Concerns raised 4 Inadequate warning signage for known flood risks View source Failure to maintain drainage gullies regularly View source Known flood risk in the area View source Surface water on the road View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
James Alexander SCOTT · 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
James Alexander Scott died at the scene after his Vauxhall Corsa lost control on standing water during a road traffic collision on the A33 on 5 July 2024. The standing water was identified as a contributory factor, with concerns about the known flood risk, blocked drainage gullies, maintenance frequency, and the presence of only a temporary warning sign.
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 Hampshire County Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate warning signage for known flood risks
Wider context from the report “(3) The fact that only a Temporary Sign was in place in an area known for years to be a flood risk
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hampshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain drainage gullies regularly
Wider context from the report “(2) Whilst the precise cause of the flooding is unknown, a more regular maintenance schedule may have prevented the buildup of vegetation within the gullies and therefore assisted in the drainage of the heavy rainfall experienced that day thus reducing the amount of surface water present on 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 Hampshire County Council; that does not assign responsibility.
PFD Monitor interpretation Known flood risk in the area
Wider context from the report “(1) The area is a known flood risk
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hampshire County Council; that does not assign responsibility.
PFD Monitor interpretation Surface water on the road
Wider context from the report “(4) The surface water was a contributory factor in this death
” Open source report
Concerns raised 3 Inability of drivers to see the road immediately beyond the crest View source Absence of warning signs for the crest hazard at night View source Road crest permitting loss of vehicle control at the national speed limit View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
George Robert DILLON · 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
George Robert DILLON, aged 19, lost control of a VW Golf while driving over a crest on Lee Lane at night on 18 May 2023 and collided with a tree. He suffered catastrophic injuries and died in hospital on 20 May 2023. The report raises concern that the hazard posed by the crest is not readily apparent at night, even to vehicles travelling within the speed limit, and that warning signs are absent.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hampshire County Council; that does not assign responsibility.
PFD Monitor interpretation Inability of drivers to see the road immediately beyond the crest
Wider context from the report “C. When travelling south, approaching the crest, as the Deceased did, it is possible to see a bend in the road in the distance, but the road immediately beyond the crest is not visible to a car driver .
” 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 Hampshire County Council; that does not assign responsibility.
PFD Monitor interpretation Absence of warning signs for the crest hazard at night
Wider context from the report “E. I am concerned that at night the extent of the hazard posed by the crest even to a vehicle travelling within the speed limit is not readily apparent and there is an absence of warning signs
” 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 Hampshire County Council; that does not assign responsibility.
PFD Monitor interpretation Road crest permitting loss of vehicle control at the national speed limit
Wider context from the report “B. The maximum speed at which a person can travel over the crest whilst remaining in full control of the vehicle is 45mph. A driver negotiating the crest around the speed limit of 60 mph will run the risk of the vehicle leaving the ground, or at the very least a momentary loss of effective steering control, followed by the underside ‘bottoming out’ on the road surface. Numerous historical gouge marks on the road surface either side of the junction demonstrate that “numerous vehicles have previously ‘bottomed out.”
” 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 Recommend providing crossroads warning signs, reduce-speed-now signs and SLOW road markings on both approaches to the Spaniard’s Lane crossroads.
Verbatim wording from the response “In summary, after careful consideration, we have recommended that crossroad warning signs and reduce speed now signs together with SLOW road markings are provided along Lee Lane on both approaches to the Spaniard’s Lane crossroads.” Source location Response from Hampshire County Council
Open published response
Concerns raised 7 Lack of monitored CCTV coverage of the bridge and approach area View source Insufficient physical safety measures at bridges associated with self-harm incidents View source Lack of signposting to mental health assistance and support View source Insufficient measures to prevent deaths from jumping from bridges View source Absence of means for people in crisis to summon help View source Lack of means for people experiencing mental health crisis to summon help at bridges View source Lack of physical measures preventing access over or around bridge railings and jumping to the carriageway View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Seth Curtis Palminder · 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
Seth Curtis Palminder died instantly on 6 February 2022 after falling from a road bridge and being struck by southbound vehicles. The report states that he had recently been discharged from mental health care, had taken overdoses of prescribed medication, and impulsively jumped from the bridge intending to take his own life. Concerns included inadequate bridge safety measures, a lack of means to summon help or access mental health support, insufficient CCTV monitoring, and repeated previous crisis incidents and fatalities at the location.
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 Hampshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of monitored CCTV coverage of the bridge and approach area
Wider context from the report “3. There are no known monitored CCTV cameras covering the bridge or approach area , rendering monitoring of a recognised danger spot actionless .
4. At the incident location, according to Hampshire Police Record Management Systems, there have been 12 crisis incidents in the last 5 years (of which the Police are aware) - including 7 self-harm (jumping) attempts, 2 successful jumps from which the individual has survived and 3 fatalities. There have been a further 89 known 'concern for safety' incidents at the location.
” 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 Hampshire County Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient physical safety measures at bridges associated with self-harm incidents
Wider context from the report “5. Wider reports of self-harm incidents and fatalities are well known from ████████ ███████████████████████████████████████████████████████████████████████████ most of which do not have sufficient safety measures in place (as above) or means of summonsing help at a point of mental health crisis.
” 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 Hampshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of signposting to mental health assistance and support
Wider context from the report “2. At the incident location there are no means of summonsing help or calling for help should a person be in crisis and require assistance. There are no signs or signposting for mental health assistance or support (such as Samaritans).
” 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 Hampshire County Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient measures to prevent deaths from jumping from bridges
Wider context from the report “6. Deaths continue to occur as a result of individuals jumping from these bridges and insufficient measures have so far been taken to address and prevent their occurrence .
” 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 Hampshire County Council; that does not assign responsibility.
PFD Monitor interpretation Absence of means for people in crisis to summon help
Wider context from the report “2. At the incident location there are no means of summonsing help or calling for help should a person be in crisis and require assistance . There are no signs or signposting for mental health assistance or support (such as Samaritans).
” 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 Hampshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of means for people experiencing mental health crisis to summon help at bridges
Wider context from the report “5. Wider reports of self-harm incidents and fatalities are well known from ████████ ███████████████████████████████████████████████████████████████████████████ most of which do not have sufficient safety measures in place (as above) or means of summonsing help at a point of mental health crisis .
” 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 Hampshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of physical measures preventing access over or around bridge railings and jumping to the carriageway
Wider context from the report “1. At the incident location ████████ there is little if anything by way of safety measures that would prevent anyone from being able to climb over, around or on top of the side railings of the bridge or to prevent them from jumping from the bridge to the carriageway . There is for example no enclosure of the walkway to prevent this .
” 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 Engage specialist teams and agencies to assess whether interventions are warranted when similar risks are identified on County Council highway bridges.
Verbatim wording from the response “For your information and reassurance, the County Council has its own highway bridge assets, and where similar risks have been identified highway officers have routinely engaged with other specialist teams and agencies e.g. Hampshire County Council’s Public Health team, the NHS etc, to determine whether an intervention by the Highway Authority is warranted. The County Council will also review and consider advice and guidance from relevant charity organisations, or special-interest groups, that specialise in mental health matters.” Source location Response from Hampshire County Council
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation National Highways, as bridge asset owner, must essentially consider the required action, while the County Council can collaborate on potential solutions.
Verbatim wording from the response “The bridge at ████████ over the A3(████████) is owned, managed, and maintained by National Highways and forms part of the Strategic Road Network. This would apply to all the overbridges along the A3(████████) corridor, regardless of their primary usage. The ████████ bridge carries a public bridleway which is managed by the County Council’s Countryside Service, as a right-of-way, and they have confirmed that it is mainly used by pedestrians and cyclists.” Source location Response from Hampshire County Council
Open published response
Concerns raised 2 Insufficient training for residential home staff in recognising intracranial injury View source Lack of clear direction in the post-falls process on when to call 999/111 for possible or suspected head injury View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Arthur Edward JOHNSON · 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
Arthur Edward JOHNSON died on 20 April 2020 after an unwitnessed fall at a residential home caused a head injury and intracerebral haemorrhage; a spontaneous intracranial haemorrhage also contributed to the death. Concerns were raised that the residential home’s post-falls process did not clearly distinguish between possible and suspected head injury or specify when 999/111 should be called, and about staff training to recognise intracranial injury.
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 Hampshire County Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient training for residential home staff in recognising intracranial injury
Wider context from the report “Oakridge House Residential Home is staffed by non-medically trained personnel.
The “Post-Falls” process/policy direct that 999/111 should be called when a head injury is suspected.
The evidence at inquest indicated that where a head injury was considered a possibility 999/111 was not called.
My concern is that the present process does not give adequate direction, provide sufficient clarity nor distinguish between “possible” and “suspected” head injury. It is not clear when 999/111 should be called.
Further, I have concerns in relation to the training provided to assist Residential Home staff in the recognition of intracranial injury.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hampshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of clear direction in the post-falls process on when to call 999/111 for possible or suspected head injury
Wider context from the report “Oakridge House Residential Home is staffed by non-medically trained personnel.
The “Post-Falls” process/policy direct that 999/111 should be called when a head injury is suspected.
The evidence at inquest indicated that where a head injury was considered a possibility 999/111 was not called.
My concern is that the present process does not give adequate direction, provide sufficient clarity nor distinguish between “possible” and “suspected” head injury. It is not clear when 999/111 should be called.
Further, I have concerns in relation to the training provided to assist Residential Home staff in the recognition of intracranial injury.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require residential staff to complete a standalone learning module on falls management, including the risk of head injury.
Verbatim wording from the response “Regarding staff training, previously staff were trained in how to respond to head injury events during our “Emergency Aid” course. Following your comments, this has been reviewed. Although staff working in a residential setting are not clinically trained, they will now be required to participate in a standalone learning module designed specifically to focus on falls management issues, including risk of head injury. This will compliment other practice guidance for example risk assessment and risk management plans for mobile elderly people in a communal living setting.” Source location 2021-0003-Response-from-Hampshire-County-Council-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 and update the falls protocol in line with current NICE guidance, directing staff to contact 999 or 111.
Verbatim wording from the response “I understand that when you requested the documentation for Mr Johnson’s inquest, you received only part of the current “falls protocol”. As a result of your recommendations the entire protocol has been reviewed and updated in line with current NICE guidance. This clearly directs staff to contact 999 or 111. The revised protocol is attached and I trust addresses the concern relating to the clarity of practice guidance.” Source location 2021-0003-Response-from-Hampshire-County-Council-Redacted
Open published response
23 Dec 2019 Adam Wilcox · Prevention of Future Deaths report Hampshire (Central)
View report summary
Concerns raised 2 Failure to warn motorists of pedestrian and cyclist crossings on the A27 Mansbridge Road View source Lack of a safe pedestrian and cycle crossing on the A27 Mansbridge Road View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Adam Wilcox · 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
Adam Wilcox was struck by a motorcycle while crossing the A27 Mansbridge Road on 7 March 2019 and died in hospital from his injuries. The report raised concerns that this stretch of road had no safe pedestrian or cycle crossing, no warnings to motorists, and that pedestrians and cyclists were likely to cross where the footpath ended and barriers began. It also identified the road as busy and noted previous collisions, including incidents involving pedestrians.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hampshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to warn motorists of pedestrian and cyclist crossings on the A27 Mansbridge Road
Wider context from the report “(1) The A27 Mansbridge Road at the stretch of carriageway from well before the White Swan pub to beyond the scene of this incident (as far as Gaters Hill) does not provide any form of (safe) pedestrian or cycle crossing or any warnings to motorists that pedestrians or cyclist are crossing along its length .
(2) For pedestrians walking (or cyclists not on the carriageway heading) east on the southern side, the only option to travel beyond the scene of this incident is on the northern side of the A27 carriageway. As such, anyone who has not sought to cross the carriageway at a much earlier juncture is either forced to retrace their steps to find another point to cross or (as is more likely) to attempt to cross the carriageway once the path way runs out, where it tapers and stops at the metal barriers and at its junction with the Itchen Navigation. In either event, neither pedestrians nor cyclists have a defined or safe means by which to cross the carriageway and no warnings are given to motorists that they may do so .
(3) The A27 Mansbridge Road is a busy, popular and major thoroughfare, running east-west and south of and parallel to the M27. As such it presents an increased risk to pedestrians and cyclists alike.
(4) I am advised by the Roads Policing Unit that during their visit to the scene (in the conduct of the forensic examination for this inquest) they themselves saw several pedestrians and cyclists crossing the road, at either end, often climbing the metal barrier where the pavement ended.
(5) I am advised that in the past 5 years there have been 15 collisions on the A27 between Itchen Side Close and Allington Lane, of which 5 were classed as serious collisions and 10 classed as slight, with 11 occurring within daylight hours. 2 specific incidents (excluding this fatality) involved pedestrians being struck by vehicles.
” 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 Hampshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a safe pedestrian and cycle crossing on the A27 Mansbridge Road
Wider context from the report “(1) The A27 Mansbridge Road at the stretch of carriageway from well before the White Swan pub to beyond the scene of this incident (as far as Gaters Hill) does not provide any form of (safe) pedestrian or cycle crossing or any warnings to motorists that pedestrians or cyclist are crossing along its length.
(2) For pedestrians walking (or cyclists not on the carriageway heading) east on the southern side, the only option to travel beyond the scene of this incident is on the northern side of the A27 carriageway. As such, anyone who has not sought to cross the carriageway at a much earlier juncture is either forced to retrace their steps to find another point to cross or (as is more likely) to attempt to cross the carriageway once the path way runs out, where it tapers and stops at the metal barriers and at its junction with the Itchen Navigation. In either event, neither pedestrians nor cyclists have a defined or safe means by which to cross the carriageway and no warnings are given to motorists that they may do so.
(3) The A27 Mansbridge Road is a busy, popular and major thoroughfare, running east-west and south of and parallel to the M27. As such it presents an increased risk to pedestrians and cyclists alike.
(4) I am advised by the Roads Policing Unit that during their visit to the scene (in the conduct of the forensic examination for this inquest) they themselves saw several pedestrians and cyclists crossing the road, at either end, often climbing the metal barrier where the pavement ended.
(5) I am advised that in the past 5 years there have been 15 collisions on the A27 between Itchen Side Close and Allington Lane, of which 5 were classed as serious collisions and 10 classed as slight, with 11 occurring within daylight hours. 2 specific incidents (excluding this fatality) involved pedestrians being struck by vehicles.
” Open source report
Concerns raised 2 Insufficient liaison between involved practitioners about crisis support View source Lack of clarity about agency responsibility for immediate assistance 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
George Daniel TWIDDY · 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
George Daniel TWIDDY was found hanging from a tree on 15 November 2017 and died in hospital on 17 November 2017 after suffering an untreatable brain injury. The principal concern was a lack of clarity between the Hampshire AMHP Service and Southern Health NHS Trust’s Early Intervention Psychosis Team about responsibility for providing immediate assistance, leaving his parents and practitioners unclear about where help would come from.
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 Hampshire County Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient liaison between involved practitioners about crisis support
Wider context from the report “At George's Inquest I heard evidence that there was a lack of clarity in the days leading up to his death as to which of the two agencies that had been involved in his care (Hampshire AMHP Service and Southern Health NHS Trust's Early Intervention Psychosis Team) were in a position to provide him with immediate assistance. His parents were confused as to where help would come from and practitioners from the two agencies were unclear as to where the responsibility lay. Although an improved explanatory leaflet for families about the responsibilities of the agencies is now in the course of being finalised and liaison to clarify respective roles has now taken place between senior managers of the agencies, it appears to me that a better understanding of those roles would be achieved if the practitioners actually involved in patient care themselves liaised more about what action and support should be made available to patients and relatives in crisis situations such as that faced by George and his family in the last days of his life.
” 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 Hampshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about agency responsibility for immediate assistance
Wider context from the report “At George's Inquest I heard evidence that there was a lack of clarity in the days leading up to his death as to which of the two agencies that had been involved in his care (Hampshire AMHP Service and Southern Health NHS Trust's Early Intervention Psychosis Team) were in a position to provide him with immediate assistance . His parents were confused as to where help would come from and practitioners from the two agencies were unclear as to where the responsibility lay . Although an improved explanatory leaflet for families about the responsibilities of the agencies is now in the course of being finalised and liaison to clarify respective roles has now taken place between senior managers of the agencies, it appears to me that a better understanding of those roles would be achieved if the practitioners actually involved in patient care themselves liaised more about what action and support should be made available to patients and relatives in crisis situations such as that faced by George and his family in the last days of his life.
” Open source report
25 Oct 2016 Richard Walsh · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 6 Failure to consider the whole person and reconcile or communicate missing and discordant information during proforma completion View source Failure of detained organisations to pass risk information consistently between one another View source Inadequate nurse assessment of fitness for segregation View source Lack of an agreed system for transferring health care information from police stations or courts to prisons View source Inadequate standard of Mental Health Act assessments View source Lack of clear responsibility for passing or seeking relevant information View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Richard Walsh · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Richard Walsh was detained after being charged with attempted murder and, while experiencing delusions, refused food and drink with the stated intention of dying. He was transferred between HMP Highdown and HMP Belmarsh, where he was isolated in a single cell for 23½ hours a day and later died by hanging. The principal concerns were failures in communication and information-sharing between police, mental health, court and prison services, inadequate mental health assessment, and inadequate assessment of his fitness for segregation and suicide risk.
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 Hampshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to consider the whole person and reconcile or communicate missing and discordant information during proforma completion
Wider context from the report “There appeared to be a focus by individuals on completing the proforma or questionnaire required by the system, by rote with either no time to consider the whole person , or no sense that it was their responsibility to consider missing or discordant information or to be proactive in communicating gaps in knowledge or concerns . From the evidence of a number of witnesses, the pattern of communication was not exceptional in this instance but reflected what usually happened.
” 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 Hampshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure of detained organisations to pass risk information consistently between one another
Wider context from the report “There was no agreed system for transfer of health care information from police station or court, or from either to prison. There was no functioning and consistent system of passing risk information from one detained organization to another. There was not agreement whether there just was a duty to pass the information or if it was not in possession, whether there was also one to ask for it and if so which individual bore that responsibility.
” 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 Hampshire County Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate nurse assessment of fitness for segregation
Wider context from the report “3. That the inadequacy of the nurse assessment of fitness for segregation in HMP Highdown (see m) above) is a risk. ████████ was not ACCT trained and it appeared that he was unaware of PSI 1700. The inadequacy may reflect individual or wider weaknesses in assessment or choice of assessors that mean that prisoners go to segregation when they should be in the health care wing, or that they go without observation, when they should be on an ACCT and receive extra support.
” 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 Hampshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of an agreed system for transferring health care information from police stations or courts to prisons
Wider context from the report “There was no agreed system for transfer of health care information from police station or court, or from either to prison. There was no functioning and consistent system of passing risk information from one detained organization to another. There was not agreement whether there just was a duty to pass the information or if it was not in possession, whether there was also one to ask for it and if so which individual bore that responsibility.
” 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 Hampshire County Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate standard of Mental Health Act assessments
Wider context from the report “2. That the standard of Mental Health Act assessments by these individuals needs to be improved , and, given all three were in complete agreement, that also training and provision for MHA assessments in police stations more widely may need to be reviewed.
” 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 Hampshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of clear responsibility for passing or seeking relevant information
Wider context from the report “There was no agreed system for transfer of health care information from police station or court, or from either to prison. There was no functioning and consistent system of passing risk information from one detained organization to another. There was not agreement whether there just was a duty to pass the information or if it was not in possession, whether there was also one to ask for it and if so which individual bore that responsibility.
” Open source report
Concerns raised 2 Failure of lorry nearside visibility equipment to eliminate significant blind spots View source Pedestrians commonly cutting the corner and crossing from the wrong side of the traffic light View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Yogalakshmi Sinnaiah · 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
Yogalakshmi Sinnaiah, aged 58, was struck by a lorry while crossing Dragon Street in Petersfield on 26 January 2016 and sustained instantly fatal multiple injuries. The report raised concern that the lorry’s nearside mirrors left a significant blind spot and that a passenger-side safety lens might have reduced the risk of the collision.
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 Hampshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure of lorry nearside visibility equipment to eliminate significant blind spots
Wider context from the report “1. Whilst the mirrors fitted to the nearside of the lorry involved in the collision with Ms Sinnaiah met with all present construction and use requirements, they left a significant blind spot on the nearside of the vehicle and it is most likely that Ms Sinnaiah was in that blind spot when the lorry started to move after the lights changed in its favour on the pedestrian crossing.
2. I was told in evidence that the nearside cab window of the lorry had been fitted with a passenger side safety side lens, (e.g. a Fresnel Lens) this blind spot would have been reduced and the driver might have seen Ms Sinnaiah before the lorry started to move.
3. It occurs to me that if passenger side safety lenses were mandatory for heavy goods vehicles , it would make a significant contribution to reducing the risk of further fatalities in circumstances similar to Ms Sinnaiah’s death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hampshire County Council; that does not assign responsibility.
PFD Monitor interpretation Pedestrians commonly cutting the corner and crossing from the wrong side of the traffic light
Wider context from the report “1. Ms Sinnajah crossed Dragon Street using the pelican crossing and I was told in evidence that she started to cross the road from the "wrong side" of the traffic light at the crossing, "cutting the corner".
2. I was also told in evidence that using the crossing in this manner is a common occurrence and that there have been a number of near misses of pedestrians in consequence .
3. It occurs to me that provision of railings at this crossing either side of the actual crossing would prevent this happening and would thereby reduce the potential for future incidents of the type involving Ms Sinnajah.
” 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 Bring forward replacement of the Pelican crossing with a Puffin crossing by three years.
Verbatim wording from the response “The current pedestrian crossing is a ‘Pelican’ type and, as we are aware you understand from your investigations, these crossings have a high level ‘flashing green figure’ for pedestrians on the opposite side of the crossing which initially operates concurrently with the flashing amber for waiting vehicles. As shown by the Police evidence within the transcript of the inquest Ms Sinnaiah attempted to cross on a flashing green figure when she approached the crossing at the same time that the Mercedes lorry driver had the flashing amber light and no sight of Ms Sinnaiah. Due to significant reservations about the safety of installing pedestrian guard railing at this location and the lack of previous personal injury accidents at the location, the County Council proposes to bring forward the upgrading of the Pelican crossing by 3” Source location 2016-0264-Response-by-Hampshire-County-Council
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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 Raise the tree crown on the northbound approach to improve crossing signal and pedestrian visibility.
Verbatim wording from the response “In addition to these works the crown on the trees on the northbound approach to the crossing will be raised to improve the visibility of the signals, intervisibility between pedestrians and oncoming vehicles and overall conspicuity of the crossing.” Source location 2016-0264-Response-by-Hampshire-County-Council
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The proposed guard railing is not supported because no pedestrian injury accidents or complaints are recorded, and barriers may create additional safety risks.
Verbatim wording from the response “Whilst on site we examined our entire database of personal injury accident history at the crossing and found no recorded personal injury accidents involving pedestrians between January 1990 and 30th November 2015. Our Traffic Management, Highway Maintenance and East Hants District Council colleagues confirmed no history of complaints or concerns from members of the public concerning the crossing.” Source location 2016-0264-Response-by-Hampshire-County-Council
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Concerns raised 2 Insufficient training and support for Shared Lives Carers working with clients with mental health and emotional problems View source Failure to record rationales for changes to risk assessments View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Tessa Karen Elizabeth Summers · 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
Tessa Karen Elizabeth Summers, aged 20, was found collapsed in bed after taking an overdose of medication and died at hospital on 9 September 2013. Concerns included the failure to record the rationale for downgrading her self-harm risk assessment and allowing unsupervised access to medication, and the need for more training and support for Shared Lives Carers working with clients with mental health and emotional problems.
Read the report on judiciary.uk
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hampshire County Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient training and support for Shared Lives Carers working with clients with mental health and emotional problems
Wider context from the report “2. I gained the impression from some of the inquest witnesses that Adult Social Services could beneficially provide more training and support for Shared Lives Carers where the carers would be called upon to work with clients with mental health and emotional problems .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hampshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to record rationales for changes to risk assessments
Wider context from the report “1. I heard in evidence that the social workers who decided on amendments to Tessa’s risk assessment did not record in that document their rationale for downgrading her from high to low risk of self-harm and allowing her to have access to her medication which she could then take without supervision by her Shared Lives Carer. I was told the social workers were not required to do so as a matter of routine to record why details of risk assessments for any of the clients were being changed .
” Open source report
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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 Shared Lives Carers’ training and support needs when working with people experiencing mental health and emotional problems.
Verbatim wording from the response “This case has highlighted for us the importance of Shared Lives Carers being suitably equipped to support people with emotional difficulties. We will be undertaking a review of the training and support needs of the Shared Lives Carers when working alongside people with mental health and emotional problems. We will have reached conclusions on this by end of November 2014. We will also be undertaking a broader review of the Hampshire Shared Lives Scheme. We expect the outcome of that review and recommendations for consideration to be available by the end of March 2015. Hampshire County Council is committed to the provision of the best possible services for the residents of Hampshire.” Source location 2014-0383-Response-by-Hampshire-County-Council
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No further action is needed regarding the general system for assessing and managing risk.
Verbatim wording from the response “In reviewing the practice in the support offered to Tessa and her family, we have not identified that any action is needed in respect of the system of assessing and managing risk more generally.” Source location 2014-0383-Response-by-Hampshire-County-Council
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations