inquest evidence was heard from the lead road traffic collision investigator in the case that there are significant concerns in relation to the adequacy and layout of this particular junction and the five other junctions on this stretch of road (A690). Evidence was given that since this fatality, there has been another fatal road traffic collision on the 22/12/22, at the junction directly opposite. Further that between 11/01/00 and 31/12/22 there have been 21 collisions at this junction (including this fatality and 3 other serious collisions) and that there have been 29 collisions at the other junctions on this stretch of road (including one further fatality and 6 other serious collisions).
The concerns in relation to this junction, and the other junctions relate to:-
1. The volume of traffic that the junctions must manage.
2. The complexity of traffic movement at the junctions.
3. The speed limit in the vicinity of the junctions.
Concerns were also raised in relation to the planned extensive expansion/development of the area in the vicinity of the junction, including increased housing development, a proposed retail park, football site, as well as developments occurring more widely in the area which will lead to increased traffic , and that any proposed improvements to the junction are not required until prior to the occupation of the 39th dwelling on the site. The concern is that the proposals to improve the safety of the junction are not sufficient nor timely, and that consideration does not appear to have been given to reducing the speed limit within the junction series. A further concern was raised that the proposed improvements to the junction considered this junction in isolation, and did not consider the series of junctions on this stretch of road.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to assess junction improvements across the junction series
Wider context from the report “During the course of the Inquest evidence was heard from the lead road traffic collision investigator in the case that there are significant concerns in relation to the adequacy and layout of this particular junction and the five other junctions on this stretch of road (A690). Evidence was given that since this fatality, there has been another fatal road traffic collision on the 22/12/22, at the junction directly opposite. Further that between 11/01/00 and 31/12/22 there have been 21 collisions at this junction (including this fatality and 3 other serious collisions) and that there have been 29 collisions at the other junctions on this stretch of road (including one further fatality and 6 other serious collisions).
The concerns in relation to this junction, and the other junctions relate to:-
1. The volume of traffic that the junctions must manage.
2. The complexity of traffic movement at the junctions.
3. The speed limit in the vicinity of the junctions.
Concerns were also raised in relation to the planned extensive expansion/development of the area in the vicinity of the junction, including increased housing development, a proposed retail park, football site, as well as developments occurring more widely in the area which will lead to increased traffic, and that any proposed improvements to the junction are not required until prior to the occupation of the 39th dwelling on the site. The concern is that the proposals to improve the safety of the junction are not sufficient nor timely, and that consideration does not appear to have been given to reducing the speed limit within the junction series. A further concern was raised that the proposed improvements to the junction considered this junction in isolation, and did not consider the series of junctions on this stretch of road.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Delays in implementing junction safety improvements
Wider context from the report “During the course of the Inquest evidence was heard from the lead road traffic collision investigator in the case that there are significant concerns in relation to the adequacy and layout of this particular junction and the five other junctions on this stretch of road (A690). Evidence was given that since this fatality, there has been another fatal road traffic collision on the 22/12/22, at the junction directly opposite. Further that between 11/01/00 and 31/12/22 there have been 21 collisions at this junction (including this fatality and 3 other serious collisions) and that there have been 29 collisions at the other junctions on this stretch of road (including one further fatality and 6 other serious collisions).
The concerns in relation to this junction, and the other junctions relate to:-
1. The volume of traffic that the junctions must manage.
2. The complexity of traffic movement at the junctions.
3. The speed limit in the vicinity of the junctions.
Concerns were also raised in relation to the planned extensive expansion/development of the area in the vicinity of the junction, including increased housing development, a proposed retail park, football site, as well as developments occurring more widely in the area which will lead to increased traffic, and that any proposed improvements to the junction are not required until prior to the occupation of the 39th dwelling on the site . The concern is that the proposals to improve the safety of the junction are not sufficient nor timely , and that consideration does not appear to have been given to reducing the speed limit within the junction series. A further concern was raised that the proposed improvements to the junction considered this junction in isolation, and did not consider the series of junctions on this stretch of road.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient junction safety improvements
Wider context from the report “During the course of the Inquest evidence was heard from the lead road traffic collision investigator in the case that there are significant concerns in relation to the adequacy and layout of this particular junction and the five other junctions on this stretch of road (A690). Evidence was given that since this fatality, there has been another fatal road traffic collision on the 22/12/22, at the junction directly opposite. Further that between 11/01/00 and 31/12/22 there have been 21 collisions at this junction (including this fatality and 3 other serious collisions) and that there have been 29 collisions at the other junctions on this stretch of road (including one further fatality and 6 other serious collisions).
The concerns in relation to this junction, and the other junctions relate to:-
1. The volume of traffic that the junctions must manage.
2. The complexity of traffic movement at the junctions.
3. The speed limit in the vicinity of the junctions.
Concerns were also raised in relation to the planned extensive expansion/development of the area in the vicinity of the junction, including increased housing development, a proposed retail park, football site, as well as developments occurring more widely in the area which will lead to increased traffic, and that any proposed improvements to the junction are not required until prior to the occupation of the 39th dwelling on the site . The concern is that the proposals to improve the safety of the junction are not sufficient nor timely, and that consideration does not appear to have been given to reducing the speed limit within the junction series. A further concern was raised that the proposed improvements to the junction considered this junction in isolation, and did not consider the series of junctions on this stretch of road.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to safely manage complex traffic movements at junctions
Wider context from the report “During the course of the Inquest evidence was heard from the lead road traffic collision investigator in the case that there are significant concerns in relation to the adequacy and layout of this particular junction and the five other junctions on this stretch of road (A690). Evidence was given that since this fatality, there has been another fatal road traffic collision on the 22/12/22, at the junction directly opposite. Further that between 11/01/00 and 31/12/22 there have been 21 collisions at this junction (including this fatality and 3 other serious collisions) and that there have been 29 collisions at the other junctions on this stretch of road (including one further fatality and 6 other serious collisions).
The concerns in relation to this junction, and the other junctions relate to:-
1. The volume of traffic that the junctions must manage.
2. The complexity of traffic movement at the junctions.
3. The speed limit in the vicinity of the junctions.
Concerns were also raised in relation to the planned extensive expansion/development of the area in the vicinity of the junction, including increased housing development, a proposed retail park, football site, as well as developments occurring more widely in the area which will lead to increased traffic, and that any proposed improvements to the junction are not required until prior to the occupation of the 39th dwelling on the site. The concern is that the proposals to improve the safety of the junction are not sufficient nor timely, and that consideration does not appear to have been given to reducing the speed limit within the junction series. A further concern was raised that the proposed improvements to the junction considered this junction in isolation, and did not consider the series of junctions on this stretch of road.
” 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 Secure funding to bring forward signal-control improvements at the West Rainton and Pittington Lane junctions.
Verbatim wording from the response “Appraisal of the TA established that the West Rainton junction would be over capacity as the development became occupied and mitigation measures were required to alleviate traffic pressures. For this reason, a planning condition was placed on the developer to install traffic lights at the West Rainton location only upon occupancy of the 39th dwelling, and the impacts on the Pittington Road / A690 junction were assessed as being negligible. However, the Council took the opportunity to maximise improvements around this junction and made the decision to improve the Pittington Road / A690 junction in tandem with the West Rainton junction, using central government funding via the Local Transport Plan.” Source location Response from Durham County Council
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 Implement signal control at the West Rainton and Pittington Lane junctions.
Verbatim wording from the response “Whilst the planning approval included the ‘trigger’ for signal installation, officers have worked closely with the developer and have successfully secured the necessary funding to allow the signal installation to be brought forward and a scheme to implement signal control at both the West Rainton and Pittington Lane junctions is programmed to commence 2nd May for approximately 14 weeks.” Source location Response from Durham County Council
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No further accident investigation and prevention intervention was warranted because accident frequency remained unchanged and traffic signals were being developed.
Verbatim wording from the response “However, given that the annual average accident total was remaining the same and, on the understanding that the impending traffic signals scheme was in development, it was considered that no further action was warranted in terms of AIP intervention.” Source location Response from Durham County Council
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A lower speed limit would not be credible or appropriate and could increase danger because a significant proportion of motorists might ignore it.
Verbatim wording from the response “A speed limit is an absolute maximum, and it is the driver’s responsibility to drive at a speed suitable to the environment and conditions. It is an intention of the Department for Transport guidance to ensure that speed limits are credible with the aim that they become self-evident and self-enforcing, by virtue of their surroundings. A limit lower than the current posted limit would not be credible or appropriate and would likely result in a significant proportion of motorists ignoring the limit. In addition, the imposition of non-credible lower limits can raise expectations that the speeds of vehicles will be reduced but seldom realised in practice, resulting in greater danger with drivers making decisions based on incorrect assumptions, and also unfair criticism of the police who have to enforce the speed limits.” Source location Response from Durham County Council
Open published response
Concerns raised 4 Risk of death to persons falling from the bridge View source Risk of death to persons near the foot of the bridge when persons fall View source Accessible bridge parapet and railing View source Absence of monitored CCTV, lighting or other means of detecting persons at immediate risk View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Leanne DUNN · 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
Leanne DUNN died after falling from the bridge at Newton Cap; the inquest concluded that her death was suicide. Concerns related to pedestrian access to the bridge parapet and railing, the absence of monitored CCTV and lighting or other detection measures, and the risk of death to people falling or present at the foot of the bridge.
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 Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Risk of death to persons falling from the bridge
Wider context from the report “All concerns relate to the bridge ████████, which carries a road and two footpaths up to around 30m (100ft) above the reiver Weir
(1) the bridge’s parapet and railing is accessible to pedestrians on the bridge;
████████
████████
(3) there is absence of monitored CCTV and lighting or other means of detecting those at immediate risk; and
(4) there is a risk of death to persons falling AND to those near the foot of the bridge at any time when persons fall.
” 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 Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Risk of death to persons near the foot of the bridge when persons fall
Wider context from the report “All concerns relate to the bridge ████████, which carries a road and two footpaths up to around 30m (100ft) above the reiver Weir
(1) the bridge’s parapet and railing is accessible to pedestrians on the bridge;
████████
████████
(3) there is absence of monitored CCTV and lighting or other means of detecting those at immediate risk; and
(4) there is a risk of death to persons falling AND to those near the foot of the bridge at any time when persons fall.
” 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 Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Accessible bridge parapet and railing
Wider context from the report “All concerns relate to the bridge ████████, which carries a road and two footpaths up to around 30m (100ft) above the reiver Weir
(1) the bridge’s parapet and railing is accessible to pedestrians on the bridge;
████████
████████
(3) there is absence of monitored CCTV and lighting or other means of detecting those at immediate risk; and
(4) there is a risk of death to persons falling AND to those near the foot of the bridge at any time when persons fall.
” 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 Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Absence of monitored CCTV, lighting or other means of detecting persons at immediate risk
Wider context from the report “All concerns relate to the bridge ████████, which carries a road and two footpaths up to around 30m (100ft) above the reiver Weir
(1) the bridge’s parapet and railing is accessible to pedestrians on the bridge;
████████
████████
(3) there is absence of monitored CCTV and lighting or other means of detecting those at immediate risk; and
(4) there is a risk of death to persons falling AND to those near the foot of the bridge at any time when persons fall.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No further response is considered necessary at this stage after reviewing the existing submission and Regulation 28 report.
Verbatim wording from the response “As you note in the report, Durham County Council provided a written submission to the inquest, dated 30 November 2022, which addresses the points raised. Having reviewed the Regulation 28 report and the letter of 30 November, I do not feel that there is anything further to add at this stage, other than to reaffirm the commitment of Durham County Council to suicide prevention.” Source location Response Durham County Council
Open published response
Concerns raised 4 Failure to prevent pedestrian access to the area where people falling from the bridge may land View source Absence of monitored CCTV, lighting or other means of detecting people at immediate risk View source Failure to prevent pedestrians climbing over the bridge parapet View source Bridge frequently identified as a location for suicide by jumping View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Joseph William DENT · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Joseph William DENT was seen parking a car near Newton Cap Viaduct in the early hours of 20 June 2021, and his body was found near the base of the bridge shortly after 08:00. The investigation found that he died from multiple injuries after falling from the bridge, with an open conclusion because it was unclear how he came to fall. Concerns included pedestrian access to the bridge parapet and the area below, the lack of effective climbing prevention, the absence of monitored CCTV and lighting or other detection measures, and the bridge’s reported association with suicide by jumping.
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 Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent pedestrian access to the area where people falling from the bridge may land
Wider context from the report “All concerns relate to the bridge, which carries a road and two footpaths up to around 30m (100ft) above the River Wear
(1) the bridge’s parapet and railing is accessible to pedestrians on the bridge;
(2) the bridge is frequently discussed on social media as suitable location for suicide by jumping;
(3) there is absence of monitored CCTV and lighting or other means of detecting those at immediate risk; and
(4) there is a risk of death to persons falling AND to those near the foot of the bridge at any time when persons fall
Detective Sergeant ████████ gave evidence that:
(a) there is pedestrian access to either side of the bridge;
(b) the bridge lacks effective measures to prevent persons climbing over the parapet;
(c) the bridge is “a well-known area for suicide” (and is openly discussed as such on social media); and that
(d) police frequently (possibly as much as daily) have to attend the location in response to concerns about persons falling from the bridge.
Photographs reveal that the area around the foot of the bridge, where falling objects or persons may land, is accessible to pedestrians .
My records indicate that there have been four other deaths of persons falling from this bridge in the past five years; the conclusions in all of their inquests were suicide.
” 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 Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Absence of monitored CCTV, lighting or other means of detecting people at immediate risk
Wider context from the report “All concerns relate to the bridge, which carries a road and two footpaths up to around 30m (100ft) above the River Wear
(1) the bridge’s parapet and railing is accessible to pedestrians on the bridge;
(2) the bridge is frequently discussed on social media as suitable location for suicide by jumping;
(3) there is absence of monitored CCTV and lighting or other means of detecting those at immediate risk ; and
(4) there is a risk of death to persons falling AND to those near the foot of the bridge at any time when persons fall
Detective Sergeant ████████ gave evidence that:
(a) there is pedestrian access to either side of the bridge;
(b) the bridge lacks effective measures to prevent persons climbing over the parapet;
(c) the bridge is “a well-known area for suicide” (and is openly discussed as such on social media); and that
(d) police frequently (possibly as much as daily) have to attend the location in response to concerns about persons falling from the bridge.
Photographs reveal that the area around the foot of the bridge, where falling objects or persons may land, is accessible to pedestrians.
My records indicate that there have been four other deaths of persons falling from this bridge in the past five years; the conclusions in all of their inquests were suicide.
” 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 Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent pedestrians climbing over the bridge parapet
Wider context from the report “All concerns relate to the bridge, which carries a road and two footpaths up to around 30m (100ft) above the River Wear
(1) the bridge’s parapet and railing is accessible to pedestrians on the bridge ;
(2) the bridge is frequently discussed on social media as suitable location for suicide by jumping;
(3) there is absence of monitored CCTV and lighting or other means of detecting those at immediate risk; and
(4) there is a risk of death to persons falling AND to those near the foot of the bridge at any time when persons fall
Detective Sergeant ████████ gave evidence that:
(a) there is pedestrian access to either side of the bridge;
(b) the bridge lacks effective measures to prevent persons climbing over the parapet ;
(c) the bridge is “a well-known area for suicide” (and is openly discussed as such on social media); and that
(d) police frequently (possibly as much as daily) have to attend the location in response to concerns about persons falling from the bridge.
Photographs reveal that the area around the foot of the bridge, where falling objects or persons may land, is accessible to pedestrians.
My records indicate that there have been four other deaths of persons falling from this bridge in the past five years; the conclusions in all of their inquests were suicide.
” 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 Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Bridge frequently identified as a location for suicide by jumping
Wider context from the report “All concerns relate to the bridge, which carries a road and two footpaths up to around 30m (100ft) above the River Wear
(1) the bridge’s parapet and railing is accessible to pedestrians on the bridge;
(2) the bridge is frequently discussed on social media as suitable location for suicide by jumping ;
(3) there is absence of monitored CCTV and lighting or other means of detecting those at immediate risk; and
(4) there is a risk of death to persons falling AND to those near the foot of the bridge at any time when persons fall
Detective Sergeant ████████ gave evidence that:
(a) there is pedestrian access to either side of the bridge;
(b) the bridge lacks effective measures to prevent persons climbing over the parapet;
(c) the bridge is “a well-known area for suicide” (and is openly discussed as such on social media) ; and that
(d) police frequently (possibly as much as daily) have to attend the location in response to concerns about persons falling from the bridge.
Photographs reveal that the area around the foot of the bridge, where falling objects or persons may land, is accessible to pedestrians.
My records indicate that there have been four other deaths of persons falling from this bridge in the past five years; the conclusions in all of their inquests were suicide.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider implementing lighting and CCTV at the viaduct through feasibility and planning processes.
Verbatim wording from the response “• Consideration of the potential to implement lighting and CCTV on the viaduct (subject to a Feasibility Study and Planning Application).” Source location 2021-0297-Response-from-Durham-County-Council_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 Source an external consultant specialising in designing out suicide to progress viaduct prevention measures.
Verbatim wording from the response “This more detailed work also includes the requirement for assessments on the impact for road traffic accidents if a barrier was to be installed, Listed Building Consent, Planning Consent and a full design and approval process. The council is currently sourcing an external consultant versed in the speciality of ‘designing out suicide’ to progress next steps. Any changes made to the viaduct will depend on the ability of the structure’s foundations to host any suggested measures whilst also accommodating wind speeds and the needs of local residents, road users, cyclists and conservation. A provisional date for the completion of this assessment work still requires formal confirmation from the provider.” Source location 2021-0297-Response-from-Durham-County-Council_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 Work with local partnerships and elected members to discourage perceptions that the viaduct is a frequent suicide location.
Verbatim wording from the response “Floral tributes for those involved in road traffic accidents may exacerbate the perception that suicides from this location are frequent. We have worked with the council’s Area Action Partnership and local Elected Members to try and address these perceptions without drawing further attention to this and discourage it as a frequency location.” Source location 2021-0297-Response-from-Durham-County-Council_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 Undertake detailed design and approval assessments for a potential additional parapet fence, including structural, traffic, heritage and planning considerations.
Verbatim wording from the response “In 2018, the Council’s Public Health department produced a High Frequency Location Report for Suicide Prevention, which reviewed a number of high-risk geographical locations across County Durham, including Newton Cap Viaduct. This review initiated a Feasibility Study (2019) which was undertaken to assess options for any suicide prevention measures specifically for Newton Cap Viaduct. After the unprecedented public health protection pressures on the Council during the Covid-19 pandemic subsided, a further options appraisal was developed, and a preferred option (Option 1) was identified. On 15th September 2021, the Council’s Corporate Management Team (CMT) requested further detailed work be undertaken on Option 1 to consider the possibility of mounting an additional fence to the face of the concrete parapet upstand of the structure on both east and west elevations.” Source location 2021-0297-Response-from-Durham-County-Council_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 Complete high-risk-location review, feasibility study and options appraisal to identify a preferred suicide-prevention measure for Newton Cap Viaduct.
Verbatim wording from the response “In 2018, the Council’s Public Health department produced a High Frequency Location Report for Suicide Prevention, which reviewed a number of high-risk geographical locations across County Durham, including Newton Cap Viaduct. This review initiated a Feasibility Study (2019) which was undertaken to assess options for any suicide prevention measures specifically for Newton Cap Viaduct. After the unprecedented public health protection pressures on the Council during the Covid-19 pandemic subsided, a further options appraisal was developed, and a preferred option (Option 1) was identified. On 15th September 2021, the Council’s Corporate Management Team (CMT) requested further detailed work be undertaken on Option 1 to consider the possibility of mounting an additional fence to the face of the concrete parapet upstand of the structure on both east and west elevations.” Source location 2021-0297-Response-from-Durham-County-Council_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 Promote sensitive suicide reporting and positive mental-health messages through media liaison and corporate social-media channels.
Verbatim wording from the response “In terms of your concerns about the reporting of potential deaths by suicide on social media, this provides a challenge for all local councils. Work is taking place on a regional Integrated Care System (ICS) basis to explore methods for addressing the issue directly with social media companies. However, the County Durham Public Health Department continues to advocate recommendations made within Samaritans Media Guidance and regularly liaises with media outlets to help promote sensitive reporting on suicides. Corporate social media methods are also used to promote positive mental health and wellbeing messages to de-escalate public perceptions. Samaritan signage is present on Newton Cap Viaduct with relevant support phone numbers for those finding themselves in distress.
https://media.samaritans.org/documents/Media_Guidelines_FINAL_v2_TABa8C6.pdf” Source location 2021-0297-Response-from-Durham-County-Council_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 Assess whether lighting and CCTV can be implemented at an earlier stage as part of the viaduct prevention work.
Verbatim wording from the response “The assessment process will also include any potential for lighting and CCTV to be implemented at an earlier stage (yet to be confirmed), which addresses concerns raised in the Regulation 28 report. A Suicide Prevention Reference Group has been initiated to project manage this work and govern the representation of residents and people using the viaduct and the paths below. This group met for the first time on 11th October 2021. Full updates from this group on progress of this work can be given to your Office on a regular basis.” Source location 2021-0297-Response-from-Durham-County-Council_Published
Open published response
Concerns raised 3 Lack of warning signs at a reduced-visibility bend View source Lack of double white hazard warning lines at a reduced-visibility bend View source Failure to ensure consistent speed-limit messaging through road markings and signs View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Frazer GOLDEN · 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
Frazer Golden, aged 30, died on 9 April 2017 after his motorcycle collided with another motorcycle on the A689 road near Whit’s Hill, County Durham. Concerns included potentially confusing “SLOW” road markings alongside a change from a 30 mph to a 60 mph limit, and the absence of warning signs or double white hazard lines at a bend where forward visibility was reduced.
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 Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of warning signs at a reduced-visibility bend
Wider context from the report “I heard evidence from 2 police collision experts who could not explain in their examination of the A689 road between Ireshopeburn & St Johns Chapel why SLOW road markings were displayed on the carriageway when immediately leaving these 2 villages and the 30mph limit and entering a 60mph limit.
The evidence heard was that it would appear to be confusing that a warning to SLOW was displayed when the immediately adjacent signs were confirming a change in speed limit from 30 to 60 mph.
Evidence was also heard that at the collision location near Whit’s Hill on the A689 road between the 2 villages there is a bend where forward visibility is reduced . This is accepted in a Durham County Council Highways report read as evidence at the inquest. There are no warning signs or double white hazard warning lines approaching the bend or at the bend in either direction.
The police experts further opined that a speed travelled by one of the motorcyclists into the bend of 51mph was not supported when considering the reduced view created by the bend. The speed limit in this area of the A689 is 60 mph.
” 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 Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of double white hazard warning lines at a reduced-visibility bend
Wider context from the report “I heard evidence from 2 police collision experts who could not explain in their examination of the A689 road between Ireshopeburn & St Johns Chapel why SLOW road markings were displayed on the carriageway when immediately leaving these 2 villages and the 30mph limit and entering a 60mph limit.
The evidence heard was that it would appear to be confusing that a warning to SLOW was displayed when the immediately adjacent signs were confirming a change in speed limit from 30 to 60 mph.
Evidence was also heard that at the collision location near Whit’s Hill on the A689 road between the 2 villages there is a bend where forward visibility is reduced . This is accepted in a Durham County Council Highways report read as evidence at the inquest. There are no warning signs or double white hazard warning lines approaching the bend or at the bend in either direction.
The police experts further opined that a speed travelled by one of the motorcyclists into the bend of 51mph was not supported when considering the reduced view created by the bend. The speed limit in this area of the A689 is 60 mph.
” 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 Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure consistent speed-limit messaging through road markings and signs
Wider context from the report “I heard evidence from 2 police collision experts who could not explain in their examination of the A689 road between Ireshopeburn & St Johns Chapel why SLOW road markings were displayed on the carriageway when immediately leaving these 2 villages and the 30mph limit and entering a 60mph limit .
The evidence heard was that it would appear to be confusing that a warning to SLOW was displayed when the immediately adjacent signs were confirming a change in speed limit from 30 to 60 mph .
Evidence was also heard that at the collision location near Whit’s Hill on the A689 road between the 2 villages there is a bend where forward visibility is reduced. This is accepted in a Durham County Council Highways report read as evidence at the inquest. There are no warning signs or double white hazard warning lines approaching the bend or at the bend in either direction.
The police experts further opined that a speed travelled by one of the motorcyclists into the bend of 51mph was not supported when considering the reduced view created by the bend. The speed limit in this area of the A689 is 60 mph.
” 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 Erect bend warning signs on both approaches to the bend.
Verbatim wording from the response “• Bend warning signs: a bend warning sign will be erected on both approaches to the bend;” Source location 2020-0197-Response-from-Durham-County-Council_Redacted.pdf
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 Remove the two SLOW road markings.
Verbatim wording from the response “• The two SLOW road markings: there is no valid road safety / traffic management reason for these road markings. As such, I will arrange to have the two road markings removed;” Source location 2020-0197-Response-from-Durham-County-Council_Redacted.pdf
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 Double white hazard lines will not be installed because the road does not meet the intervention criteria and the accident did not involve overtaking.
Verbatim wording from the response “• Double White Lines: the installation of a system of double white lines at this location is not considered appropriate as the road’s layout does not meet the criteria for this type of intervention as set out in the Traffic Signs Manual Chapter 5 Road Markings 2018. As stated in the Manual “It is important to note that the marking is not to be used where appropriate criteria are not satisfied otherwise it will be brought into disrepute”. It is also noted that the accident did not involve an overtaking manoeuvre” Source location 2020-0197-Response-from-Durham-County-Council_Redacted.pdf
Open published response
Concerns raised 3 Insufficient pedestrian visibility distance for safe stopping View source Lack of a footpath alongside the A690 View source Foreseeable pedestrian crossing of an unlit high-speed dual carriageway View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Bartosz Cezary KUSIAK · 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
Bartosz Cezary Kusiak was struck by a motor vehicle while walking on the unlit A690 in Durham on 23 January 2020 and later died in hospital from fatal injuries. Concerns included the limited visibility of pedestrians to drivers, the emergency stopping distance being greater than the available visibility distance, and the absence of a footpath alongside the road.
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 Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient pedestrian visibility distance for safe stopping
Wider context from the report “The evidence established that at the point in the road where the impact occurred, a pedestrian was visible to a car being driven appropriately with headlights on and well within the prescribed speed limit only at a distance of 29 metres . The emergency stopping distance for such a car is between 75 and 87 metres .
” 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 Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a footpath alongside the A690
Wider context from the report “There is no footpath alongside the A690 along the stretch where the accident occurred .
” 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 Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Foreseeable pedestrian crossing of an unlit high-speed dual carriageway
Wider context from the report “The evidence established that the collision between Mr Kusiak and a motor vehicle occurred on an unlit dual carriageway subject to the national speed limit that runs alongside a housing estate and an industrial estate in Belmont . It is foreseeable that pedestrians will attempt to cross the road .
” 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 Clear foliage and install a timber post-and-rail fence to improve the retained footpath and discourage access to the A690 beyond the footbridge.
Verbatim wording from the response “• The council is committed to reducing the potential for similar accidents to occur. To that end the recommendation in the independent consultant’s report is accepted to introduce interventions to proactively deter access to the A690 dual carriageway and promote existing pedestrian routes. These measures include:” Source location Response from Durham County Council
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 Install signs directing pedestrians from the northern A690 footway through the Gilesgate footbridge route.
Verbatim wording from the response “• The council is committed to reducing the potential for similar accidents to occur. To that end the recommendation in the independent consultant’s report is accepted to introduce interventions to proactively deter access to the A690 dual carriageway and promote existing pedestrian routes. These measures include:” Source location Response from Durham County Council
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete an independent road safety assessment covering street lighting and pedestrian-route provision along the A690.
Verbatim wording from the response “As a result of these discussions it has been agreed that an independent road safety assessment will be commissioned at the earliest possibility. The results of which will be reviewed and discussed further with our partners, Durham Constabulary.
2 | In addition to the request outlined in Item 1, the Police have also asked if a similar assessment process can be undertaken in consideration of footway provision adjacent to this section of the A690. | This matter has been discussed with both Traffic Assets Team, Street Lighting Team and Strategic Highways Team in relation to the provision of street lighting and footways. As a result of these discussion it has been agreed that an independent road safety assessment will be commissioned at the earliest possibility. The results of which will be reviewed and discussed further with our partners, Durham Constabulary.” Source location Response from Durham County Council
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 Remove access to the public footpath on the south-westbound on-slip at the C13 junction.
Verbatim wording from the response “• The council is committed to reducing the potential for similar accidents to occur. To that end the recommendation in the independent consultant’s report is accepted to introduce interventions to proactively deter access to the A690 dual carriageway and promote existing pedestrian routes. These measures include:” Source location Response from Durham County Council
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 Install guardrail and wayfinding signs to discourage pedestrian access to the south-westbound carriageway and south-eastern verge.
Verbatim wording from the response “• The council is committed to reducing the potential for similar accidents to occur. To that end the recommendation in the independent consultant’s report is accepted to introduce interventions to proactively deter access to the A690 dual carriageway and promote existing pedestrian routes. These measures include:” Source location Response from Durham County Council
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 section of the A690 has no fundamental safety issues requiring further action.
Verbatim wording from the response “The council is aware of the concerns expressed about this section of the A690 and have reviewed safety issues on a number of occasions, most recently in the form of an independent consultant’s report. The council remain of the view that there are no fundamental issues with this section of road which need to be addressed; however, a number of minor beneficial improvements have been identified and implemented as a result of a previous accident. These are listed in the Table 1 below.” Source location Response from Durham County Council
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 Street lighting and associated footway works are not proposed because lighting is cost-neutral and additional footway and fencing would increase scheme costs.
Verbatim wording from the response “No. | Action | Recommendation
1 | Appropriateness of introducing street lighting on the A690 between Gilesgate and A1(M) Junction 62. | A Cost / Benefit Analysis (C/BA) for a street lighting scheme between Gilesgate and the C13 Belmont Link Road junction, with costs estimated at £1.65 million discounted to 2010 prices, resulted in a Benefit Cost Ratio (BCR) of 1.01.” Source location Response from Durham County Council
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing parallel, street-lit, lower-speed pedestrian routes are considered sufficient, so lighting and footways will not be added to the A690.
Verbatim wording from the response “This means the investment would be cost neutral with no positive return on the investment, particularly as the lighting appraisal undertaken in accordance Department of Transport Document TA 501 (Road Lighting Appraisal) does not include non-lighting costs that would be required, for example provision of a footway and associated fencing along the length of the A690.
2 | Review of pedestrian footway provision along the A690. | The predominant movements between trip generators in the area are provided for via existing footway / footpath routes including:” Source location Response from Durham County Council
Open published response
Concerns raised 2 Failure to set a vehicle speed limit compatible with pedestrian detection and stopping distances View source Lack of lighting at a pedestrian crossing point View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
David Stewart MOORE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David Stewart Moore died after being struck by a motor car while crossing an unlit section of the A693 at around 1830hrs on 28 January 2019. The principal concerns were that the location was a natural pedestrian crossing point without street lighting, was in complete darkness, and had a 60mph speed limit, leaving drivers insufficient distance to detect and stop for pedestrians.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to set a vehicle speed limit compatible with pedestrian detection and stopping distances
Wider context from the report “The section of the A693 where the collision occurred is:
• a de facto pedestrian crossing point connecting footpaths intersecting that road ;
• an area to which the national speed limit applies (60mph for cars);
• very dark at night, being unaffected by ambient illumination;
• without street lighting
The material section of road is a natural crossing point for pedestrians travelling between two footpaths leading between the collision site: and (i) the village of No Place, to the south of the A693 and (ii) the village of Kip Hill, to the north of the A693.
I accepted the following evidence about the material section of road (given by a police Collision Investigator): (i) the road is approximately 12m wide, and after nightfall is “in complete darkness”, being bordered by dense trees and unaffected by discernible ambient light; (ii) drivers are entirely reliant on headlamp illumination to detect pedestrians; (iii) in reliance on his own dipped headlamps, a driver could gain first sight of a static pedestrian in the carriageway at a distance of no more than 40m from that pedestrian; and (iv) a motor car travelling at 60mph would require significantly more than 40m (around 80m) to come to a halt (taking into account driver reaction time and mechanical stopping distance).
In this case, the driver first saw the deceased “just prior to the collision” when the latter was running “with large strides” towards the southern side of the A693. Despite emergency braking, he failed to avoid the collision. It was impossible to stop in the available distance.
” 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 Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of lighting at a pedestrian crossing point
Wider context from the report “The section of the A693 where the collision occurred is:
• a de facto pedestrian crossing point connecting footpaths intersecting that road ;
• an area to which the national speed limit applies (60mph for cars);
• very dark at night, being unaffected by ambient illumination ;
• without street lighting
The material section of road is a natural crossing point for pedestrians travelling between two footpaths leading between the collision site: and (i) the village of No Place, to the south of the A693 and (ii) the village of Kip Hill, to the north of the A693.
I accepted the following evidence about the material section of road (given by a police Collision Investigator): (i) the road is approximately 12m wide, and after nightfall is “in complete darkness” , being bordered by dense trees and unaffected by discernible ambient light; (ii) drivers are entirely reliant on headlamp illumination to detect pedestrians ; (iii) in reliance on his own dipped headlamps, a driver could gain first sight of a static pedestrian in the carriageway at a distance of no more than 40m from that pedestrian; and (iv) a motor car travelling at 60mph would require significantly more than 40m (around 80m) to come to a halt (taking into account driver reaction time and mechanical stopping distance).
In this case, the driver first saw the deceased “just prior to the collision” when the latter was running “with large strides” towards the southern side of the A693. Despite emergency braking, he failed to avoid the collision. It was impossible to stop in the available distance.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Additional street lighting or engineering measures were not considered appropriate because risk assessment, accident history, visibility and warning signage indicated existing controls were sufficient.
Verbatim wording from the response “The A693 is a principal road through the County which is primarily rural in nature and follows the topography of the land through which it passes. The road bisects many Public Footpaths, Bridleways and footways linking communities. Along the route there are sections of the road which have systems of street lighting where there are areas of conflict such as at junctions and roundabouts. However, the street lighting does not cover all pedestrian or bridleway crossing points. The non-provision of street lighting along the route was considered and examined through a robust Risk Assessment process between 2013 and 2015, with this location being assessed in 2013.” Source location Response from Durham County Council
Open published response
Concerns raised 1 Failure to provide double solid white line markings to prevent overtaking at the collision location 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
Shaun David Neal · 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
Shaun David Neal was killed in a road traffic collision while riding his motorcycle on the A68 near Tow Law, County Durham, on 2 September 2017. An oncoming vehicle struck him after overtaking in the opposing lane, causing fatal injuries. Concerns related to the use of broken hazard white lines at the collision location and expert evidence that double solid white lines might have prevented the overtaking manoeuvre.
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 Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide double solid white line markings to prevent overtaking at the collision location
Wider context from the report “1. Evidence heard at inquest confirms only ‘broken’ white line hazard road markings were present on the road surface at the location of the collision
2. Durham County Council Traffic Section have surveyed the scene and found no requirement to change the road markings from broken hazard white lines to double solid white lines as it was thought a short section of double white lines may confuse drivers.
3. Expert evidence from a police collision investigator believed the presence of double white solid line markings would, in a driver obeying the restriction prevent such a manoeuvre that led to the collision, by removing the option to overtake on that section of road .
” Open source report
Concerns raised 3 Failure to discuss and agree care plans and needs assessments with service users’ families View source Inconsistent application of controls preventing service commencement without a care plan and needs assessment View source Care plans and needs assessments failing to incorporate complete available information 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
Stanley Langdon · 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
Stanley Langdon died at Dipton Manor Care Home on 21 May 2017 from complications arising from a periprosthetic left femoral fracture sustained while carers assisted him to climb onto a minibus. The report states that he would not have sustained the fracture if he had been transferred in a wheelchair using the available hydraulic lift. The principal concerns were that services began without an adequate care plan or needs assessment, and that care planning was not based on complete information or agreed with his family, creating a risk of similar accidents and deaths in future.
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 Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to discuss and agree care plans and needs assessments with service users’ families
Wider context from the report “(4) The inquest was told in evidence that Durham County Council had systems in place to ensure that service providers such as the Haven Day Care Centre would not be authorised to provide services unless and until they had received a care plan and assessment of needs in relation to any specific service user.
(5) The inquest was also told in evidence that the systems referred to in (4) were not being applied consistently, and service providers (specifically Haven Day Care Centre) were still commencing the provision of services to service users without receiving care plans and assessments of need for particular service users.
(6) The care plan that was put in place for the deceased at the Haven Day Care Centre after services had begun to be provided to him was not based on all the information that was or should have been available, and that the said care plan had not been discussed and agreed with the deceased’s family (it being noted that the deceased was a dementia sufferer heavily reliant on his family for care from day to day)
(7) It appears to me that there is a risk that similar situations as that applying to the deceased may arise in the future, whereby the Haven Day Care Centre may begin to provide services to a service user without having been provided with relevant information in the form of a care plan and needs assessment from Durham County Council, and without having in place their own care plan and needs assessment based on complete information and adequate discussion with a service user’s family (in circumstances where the service user was heavily reliant on the family for care from day to day).
” 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 Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Inconsistent application of controls preventing service commencement without a care plan and needs assessment
Wider context from the report “(4) The inquest was told in evidence that Durham County Council had systems in place to ensure that service providers such as the Haven Day Care Centre would not be authorised to provide services unless and until they had received a care plan and assessment of needs in relation to any specific service user.
(5) The inquest was also told in evidence that the systems referred to in (4) were not being applied consistently , and service providers (specifically Haven Day Care Centre) were still commencing the provision of services to service users without receiving care plans and assessments of need for particular service users .
(6) The care plan that was put in place for the deceased at the Haven Day Care Centre after services had begun to be provided to him was not based on all the information that was or should have been available, and that the said care plan had not been discussed and agreed with the deceased’s family (it being noted that the deceased was a dementia sufferer heavily reliant on his family for care from day to day)
(7) It appears to me that there is a risk that similar situations as that applying to the deceased may arise in the future, whereby the Haven Day Care Centre may begin to provide services to a service user without having been provided with relevant information in the form of a care plan and needs assessment from Durham County Council , and without having in place their own care plan and needs assessment based on complete information and adequate discussion with a service user’s family (in circumstances where the service user was heavily reliant on the family for care from day to day).
” 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 Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Care plans and needs assessments failing to incorporate complete available information
Wider context from the report “(4) The inquest was told in evidence that Durham County Council had systems in place to ensure that service providers such as the Haven Day Care Centre would not be authorised to provide services unless and until they had received a care plan and assessment of needs in relation to any specific service user.
(5) The inquest was also told in evidence that the systems referred to in (4) were not being applied consistently, and service providers (specifically Haven Day Care Centre) were still commencing the provision of services to service users without receiving care plans and assessments of need for particular service users.
(6) The care plan that was put in place for the deceased at the Haven Day Care Centre after services had begun to be provided to him was not based on all the information that was or should have been available , and that the said care plan had not been discussed and agreed with the deceased’s family (it being noted that the deceased was a dementia sufferer heavily reliant on his family for care from day to day)
(7) It appears to me that there is a risk that similar situations as that applying to the deceased may arise in the future, whereby the Haven Day Care Centre may begin to provide services to a service user without having been provided with relevant information in the form of a care plan and needs assessment from Durham County Council, and without having in place their own care plan and needs assessment based on complete information and adequate discussion with a service user’s family (in circumstances where the service user was heavily reliant on the family for care from day to day).
” Open source report
Concerns raised 1 Inadequate warning signage on the approach to the corner View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Warren Michael Myers · 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
Warren Michael Myers died in a fatal road traffic collision on 22 June 2016 while riding a motorised trike on a bend in County Durham. The principal concern was that the warning signage approaching the bend was inadequate.
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 Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate warning signage on the approach to the corner
Wider context from the report “1. The warning signage on the approach to the corner is inadequate.
” 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 Erect an additional chevron sign for eastbound traffic beside the dropped kerbs and track.
Verbatim wording from the response “4. | Due to the amount of kerb strikes, this bend may benefit from additional engineering measures to warn of the bend and reduce approach speeds in both directions of travel. | An additional chevron sign (TSRGD Diagram 515) has been erected for eastbound traffic, offset to the right of the dropped kerbs/track.” Source location 2017-0032-Response-by-Durham-County-Council
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 Install a “Reduce Speed Now” plate below the existing eastbound bend-warning and horse-warning sign arrangement by the end of May 2017.
Verbatim wording from the response “The above criteria is met for this sign and therefore we will install a “Reduce Speed Now” sign plate below the existing eastbound combined ‘bend to the right/horse warning’ sign arrangement by the end of May 2017.” Source location 2017-0032-Response-by-Durham-County-Council
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 Increase both bend-ahead warning signs from 600mm to 750mm high.
Verbatim wording from the response “1. | Provide suitable ‘Bend ahead’ warning signs in-line with the 85th percentile speeds on approach to the bend in both directions of travel. | Both ‘Bend Ahead’ warning signs have been increased in size from 600mm high to 750mm high.” Source location 2017-0032-Response-by-Durham-County-Council
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 Re-erect the westbound chevron sign to restore clear visibility.
Verbatim wording from the response “2. | The existing chevron plate for w/bound motorists has slipped down the post and is now not clearly visible. | The chevron sign has been re-erected and is clearly visible.” Source location 2017-0032-Response-by-Durham-County-Council
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 chevron sign remains functional, so no changes are required until it needs replacement.
Verbatim wording from the response “3. | The appropriately sized chevrons (including appropriate yellow backing) should be provided on the bend to benefit both directions of travel. Clear visibility of the signs should be provided. | The size of the yellow boarder on the chevron signs conforms to TSRGD 1994. The chevron sign is still functional and therefore no requirement to make changes until the chevron needs to be replaced.” Source location 2017-0032-Response-by-Durham-County-Council
Open published response
Concerns raised 4 Lack of formal learning and information sharing within Technical Services Management Team View source Failure of winter road maintenance policy and decision-making processes to accommodate local extreme variations in road conditions View source Lack of formal review of winter maintenance decision-making process and policy View source Winter maintenance policy failing to provide for changing conditions between maintenance decisions View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Nathan Luke Charman · 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
Nathan Luke Charman died on 5 March 2016 after his car left an untreated, icy road, hit a tree and rolled. The report identified concerns that winter maintenance policy and decision-making did not account for extreme local or changing road conditions, and that the incident had not prompted formal review, learning or information sharing.
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 Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of formal learning and information sharing within Technical Services Management Team
Wider context from the report “3. The evidence of the Highway Services Manager was that this incident has not prompted a formal review of the decision making process or the policy in the light of this incident, or any form of formal learning or information sharing in and by Technical Services Management Team .
” 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 Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Failure of winter road maintenance policy and decision-making processes to accommodate local extreme variations in road conditions
Wider context from the report “1. The decision by the Highway Services Manager followed the policy and applied the weather forecast. The unsafe road conditions were the incident occurred were restricted to that immediate locality. However, neither the policy nor the decision making process accommodated the possibility of extreme variations in road conditions or the existence of what the Police identified as “microclimatic” conditions at particular points and “extreme and freakish” conditions that led directly to 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 Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of formal review of winter maintenance decision-making process and policy
Wider context from the report “3. The evidence of the Highway Services Manager was that this incident has not prompted a formal review of the decision making process or the policy in the light of this incident , or any form of formal learning or information sharing in and by Technical Services Management Team.
” 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 Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Winter maintenance policy failing to provide for changing conditions between maintenance decisions
Wider context from the report “2. The winter maintenance policy does not provide for variations in conditions during the time between decisions being made concerning winter maintenance action .
” 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 Reassign gritting route 28 from the Central to the Low Pennines weather forecasting domain.
Verbatim wording from the response “As part of this review we examined the accuracy of the weather forecast with MeteoGroup and they advised that gritting route 28 on which this incident occurred would be better aligned with the Low Pennines weather forecasting domain rather than the Central weather forecasting domain. This was implemented on Monday 7 March 2016.” Source location 2016-0267-Response-by-Durham-County-Council
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 Test all assumptions in the Winter Maintenance Operational Plan to confirm that they remain valid.
Verbatim wording from the response “All the assumptions within the Winter Maintenance Operational Plan have been tested to ensure that they remain valid.” Source location 2016-0267-Response-by-Durham-County-Council
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing winter maintenance procedures provide robust arrangements for responding to variations in weather conditions in accordance with the national Code.
Verbatim wording from the response “1.6 Winter Maintenance Duty Managers (WMDMs) will ensure that appropriate action is taken and will at all times ensure that the safety of the highway network is the paramount consideration. Should there be any doubt with regards to the decision making process, the WMDM will always take a safety first approach and ensure the appropriate resource is in place to respond to changing conditions as quickly as is practicable.” Source location 2016-0267-Response-by-Durham-County-Council
Open published response
30 Mar 2016 Steven Nicholson · Prevention of Future Deaths report Newcastle upon Tyne
View report summary
Concerns raised 2 Lack of appropriate flood-risk warning signage on the A1018 slip road View source Lack of appropriate lighting on the A1018 slip road View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Steven Nicholson · 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 Nicholson was driving on the A1018 entry slip road in poor visibility when his vehicle struck a large area of standing water, causing him to lose control and sustain fatal head injuries. The substantive concerns were the absence of appropriate lighting and warning signs about flooding on the slip road.
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 Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of appropriate flood-risk warning signage on the A1018 slip road
Wider context from the report “(1) The absence of appropriate lighting on the A1018 slip road, to assist motorists in identifying and reacting to sudden unexpected hazards.
(2) The absence of appropriate signage warning motorists of the risk of flooding on the A1018 slip road .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of appropriate lighting on the A1018 slip road
Wider context from the report “(1) The absence of appropriate lighting on the A1018 slip road , to assist motorists in identifying and reacting to sudden unexpected hazards.
(2) The absence of appropriate signage warning motorists of the risk of flooding on the A1018 slip road.
” 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 Deploy temporary flood-warning signs until the highway drainage improvement works are complete.
Verbatim wording from the response “Absence of Flood Warning Signs
The Inquest confirmed that highway flooding had occurred at this location although we were not aware of any issues prior to this incident. If we had received reports of flooding we would have deployed temporary flood warning signs in line with our standard procedures.” Source location Durham-City-Council-Response
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 Permanent flood warning signs will not be installed because traffic-sign regulations provide only for their temporary use.
Verbatim wording from the response “Flood warning signs are prescribed in the Department for Transport’s traffic sign regulations for temporary use only to warn of occasional hazards. They should be retained only for so long as the hazard continues to exist or is expected to recur in the near future. There is no provision in the Department for Transport’s traffic sign regulations, which we are obliged to follow, for the installation of permanent flood warning signs. Therefore we do not propose to install permanent flood warning signs.” Source location Durham-City-Council-Response
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 Street lighting is not considered necessary because the existing policy and alternative drainage mitigation are considered more appropriate and effective for the flooding risk.
Verbatim wording from the response “Absence of Street Lighting
The Council provides street lighting in accordance with our Street Lighting Policy which was approved by our Cabinet on 20th November 2013 following extensive public consultation. The majority of consultation responses were supportive of the updated policy. Please find link to the report:” Source location Durham-City-Council-Response
Open published response
Concerns raised 2 Inadequate warning signage for river-path users about the deep pool and strong currents View source Particularly deep pool with strong currents in the River Wear View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
JORDAN LEE ROBERTS · 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
JORDAN LEE ROBERTS, aged 17, was playing in the River Wear near Finchale Abbey when he entered a particularly deep area known as the bombhole and was not seen again above the surface. He was found in more than two metres of water by emergency services the next day. The principal concern was that warning signs were inadequate, not readily visible, and did not specifically highlight the danger from the sudden deep water and strong currents.
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 Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate warning signage for river-path users about the deep pool and strong currents
Wider context from the report “(1) The depth of the water in the River Wear which the three young men waded through is not particularly deep or particularly hazardous except where there is this particularly deep pool where the dangers are also compounded by strong currents. There is one warning sign on the Finchale Abbey side of the river but people walking down the well established river path on the County Council river bank side would be unaware of this sign and the three small square warning signs that are in place seem inadequate and not fit for purpose particularly bearing in mind that the water bailiff himself was unaware of their existence. Consideration therefore should be given to the question of the erection of appropriate warning signs on both sides of the River Wear in this area particularly highlighting known dangers of this particularly deep expanse of water.
” 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 Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Particularly deep pool with strong currents in the River Wear
Wider context from the report “(1) The depth of the water in the River Wear which the three young men waded through is not particularly deep or particularly hazardous except where there is this particularly deep pool where the dangers are also compounded by strong currents . There is one warning sign on the Finchale Abbey side of the river but people walking down the well established river path on the County Council river bank side would be unaware of this sign and the three small square warning signs that are in place seem inadequate and not fit for purpose particularly bearing in mind that the water bailiff himself was unaware of their existence. Consideration therefore should be given to the question of the erection of appropriate warning signs on both sides of the River Wear in this area particularly highlighting known dangers of this particularly deep expanse of water.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete a safety assessment of the northern section of the river bank.
Verbatim wording from the response “Following the tragic death of Jordan Lee Roberts, a safety assessment of the northern section of the river bank has been undertaken by Durham County Council. The assessment process has also involved a Royal Society for the Prevention of Accidents (ROSPA) consultant. ROSPA have also been engaged by the Durham City Safety Group to undertake an independent review of river safety in Durham City Centre. As part of this process, ROSPA are also reviewing various other locations across the County including Finchale Abbey.” Source location 2015-0042-Response-by-Durham-County-Council
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 Improve sections of fencing along the northern river bank near the footbridge.
Verbatim wording from the response “Furthermore, additional work will also be undertaken to improve sections of fencing along the northern side of river bank in the vicinity of the footbridge. Information will also be provided on the Durham County Council Cocken Wood picnic area webpages regarding the hazards associated with the river, particularly for those visiting this attraction that may be unaware.” Source location 2015-0042-Response-by-Durham-County-Council
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 Replace existing warning signs with larger hazard signs at three key northern river-bank locations and maintain them through ongoing inspection and replacement.
Verbatim wording from the response “The safety assessment has resulted in actions being taken to replace the existing warning signs which were identified in the matters of concern. Larger, improved hazard warning signs have been erected at 3 key locations along the northern river bank. This will warn river path users that there are river related hazards, specifically strong currents and deep water. The signs being erected are in accordance with The Health and Safety (Safety Signs and Signals) Regulations and ROSPA national water safety signage specification for public areas. All signs will be subject to ongoing inspection and monitoring regimes and replacements will be erected on an ongoing basis where required.” Source location 2015-0042-Response-by-Durham-County-Council
Open published response
Concerns raised 4 Absence of a handrail on steps View source Low riverside wall providing inadequate safety barrier View source Poor illumination of steps View source Steep steps creating difficulty of negotiation View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sopeluwa Babatunde Peters · 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
Sopeluwa Babatunde Peters died by drowning in the River Wear on 30 October 2013, after likely falling into the river while descending steep steps in Drury Lane, Durham City, while under the influence of alcohol. Concerns included poor illumination, the absence of a handrail, the steepness of the steps, and a low riverside wall that provided limited safety protection.
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 Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Absence of a handrail on steps
Wider context from the report “(1) The steps are steep, poorly illuminated, with no handrail and on the evidence are said to be particularly difficult to negotiate at any time even more so by an individual who may be under the influence of alcohol. The wall at the riverside on the path opposite the steps/alleyway is only 690 mm’s high and does not create much of a safety barrier.
” 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 Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Low riverside wall providing inadequate safety barrier
Wider context from the report “(1) The steps are steep, poorly illuminated, with no handrail and on the evidence are said to be particularly difficult to negotiate at any time even more so by an individual who may be under the influence of alcohol. The wall at the riverside on the path opposite the steps/alleyway is only 690 mm’s high and does not create much of a safety barrier .
” 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 Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Poor illumination of steps
Wider context from the report “(1) The steps are steep, poorly illuminated , with no handrail and on the evidence are said to be particularly difficult to negotiate at any time even more so by an individual who may be under the influence of alcohol. The wall at the riverside on the path opposite the steps/alleyway is only 690 mm’s high and does not create much of a safety barrier.
” 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 Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Steep steps creating difficulty of negotiation
Wider context from the report “(1) The steps are steep , poorly illuminated, with no handrail and on the evidence are said to be particularly difficult to negotiate at any time even more so by an individual who may be under the influence of alcohol. The wall at the riverside on the path opposite the steps/alleyway is only 690 mm’s high and does not create much of a safety barrier.
” 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 Install a timber barrier beside the wall opposite Drury Lane’s exit to reduce the risk of falls into the river.
Verbatim wording from the response “I can confirm that whilst no action is being proposed in respect of the above mentioned matters, the Council will be installing a timber barrier in the riverside footpath, adjacent to the wall opposite the exit from Drury Lane. The installation of a barrier should reduce any potential risk of someone falling or running down the steps and going over the wall into the river at this location. This barrier will be placed within the footpath itself, as the path is within the control of the County Council. It is anticipated that this barrier will be installed within the next two weeks.” Source location 2014-0206-Response-by-Durham-County-Council
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 Undertake a riverbank risk assessment with police representatives to identify locations associated with evening and night-time activity.
Verbatim wording from the response “The County Council will also be undertaking a risk assessment along sections of the river bank. This assessment will include representatives from the police who will identify locations, from their local knowledge of where there is a volume of evening and night time activity. If further risks are identified these will be assessed and action will be taken by the County Council to minimise such risks as is considered appropriate.” Source location 2014-0206-Response-by-Durham-County-Council
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 Lighting the location is not considered helpful because it would create dangerous light-dark contrast and lighting all riverbank paths is impractical and inappropriate.
Verbatim wording from the response “Whilst lighting the location may assist, it would result in a lit area leading to unlit riverside paths, creating greater contrast between areas of light and dark. It is felt that lighting all the riverbank paths would be both impractical and inappropriate due to the detrimental effect on the setting of the World Heritage Site. On balance it is not considered helpful to light this location.” Source location 2014-0206-Response-by-Durham-County-Council
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 steps cannot be meaningfully modified because the path is too narrow to alleviate the steep slope.
Verbatim wording from the response “With reference to your concern about the steepness of the steps and lack of handrail on Drury Lane; the lane has been inspected by the County Council’s Rights of Way Officer and he is satisfied that the steps themselves are in a good state of repair. It is acknowledged that these steps are steep, requiring some care when descending them. However, these steps have been in existence for a considerable period of time and to our knowledge there has been only one previous report of a tripping or slipping accident, and that defect was rectified. It is in any event difficult to see how these steps could be modified as the path is too narrow to achieve any meaningful alleviation of this slope.” Source location 2014-0206-Response-by-Durham-County-Council
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A handrail cannot readily be installed because the narrow path would be further obstructed and the adjoining walls are unsuitable for attachment.
Verbatim wording from the response “Turning to the provision of handrails; as mentioned in previous correspondence, due to the narrowness of the path it would be very difficult to install a handrail, because this would further reduce the width, which could be viewed as an obstacle by some footpath users. In any event the hand rails would need to be attached to the abutting walls, which are not within the County Council’s ownership. The walls have been inspected and are considered to be unsuitable for attaching rails of this nature because of their age, and in places the walls are in fairly fragile condition.” Source location 2014-0206-Response-by-Durham-County-Council
Open published response
Concerns raised 2 Lack of collective information sharing between police and the local authority View source Failure of County Council practices and procedures to ensure a timely and proportionate response to potentially dangerous road conditions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
MELVIN BANDTOCK · 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
MELVIN BANDTOCK, aged 55, died after losing control of his motorcycle on black ice and colliding with an oncoming bus on 28 December 2013. The road had not been treated under the local authority’s gritting or salting regime. Concerns included information sharing between Durham Constabulary and the local authority and reviewing procedures to ensure a timely and proportionate response to potentially dangerous road conditions.
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 Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of collective information sharing between police and the local authority
Wider context from the report “Evidence was given that there is a Duty Manager on call to assess changing weather reports and the collation of information obtained from other sources, in particular the police, in order to decide whether salting/gritting machines should be deployed either on a local or County wide basis. On the day in question the Duty Manager believed that weather temperatures would increase in a relatively short period of time whereas in reality they did not do so. There were a high number of collision incidents reported to the police that morning some of which resulted in report being made to the County Council. Some gritting/salting vehicles were deployed. It will take about an hour for gritting/salting lorries to be able to commence their work and a route would take up to three hours to complete. The time that it therefore takes to complete a gritting/salting run is a factor which is considered by the Duty Manager on the question of whether to deploy or not in conjunction with the weather condition reports and as a result of information gleaned from road temperature monitoring. It was said that this procedure had been in place for many years and was tried and tested. A Regulation 28 report is being sent to Durham Constabulary and a copy provided to the local authority herewith and the evidence indicates that a better collective sharing of information between the two organisations may well be of benefit together with a review of the County Council's own practices and procedures to ensure that a timely and proportionate response to potentially dangerous road conditions can be delivered to promote the safety of all road users. The Highways Manager indicated that with the information that the Duty Manager had following receipt of the 6.00 a.m. weather report his decision not to deploy gritting/salting vehicles was a reasonable one but that with the benefit of hindsight knowing what happened with regard to ambient temperature conditions and incidents around the County on the road network this decision was regrettable. I confirmed that it was not my intention to blame or be seen to blame any individual for the death in this case but it was my statutory obligation to draw to the appropriate authorities attention relevant issues that might be appropriate to prevent future deaths. I also recognised that English weather can be unpredictable.
” 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 Durham County Council; that does not assign responsibility.
PFD Monitor interpretation Failure of County Council practices and procedures to ensure a timely and proportionate response to potentially dangerous road conditions
Wider context from the report “Evidence was given that there is a Duty Manager on call to assess changing weather reports and the collation of information obtained from other sources, in particular the police, in order to decide whether salting/gritting machines should be deployed either on a local or County wide basis. On the day in question the Duty Manager believed that weather temperatures would increase in a relatively short period of time whereas in reality they did not do so. There were a high number of collision incidents reported to the police that morning some of which resulted in report being made to the County Council. Some gritting/salting vehicles were deployed. It will take about an hour for gritting/salting lorries to be able to commence their work and a route would take up to three hours to complete. The time that it therefore takes to complete a gritting/salting run is a factor which is considered by the Duty Manager on the question of whether to deploy or not in conjunction with the weather condition reports and as a result of information gleaned from road temperature monitoring. It was said that this procedure had been in place for many years and was tried and tested. A Regulation 28 report is being sent to Durham Constabulary and a copy provided to the local authority herewith and the evidence indicates that a better collective sharing of information between the two organisations may well be of benefit together with a review of the County Council's own practices and procedures to ensure that a timely and proportionate response to potentially dangerous road conditions can be delivered to promote the safety of all road users. The Highways Manager indicated that with the information that the Duty Manager had following receipt of the 6.00 a.m. weather report his decision not to deploy gritting/salting vehicles was a reasonable one but that with the benefit of hindsight knowing what happened with regard to ambient temperature conditions and incidents around the County on the road network this decision was regrettable. I confirmed that it was not my intention to blame or be seen to blame any individual for the death in this case but it was my statutory obligation to draw to the appropriate authorities attention relevant issues that might be appropriate to prevent future deaths. I also recognised that English weather can be unpredictable.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require meaningful communication with weather forecasters when conditions are marginal or change, so revised actions can be implemented.
Verbatim wording from the response “We have reviewed our procedures and made a number of changes to improve the margin of safety against inaccurate weather forecasts and changing conditions:” Source location 2014-0147-Response-by-Durham-County-Council
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 Deploy winter maintenance vehicles on standby at strategic depots during specified low-confidence amber warnings for immediate gritting response.
Verbatim wording from the response “In circumstances where weather forecasts indicate an amber warning less than or equal to 1°C, with low confidence, winter maintenance vehicles will be deployed on standby at all strategic depots in readiness for gritting activity, therefore should weather conditions deteriorate from that forecast, an immediate gritting response can be implemented.” Source location 2014-0147-Response-by-Durham-County-Council
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 Deploy Duty Highway Inspectors on standby at strategic depots during specified low-confidence amber warnings to monitor forecasts and support decisions.
Verbatim wording from the response “Amber Warning
In circumstances where weather forecasts indicate an amber warning less than or equal to 1°C, with low confidence, Duty Highway Inspectors will be deployed on standby at the key strategic depots for the purpose of monitoring forecast information and where appropriate undertaking a route inspection to assist the Duty Manager in the decision making process.” Source location 2014-0147-Response-by-Durham-County-Council
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 Review information-sharing protocols with Durham Constabulary to identify improvements.
Verbatim wording from the response “Sharing of Information
Following receipt of your letter we met with Durham Constabulary on 29th April 2014 to review existing information sharing protocols and to identify how these could be improved.” Source location 2014-0147-Response-by-Durham-County-Council
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 Remind Duty Managers to prioritise highway-network safety and maintain appropriate resources for rapidly changing conditions.
Verbatim wording from the response “We have reviewed our procedures and made a number of changes to improve the margin of safety against inaccurate weather forecasts and changing conditions:” Source location 2014-0147-Response-by-Durham-County-Council
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 Snow and ice risks cannot be completely eliminated because forecasting and salting effectiveness depend on uncertain weather and traffic conditions.
Verbatim wording from the response “However, winter maintenance is not an exact science and the decision to deploy gritters for precautionary salting relies upon weather forecasts and professional judgement. Whilst weather forecasting has greatly improved in recent years it is not 100% accurate and the actual weather conditions on 28 December 2013 were worse than forecast which was a significant factor in this accident.” Source location 2014-0147-Response-by-Durham-County-Council
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing communication mechanisms and information-sharing protocols are considered effective for managing highways through partnership working.
Verbatim wording from the response “Sharing of Information
Following receipt of your letter we met with Durham Constabulary on 29th April 2014 to review existing information sharing protocols and to identify how these could be improved.” Source location 2014-0147-Response-by-Durham-County-Council
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The existing Winter Service Plan is considered effective and sufficient to meet the Council’s reasonably practicable highway safety duty.
Verbatim wording from the response “Statutory Duty
Section 41(1)(a) of the Highways Act 1980 (c. 66) (duty of Highway Authority to maintain highway) states:” Source location 2014-0147-Response-by-Durham-County-Council
Open published response
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations