Recipient

East Sussex County Council

First report 12 Mar 2021•Latest report 9 Jun 2022

Recipient record

Reports, concerns and published responses

Local government · English county council. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
3

Naming this recipient

Published responses
100%

Found for named reports

Concerns addressed
6

Across all linked responses

Stated actions
12

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

100%published responses found
12stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from East Sussex County Council linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. East Sussex

    AI-generated summary

    Jennifer Ann DYER · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Jennifer Ann DYER, aged 36, died after her bicycle collided with a van following contact with a defective pothole on the B2188. The pothole had a history of failed repairs and previous concerns about the danger it posed to road users. The report raises concern that its categorisation as a low-risk defect requires significant review, stating that the death was avoidable.

    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 East Sussex County Council; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to appropriately categorise pothole risks

    Wider context from the report

    “Under the East Sussex Highway Asset Inspection Manual, this pothole fell within the definition of Cat 3 - LOW for risk and remedial works. The definition is “Greater than 40mm and less than 59mm deep and at least 300mm in all directions”. Clearly, this pothole was the proximate cause of the death of a young woman, and the categorisation of potholes in East Sussex requires significant review, to prevent future avoidable deaths within the County. ”
    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

    Introduce an enhanced risk-based inspection process allowing defect categories and response times to reflect location, usage and assessed risk.

    Verbatim wording from the response

    “In May 2021 a revised Highway Inspection Manual introduced an enhanced risk assessment process where the highway inspector can consider other factors, such as the location of a defect and usage, as well as the defect category in determining whether a response is required or a different response time required. This means that, following the risk assessment, they are able to change the category of a defect such as changing a non-intervention defect to an intervention defect or reduce or increase the category response time if deemed appropriate. For example, if a category 3 pothole is located on the part of the carriageway cyclists are likely to use such as the nearside edge, this could be increased to a category 2 or 1 depending on risk assessment.”

    Source location

    Response from East Sussex County Council
    Page 2 · response
    Published 16 September 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Continue reviewing the effectiveness of the enhanced risk-based approach, including how it would have affected the incident.

    Verbatim wording from the response

    “- Continue to review the effectiveness of the implemented enhanced risk based approach and in particular review how it would have affected this case”

    Source location

    Response from East Sussex County Council
    Page 3 · response
    Published 16 September 2022

    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 enhanced risk-based inspection process makes a specific review of pothole categories unnecessary.

    Verbatim wording from the response

    “risk based approach to its safety inspection regimes which allows for a more flexible approach to determining risk for all road users and defect response times. This enables the inspector to change the categorisation of a pothole to include potholes for repair that do not meet the lowest category if required or to change the category of a pothole to a medium or high risk following an onsite risk assessment that now also considers location and road usage in addition to size and depth.”

    Source location

    Response from East Sussex County Council
    Page 3 · response
    Published 16 September 2022

    Open published response
  2. East Sussex

    AI-generated summary

    Rodney John DIXON · 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

    Rodney John Dixon took his own life at home in Eastbourne on 15 July 2019 during the course of a Mental Health Act Assessment, following deterioration in his mental and physical health. The report raised concerns that training on Mental Health Act assessments, patient risk management and assessors was sub-optimal, and that independent clinicians needed reasonable access to patient data before assessments.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Sussex County Council; that does not assign responsibility.

    PFD Monitor interpretation

    Sub-optimal training for patient risk management

    Wider context from the report

    “Mental Health Act Assessments are conducted in East Sussex deploying clinicians from both ESCC and SPT and independent clinicians such as psychiatrists. The training around Mental Health Act assessments, patient risk management, and their Assessors is sub-optimal. Reasonable access to patient data by independent clinicians for MHA assessments needs to be ensured prior to assessments. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Sussex County Council; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of timely access to patient data for independent clinicians conducting Mental Health Act assessments

    Wider context from the report

    “Mental Health Act Assessments are conducted in East Sussex deploying clinicians from both ESCC and SPT and independent clinicians such as psychiatrists. The training around Mental Health Act assessments, patient risk management, and their Assessors is sub-optimal. Reasonable access to patient data by independent clinicians for MHA assessments needs to be ensured prior to assessments. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Sussex County Council; that does not assign responsibility.

    PFD Monitor interpretation

    Sub-optimal training for Mental Health Act assessments

    Wider context from the report

    “Mental Health Act Assessments are conducted in East Sussex deploying clinicians from both ESCC and SPT and independent clinicians such as psychiatrists. The training around Mental Health Act assessments, patient risk management, and their Assessors is sub-optimal. Reasonable access to patient data by independent clinicians for MHA assessments needs to be ensured prior to assessments. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Sussex County Council; that does not assign responsibility.

    PFD Monitor interpretation

    Sub-optimal training for Mental Health Act assessors

    Wider context from the report

    “Mental Health Act Assessments are conducted in East Sussex deploying clinicians from both ESCC and SPT and independent clinicians such as psychiatrists. The training around Mental Health Act assessments, patient risk management, and their Assessors is sub-optimal. Reasonable access to patient data by independent clinicians for MHA assessments needs to be ensured prior to assessments. ”
    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review AMHP training and documentation relating to Mental Health Act assessments.

    Verbatim wording from the response

    “The Council has reviewed its’ training and documentation in respect of AMHPs”

    Source location

    Response from East Sussex County Council
    Page 2 · response
    Published 28 June 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Introduce dynamic risk assessment requirements, supervision safeguards, and access to current risk and clinical information through updated assessment forms and internal publication.

    Verbatim wording from the response

    “(1) Leon Gooding (Head of Adult Social Care) hosted a meeting with all the Council’s Approved Mental Health Practitioners (AMHPs) to discuss the issues arising from this case. During the meeting, It was agreed that the client in cases similar to that of Mr. Dixon should not be left unsupervised unless assessed to be of low risk. The Council’s Mental Health Act referral and Risk Assessment Forms have been updated. They include a new section entitled “dynamic risk assessment”.”

    Source location

    Response from East Sussex County Council
    Page 2 · response
    Published 28 June 2021

    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

    Arrange annual risk-management training for existing Approved Mental Health Practitioners with Brighton University.

    Verbatim wording from the response

    “(2) Yearly risk management training with Brighton University for existing AMHP’s has been arranged. This is part of the annual training that AMHPs undergo anyway but it will now include specific training on risk management.”

    Source location

    Response from East Sussex County Council
    Page 2 · response
    Published 28 June 2021

    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

    Recruitment and training of doctors and other medical staff is the responsibility of Sussex Partnership Foundation Trust, not the Council.

    Verbatim wording from the response

    “As a local authority, the Council is responsible for the recruitment, training, warranting and management of Approved Mental Health Practitioners (AMHPs). The Council has no input into the recruitment or training of Doctors and other medical staff who practise in this area. That is the responsibility of the Sussex Partnership Foundation Trust (SPFT) who have also been issued with a Regulation 28 notice.”

    Source location

    Response from East Sussex County Council
    Page 1 · response
    Published 28 June 2021

    Open published response
  3. Brighton and Hove

    AI-generated summary

    Lesley Powell · 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

    Lesley Powell was hit by a motor vehicle while crossing the A2100 Battle Hill and died at hospital on 4 January 2020. The report identified the absence of a safe crossing point and a history of seven incidents on or near the road between August 2016 and December 2019, including fatal and serious-injury incidents.

    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 East Sussex County Council; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of a safe crossing point on the A2100 Battle Hill

    Wider context from the report

    “(1) There is no safe crossing point on the A2100 Battle Hill, Battle, East Sussex in the vicinity of the Esso/Tesco Express Garage and shop ”
    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 preliminary design for a light-controlled crossing and a direct, level pedestrian route across the filling-station forecourt.

    Verbatim wording from the response

    “In 2020, further discussions and meetings were carried out with Esso and Tesco on alternative options for a pedestrian route across the filling station forecourt and these have resulted in a more direct and level route being identified from the edge of the proposed crossing on the A2100 to the Tesco Express entrance. A preliminary design has now been completed for both the pedestrian crossing and the forecourt pedestrian route. This design has been subject to a Stage 1 Road Safety Audit and the County Council has allocated further funding in the 2021/22 Capital Programme of Local Transport Improvements to progress the scheme through statutory/local stakeholder consultation, and subject to the outcome of this process, progress to detailed design and possible implementation in a future year’s capital programme.”

    Source location

    2021-0282-Response-from-East-Sussex-County-Council_Published
    Page 6 · response
    Published 26 August 2021

    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

    Progress the crossing scheme through statutory and local-stakeholder consultation, then toward detailed design subject to the consultation outcome.

    Verbatim wording from the response

    “In 2020, further discussions and meetings were carried out with Esso and Tesco on alternative options for a pedestrian route across the filling station forecourt and these have resulted in a more direct and level route being identified from the edge of the proposed crossing on the A2100 to the Tesco Express entrance. A preliminary design has now been completed for both the pedestrian crossing and the forecourt pedestrian route. This design has been subject to a Stage 1 Road Safety Audit and the County Council has allocated further funding in the 2021/22 Capital Programme of Local Transport Improvements to progress the scheme through statutory/local stakeholder consultation, and subject to the outcome of this process, progress to detailed design and possible implementation in a future year’s capital programme.”

    Source location

    2021-0282-Response-from-East-Sussex-County-Council_Published
    Page 6 · response
    Published 26 August 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Complete a Stage 1 Road Safety Audit of the preliminary crossing and forecourt-route design.

    Verbatim wording from the response

    “In 2020, further discussions and meetings were carried out with Esso and Tesco on alternative options for a pedestrian route across the filling station forecourt and these have resulted in a more direct and level route being identified from the edge of the proposed crossing on the A2100 to the Tesco Express entrance. A preliminary design has now been completed for both the pedestrian crossing and the forecourt pedestrian route. This design has been subject to a Stage 1 Road Safety Audit and the County Council has allocated further funding in the 2021/22 Capital Programme of Local Transport Improvements to progress the scheme through statutory/local stakeholder consultation, and subject to the outcome of this process, progress to detailed design and possible implementation in a future year’s capital programme.”

    Source location

    2021-0282-Response-from-East-Sussex-County-Council_Published
    Page 6 · response
    Published 26 August 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Complete a feasibility study of pedestrian-crossing options and wider Battle Hill safety measures.

    Verbatim wording from the response

    “However, following a serious pedestrian-related crash on Battle Hill, a petition was presented to the County Council on 15 May 2018. The petition was considered by the then Lead Member for Transport and Environment at their decision making meeting on 16 July 2018, where it was resolved that, after liaising with Sussex Police, the County Council would commission their term contractor ‘East Sussex Highways’ to conduct a feasibility study to determine whether some form of pedestrian crossing facility could be introduced at this location and potentially funded through a future capital programme for local transport improvements.”

    Source location

    2021-0282-Response-from-East-Sussex-County-Council_Published
    Page 5 · response
    Published 26 August 2021

    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

    Pedestrian safety within the filling-station forecourt requires cooperation and legal agreements with its private owner and operators.

    Verbatim wording from the response

    “Whilst limited informal internal footways and pedestrian markings were already provided within the filling station forecourt area, these were located some distance from what the desire line of pedestrians using the proposed crossing facility on the A2100. This also presented difficulties to pedestrians of limited, or restricted mobility and specifically those using wheelchairs/mobility scooters, due to the gradients on the wider cartilage of the forecourt. The forecourt is privately owned and not under the control of the Highway Authority (East Sussex County Council). The County Council was concerned that, in addressing the issue of safe passage across the A2100 through the introduction of a formal controlled crossing facility, pedestrians could be placed in danger through uncontrolled movement across a busy forecourt on which drivers are not focused on pedestrian movement.”

    Source location

    2021-0282-Response-from-East-Sussex-County-Council_Published
    Page 6 · response
    Published 26 August 2021

    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 location did not meet the established crash-frequency or severity criteria requiring an annual Road Safety Team review.

    Verbatim wording from the response

    “The area identified by the Coroner is within an approximate 100-metre radius of the Tesco Express/Esso filling Station on Battle Hill and the period cited by the Coroner of August 2016 to December 2019 covers a 41-month period. This area did not fall inside our parameters for the identification of a crash site because four or more crashes did not occur within a 25-metre radius within the relevant three year period, which was between 1 January 2018 and 31 December 2020.”

    Source location

    2021-0282-Response-from-East-Sussex-County-Council_Published
    Page 2 · response
    Published 26 August 2021

    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 cannot confirm the crossing works or completion timeframe because funding is limited and capital expenditure follows an approved process.

    Verbatim wording from the response

    “A potential pedestrian crossing scheme is currently being developed in 2021/22 through the County Council’s Capital Programme of Local Transport Improvements. Whilst we are unable to confirm precisely the actions that will be taken at this location (or a timeframe for any works to be completed) due to the limited availability of funding and our approved process for agreeing capital expenditure, we consider that the actions outlined above are appropriate and proportionate to the issues raised and have due regard to the priority this site has, in terms of all other identified and prioritised commitments.”

    Source location

    2021-0282-Response-from-East-Sussex-County-Council_Published
    Page 6 · response
    Published 26 August 2021

    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

    Crash analysis did not identify a clear causal factor or consistent manoeuvre that could be addressed solely through an engineered intervention.

    Verbatim wording from the response

    “The crash analysis did not indicate that there is any clear causation factor or consistent manoeuvre involved in the crashes occurring at this location that could be solely addressed by an engineered intervention.”

    Source location

    2021-0282-Response-from-East-Sussex-County-Council_Published
    Page 5 · response
    Published 26 August 2021

    Open published response
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

100%
100%All other recipients 58%
0%100%

How actions were described at the time

This respondent
58%25%17%
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026