29 Dec 2025 Brian Mitchell · Prevention of Future Deaths report East London
View report summary
Concerns raised 4 Lack of clear data demonstrating improved expedition and clarity of station staff communication in emergencies View source Lack of clear evidence that risks of fatal harm have been mitigated View source Lack of clear data demonstrating improved train-operator concentration and track observation during ATO operation View source Failure to implement technological measures detecting and alerting staff to persons on the tracks at Stratford station View source See 1 more concern
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AI-generated summary
Brian Mitchell · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Brian Mitchell, aged 72, was struck by multiple trains after falling onto the tracks at platform 13 at Stratford Underground Station on 26 December 2023. The report identifies concerns that train operators failed to notice him or override automatic train operation, and that technological measures and training intended to mitigate similar risks had not been clearly implemented or shown to improve performance.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater London Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of clear data demonstrating improved expedition and clarity of station staff communication in emergencies
Wider context from the report “4. No clear data is available to demonstrate that station staff training has improved expedition or clarity of communication in emergency circumstances.
” 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 Greater London Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of clear evidence that risks of fatal harm have been mitigated
Wider context from the report “1. In the two years that have elapsed since Brian’s death investigations have been conducted by the British Transport Police, The Rail Accident Investigation Branch (“RAIB”) and TFL into the circumstances that led to this incident. There is no clear evidence to demonstrate that risks of fatal harm have been mitigated.
” 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 Greater London Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of clear data demonstrating improved train-operator concentration and track observation during ATO operation
Wider context from the report “3. No clear data is available to demonstrate that training provided to train operators (drivers) to ensure that they concentrate and look at the tracks before them whilst operating trains using ATO has resulted in positive improvement in performance.
” 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 Greater London Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to implement technological measures detecting and alerting staff to persons on the tracks at Stratford station
Wider context from the report “2. Recommended technological measures to detect and alert staff to the presence of persons on the tracks have not been implemented at Stratford station.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit the effectiveness of in-service train-operator competence assessments.
Verbatim wording from the response “Our Operational Training and Skills Development Team have completed a review of in-service competence assessments of train operators over the last 12 months. This has provided us with evidence that train operators are observing both the PTI and the track when they are berthing in platforms. As a result of this review, we have identified further improvements relating to how these assessments are recorded and by the end of April 2026, we will provide further advice and guidance to our internal competence assessors. This will strengthen the focus on PTI and track observations during train operator competence assessments. Monitoring of assessments will continue as part of our business-as-usual processes and a more detailed audit on the effectiveness of the approach we are taking on in-service competence assessments will be completed by September 2026.” Source location Response from TfL and Mayor of London
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remove the remote Stratford platform bench associated with the incident.
Verbatim wording from the response “While recognising the benefits of providing seating for customers in our stations, we are finalising plans to remove the specific bench on which Mr Mitchell sat from this location, given that it is a location which is not regularly frequented by customers and there are other benches on the platform, which are less remote from passage of other customers and staff. We have started plans to remove the bench and this will be completed by 6th March. These steps will hopefully mitigate the risk of a similar incident happening at Stratford station.” Source location Response from TfL and Mayor of London
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Trial CCTV and sensor-based technology across three services to detect track access, falls between trains and platforms, and train-door entrapment.
Verbatim wording from the response “We shared information on TfL’s PTI New Technology Programme in TfL’s witness evidence for the inquest. We are actively trialling technology to allow us to detect someone in the track environment - whether they fall unintentionally or access the track deliberately. I have set out an update on the PTI new technology trials below.” Source location Response from TfL and Mayor of London
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement an evaluation framework measuring safety-critical communication learning and workplace transfer for train operators and station staff.
Verbatim wording from the response “We undertake routine monitoring of safety critical communications which includes recordings of safety critical communications used during day-to-day activities as well as during incident scenarios. We monitor the communications from both routine and incident situations to make sure that the appropriate communications protocols are used during both.” Source location Response from TfL and Mayor of London
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update security rules and training to require frontline track checks when items near the track are declared non-suspicious.
Verbatim wording from the response “We have also updated our security rules for station colleagues and train operators to help them identify whether lost property is suspicious or not. Our rules now require our front-line teams to visually check the track for unauthorised persons (once an item has been declared non-suspicious) when items are discovered near the track (including platforms and overbridges). This also includes appropriate checking when a train is berthed in a platform. All stations, trains and service control colleagues had been fully briefed on these rules by 12 May 2025 and the Rule Book and associated training updated in line with the change. The change has also been incorporated into training for new station colleagues and train operators.” Source location Response from TfL and Mayor of London
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase station visual checks and formalize the changes in operational safety rules and training.
Verbatim wording from the response “We have taken clear action so that, should a similar incident occur, our station staff and train operators are more likely to identify unattended property and potentially the length of time a customer may be waiting on a platform. This includes changes to our operational procedures and staff training, which are detailed below.” Source location Response from TfL and Mayor of London
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update train-operator training to improve concentration and observation of the platform-train interface and track when berthing.
Verbatim wording from the response “3. No ©Hear data is available to demonstrate that training provided to train operators (drivers) to ensure that they concentrate and look at the tracks before them whilst operating trains using ATO has resulted in positive improvement in performance” Source location Response from TfL and Mayor of London
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide competence assessors with further guidance strengthening assessment of platform-train interface and track observations.
Verbatim wording from the response “Our Operational Training and Skills Development Team have completed a review of in-service competence assessments of train operators over the last 12 months. This has provided us with evidence that train operators are observing both the PTI and the track when they are berthing in platforms. As a result of this review, we have identified further improvements relating to how these assessments are recorded and by the end of April 2026, we will provide further advice and guidance to our internal competence assessors. This will strengthen the focus on PTI and track observations during train operator competence assessments. Monitoring of assessments will continue as part of our business-as-usual processes and a more detailed audit on the effectiveness of the approach we are taking on in-service competence assessments will be completed by September 2026.” Source location Response from TfL and Mayor of London
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Station staff competence data and routine communications monitoring indicate strong understanding and use of core safety-critical communication requirements.
Verbatim wording from the response “We undertake routine monitoring of safety critical communications which includes recordings of safety critical communications used during day-to-day activities as well as during incident scenarios. We monitor the communications from both routine and incident situations to make sure that the appropriate communications protocols are used during both.” Source location Response from TfL and Mayor of London
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Incidents are not location-specific; falls on track can occur anywhere on the network, so Stratford does not present a uniquely identifiable risk profile.
Verbatim wording from the response “As well as the measures identified above, since the inquest, we have reflected on the controls in place at Stratford station. We have reviewed incidents of falls on track at terminus platforms (such as platform 13 at Stratford station). This has not identified any location specific trends in relation to incidents of this nature. This is reflective of the analysis we have also undertaken at all platforms (e.g. terminus and non-terminus platforms). Incidents by platform are low level and can occur anywhere on the LU network without platform edge doors.” Source location Response from TfL and Mayor of London
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Technology to detect track incidents is not yet readily available or sufficiently accurate and reliable for immediate implementation at Stratford station.
Verbatim wording from the response “We recognised at the time that the mitigations needed to further reduce this risk are not readily available to the rail industry. We consider that technology has a role to play in, for example, detecting someone on the track which would allow us to take action to stop train movements. We have set out details below on the action we have taken, and our plans, in our response to the Senior Coroner’s second area of concern.” Source location Response from TfL and Mayor of London
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Because accidental falls are infrequent, the absolute impact of train-operator training cannot be quantified; effectiveness is assessed through competence reviews instead.
Verbatim wording from the response “Following this tragic incident at Stratford station, we recognised the need to improve training for train operators. During 2024, we updated our training and started delivering this training in November 2024. It takes a year to completely refresh and train our existing 3500 train operators, and delivery of this training was completed in December 2025. New train operators are also receiving this as part of their training.” Source location Response from TfL and Mayor of London
Open published response
7 Aug 2024 Malika HIBU · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 6 Failure to make an identified unsafe barrier safer or secure its remediation View source Failure to risk assess the canal barrier View source Failure to consider barrier safety during housing development planning View source Failure to act on resident complaints about the barrier View source Lack of knowledge of the ownership boundary View source Inadequate canal-side railing protection for children and adults View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Malika HIBU · 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
Malika Hibu, a five-year-old girl with autism spectrum disorder, left her home, fell into Regent’s Canal on 17 February 2024, and died after efforts to resuscitate her. The report raised concerns that the canal-side railing did not protect small children, that the housing association had not adequately assessed or acted on safety concerns, and that the development’s planning process had not considered the barrier’s safety.
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 Greater London Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to make an identified unsafe barrier safer or secure its remediation
Wider context from the report “The railing next to the canal afforded no protection against the water for a small child. In fact, an adult could easily fit through it.
1. Peabody Housing Association owned the development where Malika lived. However, I heard evidence that Peabody:
- did not know where its ownership boundary finished;
- did not risk assess the barrier to the canal;
- did not act on complaints made by residents about the barrier;
- having noticed in October 2023 that the barrier was unsafe, did not attempt to make it safer and did not make any significant attempt to ask anyone else to make it safer .
2. I also heard that when the planning application for the 2015 housing development was considered in the first place, no consideration was given to the safety of the barrier as part of the development.
I have been told that the government has announced a consultation on the national planning policy framework (NPPF). I have also been given to understand that section 12 sets out policies relating to the achievement of safe, inclusive and accessible spaces. It has been put to me that paragraph 135(f) could include a requirement that when development takes place in proximity to open water, railways and other hazards, special regard should be paid to ensuring the safety of children, young people and vulnerable adults.
There will of course be many planning applications considered before any changes can be made to the NPPF.
” 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 Greater London Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to risk assess the canal barrier
Wider context from the report “The railing next to the canal afforded no protection against the water for a small child. In fact, an adult could easily fit through it.
1. Peabody Housing Association owned the development where Malika lived. However, I heard evidence that Peabody:
- did not know where its ownership boundary finished;
- did not risk assess the barrier to the canal ;
- did not act on complaints made by residents about the barrier;
- having noticed in October 2023 that the barrier was unsafe, did not attempt to make it safer and did not make any significant attempt to ask anyone else to make it safer.
2. I also heard that when the planning application for the 2015 housing development was considered in the first place, no consideration was given to the safety of the barrier as part of the development.
I have been told that the government has announced a consultation on the national planning policy framework (NPPF). I have also been given to understand that section 12 sets out policies relating to the achievement of safe, inclusive and accessible spaces. It has been put to me that paragraph 135(f) could include a requirement that when development takes place in proximity to open water, railways and other hazards, special regard should be paid to ensuring the safety of children, young people and vulnerable adults.
There will of course be many planning applications considered before any changes can be made to the NPPF.
” 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 Greater London Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to consider barrier safety during housing development planning
Wider context from the report “The railing next to the canal afforded no protection against the water for a small child. In fact, an adult could easily fit through it.
1. Peabody Housing Association owned the development where Malika lived. However, I heard evidence that Peabody:
- did not know where its ownership boundary finished;
- did not risk assess the barrier to the canal;
- did not act on complaints made by residents about the barrier;
- having noticed in October 2023 that the barrier was unsafe, did not attempt to make it safer and did not make any significant attempt to ask anyone else to make it safer.
2. I also heard that when the planning application for the 2015 housing development was considered in the first place, no consideration was given to the safety of the barrier as part of the development .
I have been told that the government has announced a consultation on the national planning policy framework (NPPF). I have also been given to understand that section 12 sets out policies relating to the achievement of safe, inclusive and accessible spaces. It has been put to me that paragraph 135(f) could include a requirement that when development takes place in proximity to open water, railways and other hazards, special regard should be paid to ensuring the safety of children, young people and vulnerable adults.
There will of course be many planning applications considered before any changes can be made to the NPPF.
” 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 Greater London Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to act on resident complaints about the barrier
Wider context from the report “The railing next to the canal afforded no protection against the water for a small child. In fact, an adult could easily fit through it.
1. Peabody Housing Association owned the development where Malika lived. However, I heard evidence that Peabody:
- did not know where its ownership boundary finished;
- did not risk assess the barrier to the canal;
- did not act on complaints made by residents about the barrier ;
- having noticed in October 2023 that the barrier was unsafe, did not attempt to make it safer and did not make any significant attempt to ask anyone else to make it safer.
2. I also heard that when the planning application for the 2015 housing development was considered in the first place, no consideration was given to the safety of the barrier as part of the development.
I have been told that the government has announced a consultation on the national planning policy framework (NPPF). I have also been given to understand that section 12 sets out policies relating to the achievement of safe, inclusive and accessible spaces. It has been put to me that paragraph 135(f) could include a requirement that when development takes place in proximity to open water, railways and other hazards, special regard should be paid to ensuring the safety of children, young people and vulnerable adults.
There will of course be many planning applications considered before any changes can be made to the NPPF.
” 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 Greater London Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge of the ownership boundary
Wider context from the report “The railing next to the canal afforded no protection against the water for a small child. In fact, an adult could easily fit through it.
1. Peabody Housing Association owned the development where Malika lived. However, I heard evidence that Peabody:
- did not know where its ownership boundary finished ;
- did not risk assess the barrier to the canal;
- did not act on complaints made by residents about the barrier;
- having noticed in October 2023 that the barrier was unsafe, did not attempt to make it safer and did not make any significant attempt to ask anyone else to make it safer.
2. I also heard that when the planning application for the 2015 housing development was considered in the first place, no consideration was given to the safety of the barrier as part of the development.
I have been told that the government has announced a consultation on the national planning policy framework (NPPF). I have also been given to understand that section 12 sets out policies relating to the achievement of safe, inclusive and accessible spaces. It has been put to me that paragraph 135(f) could include a requirement that when development takes place in proximity to open water, railways and other hazards, special regard should be paid to ensuring the safety of children, young people and vulnerable adults.
There will of course be many planning applications considered before any changes can be made to the NPPF.
” 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 Greater London Authority; that does not assign responsibility.
PFD Monitor interpretation Inadequate canal-side railing protection for children and adults
Wider context from the report “The railing next to the canal afforded no protection against the water for a small child. In fact, an adult could easily fit through it .
1. Peabody Housing Association owned the development where Malika lived. However, I heard evidence that Peabody:
- did not know where its ownership boundary finished;
- did not risk assess the barrier to the canal;
- did not act on complaints made by residents about the barrier;
- having noticed in October 2023 that the barrier was unsafe, did not attempt to make it safer and did not make any significant attempt to ask anyone else to make it safer.
2. I also heard that when the planning application for the 2015 housing development was considered in the first place, no consideration was given to the safety of the barrier as part of the development.
I have been told that the government has announced a consultation on the national planning policy framework (NPPF). I have also been given to understand that section 12 sets out policies relating to the achievement of safe, inclusive and accessible spaces. It has been put to me that paragraph 135(f) could include a requirement that when development takes place in proximity to open water, railways and other hazards, special regard should be paid to ensuring the safety of children, young people and vulnerable adults.
There will of course be many planning applications considered before any changes can be made to the NPPF.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Submit a consultation response addressing the strategic aspects of the National Planning Policy Framework consultation.
Verbatim wording from the response “It would be the responsibility of the Secretary of State for Housing, Communities and Local Government to consider any proposed changes to the NPPF. The PFD report refers to a consultation on the NPPF. This consultation opened on 30 July 2024 and closed on 24 September 2024 and was in relation to some very specific questions. The Mayor submitted a response to the consultation which focused on the strategic aspects of the consultation.” Source location Response from Mayor of London - Greater London Authority
Open published response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the London Plan and consider the safety concerns raised in the PFD report through that review.
Verbatim wording from the response “The GLA is currently in the early stages of reviewing the London Plan. The current timescales for this include a consultation on a revised London Plan in the second half of 2025, followed by examination in public of the revised version in 2026-27, followed by the adoption of the revised London Plan in 2027.” Source location Response from Mayor of London - Greater London Authority
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Mayor cannot comment on or intervene in planning applications that do not meet the criteria for potential strategic importance.
Verbatim wording from the response “We have looked at the original planning application for the development where Malika lived and we do not believe it would have been referable to the Mayor as it would not have met any of the criteria for a PSI application. The Mayor does not have any powers to comment or intervene on proposals that do not meet the criteria set out within the 2008 Order. Those proposals are the responsibility of the local planning authority who will assess the application against the Development Plan.” Source location Response from Mayor of London - Greater London Authority
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The London Plan addresses strategic planning matters and does not prescribe detailed safety measures for particular locations.
Verbatim wording from the response “The London Plan, together with each borough’s own Local Plan (and any made Neighbourhood Plans covering the area) form the statutory development plan against which planning applications are assessed in London. The Mayor’s policies within his London Plan are required by the Act to only deal with matters which are of strategic importance to Greater London, leaving the detail and specific content to the Local Plans for each respective borough in London which must be in ‘general conformity’ with the London Plan.” Source location Response from Mayor of London - Greater London Authority
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local planning authorities are responsible for assessing non-strategic planning applications against the Development Plan.
Verbatim wording from the response “We have looked at the original planning application for the development where Malika lived and we do not believe it would have been referable to the Mayor as it would not have met any of the criteria for a PSI application. The Mayor does not have any powers to comment or intervene on proposals that do not meet the criteria set out within the 2008 Order. Those proposals are the responsibility of the local planning authority who will assess the application against the Development Plan.” Source location Response from Mayor of London - Greater London Authority
Open published response
14 Dec 2022 Fatima Abukar · Prevention of Future Deaths report East London
View report summary
Concerns raised 3 Reduced legal enforcement of unlawful e-scooter use View source Failure to provide prominent written warnings about the illegal use of e-scooters View source Failure to require head protection for riders of legally authorised scooters View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Fatima Abukar · 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
Fatima Abukar, a 14-year-old girl, died from catastrophic head injuries after the privately owned e-scooter she was riding entered the carriageway and struck a mini-bus. The concerns included e-scooter fatalities and enforcement, the absence of a requirement for riders of legally authorised scooters to wear head protection, and inconsistent or insufficiently prominent warnings about illegal e-scooter use.
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 Greater London Authority; that does not assign responsibility.
PFD Monitor interpretation Reduced legal enforcement of unlawful e-scooter use
Wider context from the report “1. Evidence in this inquest confirmed that since 2019 here have been 8 recorded fatalities involving e-scooters in London and 31 in the country at large. At the time of her death Ms Abukar was riding a privately owned e-scooter on a public highway. Despite the ubiquity of such devices on London’s streets, riding them on public roads is unlawful.
Whereas approximately 4000 unlawfully used scooters were seized by the Metropolitan Police Service in 2021, only 1100 were confiscated in 2022 . The reduction is attributable to a change in policy introduced in November 2021.
An inverse correlation exists between the rate of legal enforcement and the rate of deaths caused by e-scooters. The number of deaths in Q1 & 2 of 2022 is more than double that of Q1 & 2 of 2021.
” 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 Greater London Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to provide prominent written warnings about the illegal use of e-scooters
Wider context from the report “3. Some manufacturers and retailers of e-scooters in England and Wales provide consumers with written warnings about the illegal use of e-scooters, others do not. Where such warnings are present, often they are not prominent.
” 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 Greater London Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to require head protection for riders of legally authorised scooters
Wider context from the report “2. Ms Abukar died due to traumatic head injuries. Riders of legally authorised scooters (those hired from licenced operators) are not required to wear head protection.
” Open source report
20 Apr 2021 Ella Adoo-Kissi-Debrah · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 6 Insufficient undergraduate teaching on the health effects of air pollution View source Insufficient postgraduate education on the health effects of air pollution View source Insufficient detail and monitoring capacity for air quality information View source Insufficient professional guidance on communicating the health effects of air pollution View source Low public awareness of sources of national and local pollution information View source National Particulate Matter limits exceeding WHO guideline levels View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Ella Adoo-Kissi-Debrah · 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
Ella Adoo-Kissi-Debrah died aged 9 after an asthmatic episode led to cardiac arrest on 15 February 2013. The report states that air pollution, including exposure to nitrogen dioxide and particulate matter from traffic emissions, significantly contributed to her asthma and death. It also identifies concerns about pollution limits, public access to pollution information, and communication of air-pollution health risks by healthcare professionals.
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 Greater London Authority; that does not assign responsibility.
PFD Monitor interpretation Insufficient undergraduate teaching on the health effects of air pollution
Wider context from the report “(3) The adverse effects of air pollution on health are not being sufficiently communicated to patients and their carers by medical and nursing professionals. The evidence at the inquest was that this needs to be addressed at three levels:
a. Undergraduate. I am informed that undergraduate teaching is the responsibility of the GMC, Health Education England and the NMC.
b. Postgraduate. I am informed that postgraduate education is the responsibility of the Royal Colleges, in this case the Royal College of Physicians, the Royal College of Paediatrics and Child Health, the Royal College of General Practitioners, and the NMC.
c. Professional guidance. In this case relevant organisations are NICE and the British Thoracic Society.
” 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 Greater London Authority; that does not assign responsibility.
PFD Monitor interpretation Insufficient postgraduate education on the health effects of air pollution
Wider context from the report “(3) The adverse effects of air pollution on health are not being sufficiently communicated to patients and their carers by medical and nursing professionals. The evidence at the inquest was that this needs to be addressed at three levels:
a. Undergraduate. I am informed that undergraduate teaching is the responsibility of the GMC, Health Education England and the NMC.
b. Postgraduate. I am informed that postgraduate education is the responsibility of the Royal Colleges, in this case the Royal College of Physicians, the Royal College of Paediatrics and Child Health, the Royal College of General Practitioners, and the NMC.
c. Professional guidance. In this case relevant organisations are NICE and the British Thoracic Society.
” 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 Greater London Authority; that does not assign responsibility.
PFD Monitor interpretation Insufficient detail and monitoring capacity for air quality information
Wider context from the report “(2) There is a low public awareness of the sources of information (such as UK-Air website) about national and local pollution levels. Greater awareness would help individuals reduce their personal exposure to air pollution. It was clear from the evidence at the inquest that publicising this information is an issue that needs to be addressed by national as well as local government. The information must be sufficiently detailed and this is likely to require enlargement of the capacity to monitor air quality, for example by increasing the number of air quality sensors .
” 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 Greater London Authority; that does not assign responsibility.
PFD Monitor interpretation Insufficient professional guidance on communicating the health effects of air pollution
Wider context from the report “(3) The adverse effects of air pollution on health are not being sufficiently communicated to patients and their carers by medical and nursing professionals. The evidence at the inquest was that this needs to be addressed at three levels:
a. Undergraduate. I am informed that undergraduate teaching is the responsibility of the GMC, Health Education England and the NMC.
b. Postgraduate. I am informed that postgraduate education is the responsibility of the Royal Colleges, in this case the Royal College of Physicians, the Royal College of Paediatrics and Child Health, the Royal College of General Practitioners, and the NMC.
c. Professional guidance. In this case relevant organisations are NICE and the British Thoracic Society.
” 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 Greater London Authority; that does not assign responsibility.
PFD Monitor interpretation Low public awareness of sources of national and local pollution information
Wider context from the report “(2) There is a low public awareness of the sources of information (such as UK-Air website) about national and local pollution levels. Greater awareness would help individuals reduce their personal exposure to air pollution. It was clear from the evidence at the inquest that publicising this information is an issue that needs to be addressed by national as well as local government . The information must be sufficiently detailed and this is likely to require enlargement of the capacity to monitor air quality, for example by increasing the number of air quality sensors.
” 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 Greater London Authority; that does not assign responsibility.
PFD Monitor interpretation National Particulate Matter limits exceeding WHO guideline levels
Wider context from the report “(1) The national limits for Particulate Matter are set at a level far higher than the WHO guidelines. The evidence at the inquest was that there is no safe level for Particulate Matter and that the WHO guidelines should be seen as minimum requirements. Legally binding targets based on WHO guidelines would reduce the number of deaths from air pollution in the UK.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Host stakeholder workshops to raise awareness of the Breathe London monitoring network and its benefits.
Verbatim wording from the response “I have also secured funding from Bloomberg Philanthropies who are contributing an additional £720,000 towards the Breathe London network to fund 60 more sensors over three years, in part to support a sponsorship programme that will enable organisations and individuals to apply for a free sensor. In response to demand, businesses and other groups will also be able to buy into the network, at a reduced rate, thereby choosing their own sensor location. Throughout June we will be hosting workshops with various stakeholder groups, including schools, businesses, and health organisations to raise awareness of the network and its benefits.” Source location 2021-0113-Response-from-Mayor-of-London-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Submit consultation responses advocating legally binding PM2.5 targets based on World Health Organization guidelines.
Verbatim wording from the response “If London can meet the target, with the multiple challenges it faces, so also can the rest of England and Wales. The GLA has submitted responses to Government consultations on the draft Environment Bill and on setting new targets for PM₂.₅. In these responses we highlighted the importance and achievability of setting legally binding PM₂.₅ targets based on the WHO guidelines. The Environment Bill provides an ideal opportunity to do so. I previously called on Government to introduce a new Clean Air Act. In its absence I would encourage the Government to, at the very least, take this opportunity to amend the Bill to enshrine the WHO targets in law.” Source location 2021-0113-Response-from-Mayor-of-London-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish real-time, localised Breathe London air-quality data through the network website.
Verbatim wording from the response “Following its successful pilot, I have since provided an additional £779,000 to fund 135 new Breathe London air quality sensors across London. These sensors are being delivered by Imperial College London. This new phase is prioritising hospitals, schools and community groups, as well as providing at least one sensor per borough. Sensors have already been installed at hospitals and reference sites with the remaining sensors to be installed by the end of July. Air quality data is now available through the Breathe London website (https://www.breathelondon.org/) which launched in March 2021, making it easier for all Londoners to access reliable, localised, real-time air quality data.” Source location 2021-0113-Response-from-Mayor-of-London-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Expand the Breathe London monitoring network with 135 additional air-quality sensors.
Verbatim wording from the response “Following its successful pilot, I have since provided an additional £779,000 to fund 135 new Breathe London air quality sensors across London. These sensors are being delivered by Imperial College London. This new phase is prioritising hospitals, schools and community groups, as well as providing at least one sensor per borough. Sensors have already been installed at hospitals and reference sites with the remaining sensors to be installed by the end of July. Air quality data is now available through the Breathe London website (https://www.breathelondon.org/) which launched in March 2021, making it easier for all Londoners to access reliable, localised, real-time air quality data.” Source location 2021-0113-Response-from-Mayor-of-London-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with national departments and London boroughs to share effective approaches, improve scientific understanding and promote air-quality information and campaigns.
Verbatim wording from the response “I have hosted several national and international air quality summits, bringing together central Government, Metro Mayors and city leaders from across the UK as well as academics and medical professionals from across the globe to raise awareness of the problem of air pollution. Furthermore, I work closely with environmental and health NGOs to inform and amplify my policies and awareness campaigns. Through London’s leadership of the C40 Air Quality Network, the GLA shares lessons from London’s successful policies and learns from other interventions implemented by cities across the world. I will continue to work closely with these organisations to inform and broaden the reach of my work wherever possible.” Source location 2021-0113-Response-from-Mayor-of-London-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop London health-and-care structures and engagement approaches to improve communication of air pollution risks and mitigation to clinicians and carers.
Verbatim wording from the response “The London Health and Care Vision sets out the ambition shared by me, London Councils, the NHS and PHE to make London the world’s healthiest global city and the best global city in which to receive health and care services. Together we have identified 10 priority areas for pan-London collaboration, including improving air quality. Building on this, and in light of your PFD report, we have committed to work even more closely together to increase awareness of air pollution, its health impacts and mitigation measures, and to maximise health and care system support for vital structural changes such as the expansion of ULEZ and enabling more walking and cycling. This will also necessitate improved information sharing and communication across London’s health and care networks.” Source location 2021-0113-Response-from-Mayor-of-London-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate Londonwide air-quality alerts through transport signs, station displays, email, social media and partner dissemination.
Verbatim wording from the response “Raising awareness about air pollution has been a major priority for me. In 2016, I instituted an alerts system to warn Londoners about air pollution episodes. During high and very high air pollution days, air quality alerts are displayed at:” Source location 2021-0113-Response-from-Mayor-of-London-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Fund 60 further Breathe London sensors over three years through sponsorship and network participation.
Verbatim wording from the response “I have also secured funding from Bloomberg Philanthropies who are contributing an additional £720,000 towards the Breathe London network to fund 60 more sensors over three years, in part to support a sponsorship programme that will enable organisations and individuals to apply for a free sensor. In response to demand, businesses and other groups will also be able to buy into the network, at a reduced rate, thereby choosing their own sensor location. Throughout June we will be hosting workshops with various stakeholder groups, including schools, businesses, and health organisations to raise awareness of the network and its benefits.” Source location 2021-0113-Response-from-Mayor-of-London-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Londonwide air-quality alerts system, including message testing and methods to reach vulnerable populations.
Verbatim wording from the response “However, I appreciate that some of the most vulnerable Londoners may not be aware of the alerts which is why my officers are currently undertaking a review of my Londonwide alerts system, including message testing and exploring additional methods to increase its use by vulnerable populations. As part of this process, we are working with the London boroughs to understand how they share the alerts with their communities and explore how we can support them further to share the messaging.” Source location 2021-0113-Response-from-Mayor-of-London-Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Tackling pollution from sources outside London requires a national approach and appropriate powers and funding from Government.
Verbatim wording from the response “The GLA has set out in detail the key sources of PM₂.₅ for London and the additional measures needed to meet the WHO guidelines in a report published in October 2019. Despite having some of the highest concentrations of PM₂.₅ in the UK the report shows that, with the delegation of appropriate funding and powers, such as over construction machinery, commercial cooking and woodburning, it would be possible for London to meet this target. Additionally, around half of all PM₂.₅ measured in London comes from sources outside of the city, such as from industry and agriculture. This means a national approach to tackling air pollution is needed.” Source location 2021-0113-Response-from-Mayor-of-London-Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A national awareness campaign and national alerts system require central Government leadership beyond regional and local government’s capacity.
Verbatim wording from the response “I am fully committed to working closely with Defra, the Department for Transport and the Department for Health and Social Care as well as the London boroughs to share examples of what has worked in London, and to improve scientific understanding, including of the sources of pollution. I am also committed to working in partnership to promote existing and upcoming campaigns and sources of information to further raise public awareness. As part of this, I am exploring opportunities to bring together ministers and health professionals to agree on how best to take this collaboration forward in London.” Source location 2021-0113-Response-from-Mayor-of-London-Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improving clinicians’ and carers’ communication requires Government leadership and national support from relevant professional organisations.
Verbatim wording from the response “The London Health and Care Vision sets out the ambition shared by me, London Councils, the NHS and PHE to make London the world’s healthiest global city and the best global city in which to receive health and care services. Together we have identified 10 priority areas for pan-London collaboration, including improving air quality. Building on this, and in light of your PFD report, we have committed to work even more closely together to increase awareness of air pollution, its health impacts and mitigation measures, and to maximise health and care system support for vital structural changes such as the expansion of ULEZ and enabling more walking and cycling. This will also necessitate improved information sharing and communication across London’s health and care networks.” Source location 2021-0113-Response-from-Mayor-of-London-Redacted
Open published response
26 Feb 2021 Mr Joseph Agnew · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 6 Failure to recognise snoring as a potential sign of partial airway obstruction requiring medical attention in people with reduced consciousness View source Failure to train officers to assess whether an intoxicated person meets the criteria for being “drunk and incapable” View source Failure of post-incident performance review and organisational learning processes View source Failure to train officers on when to refer an intoxicated person for medical attention View source Lack of a safe referral facility for acutely intoxicated homeless people found on buses View source Failure to train officers to effectively monitor breathing and recognise dangerous breathing patterns View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Joseph Agnew · 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
Mr Joseph Agnew suffered an out-of-hospital cardiac arrest after being removed from a bus and left in a bus shelter, was later found unresponsive, and died five days after admission with a devastating brain injury. The report raised concerns about police training and assessment of intoxicated people with reduced responsiveness, including recognising snoring and monitoring breathing, post-incident learning, and the lack of a safe referral facility for acutely intoxicated homeless people found on buses.
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 Greater London Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise snoring as a potential sign of partial airway obstruction requiring medical attention in people with reduced consciousness
Wider context from the report “2. For the attention of CoLP, MPS and College of Policing:
No police officers who gave evidence understood the significance of snoring in a person with a reduced level of consciousness , nor how to monitor breathing. My independent expert in A&E gave evidence that snoring indicates partial airway obstruction . He dismissed perceptions of officers that there was such a thing as good or bad snoring. He opined that in a person with reduced consciousness officers should assume that snoring needs medical attention . The person needs assessment to exclude when it is not a concern. Whilst he acknowledged the difficulty of assessing breathing, he stressed its importance as an indication of medical emergency, gave little weight to the value of chest movements which officers used, and highlighted the danger signs of very slow or very fast breathing. He also stressed that concern for medical attention should be triggered by unrousability. The evidence suggested that officers were unaware of all these matters and had not learnt how to effectively monitor breathing.
” 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 Greater London Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to train officers to assess whether an intoxicated person meets the criteria for being “drunk and incapable”
Wider context from the report “1. For the attention of CoLP and College of Policing:
CoLP officers were not taught how to assess people to meet the agreed criteria for finding someone “drunk and incapable” . A senior officer was not content that the officers involved had given a satisfactory level of questioning nor welfare checks. The risk to life continues since there appears to be no clarity for officers from their training as to when to refer an intoxicated person for medical attention.
” 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 Greater London Authority; that does not assign responsibility.
PFD Monitor interpretation Failure of post-incident performance review and organisational learning processes
Wider context from the report “3. For the attention of the MPS:
Two MPS officers who attended the scene gave evidence that they would do nothing different even in hindsight. No evidence was presented as to the post incident performance reviews and individual learning , and there is uncertainty about the adequacy of the corporate process of learning from incidents . There is a lack of assurance to the public that the risks related to the decisions of these officers or other incidents have been mitigated for the future .
” 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 Greater London Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to train officers on when to refer an intoxicated person for medical attention
Wider context from the report “1. For the attention of CoLP and College of Policing:
CoLP officers were not taught how to assess people to meet the agreed criteria for finding someone “drunk and incapable”. A senior officer was not content that the officers involved had given a satisfactory level of questioning nor welfare checks. The risk to life continues since there appears to be no clarity for officers from their training as to when to refer an intoxicated person for medical attention .
” 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 Greater London Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of a safe referral facility for acutely intoxicated homeless people found on buses
Wider context from the report “4. For the attention of the Mayor of London:
Evidence was heard that whilst the police can refer chronic rough sleepers to charities, there is no facility to which police can refer acutely intoxicated homeless people found on buses . It was reported that such facilities do exist elsewhere and that they create a place of safe refuge where monitoring can be effectively conducted. The potential of such a facility to save lives is drawn to the attention of the Mayor.
” 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 Greater London Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to train officers to effectively monitor breathing and recognise dangerous breathing patterns
Wider context from the report “2. For the attention of CoLP, MPS and College of Policing:
No police officers who gave evidence understood the significance of snoring in a person with a reduced level of consciousness, nor how to monitor breathing . My independent expert in A&E gave evidence that snoring indicates partial airway obstruction. He dismissed perceptions of officers that there was such a thing as good or bad snoring. He opined that in a person with reduced consciousness officers should assume that snoring needs medical attention. The person needs assessment to exclude when it is not a concern. Whilst he acknowledged the difficulty of assessing breathing, he stressed its importance as an indication of medical emergency, gave little weight to the value of chest movements which officers used, and highlighted the danger signs of very slow or very fast breathing . He also stressed that concern for medical attention should be triggered by unrousability. The evidence suggested that officers were unaware of all these matters and had not learnt how to effectively monitor breathing .
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Intoxication management services are commissioned by borough public health teams, the London Ambulance Service and NHS, rather than the Mayor.
Verbatim wording from the response “There are several alcohol intoxication management services (AIMS) that have been commissioned by local borough public health teams, the London Ambulance Service (LAS) and the NHS, such as the SOS bus in the City of London and Alcohol Recovery Centres that run in several London boroughs. These services are not run by the Mayor. These services are designed to receive, treat and monitor intoxicated patients who would normally attend Emergency Departments and to lessen the burden that alcohol-misuse places on A&E services. These mainly operate at Christmas and other busy times of the year when demand for the London Ambulance and A&E services is high.” Source location 2021-0055-Response-from-Greater-London-Authority-on-behalf-of-Mayor-of-London-Redacted
Open published response
19 Aug 2016 Amanda Coppen · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 3 Road layout misleading pedestrians and motorists about traffic direction View source Potential risk to schoolchildren from increased pedestrian use of junction View source Presence of ordinary traffic in the dedicated busway 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
Amanda Coppen · 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
Amanda Coppen suffered fatal injuries when she was struck by a bus while crossing Pilot Busway on 4 January 2016. The inquest evidence indicated that she was crossing on a signal-controlled pedestrian crossing when the signal was red to pedestrians and green to traffic. Concerns included the unusual road layout potentially misleading pedestrians and motorists, and a possible increased risk to schoolchildren following the construction of a nearby school.
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 Greater London Authority; that does not assign responsibility.
PFD Monitor interpretation Road layout misleading pedestrians and motorists about traffic direction
Wider context from the report “The evidence at the inquest was that Ms Coppen was crossing the busway on a signal controlled pedestrian crossing while the signal was red to pedestrians and green to traffic. However, the evidence also suggested that the layout of Pilot Busway and the neighbouring road (West Parkside) is unusual: they run side by side; West Parkside consists of a single carriageway in each direction; Pilot Busway consists of a single dedicated bus lane in each direction . The evidence was that this layout could mislead road users (pedestrians and motorists) into believing that this is a standard dual carriageway . Ordinary traffic has been seen in the dedicated busway, and pedestrians could be misled into looking the wrong way when crossing the 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 Greater London Authority; that does not assign responsibility.
PFD Monitor interpretation Potential risk to schoolchildren from increased pedestrian use of junction
Wider context from the report “I understand that a new school is shortly to be built close to this junction . This may increase the numbers of pedestrians using the junction and there is a potential risk to schoolchildren .
” 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 Greater London Authority; that does not assign responsibility.
PFD Monitor interpretation Presence of ordinary traffic in the dedicated busway
Wider context from the report “The evidence at the inquest was that Ms Coppen was crossing the busway on a signal controlled pedestrian crossing while the signal was red to pedestrians and green to traffic. However, the evidence also suggested that the layout of Pilot Busway and the neighbouring road (West Parkside) is unusual: they run side by side; West Parkside consists of a single carriageway in each direction; Pilot Busway consists of a single dedicated bus lane in each direction. The evidence was that this layout could mislead road users (pedestrians and motorists) into believing that this is a standard dual carriageway. Ordinary traffic has been seen in the dedicated busway , and pedestrians could be misled into looking the wrong way when crossing the road.
” Open source report
17 Oct 2013 Brian Robert DORLING and Philippine Marthe Anne Marie de GERIN-RICARD · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 4 Insufficient education of cyclists and motorists about safer riding techniques View source Use of unbordered blue strips that confuse cyclists and motorists about cycle-lane status and positioning View source Difficult-to-negotiate junction at Whitechapel High Street and Commercial Street View source Lack of research into the effects of unbordered blue strips View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 14
Action
Minimise unbordered blue surfacing near signalised junctions and on route links, using logo patches or advisory line markings where appropriate.
Stated plannedThe respondent said that this action was planned when they made their response on 17 October 2013. View source
Action
Develop an innovative junction layout, consult key stakeholders and conduct rigorous off-street safety testing.
Stated in progressThe respondent said that this action was in progress when they made their response on 17 October 2013. View source
Action
Avoid applying unbordered blue surfacing at Bow Roundabout’s north-east and south-east slip roads pending further research.
Stated plannedThe respondent said that this action was planned when they made their response on 17 October 2013. View source
Action
Replace unbordered blue surfacing at signal-controlled junctions with logo patches, retaining blue patches where junctions contain yellow boxes.
Stated plannedThe respondent said that this action was planned when they made their response on 17 October 2013. View source
Action
Install full segregation and cycle-separated junctions on Whitechapel High Street as part of the Cycle Superhighway 2 upgrade.
Stated in progressThe respondent said that this action was in progress when they made their response on 17 October 2013. View source
Action
Trial cycle-separated junctions and cyclist-specific traffic lights through Transport Research Laboratory safety research before on-street implementation.
Stated plannedThe respondent said that this action was planned when they made their response on 17 October 2013. View source
Action
Commission, manage, review and act on research into coloured cycle-route surfacing and road-user interaction.
Stated plannedThe respondent said that this action was planned when they made their response on 17 October 2013. View source
Action
Replace existing blue surfacing at Bow Roundabout’s north-west and south-west slip roads with blue logo patches.
Stated completedThe respondent said that this action was complete when they made their response on 17 October 2013. View source
Action
Continue using advisory cycle lanes with dashed white lines through signal-controlled junctions on Cycle Superhighway 2.
Stated in progressThe respondent said that this action was in progress when they made their response on 17 October 2013. View source
Action
Minimise unbordered blue surfacing at priority junctions and use blue surfacing with dashed white lane markings wherever possible.
Stated plannedThe respondent said that this action was planned when they made their response on 17 October 2013. View source
Action
Design the Aldgate-to-Bow Cycle Superhighway 2 upgrade, including improved junctions and segregation measures.
Stated in progressThe respondent said that this action was in progress when they made their response on 17 October 2013. View source
Action
Suspend new applications of unbordered blue surfacing through signal-controlled junctions pending risk assessment and further research.
Stated plannedThe respondent said that this action was planned when they made their response on 17 October 2013. View source
Action
Consider changes to current and planned Cycle Superhighway designs after the further surfacing research concludes.
Stated plannedThe respondent said that this action was planned when they made their response on 17 October 2013. View source
Action
Operate and fund cycle and HGV safety education, training, advertising campaigns and cyclist-driver awareness events.
Stated completedThe respondent said that this action was complete when they made their response on 17 October 2013. View source See 11 more actions
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AI-generated summary
Brian Robert DORLING and Philippine Marthe Anne Marie de GERIN-RICARD · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Brian Robert Dorling and Philippine Marthe Anne Marie de Gerin-Ricard died in separate collisions involving the pedal cycles they were riding and heavy goods vehicles on Cycle Super Highway 2 in London. The concerns included confusion caused by unbordered blue strips, the need for better education about safer cycling and driving techniques, and the difficulty of negotiating the junction where Ms de Gerin-Ricard sustained her fatal injuries.
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 Greater London Authority; that does not assign responsibility.
PFD Monitor interpretation Insufficient education of cyclists and motorists about safer riding techniques
Wider context from the report “2. It seems that, despite the efforts already made, more work could usefully be undertaken to educate cyclists (and motorists) about safer riding techniques.
For example, it may seem counter intuitive to some cyclists to take the lane, in other words not always to ride over to the left of the lane, but sometimes more towards the middle. However, sometimes this is the safest option.
And most especially, the dangers of a cycle overtaking vehicular traffic on the inside in the approach to a junction, cannot be over stressed.
Public information advertising in cycle shops, on websites, or even on television, could assist in changing the culture in this respect.
” 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 Greater London Authority; that does not assign responsibility.
PFD Monitor interpretation Use of unbordered blue strips that confuse cyclists and motorists about cycle-lane status and positioning
Wider context from the report “1. Whilst the cycle super highways have been implemented with a range of measures that many cyclists have found helpful, the unbordered blue strips that have been painted on some roads are confusing .
I heard evidence that many cyclists and motorists simply do not appreciate that such a blue strip without a white line border (whether unbroken or broken) is not a cycle lane .
Whilst research has been carried out into the effect of the cycle super highways, no research has been carried out specifically into the effect of unbordered blue strips.
The confusion has the following potential consequences.
• Cyclists wrongly assume (as Mr Dorling may have done) that they have priority, and are lulled into a false sense of security.
• Cyclists believe that they have to ride on the blue strips, which may not be the correct position for them to assume in particular circumstances, most particularly when going round a roundabout.
• Motorists’ awareness of the possible presence of cyclists is raised, but they expect these cyclists to be on the blue strips, which the cyclists may not be if they are assuming the safest position, particularly when going round a roundabout.
• When the strips are painted within a lane that is plainly not wide enough to accommodate vehicular and cycle traffic, motorists may form the incorrect view that they have to stay out of the strip and so straddle lanes , rather than simply overtaking a cyclist at the appropriate time.
• Alternatively, motorists may drive over the blue strips, which they are perfectly entitled to do, but then get into the habit of driving over coloured strips, and not notice when these are actually bordered by white lines and so are cycle lanes . Thus, cyclists riding in cycle lanes elsewhere in London and the rest of the country, are put in greater danger.
” 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 Greater London Authority; that does not assign responsibility.
PFD Monitor interpretation Difficult-to-negotiate junction at Whitechapel High Street and Commercial Street
Wider context from the report “3. The junction of Whitechapel High Street and Commercial Street in London E1 (where Ms de Gerin-Ricard sustained her fatal injuries) remains difficult to negotiate.
As I am sure you are aware, innovative solutions need to be considered, whether this be in terms of infrastructure or other.
For example, I note that in York there is currently a trial of the Cycle Alert system, where an HGV can be fitted with a sensor that detects the presence of a cycle also so fitted, the cycle equipment being available for as little as £5.
I do not say that this is the answer, I merely seek to illustrate the sort of thinking that may be helpful.
” 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 Greater London Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of research into the effects of unbordered blue strips
Wider context from the report “1. Whilst the cycle super highways have been implemented with a range of measures that many cyclists have found helpful, the unbordered blue strips that have been painted on some roads are confusing.
I heard evidence that many cyclists and motorists simply do not appreciate that such a blue strip without a white line border (whether unbroken or broken) is not a cycle lane.
Whilst research has been carried out into the effect of the cycle super highways, no research has been carried out specifically into the effect of unbordered blue strips.
The confusion has the following potential consequences.
• Cyclists wrongly assume (as Mr Dorling may have done) that they have priority, and are lulled into a false sense of security.
• Cyclists believe that they have to ride on the blue strips, which may not be the correct position for them to assume in particular circumstances, most particularly when going round a roundabout.
• Motorists’ awareness of the possible presence of cyclists is raised, but they expect these cyclists to be on the blue strips, which the cyclists may not be if they are assuming the safest position, particularly when going round a roundabout.
• When the strips are painted within a lane that is plainly not wide enough to accommodate vehicular and cycle traffic, motorists may form the incorrect view that they have to stay out of the strip and so straddle lanes, rather than simply overtaking a cyclist at the appropriate time.
• Alternatively, motorists may drive over the blue strips, which they are perfectly entitled to do, but then get into the habit of driving over coloured strips, and not notice when these are actually bordered by white lines and so are cycle lanes. Thus, cyclists riding in cycle lanes elsewhere in London and the rest of the country, are put in greater danger.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Minimise unbordered blue surfacing near signalised junctions and on route links, using logo patches or advisory line markings where appropriate.
Verbatim wording from the response “Unbordered blue surface on the approach to and exit from signalised junctions” Source location 2013-0265-Response-by-Mayor-of-London
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 Develop an innovative junction layout, consult key stakeholders and conduct rigorous off-street safety testing.
Verbatim wording from the response “TfL anticipates announcing plans for an innovative layout for consultation in early 2014. In the meantime, TfL is working with key stakeholders on these designs which will also be used at other junctions. In view of the innovative nature of the design, TfL will also oversee rigorous off street testing to ensure that the design meets safety requirements.” Source location 2013-0265-Response-by-Mayor-of-London
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 Avoid applying unbordered blue surfacing at Bow Roundabout’s north-east and south-east slip roads pending further research.
Verbatim wording from the response “Unbordered blue surface across the entry and exit slip roads at Bow Roundabout” Source location 2013-0265-Response-by-Mayor-of-London
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 unbordered blue surfacing at signal-controlled junctions with logo patches, retaining blue patches where junctions contain yellow boxes.
Verbatim wording from the response “In the meantime, where unbordered blue surface was to be used across signal controlled junctions, it will be replaced by appropriately sized and placed ‘logo patches’ which will comprise a square patch of blue colour with a cycle and the Cycle Superhighway route number logo marked in white on top. Where a junction contains a yellow box, the white logo markings will not be used, but the blue patches will be retained. This will retain some of the demonstrated benefits of the blue surface strips, but will not provide any opportunity to be mistaken as any form of continuous cycle lane marking.” Source location 2013-0265-Response-by-Mayor-of-London
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 full segregation and cycle-separated junctions on Whitechapel High Street as part of the Cycle Superhighway 2 upgrade.
Verbatim wording from the response “3. Junction of Whitechapel High Street and Commercial Street” Source location 2013-0265-Response-by-Mayor-of-London
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 Trial cycle-separated junctions and cyclist-specific traffic lights through Transport Research Laboratory safety research before on-street implementation.
Verbatim wording from the response “The cycle-separated junctions, which are proposed to be used at all the busy junctions on the route, are the first in Britain. They are planned to be trialled as part of TfL’s cycle safety research being undertaken at the Transport Research Laboratory before being implemented on street. They will include segregated approaches and special cycle-specific traffic lights with a cyclist phase to guard against conflict with turning motor traffic.” Source location 2013-0265-Response-by-Mayor-of-London
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 Commission, manage, review and act on research into coloured cycle-route surfacing and road-user interaction.
Verbatim wording from the response “As was included in the evidence from ████████ TfL had commissioned research into the use of unbordered blue surfacing on the Cycle Superhighways. Further research into the use of coloured carriageway surfacing on cycle routes (and in particular Cycle Superhighways) and the interaction of road users with regards to that colour. That research will be commissioned, managed, reviewed and acted upon by TfL. TfL anticipate that it will take six months to conclude and we will let you know the findings of this work once complete.” Source location 2013-0265-Response-by-Mayor-of-London
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 blue surfacing at Bow Roundabout’s north-west and south-west slip roads with blue logo patches.
Verbatim wording from the response “Unbordered blue surface across the entry and exit slip roads at Bow Roundabout” Source location 2013-0265-Response-by-Mayor-of-London
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 using advisory cycle lanes with dashed white lines through signal-controlled junctions on Cycle Superhighway 2.
Verbatim wording from the response “Blue colour through signal controlled junctions” Source location 2013-0265-Response-by-Mayor-of-London
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 Minimise unbordered blue surfacing at priority junctions and use blue surfacing with dashed white lane markings wherever possible.
Verbatim wording from the response “Unbordered blue surface at priority junctions” Source location 2013-0265-Response-by-Mayor-of-London
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 Design the Aldgate-to-Bow Cycle Superhighway 2 upgrade, including improved junctions and segregation measures.
Verbatim wording from the response “The new section of Cycle Superhighway 2, between Bow and Stratford, has just under 2 miles of new cycle lanes physically separated from traffic, along with “bus stop bypasses” to protect cyclists. Two more substantially-segregated cycle routes will be built through the heart of central London with a north-south route from Elephant and Castle to the London Borough of Islington complementing the east-west route previously announced in my Cycling Vision.” Source location 2013-0265-Response-by-Mayor-of-London
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Suspend new applications of unbordered blue surfacing through signal-controlled junctions pending risk assessment and further research.
Verbatim wording from the response “There is evidence provided through existing research, commissioned by TfL, that there are safety benefits from the use of unbordered blue surface through signalised junctions. However there is currently no evidence to address the observational claims of a ‘false sense of security’ for cyclists. Such use of unbordered blue therefore becomes a balance between an established benefit and a potential risk.” Source location 2013-0265-Response-by-Mayor-of-London
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider changes to current and planned Cycle Superhighway designs after the further surfacing research concludes.
Verbatim wording from the response “Pending the completion of this further research TfL will consider what actions, if any, should be taken with regards to the current design of Cycle Superhighway extensions and upgrades as well as on new Cycle Superhighway routes.” Source location 2013-0265-Response-by-Mayor-of-London
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 Operate and fund cycle and HGV safety education, training, advertising campaigns and cyclist-driver awareness events.
Verbatim wording from the response “You poignantly pointed out at the inquest into the death of Philippine De Gerin-Ricard that she had no awareness of the danger she had put herself in. And as you acknowledged at the inquest into the death of Brian Dorling, both Mr Dorling and the HGV driver had gone through a red light. I remain absolutely committed to providing education and training for road users in the Capital. Alongside substantial investment in improving infrastructure and funding the MPS Task Force, TfL also organises and funds an extensive programme of safety training and marketing campaigns, aimed at both drivers and cyclists. Details of this are outlined below.” Source location 2013-0265-Response-by-Mayor-of-London
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Further research is required before implementing new unbordered blue surfacing or retrospectively removing existing applications.
Verbatim wording from the response “Until the potential risk can be properly assessed through further research, no new applications of unbordered blue surface through signal controlled junctions will be implemented. Unbordered blue surface may be adopted and applied again in the future if a net safety benefit is concluded as a result of consideration and further research.” Source location 2013-0265-Response-by-Mayor-of-London
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The existence of cyclist and road-user confusion from unbordered blue surfacing is neither substantiated nor negated by existing research.
Verbatim wording from the response “The acknowledgement in your report that the current use of unbordered blue surfacing may have consequences in terms of the perceptions and behaviours of cyclists and other road users is noted. You refer to the fact that possible confusion (the existence of which is neither substantiated nor negated by any existing research) has “potential” consequences, without stating definitively that these consequences arise, or have arisen, in practice.” Source location 2013-0265-Response-by-Mayor-of-London
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Blue surfacing will be retained in bus lanes because mandatory markings and bus-lane enforcement provide cyclists with formally protected space.
Verbatim wording from the response “A 1.5m wide blue surface will be retained in bus lanes as the enforcement of the bus lane itself (at the minimum operating during peak usage times for cars commuting cyclists, and sometimes for longer) provides a formally protected space for cyclists, with a mandatory line at the edge of the bus lane.” Source location 2013-0265-Response-by-Mayor-of-London
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Unbordered blue surfacing will be retained at limited locations where lane width prevents formal cycle-lane markings and traffic conflict is not expected.
Verbatim wording from the response “In a limited number of circumstances, where there is insufficient lane width to formally mark an advisory or mandatory cycle lane, the unbordered blue will be retained where there is no potential conflict with left turning vehicles and there is considered to be benefits to cyclists as there is sufficient room for most motorised traffic to avoid overrunning the blue surface.” Source location 2013-0265-Response-by-Mayor-of-London
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation TfL is responsible for commissioning, managing, reviewing and acting on further research into coloured cycle-route surfacing.
Verbatim wording from the response “As was included in the evidence from ████████ TfL had commissioned research into the use of unbordered blue surfacing on the Cycle Superhighways. Further research into the use of coloured carriageway surfacing on cycle routes (and in particular Cycle Superhighways) and the interaction of road users with regards to that colour. That research will be commissioned, managed, reviewed and acted upon by TfL. TfL anticipate that it will take six months to conclude and we will let you know the findings of this work once complete.” Source location 2013-0265-Response-by-Mayor-of-London
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations