9 Jan 2026 Ayan SEDIQI · Prevention of Future Deaths report Greater Lincolnshire
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Concerns raised 1 Lack of public awareness about who, where and how to report immediate dangers to road users View source
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. 7
Action
Amend FixMyStreet webpage wording to clarify reporting responsibilities for different defect types.
Status unclearThe respondent did not make the status of this action clear when they made their response on 20 January 2026. View source
Action
Improve asset data and ownership clarity for LCC and non-LCC assets, enabling additional customer information across reporting categories.
Stated in progressThe respondent said that this action was in progress when they made their response on 20 January 2026. View source
Action
Continue developing and promoting FixMyStreet through a prioritised enhancement pipeline improving reports, planned-works visibility and asset-management integration.
Stated in progressThe respondent said that this action was in progress when they made their response on 20 January 2026. View source
Action
Audit public-facing highways website information by March 2026 and deliver identified improvements to accessibility, quality, consistency and completeness.
Stated plannedThe respondent said that this action was planned when they made their response on 20 January 2026. View source
Action
Liaise with the Communications Team to promote reporting methods, responsible organisations and emergency reporting procedures.
Status unclearThe respondent did not make the status of this action clear when they made their response on 20 January 2026. View source
Action
Explore additional reporting guidance, prompts, clearer map keys and What3Words functionality to improve report accuracy and triage.
Stated plannedThe respondent said that this action was planned when they made their response on 20 January 2026. View source
Action
Promote highways service information and self-service tools through targeted stakeholder communications, newsletters, public events and social media.
Stated plannedThe respondent said that this action was planned when they made their response on 20 January 2026. View source See 4 more actions
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AI-generated summary
Ayan SEDIQI · 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
Ayan Sediqi, aged 7 months, died on 3 January 2025 from injuries sustained when the vehicle in which he was travelling slid on ice and collided with a tree on the A1. The ice formed where water was flowing across the carriageway from a blocked drainage pipe. The principal concern was a lack of public awareness about who, where and how motorists should report conditions presenting an immediate danger to road users.
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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 Lincolnshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of public awareness about who, where and how to report immediate dangers to road users
Wider context from the report “Responsibility for road repairs and drainage of Lincolnshire’s roads is shared between Lincolnshire County Council and the Highways Agency and is dependent on the particular road and location. Maintenance and repair of drains at the A1 at this point is the responsibility of National Highways. Both National Highways (Midlands Region) and Lincolnshire County Council described their websites during the inquest. Both include an online reporting process for concerns and faults encountered on the roads. Lincolnshire County Council also have a general telephone number for their Customer Service Centre (office hours) and outside this time, if the fault represents an immediate danger, their online guidance recommends contacting the police on 101. The National Highways website refers to reporting any emergency via 999, and that any other incidents relating to maintenance issues can be reported to their Customer Contact Centre on the number provided. This operates on a 24/7 basis. The Highways Agency also advised that they also do have available signage which displays their telephone number, but that this is usually only deployed, on a temporary basis, at sites of major pre-planned roadworks.
Under the heading ‘Report a Road Traffic Incident’ the Lincolnshire Police website advises that in an emergency situation (this includes incidents where there is an ‘immediate danger to life’), the user should call 999. Their online system for reporting road traffic incidents to the police refers to reporting collisions and driving offences only.
As part of my investigation, the National Highways (Midlands Region), Lincolnshire County Council and Lincolnshire Police all checked their reporting systems, and confirmed they had not received any reports about flowing water or ice on this stretch of the A1 on 2 January 2025, and for the period of two months prior to this accident.
Given the duration and extent of the flowing water / ice on the A1 at the location of this collision, and the number of road users who would have passed over it, it is my view that there is a lack of public awareness as to who, where and how motorists should report circumstances which present a risk of immediate danger to road users.
” 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 Amend FixMyStreet webpage wording to clarify reporting responsibilities for different defect types.
Verbatim wording from the response “As stated above, LCC rely on the reporting mechanisms they have in place and the following improvements are currently being considered/implemented:” Source location Response from Lincolnshire County Council
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 Improve asset data and ownership clarity for LCC and non-LCC assets, enabling additional customer information across reporting categories.
Verbatim wording from the response “Work is ongoing to improve asset data and ownership clarity for both LCC and non-LCC assets, this will enable additional information to be rolled out across other categories resulting in increased transparency and awareness for customers.” Source location Response from Lincolnshire County Council
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue developing and promoting FixMyStreet through a prioritised enhancement pipeline improving reports, planned-works visibility and asset-management integration.
Verbatim wording from the response “Continue to develop and promote FixMyStreet (FMS)” Source location Response from Lincolnshire County Council
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 Audit public-facing highways website information by March 2026 and deliver identified improvements to accessibility, quality, consistency and completeness.
Verbatim wording from the response “By the end of March 2026, we will complete an audit of all public-facing highways information on the LCC website. Following this we will deliver identified improvements and undertake quarterly reviews to ensure quality and accessibility are maintained. We will seek to raise public awareness of service information and resources through targeted stakeholder communication and will measure performance using website analytics data including unique visitor numbers for key website pages. Data from 2024/25 will provide a baseline from which we aim to achieve an annual increase in unique website visitors.” Source location Response from Lincolnshire County Council
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 Liaise with the Communications Team to promote reporting methods, responsible organisations and emergency reporting procedures.
Verbatim wording from the response “As stated above, LCC rely on the reporting mechanisms they have in place and the following improvements are currently being considered/implemented:” Source location Response from Lincolnshire County Council
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 Explore additional reporting guidance, prompts, clearer map keys and What3Words functionality to improve report accuracy and triage.
Verbatim wording from the response “Planned Improvements” Source location Response from Lincolnshire County Council
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 Promote highways service information and self-service tools through targeted stakeholder communications, newsletters, public events and social media.
Verbatim wording from the response “By the end of March 2026, we will complete an audit of all public-facing highways information on the LCC website. Following this we will deliver identified improvements and undertake quarterly reviews to ensure quality and accessibility are maintained. We will seek to raise public awareness of service information and resources through targeted stakeholder communication and will measure performance using website analytics data including unique visitor numbers for key website pages. Data from 2024/25 will provide a baseline from which we aim to achieve an annual increase in unique website visitors.” Source location Response from Lincolnshire County Council
Open published response
23 Jun 2025 David Lee WALSH · Prevention of Future Deaths report Greater Lincolnshire
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Concerns raised 2 Failure to immediately report highway-condition-related injury or fatality collisions to the Highways Department View source Delays in reviewing collision information for highway safety intervention 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
David Lee 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
David Lee Walsh died at the scene after the Mercedes GLC300 he was travelling in left the road at Whitegates Farm, Tetney Lock Road, Tetney, and entered the Louth Canal on 6 January 2024. The concern was that highway-related collisions are not reported directly to the Highways Department immediately, meaning incidents may occur before the annual review and potentially before preventative action is taken.
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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 Lincolnshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to immediately report highway-condition-related injury or fatality collisions to the Highways Department
Wider context from the report “During the evidence provided by the Highways Department, the Highways Officer reported that road traffic collisions, where there are injuries or fatalities that may have been contributed to by the condition of the highway, are not immediately reported directly to the Highways Department by the Police . The Police complete a Stat 19 Form which is then sent to the Lincolnshire Road Safety Partnership. The information from the Stat 19 Form is then collated and placed onto the WINGS software programme which is a Council owned software programme. This information is reviewed on an annual basis where the types of incidents are considered along with the traffic flow on that road and it gives a score. Based on the score there is then a ranking of sites where there has been more than one collision within a set area (known as a Cluster). The score is used to decide where the Highways Department should intervene first on looking at potential safety improvements. The Accident Investigation Team and the Road Safety Partnership then look at each of those Cluster Sites and investigate those sites. Consideration will then be given to what improvements could be made to the highway to reduce the risk of future incidents. As these reports are only considered annually there is the possibility that other incidents can occur prior to the annual review that could have been prevented had a report been made to the Highways Department at the time of the incident .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lincolnshire County Council; that does not assign responsibility.
PFD Monitor interpretation Delays in reviewing collision information for highway safety intervention
Wider context from the report “During the evidence provided by the Highways Department, the Highways Officer reported that road traffic collisions, where there are injuries or fatalities that may have been contributed to by the condition of the highway, are not immediately reported directly to the Highways Department by the Police. The Police complete a Stat 19 Form which is then sent to the Lincolnshire Road Safety Partnership. The information from the Stat 19 Form is then collated and placed onto the WINGS software programme which is a Council owned software programme. This information is reviewed on an annual basis where the types of incidents are considered along with the traffic flow on that road and it gives a score. Based on the score there is then a ranking of sites where there has been more than one collision within a set area (known as a Cluster). The score is used to decide where the Highways Department should intervene first on looking at potential safety improvements. The Accident Investigation Team and the Road Safety Partnership then look at each of those Cluster Sites and investigate those sites. Consideration will then be given to what improvements could be made to the highway to reduce the risk of future incidents. As these reports are only considered annually there is the possibility that other incidents can occur prior to the annual review that could have been prevented had a report been made to the Highways Department at the time of the incident.
” 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 Undertake annual collision-cluster runs and route studies reviewing the preceding five years of collisions to identify patterns, issues and locations requiring investigation.
Verbatim wording from the response “Finally, as noted during the inquest, LCC AIP staff undertake an annual collision cluster run and route study programme. This ensures that every collision in the preceding five-year period, regardless of severity is also reviewed, to identify patterns or issues, highlighting locations that require further investigation. This is a risk-based assessment that factors in the number of collisions, their severity, and the presence of vulnerable road users. This generates a work programme of 30 or more sites and three or more routes for review every year. I can confirm that whilst this work forms a vital part of LCC's activity to prevent future death and injury, it is not the only relevant programme, and LCC do not wait for the annual review before investigating fatal collisions.” Source location Response from Lincolnshire County Council & Lincolnshire Police
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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 Highlight every STATS19 collision identifying roads as a possible causation factor within the wider Highways Team for timely review or action.
Verbatim wording from the response “Every STATS19 collision form that has R1-R5 (Roads) listed as a possible causation factor will be highlighted within the wider LCC Highways Team. This will allow for any review or action to be taken at the earliest opportunity where necessary. The actions to be taken will be graded based on the severity of the collision and the weighting of the causation factor. For example, a road related causation factor rated as the most likely issue in a fatal/serious collision will indicate a more significant issue than a causation factor ranked third in likelihood for a slight collision.” Source location Response from Lincolnshire County Council & Lincolnshire Police
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 Operate the improved fatal collision notification process, distributing reports, recording potential highway issues, checking records, notifying relevant teams and considering preventive actions.
Verbatim wording from the response “Regarding the reporting of potential highway issues in fatal collisions more widely, I am pleased to confirm that LCC systems have recently been improved to ensure that any possible highway issues are identified at the earliest opportunity.” Source location Response from Lincolnshire County Council & Lincolnshire Police
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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 Fatal collisions are not left until the annual review; existing processes ensure they are considered and investigated at the earliest opportunity.
Verbatim wording from the response “As such, every fatal collision reported to LCC is considered at the earliest opportunity.” Source location Response from Lincolnshire County Council & Lincolnshire Police
Open published response
16 Aug 2023 Absolom Adolphus Abraham Zephaniah DUFFY · Prevention of Future Deaths report Lincolnshire
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Concerns raised 1 Failure of junction signage to require stopping where visibility of the major road is restricted 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
Absolom Adolphus Abraham Zephaniah DUFFY · 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
Absolom Duffy was travelling in his Land Rover Defender when he exited Sand Lane, Saxilby, onto Doddington Road and collided with another vehicle; he died from his injuries. The concern was whether the junction would be safer with a stop command rather than a give-way warning because of its restricted view.
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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 Lincolnshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure of junction signage to require stopping where visibility of the major road is restricted
Wider context from the report “The B1190 Tom Otter’s Lane junction with the C267 Sand Lane, Saxilby, Lincolnshire provides for the road user approaching from either direction on Sand Lane to give way to traffic on the major B1190 road. There is a restricted view of the B1190 as a road user approaches the junction. To be certain the B1190 road is clear a road user would be required to stop, however the road signage only requires a road user to give way. Would the junction be safer for road users if it displayed a stop command rather than a give way warning?
” 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 Regularly assess vegetation at the junction approaches and take enforcement action to maintain maximum visibility and unobstructed visibility splays.
Verbatim wording from the response “• Vegetation at approaches to this junction will be assessed regularly by the Local Highways team, with appropriate enforcement action taken to ensure that it gives maximum visibility and does not reduce the splays when exiting onto the B1190.” Source location Response from Lincolnshire Council
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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 Existing Give Way signage will not be changed because junction visibility substantially exceeds the distance at which a Stop sign might be considered.
Verbatim wording from the response “The visibility distance below which a STOP sign might be considered at this location is 90m (based on using 85th percentile speed of 60mph) as specified in Table 2.1 of Traffic Signs Manual Chapter 3.” Source location Response from Lincolnshire Council
Open published response
26 Apr 2023 Colin Robert GUMM · Prevention of Future Deaths report Lincolnshire
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Concerns raised 6 Failure to identify and assess conflicting evidence about alcohol provision View source Failure to take safeguarding action to mitigate identified risks View source Lack of safeguarding review and monitoring during periods of ongoing care View source Failure to identify and assess signs of underweight and clinical dehydration View source Premature closure of section 42 safeguarding enquiries without gathering material information View source Failure to complete Adult Social Care assessments 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
Colin Robert GUMM · 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
Colin Robert GUMM, a vulnerable adult receiving a care package, was found collapsed by his carers and died at Lincoln County Hospital on 27 November 2021 despite treatment. The concerns include gaps in Adult Social Care monitoring and safeguarding, the identification of apparent underweight and clinical dehydration only shortly before his death, conflicting evidence about alcohol provision, and the reported premature closure of a safeguarding enquiry before toxicology results were received.
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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 Lincolnshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and assess conflicting evidence about alcohol provision
Wider context from the report “6.Conflicting evidence was provided by bluebird care that :
Registered Manager (02/02/2023) - "the only drink we pour for him is water, we never poured alcohol for him"
"26th November 2021 14:24 from carer's log - "water and whiskey provided on top of ongoing medication"
EMAS report (12/04/2022) - "bottles of alcohol were found by his bed and enquired with the carers ,however they believed he doesn't drink a lot as he was unable to pour on his own".
If that is right somebody was pouring for him. Shouldn't all this have been picked up by the safeguarding assessment?
” 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 Lincolnshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to take safeguarding action to mitigate identified risks
Wider context from the report “5.The outcome from the admitted "limited information gathered" was that no risk was identified and no action taken . Despite the toxicology report still to be received the enquiry was closed and never reopened . As a result no appropriate action was taken to mitigate any risks to others .
” 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 Lincolnshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of safeguarding review and monitoring during periods of ongoing care
Wider context from the report “2. It was not until April 2021, 3 years later and despite care packages being in place and funded by Lincolnshire county Council, that the deceased became known again to Adult Social Care where it was deemed necessary to provide ongoing support of the Wellbeing team and Adult Social Care until his passing in November 2021.This was as a result of a referral from the GP.
What happened in those 3 years by way of observations upon the deceased by safeguarding and if none shouldn't there have been something in place? Nothing has been evidenced to date . Shouldn't measures have been in place to review/monitor?
” 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 Lincolnshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and assess signs of underweight and clinical dehydration
Wider context from the report “3.EMAS make there own safeguarding referral on 29th November 2021 as he appeared to them on the one time they saw the deceased that he was underweight and showing signs of clinical dehydration . If they were able to observe this why is none else in Adult Social Care making the same assessment during his lifetime?
” 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 Lincolnshire County Council; that does not assign responsibility.
PFD Monitor interpretation Premature closure of section 42 safeguarding enquiries without gathering material information
Wider context from the report “7.Instead the s.42 reporter according to the live evidence of the principal practitioner of the Adult Safeguarding team of the day, appears to have collated only limited information and closed the inquiry down prematurely without looking at material documents or even awaiting the toxicology report . At the very least it should be reopened to see if there was any missed opportunities from which lessons could be learnt and future deaths prevented and to embody the whole purpose of a s.42 assessment in deciding what action to take to support and protect the person in question. It being reiterated that this assessment was only commissioned after the deceased had passed away.
” 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 Lincolnshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to complete Adult Social Care assessments
Wider context from the report “1. Adult Social Care were first involved in 2017 due to the deceased self neglecting. It is recorded assessments were not able to be completed .
” 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 The authority was not responsible for monitoring or reviewing care when it had no commissioned care involvement or safeguarding referral.
Verbatim wording from the response “This factual basis is incorrect. There were no packages of care provided or funded by Lincolnshire County Council (‘LCC’) between 2017 and April 2021. Furthermore, there was never any doubt about Mr Gumm's capacity to make his own decisions about his own care and support and in fact he made his own private arrangements. As LCC were not involved in the commissioning of any care for him, LCC would only become involved if a safeguarding concern was raised or if he had changed his mind about wanting support and was eligible for that support. Aside from the referral already referred to in the safeguarding statement, there were no safeguarding referrals which came to the attention of LCC in those 3 years. So, in summary there would not have been, nor should there have been, observations of him by safeguarding nor reviews of his care as this was not the responsibility of LCC.” Source location Response from Lincolnshire County Council
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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 authority had no opportunity to observe privately arranged care unless a safeguarding referral was made.
Verbatim wording from the response “Adult social care was not involved in the provision of Mr Gumm’s care and therefore had no opportunity to be sighted on it unless a referral of a safeguarding nature was made. No such referral was made. Bluebird Care was the agency providing his privately arranged care.” Source location Response from Lincolnshire County Council
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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 Commercial Team and, where appropriate, CQC decide assurance actions after limited safeguarding fact-finding.
Verbatim wording from the response “However, if necessary, limited fact-finding enquiries will be made by the safeguarding team in order to ascertain whether further consideration of potential risk to others is required. This information is shared with the Commercial Team and, if appropriate, CQC, who will consider the information and decide any assurance actions, which may include if appropriate, a visit to the provider. Every contract for services with the council has its own contracts officer allocated to that provider. In the first instance, depending on the circumstances, it is likely that the contracts office will visit.” Source location Response from Lincolnshire County Council
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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 toxicology report would not have affected whether the safeguarding enquiry should be reopened because no provider concerns were identified.
Verbatim wording from the response “Mr Gumm had sadly died and therefore this ended the Local Authority's legal duty to take steps to safeguard Mr Gumm under s.42. However, the Safeguarding Team did progress with a s.42 enquiry (although it should have been recorded as a non s.42 enquiry at that time) to seek wider assurance in relation to the care providers involved and any potential wider risks. (LCC’s processes in relation to s.42 enquiries and more generally is explored below in the section on action by LCC). Proportionate enquiries/fact-findings was undertaken (in so far as the council were able to do so given the circumstances) and no concerns were identified in relation to the services provided to the deceased.” Source location Response from Lincolnshire County Council
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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 statutory safeguarding duty did not apply to a deceased individual, so a section 42 enquiry was inappropriate in these circumstances.
Verbatim wording from the response “Pursuant to LCC’s duties under s.42, a Local Authority is not required by law to carry out enquiries for those individuals who do not meet the criteria for safeguarding as set out in this section of the Act. In particular, the care act duty can have no application to a deceased individual as the purpose of the enquiry is to decide what action is to be taken in relation to the individual and by whom. In some cases, LCC may have had a safeguarding referral during the individual’s life and appropriate information about LCC’s safeguarding actions will be provided to the coroner.” Source location Response from Lincolnshire County Council
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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 Reopening the enquiry could not determine which evidence was reliable or whether the provider acted inappropriately.
Verbatim wording from the response “We can only reiterate that LCC was not providing care to Mr Gumm at the time. LCC are not therefore in a position to determine whose evidence can or should be believed” Source location Response from Lincolnshire County Council
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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 Existing council quality-assurance and multi-agency arrangements provide appropriate assurance about risks to other individuals.
Verbatim wording from the response “However, the council also has significant other quality assurance methods which may be used to monitor and improve services and work with the regulator who has the power to take formal action or in the worst-case scenario work with the regulator, who has the authority to close down an unsafe provision.” Source location Response from Lincolnshire County Council
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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 Capacity to refuse services meant the authority could not compel assessment or acceptance of care.
Verbatim wording from the response “The coroner had evidence within the safeguarding statement that the recorded assessments were not able to be completed due to the individual's lack of engagement with the authority. Where an individual has capacity to refuse to engage with a service, they are entitled to do so. LCC are not able to force an individual to accept services or an assessment.” Source location Response from Lincolnshire County Council
Open published response
26 Aug 2020 Toby Peter Edward Nieland · Prevention of Future Deaths report Lincolnshire
View report summary
Concerns raised 14 Lack of assertive outreach and organised welfare checks after community discharge View source Failure to seek immediate family views on accommodation and treatment and care pathways View source Failure to communicate immediate family concerns to relevant care agencies View source Lack of adequate guidance and training for mental health practitioners on substance misuse and Dual Diagnosis View source Lack of an adequate Care Programme Approach View source Inadequate evaluation of history, vulnerabilities, circumstances and drug misuse indicators for relapse signatures View source Unavailability of specialist Dual Diagnosis workers for complex cases View source Unavailability of a dedicated or commissioned drug and alcohol recovery service View source Lack of interface between senior or experienced providers for complex cases View source Failure of the Crisis Assessment and Home Team Protocol to provide adequately for Dual Diagnosis View source Failure to recognise and adequately manage complex Dual Diagnosis View source Failure to appoint a care coordinator to monitor care under an appropriate care plan View source Lack of coordination between mental health and addiction services View source Absence of a Dual Diagnosis protocol defining provider roles View source See 11 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
Toby Peter Edward Nieland · 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
Toby Peter Edward Nieland had a complex Dual Diagnosis, chronic pancreatitis with persistent pain, opiate addiction, and a history of self-harm and suicide attempts. After discharge from inpatient care in April 2018, he was found collapsed and unresponsive on 17 May 2018 after self-suspending himself by a belt in his room. The report identified concerns about failures to communicate family warnings, inadequate coordination and care planning, insufficient monitoring and assertive outreach, and gaps in services for people with Dual Diagnosis.
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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 Lincolnshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of assertive outreach and organised welfare checks after community discharge
Wider context from the report “6. The absence of any "assertive outreach" to the deceased when discharged into the community (that is to say, no face to contact, no alternative welfare checks being organised, undue reliance being placed on the informal supervisory role of the landlord or other agencies ) gave rise to a total disconnect between patient and healthcare provider, thereby creating a series of missed opportunities to assess the deceased, identify possible relapse signatures and potentially escalate care;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lincolnshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to seek immediate family views on accommodation and treatment and care pathways
Wider context from the report “1. The concerns of the immediate family were not communicated to any of the agencies charged with the responsibility of caring for the deceased, nor were their views sought (directly or indirectly) as to the suitability of the deceased's accommodation and/or circumstances and/or pathway of treatment and care ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lincolnshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate immediate family concerns to relevant care agencies
Wider context from the report “1. The concerns of the immediate family were not communicated to any of the agencies charged with the responsibility of caring for the deceased , nor were their views sought (directly or indirectly) as to the suitability of the deceased's accommodation and/or circumstances and/or pathway of treatment and care;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lincolnshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate guidance and training for mental health practitioners on substance misuse and Dual Diagnosis
Wider context from the report “9. The National Institute for Health and Care Excellence (NICE) Guideline Scope document "Severe mental illness and substance misuse (dual diagnosis): community health and social care services stipulates that there should be a Dual Diagnosis protocol setting out specifically the roles of the mental health provider and the drug and alcohol service provider (no such protocol being in place at the material time) and that whilst it is apparent that some thought has been deployed to re-install a bridge between mental health provision and drug and alcohol services this does not address the needs of a patient suffering from a complex Dual Diagnosis in Lincolnshire due to:
a. The lack of interface between senior or experienced care providers to deal with multi-faceted or nuanced cases;
b. The absence of specialist Dual Diagnosis workers to be deployed in complex cases;
c. The absence of adequate and robust guidance and training , in particular for mental health practitioners to be aware of substance misuse issues and a patient suffering from Dual Diagnosis that impact on appropriate pathways of treatment and care ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lincolnshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of an adequate Care Programme Approach
Wider context from the report “4. There was an absence of any adequate "Care Programme Approach" (a package of care used to plan mental health care) resulting in no care coordinator being appointed to monitor the deceased within the auspices of an appropriate care plan;
” 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 Lincolnshire County Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate evaluation of history, vulnerabilities, circumstances and drug misuse indicators for relapse signatures
Wider context from the report “5. Inadequate evaluation of the deceased's previous history; his purported non-concordance (repeated assertions of not wanting treatment/support that ought to have been interpreted as an increase in his risk); progression of his complex vulnerabilities; his personal circumstances (reaction to accommodation and relationships); events suggestive of on-going misuse of drugs - all gave rise to a missed opportunities to appreciate a series of acceptable relapse signatures ;
” 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 Lincolnshire County Council; that does not assign responsibility.
PFD Monitor interpretation Unavailability of specialist Dual Diagnosis workers for complex cases
Wider context from the report “9. The National Institute for Health and Care Excellence (NICE) Guideline Scope document "Severe mental illness and substance misuse (dual diagnosis): community health and social care services stipulates that there should be a Dual Diagnosis protocol setting out specifically the roles of the mental health provider and the drug and alcohol service provider (no such protocol being in place at the material time) and that whilst it is apparent that some thought has been deployed to re-install a bridge between mental health provision and drug and alcohol services this does not address the needs of a patient suffering from a complex Dual Diagnosis in Lincolnshire due to:
a. The lack of interface between senior or experienced care providers to deal with multi-faceted or nuanced cases;
b. The absence of specialist Dual Diagnosis workers to be deployed in complex cases ;
c. The absence of adequate and robust guidance and training, in particular for mental health practitioners to be aware of substance misuse issues and a patient suffering from Dual Diagnosis that impact on appropriate pathways of treatment and care;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lincolnshire County Council; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a dedicated or commissioned drug and alcohol recovery service
Wider context from the report “7. The circumstances of this case evidences a gap in the provision of care to a patient with a Dual Diagnosis in Lincolnshire by reason of there being no dedicated and/or commissioned drug and alcohol recovery team/service ;
” 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 Lincolnshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of interface between senior or experienced providers for complex cases
Wider context from the report “9. The National Institute for Health and Care Excellence (NICE) Guideline Scope document "Severe mental illness and substance misuse (dual diagnosis): community health and social care services stipulates that there should be a Dual Diagnosis protocol setting out specifically the roles of the mental health provider and the drug and alcohol service provider (no such protocol being in place at the material time) and that whilst it is apparent that some thought has been deployed to re-install a bridge between mental health provision and drug and alcohol services this does not address the needs of a patient suffering from a complex Dual Diagnosis in Lincolnshire due to:
a. The lack of interface between senior or experienced care providers to deal with multi-faceted or nuanced cases ;
b. The absence of specialist Dual Diagnosis workers to be deployed in complex cases;
c. The absence of adequate and robust guidance and training, in particular for mental health practitioners to be aware of substance misuse issues and a patient suffering from Dual Diagnosis that impact on appropriate pathways of treatment and care;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lincolnshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure of the Crisis Assessment and Home Team Protocol to provide adequately for Dual Diagnosis
Wider context from the report “8. The Lincolnshire Partnership NHS Trust document – "Crisis Assessment and Home Team Protocol" (Exhibit reference IJ2) makes no adequate or appropriate provision for a patient with Dual Diagnosis ;
” 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 Lincolnshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise and adequately manage complex Dual Diagnosis
Wider context from the report “2. Unequivocal evidence established that the deceased suffered from an advanced progressive addiction overlaid with a vulnerable personality amounting to a complex Dual Diagnosis – the significance of which was not appreciated and therefore not managed adequately or appropriately ;
” 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 Lincolnshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to appoint a care coordinator to monitor care under an appropriate care plan
Wider context from the report “4. There was an absence of any adequate "Care Programme Approach" (a package of care used to plan mental health care) resulting in no care coordinator being appointed to monitor the deceased within the auspices of an appropriate care plan ;
” 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 Lincolnshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of coordination between mental health and addiction services
Wider context from the report “3. In any event, even on the basis upon which community care was deemed appropriate, there was an absence of any co-ordination between mental health service provision and addiction services ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lincolnshire County Council; that does not assign responsibility.
PFD Monitor interpretation Absence of a Dual Diagnosis protocol defining provider roles
Wider context from the report “9. The National Institute for Health and Care Excellence (NICE) Guideline Scope document "Severe mental illness and substance misuse (dual diagnosis): community health and social care services stipulates that there should be a Dual Diagnosis protocol setting out specifically the roles of the mental health provider and the drug and alcohol service provider (no such protocol being in place at the material time ) and that whilst it is apparent that some thought has been deployed to re-install a bridge between mental health provision and drug and alcohol services this does not address the needs of a patient suffering from a complex Dual Diagnosis in Lincolnshire due to:
a. The lack of interface between senior or experienced care providers to deal with multi-faceted or nuanced cases;
b. The absence of specialist Dual Diagnosis workers to be deployed in complex cases;
c. The absence of adequate and robust guidance and training, in particular for mental health practitioners to be aware of substance misuse issues and a patient suffering from Dual Diagnosis that impact on appropriate pathways of treatment and care;
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider different or partnership-based approaches to commissioning services for people with dual diagnosis.
Verbatim wording from the response “ii. The council and the CCG should consider different approaches to commissioning services that cater for those with dual diagnosis, this should form part of the commissioning cycle and include alternative models and joint commissioning opportunities
Timeframe - October 2023” Source location 2020-0164-Response-from-Lincolnshire-County-Council_Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and revise the joint working protocol and implement a more robust referral pathway across mental health and substance misuse services.
Verbatim wording from the response “i. A joint working protocol is in place but has not been widely implemented across all services. The CCG, LPFT, We Are With You and Public Health should work together to review this protocol and implement a more robust” Source location 2020-0164-Response-from-Lincolnshire-County-Council_Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Evaluate dual diagnosis provision within substance misuse services and make recommendations on its adequacy and future commissioning.
Verbatim wording from the response “ii. The substance misuse provision for dual diagnosis will be a central point of the next service evaluation; this inspection should determine if current provision is adequate and appropriate to meet the needs of those accessing the service and make recommendations to the provider and commissioner regarding provision and future commissioning potential.
Timeframe - September 2021 to complete the review (Covid 19 restrictions may delay this action)” Source location 2020-0164-Response-from-Lincolnshire-County-Council_Redacted.pdf
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Care coordination and assertive outreach concerns relate to services commissioned by the CCG and provided by Lincolnshire Partnership NHS Trust.
Verbatim wording from the response “This concern is linked to the services commissioned by the Clinical Commissioning Group and provided by Lincolnshire Partnership NHS Trust. If Care coordination is in place it is imperative that the substance misuse services work in partnership with the mental health team to provide a comprehensive individually tailored care package.” Source location 2020-0164-Response-from-Lincolnshire-County-Council_Redacted.pdf
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Current substance misuse provision is considered sufficient to manage dual-diagnosis needs, subject to review if joint working significantly increases.
Verbatim wording from the response “The response to question 7 details the provision in place from We Are With You. The specification for the service is outcome focussed and expects the provider to meet all relevant guidance and provide the support and care appropriate for those using the service to make a full and sustainable recovery. This includes dual diagnosis. The current provision is sufficient to manage need however if joint working grows significantly this will be reviewed as part of the on-going management of the contract between Public Health and We Are With You.” Source location 2020-0164-Response-from-Lincolnshire-County-Council_Redacted.pdf
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Substance misuse training, advice and referral support are already available for mental health services to access.
Verbatim wording from the response “appropriate referral into specialist treatment.' This provision is in place and available for Lincolnshire Partnership NHS Trust to access.” Source location 2020-0164-Response-from-Lincolnshire-County-Council_Redacted.pdf
Open published response
15 Apr 2020 Millie TAYLOR-NOONAN · Prevention of Future Deaths report Lincolnshire
View report summary
Concerns raised 7 Lack of pedestrian railings at the school crossing area View source Lack of indication of an imminent school crossing area View source Lack of a temporary 20-mile-per-hour speed limit during school start and finish periods View source Lack of a school crossing patrol officer View source Lack of street lighting at the school crossing area View source Vulnerability of pedestrians near the school access and exit during school traffic periods View source Lack of a pedestrian crossing giving pedestrians priority 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
Millie TAYLOR-NOONAN · 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
Millie TAYLOR-NOONAN, aged 18, was struck by a car while crossing the A607 near The Sir William Robertson School on 4 December 2018. She suffered an unsurvivable head injury and died following the collision; concerns included inadequate pedestrian protections, lighting and crossing arrangements near the 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 Lincolnshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of pedestrian railings at the school crossing area
Wider context from the report “1. The location of the collision is in the immediate vicinity to the access and exit entrances to a large secondary school;
2. Whilst motorists have the benefit of advanced warning triangles indicating to road users that there is a school 100 ahead along with a speed limit repeater the location of the incident took place near a dropped kerb with a section of tactile pavement on the footpaths either side of the road, there is no indication to road users as to the imminence of what, was in reality a school crossing area and the area is also unlit;
3. The evidence demonstrated that the deceased may have been distracted by other road traffic users and in particular a school bus emerging from the school premises in the immediacy of the collision that serves to demonstrate the vulnerability of pedestrians in this location at such a time;
4. There are no other measures that exist to protect pedestrians such as:
a. Railings;
b. Street lighting;
c. An automated zebra or other form of crossing to allow a priority to be given to pedestrians;
d. A school crossing patrol officer;
e. A temporary reduction in the speed limit to 20 miles per hour at the beginning and end of the school day;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lincolnshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of indication of an imminent school crossing area
Wider context from the report “1. The location of the collision is in the immediate vicinity to the access and exit entrances to a large secondary school;
2. Whilst motorists have the benefit of advanced warning triangles indicating to road users that there is a school 100 ahead along with a speed limit repeater the location of the incident took place near a dropped kerb with a section of tactile pavement on the footpaths either side of the road, there is no indication to road users as to the imminence of what, was in reality a school crossing area and the area is also unlit;
3. The evidence demonstrated that the deceased may have been distracted by other road traffic users and in particular a school bus emerging from the school premises in the immediacy of the collision that serves to demonstrate the vulnerability of pedestrians in this location at such a time;
4. There are no other measures that exist to protect pedestrians such as:
a. Railings;
b. Street lighting;
c. An automated zebra or other form of crossing to allow a priority to be given to pedestrians;
d. A school crossing patrol officer;
e. A temporary reduction in the speed limit to 20 miles per hour at the beginning and end of the school day;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lincolnshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a temporary 20-mile-per-hour speed limit during school start and finish periods
Wider context from the report “1. The location of the collision is in the immediate vicinity to the access and exit entrances to a large secondary school;
2. Whilst motorists have the benefit of advanced warning triangles indicating to road users that there is a school 100 ahead along with a speed limit repeater the location of the incident took place near a dropped kerb with a section of tactile pavement on the footpaths either side of the road, there is no indication to road users as to the imminence of what, was in reality a school crossing area and the area is also unlit;
3. The evidence demonstrated that the deceased may have been distracted by other road traffic users and in particular a school bus emerging from the school premises in the immediacy of the collision that serves to demonstrate the vulnerability of pedestrians in this location at such a time;
4. There are no other measures that exist to protect pedestrians such as:
a. Railings;
b. Street lighting;
c. An automated zebra or other form of crossing to allow a priority to be given to pedestrians;
d. A school crossing patrol officer;
e. A temporary reduction in the speed limit to 20 miles per hour at the beginning and end of the school day;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lincolnshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a school crossing patrol officer
Wider context from the report “1. The location of the collision is in the immediate vicinity to the access and exit entrances to a large secondary school;
2. Whilst motorists have the benefit of advanced warning triangles indicating to road users that there is a school 100 ahead along with a speed limit repeater the location of the incident took place near a dropped kerb with a section of tactile pavement on the footpaths either side of the road, there is no indication to road users as to the imminence of what, was in reality a school crossing area and the area is also unlit;
3. The evidence demonstrated that the deceased may have been distracted by other road traffic users and in particular a school bus emerging from the school premises in the immediacy of the collision that serves to demonstrate the vulnerability of pedestrians in this location at such a time;
4. There are no other measures that exist to protect pedestrians such as:
a. Railings;
b. Street lighting;
c. An automated zebra or other form of crossing to allow a priority to be given to pedestrians;
d. A school crossing patrol officer;
e. A temporary reduction in the speed limit to 20 miles per hour at the beginning and end of the school day;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lincolnshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of street lighting at the school crossing area
Wider context from the report “1. The location of the collision is in the immediate vicinity to the access and exit entrances to a large secondary school;
2. Whilst motorists have the benefit of advanced warning triangles indicating to road users that there is a school 100 ahead along with a speed limit repeater the location of the incident took place near a dropped kerb with a section of tactile pavement on the footpaths either side of the road, there is no indication to road users as to the imminence of what, was in reality a school crossing area and the area is also unlit ;
3. The evidence demonstrated that the deceased may have been distracted by other road traffic users and in particular a school bus emerging from the school premises in the immediacy of the collision that serves to demonstrate the vulnerability of pedestrians in this location at such a time;
4. There are no other measures that exist to protect pedestrians such as:
a. Railings;
b. Street lighting;
c. An automated zebra or other form of crossing to allow a priority to be given to pedestrians;
d. A school crossing patrol officer;
e. A temporary reduction in the speed limit to 20 miles per hour at the beginning and end of the school day;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lincolnshire County Council; that does not assign responsibility.
PFD Monitor interpretation Vulnerability of pedestrians near the school access and exit during school traffic periods
Wider context from the report “1. The location of the collision is in the immediate vicinity to the access and exit entrances to a large secondary school;
2. Whilst motorists have the benefit of advanced warning triangles indicating to road users that there is a school 100 ahead along with a speed limit repeater the location of the incident took place near a dropped kerb with a section of tactile pavement on the footpaths either side of the road, there is no indication to road users as to the imminence of what, was in reality a school crossing area and the area is also unlit;
3. The evidence demonstrated that the deceased may have been distracted by other road traffic users and in particular a school bus emerging from the school premises in the immediacy of the collision that serves to demonstrate the vulnerability of pedestrians in this location at such a time ;
4. There are no other measures that exist to protect pedestrians such as:
a. Railings;
b. Street lighting;
c. An automated zebra or other form of crossing to allow a priority to be given to pedestrians;
d. A school crossing patrol officer;
e. A temporary reduction in the speed limit to 20 miles per hour at the beginning and end of the school day;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lincolnshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a pedestrian crossing giving pedestrians priority
Wider context from the report “1. The location of the collision is in the immediate vicinity to the access and exit entrances to a large secondary school;
2. Whilst motorists have the benefit of advanced warning triangles indicating to road users that there is a school 100 ahead along with a speed limit repeater the location of the incident took place near a dropped kerb with a section of tactile pavement on the footpaths either side of the road, there is no indication to road users as to the imminence of what, was in reality a school crossing area and the area is also unlit;
3. The evidence demonstrated that the deceased may have been distracted by other road traffic users and in particular a school bus emerging from the school premises in the immediacy of the collision that serves to demonstrate the vulnerability of pedestrians in this location at such a time;
4. There are no other measures that exist to protect pedestrians such as:
a. Railings;
b. Street lighting;
c. An automated zebra or other form of crossing to allow a priority to be given to pedestrians;
d. A school crossing patrol officer;
e. A temporary reduction in the speed limit to 20 miles per hour at the beginning and end of the school day;
” 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 Provide school staff to marshal pupils at the gate and hold them until it is safe to cross.
Verbatim wording from the response “With regard to your third point, a joint examination with the Academy of the school's vehicular access arrangements, which currently operate as a one-way system utilising the northern access and southern exit, was carried out at school exit times. For the internal operation within the school premises, of children boarding and exiting buses, this is the safest option. An option to reverse this arrangement was considered but it was agreed this would create queuing vehicles on the highway which would obscure pedestrian and vehicle visibility and, at worst, actually prevent crossing of the road.” Source location 2020-0097-Response-from-Lincolnshire-County-Council_Redacted
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 Examine the Academy’s vehicular access arrangements jointly with the school at exit times.
Verbatim wording from the response “With regard to your third point, a joint examination with the Academy of the school's vehicular access arrangements, which currently operate as a one-way system utilising the northern access and southern exit, was carried out at school exit times. For the internal operation within the school premises, of children boarding and exiting buses, this is the safest option. An option to reverse this arrangement was considered but it was agreed this would create queuing vehicles on the highway which would obscure pedestrian and vehicle visibility and, at worst, actually prevent crossing of the road.” Source location 2020-0097-Response-from-Lincolnshire-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 Install streetlighting at the school entrance as an authorised exceptional measure.
Verbatim wording from the response “b. The provision of Streetlighting at this location does not meet the requirements of the County Council's Streetlighting Policy. However, the school feel that this request would have the most significant benefit and the Executive Councillor has authorised its installation as an exceptional case.” Source location 2020-0097-Response-from-Lincolnshire-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 Improve school-entrance conspicuity by installing road markings, additional warning signs and amber flashing lights for school start and finish times.
Verbatim wording from the response “However, it is agreed that the conspicuity of the school entrance could be enhanced and I shall outline our proposed measures below.” Source location 2020-0097-Response-from-Lincolnshire-County-Council_Redacted
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 A teacher marshals pupils at the school gate, providing a safe alternative to a light-controlled crossing despite unmet eligibility criteria.
Verbatim wording from the response “c. Unusually for a large academy the vast majority of pupils access this school by coach/bus. The school roll shows that only 15 children live in Leadenham and 16 children live in Welbourn and physical counts at exit time showed less than 50 pupils cross the road. As such this location does not meet the minimum criteria to provide a light controlled crossing. However, the school has now provided a teacher to effectively marshal and hold students at the school gate until it is safe to cross the road; effectively providing a safe method of crossing.” Source location 2020-0097-Response-from-Lincolnshire-County-Council_Redacted
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 A School Safety Zone is unsuitable because this secondary-school location lacks primary-school characteristics and has no recent pedestrian collision history.
Verbatim wording from the response “With regard to your second point, the school entrance benefits from both advance warning triangles and a 30mph speed limit. There is no School Safety Zone present in the vicinity as these are largely designed for primary schools where pupils will generally have less road safety awareness and where parking around school entrances may be an issue. These factors do not apply to this location. Further, we confirm that we have no record of any other incident involving a pedestrian at this location within the last 20 years.” Source location 2020-0097-Response-from-Lincolnshire-County-Council_Redacted
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 A temporary 20 mph limit will not be implemented because evidence of speed reduction is debated and the County Council has no such policy.
Verbatim wording from the response “e. The benefits of a temporary speed limit are a matter of debate nationally as evidence suggests such a measure may not have the effect of reducing average speeds. The County Council does not therefore have a policy of implementing temporary speed limits of 20 mph in place. However, as mentioned above it is agreed that the conspicuity of the school entrance can be enhanced. Therefore, we will carry out works this year to place improved roadmarkings including SLOW and yellow SCHOOL zig-zag markings adjacent to the entrance. We will also install additional school warning signs and finally we will provide school amber flashing lights to raise awareness at start and finish times.” Source location 2020-0097-Response-from-Lincolnshire-County-Council_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 School staff at the pedestrian exit provide a suitable alternative because pupil numbers do not justify a School Crossing Patrol.
Verbatim wording from the response “d. Similarly, whilst a School Crossing Patrol does not meet the necessary criteria in terms of numbers of pupils who would use that patrol, as the school have volunteered the services of their staff at the pedestrian exit this provides a suitable alternative that ameliorates the risk.” Source location 2020-0097-Response-from-Lincolnshire-County-Council_Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The existing one-way school access system is considered safest because reversing it would obstruct visibility and prevent road crossing.
Verbatim wording from the response “With regard to your third point, a joint examination with the Academy of the school's vehicular access arrangements, which currently operate as a one-way system utilising the northern access and southern exit, was carried out at school exit times. For the internal operation within the school premises, of children boarding and exiting buses, this is the safest option. An option to reverse this arrangement was considered but it was agreed this would create queuing vehicles on the highway which would obscure pedestrian and vehicle visibility and, at worst, actually prevent crossing of the road.” Source location 2020-0097-Response-from-Lincolnshire-County-Council_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 Guardrails are not reasonably practicable because widening, utility conflicts, reduced visibility and pedestrian risks would create safety problems.
Verbatim wording from the response “a. At this location the width of the footway is such that the installation of guardrail would require significant widening works and affect underground utility services. Safety concerns would also be created due to reduced highway visibility for properties opposite the school; and also the risk that pedestrians may be tempted to walk outside the barrier if the footpath was occupied by other waiting pedestrians. It is not considered to be reasonably practicable to provide guardrail taking into account the above issues.” Source location 2020-0097-Response-from-Lincolnshire-County-Council_Redacted
Open published response
5 Dec 2019 Darren WILSON · Prevention of Future Deaths report Lincolnshire
View report summary
Concerns raised 2 Failure to provide an appropriate reduced speed limit at the hazardous location View source Failure to deploy double white lines at the hazardous location View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Darren WILSON · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Darren WILSON died at the scene after his car collided with vehicles during an overtaking manoeuvre on 20 April 2019. The inquest heard concerns that the collision location was a known accident hotspot and lacked traffic-calming measures, including a reduced speed limit and double white lines to prevent overtaking.
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 Lincolnshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide an appropriate reduced speed limit at the hazardous location
Wider context from the report “i. The Inquest heard from a Forensic Collision Investigator and a local resident who was also a former Highways Officer who both confirmed that the location of the collision was a notorious accident "hotspot", in that whilst there had been no previous fatalities, there had been innumerable "near misses" as well as non-fatal road traffic collisions;
ii. The inherent danger of the location arose because of a lack of traffic calming measures such as a reduction of the speed limit at this location as well as deployment of double white lines to inform drivers of the potential hazard and to prevent overtaking;
” 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 Lincolnshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to deploy double white lines at the hazardous location
Wider context from the report “i. The Inquest heard from a Forensic Collision Investigator and a local resident who was also a former Highways Officer who both confirmed that the location of the collision was a notorious accident "hotspot", in that whilst there had been no previous fatalities, there had been innumerable "near misses" as well as non-fatal road traffic collisions;
ii. The inherent danger of the location arose because of a lack of traffic calming measures such as a reduction of the speed limit at this location as well as deployment of double white lines to inform drivers of the potential hazard and to prevent overtaking ;
” Open source report
7 Mar 2019 Matthew Bilby · Prevention of Future Deaths report Lincolnshire
View report summary
Concerns raised 1 Dangerous and confusing layout of the A16/B1166 junction View source
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AI-generated summary
Matthew Bilby · 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
Matthew Bilby died after his motorcycle collided with a DAF Tipper Heavy Goods Vehicle at the A16/B1166 junction in Spalding, Lincolnshire, on 6 September 2018. He sustained extensive internal injuries and was pronounced dead at the scene. Concerns included evidence that the junction was dangerous and confusing, was an accident blackspot, had been the site of four fatalities, and posed an ongoing risk to road users.
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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 Lincolnshire County Council; that does not assign responsibility.
PFD Monitor interpretation Dangerous and confusing layout of the A16/B1166 junction
Wider context from the report “1. The court heard evidence from a number of current regular road users describing the layout of the A16/B1166 junction as "dangerous", "horrendous", "confusing" and "difficult" ;
2. In evidence the Lincolnshire Police confirmed that this was the fourth fatality at this junction ;
3. The junction was created as a "staggered" junction in August 2010. Following one of the previous fatalities at the junction further work had been undertaken with red thermoplastic laid in hatched areas;
4. Expert evidence received from the East Midlands Operational Support Service Serious Collision Investigation Unit confirmed the junction to be an "accident blackspot" and that the staggered junction created an on-going risk to future road users in that:
a. This junction should be reconfigured as a roundabout;
b. Alternatively there should be the deployment of considered traffic calming measures (cameras, traffic lights, speed restrictions).
” 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 Continue monitoring funding opportunities for constructing the proposed roundabout.
Verbatim wording from the response “1. We would continue to monitor funding opportunities for the roundabout and” Source location 2019-0112-Response-by-Lincolnshire-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 Lack of available funding prevents delivery of the proposed roundabout and makes further road safety improvements difficult.
Verbatim wording from the response “I have noted the comments made by the Secretary of State, specifically that 'the responsibility for traffic management on local roads rests with the relevant local highway authority.' However, as set out in the Council's response dated 11 June 2019 to the Regulation 28 Report, there is currently no funding available for the Council to proceed with a project to construct a four-arm roundabout at this location.” Source location 2019-0112-Response-by-Lincolnshire-County-Council
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18 Apr 2018 Harry James Jellicoe · Prevention of Future Deaths report Lincolnshire
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Concerns raised 3 Failure of the current speed limit to provide an appropriately low speed for restricted visibility at the bridge View source Restricted visibility through the bridge arch preventing identification of opposing traffic View source Lack of priority signage where high sided vehicles use the full carriageway 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
Harry James Jellicoe · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Harry James Jellicoe was driving on the A151 in wet conditions when he lost control of his car, which left the carriageway and struck a tree. He suffered severe injuries and died in hospital some days later. The principal concerns included the road’s restricted visibility through a bridge, the absence of a specific speed restriction or priority signage, and the potential hazard posed to unfamiliar drivers; the vehicle also had extensively worn front tyres associated with longstanding misalignment.
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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 Lincolnshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure of the current speed limit to provide an appropriately low speed for restricted visibility at the bridge
Wider context from the report “(V) Although traffic approaching from the West has a clear view of the bridge for some considerable distance, the nature of the landscape is such that it is not possible to see any significant distance beyond the bridge arch to identify traffic, especially high sided vehicles which may be occupying the centre of the carriageway, approaching from the East.
(VI) Similarly, and for the same reasons, traffic approaching from the East has a much reduced view of the approach to the bridge and cannot identify traffic approaching from the West.
(VII) In light of the current signage and proper recommendation that high sided vehicles utilise the centre of the carriageway, given the restricted line of vision through the bridge arch, you may feel that the current speed limit is too high and requires revision . Likewise, there is no signage indicating priority of passage where high sided vehicles are required to utilise the full carriageway.
(VIII) I received evidence that there have been very few reported collisions involving HGV’s at this location, there was a clear consensus among the local drivers who gave evidence that this location posed a significant potential hazard, for the reasons given above, particularly for those motorists who were not familiar with the area.
” 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 Lincolnshire County Council; that does not assign responsibility.
PFD Monitor interpretation Restricted visibility through the bridge arch preventing identification of opposing traffic
Wider context from the report “(V) Although traffic approaching from the West has a clear view of the bridge for some considerable distance, the nature of the landscape is such that it is not possible to see any significant distance beyond the bridge arch to identify traffic, especially high sided vehicles which may be occupying the centre of the carriageway, approaching from the East .
(VI) Similarly, and for the same reasons, traffic approaching from the East has a much reduced view of the approach to the bridge and cannot identify traffic approaching from the West .
(VII) In light of the current signage and proper recommendation that high sided vehicles utilise the centre of the carriageway, given the restricted line of vision through the bridge arch, you may feel that the current speed limit is too high and requires revision. Likewise, there is no signage indicating priority of passage where high sided vehicles are required to utilise the full carriageway.
(VIII) I received evidence that there have been very few reported collisions involving HGV’s at this location, there was a clear consensus among the local drivers who gave evidence that this location posed a significant potential hazard, for the reasons given above, particularly for those motorists who were not familiar with the area.
” 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 Lincolnshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of priority signage where high sided vehicles use the full carriageway
Wider context from the report “(V) Although traffic approaching from the West has a clear view of the bridge for some considerable distance, the nature of the landscape is such that it is not possible to see any significant distance beyond the bridge arch to identify traffic, especially high sided vehicles which may be occupying the centre of the carriageway, approaching from the East.
(VI) Similarly, and for the same reasons, traffic approaching from the East has a much reduced view of the approach to the bridge and cannot identify traffic approaching from the West.
(VII) In light of the current signage and proper recommendation that high sided vehicles utilise the centre of the carriageway, given the restricted line of vision through the bridge arch, you may feel that the current speed limit is too high and requires revision. Likewise, there is no signage indicating priority of passage where high sided vehicles are required to utilise the full carriageway .
(VIII) I received evidence that there have been very few reported collisions involving HGV’s at this location, there was a clear consensus among the local drivers who gave evidence that this location posed a significant potential hazard, for the reasons given above, particularly for those motorists who were not familiar with the area.
” Open source report
24 Oct 2016 Joan Lilian Green · Prevention of Future Deaths report Central Lincolnshire
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Concerns raised 1 Hazardous junction for vehicles turning across southbound traffic 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
Joan Lilian Green · 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
Joan Lilian Green, aged 77, was killed when the Audi in which she was a front-seat passenger was struck by an HGV while turning across the southbound A1 near Marston, Lincolnshire, on 21 March 2015. The principal concern was that the junction was challenging, with evidence of near misses and other fatal collisions involving vehicles turning across southbound traffic, although no road defects were identified as contributory.
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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 Lincolnshire County Council; that does not assign responsibility.
PFD Monitor interpretation Hazardous junction for vehicles turning across southbound traffic
Wider context from the report “(III) I received evidence that in order to assess the likely time taken by the Audi to cross the junction, in the days following this incident, the investigating officer carried out covert surveillance at the junction. During the period of that surveillance, of approximately one hour, he recorded one “near miss” in circumstances identical to the index accident and two further “near miss” incidents . The officer also reported that he observed an HGV waiting for a period of in excess of six minutes prior being able to turn safely across southbound traffic into Toll Bar Road .
(IV) I received evidence that whilst there were no defects with the road which could be classed as contributory to this collision, the nature of the junction may have been a contributory factor . It was described as “challenging” . I was told that since 1985 there had been 4 other fatal road traffic collisions at this junction, two of which involved vehicles turning across Southbound traffic .
” Open source report
23 Mar 2015 Robert Spring · Prevention of Future Deaths report Central Lincolnshire
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Concerns raised 4 Failure of the Air Liquide notification system to transmit smoking-related risk information to LFRS View source Failure by LFRS to assess high-risk Home Oxygen users for safety equipment View source Lack of direct notification of heightened Home Oxygen and smoking risks to LFRS View source Lack of awareness among relevant agencies of available safety equipment for high-risk patients 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.
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AI-generated summary
Robert Spring · 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
Robert Spring, who had chronic obstructive pulmonary disease and used home oxygen while smoking, died in a fire at his home on 14 March 2014. The fire was attributed to either a cigarette lighter or a dropped cigarette. The principal concerns were that relevant agencies were not fully informed of his smoking-related risk, so he was not assessed for available fire-safety equipment, and that more extensive communication between agencies was needed.
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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 Lincolnshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure of the Air Liquide notification system to transmit smoking-related risk information to LFRS
Wider context from the report “(I) Mr Spring was identified at the initial hospital assessment as being at high risk by virtue of his use of Home Oxygen and also by virtue of his smoking habit. There was no mechanism in place whereby such risk could be notified directly to LFRS notwithstanding that Mr Spring had expressly consented to his personal information being shared with them. Such reporting was deferred to Air Liquide.
(II) The fact that Mr Spring, as a smoker, was considered to be high risk was confirmed by risk assessments undertaken by representatives of Air Liquide, the Home Oxygen supplier, upon the installation of the Home Oxygen on 27 March 2013 and upon subsequent service visits undertaken on 19 June 2013 and 8 January 2014.
(III) Although a mechanism existed for the communication of that increased risk to LFRS by Air Liquide, a facet of their system, designed to prevent duplicate notifications being delivered, operated to prevent notification of his status as a smoker and LFRS were notified only that Mr Spring was a user of Home Oxygen.
(IV) Evidence was given at Inquest that LFRS have available, free of charge, a variety of safety equipment for those most at risk of such incidents. Such equipment comprises both smoke and carbon monoxide alarms, flame retardant bedding and portable “misting systems”.
(V) The absence of full notification to LFRS meant that the extent of the risk to which Mr Spring was exposed was not identified. As a consequence, he was not assessed by LFRS for the provision of the safety equipment described above.
(VI) Whilst a number of Properly Interested Persons have already met to discuss the concerns raised by this death, and whilst Air Liquide have already taken steps to ensure that their internal systems are more robust, there remains a need to put in place more extensive lines of communication between all relevant agencies, to ensure that the heightened risks posed by such patients are drawn to the attention of LFRS at the earliest opportunity.
(VII) Evidence was also given at Inquest that the availability of such safety equipment is not well known, and that by increased publicity to the relevant agencies in relation to their availability, there may be a wider distribution of such material with a consequential saving of lives.
” 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 Lincolnshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure by LFRS to assess high-risk Home Oxygen users for safety equipment
Wider context from the report “(I) Mr Spring was identified at the initial hospital assessment as being at high risk by virtue of his use of Home Oxygen and also by virtue of his smoking habit. There was no mechanism in place whereby such risk could be notified directly to LFRS notwithstanding that Mr Spring had expressly consented to his personal information being shared with them. Such reporting was deferred to Air Liquide.
(II) The fact that Mr Spring, as a smoker, was considered to be high risk was confirmed by risk assessments undertaken by representatives of Air Liquide, the Home Oxygen supplier, upon the installation of the Home Oxygen on 27 March 2013 and upon subsequent service visits undertaken on 19 June 2013 and 8 January 2014.
(III) Although a mechanism existed for the communication of that increased risk to LFRS by Air Liquide, a facet of their system, designed to prevent duplicate notifications being delivered, operated to prevent notification of his status as a smoker and LFRS were notified only that Mr Spring was a user of Home Oxygen.
(IV) Evidence was given at Inquest that LFRS have available, free of charge, a variety of safety equipment for those most at risk of such incidents. Such equipment comprises both smoke and carbon monoxide alarms, flame retardant bedding and portable “misting systems”.
(V) The absence of full notification to LFRS meant that the extent of the risk to which Mr Spring was exposed was not identified. As a consequence, he was not assessed by LFRS for the provision of the safety equipment described above.
(VI) Whilst a number of Properly Interested Persons have already met to discuss the concerns raised by this death, and whilst Air Liquide have already taken steps to ensure that their internal systems are more robust, there remains a need to put in place more extensive lines of communication between all relevant agencies, to ensure that the heightened risks posed by such patients are drawn to the attention of LFRS at the earliest opportunity.
(VII) Evidence was also given at Inquest that the availability of such safety equipment is not well known, and that by increased publicity to the relevant agencies in relation to their availability, there may be a wider distribution of such material with a consequential saving of lives.
” 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 Lincolnshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of direct notification of heightened Home Oxygen and smoking risks to LFRS
Wider context from the report “(I) Mr Spring was identified at the initial hospital assessment as being at high risk by virtue of his use of Home Oxygen and also by virtue of his smoking habit. There was no mechanism in place whereby such risk could be notified directly to LFRS notwithstanding that Mr Spring had expressly consented to his personal information being shared with them. Such reporting was deferred to Air Liquide.
(II) The fact that Mr Spring, as a smoker, was considered to be high risk was confirmed by risk assessments undertaken by representatives of Air Liquide, the Home Oxygen supplier, upon the installation of the Home Oxygen on 27 March 2013 and upon subsequent service visits undertaken on 19 June 2013 and 8 January 2014.
(III) Although a mechanism existed for the communication of that increased risk to LFRS by Air Liquide, a facet of their system, designed to prevent duplicate notifications being delivered, operated to prevent notification of his status as a smoker and LFRS were notified only that Mr Spring was a user of Home Oxygen.
(IV) Evidence was given at Inquest that LFRS have available, free of charge, a variety of safety equipment for those most at risk of such incidents. Such equipment comprises both smoke and carbon monoxide alarms, flame retardant bedding and portable “misting systems”.
(V) The absence of full notification to LFRS meant that the extent of the risk to which Mr Spring was exposed was not identified. As a consequence, he was not assessed by LFRS for the provision of the safety equipment described above.
(VI) Whilst a number of Properly Interested Persons have already met to discuss the concerns raised by this death, and whilst Air Liquide have already taken steps to ensure that their internal systems are more robust, there remains a need to put in place more extensive lines of communication between all relevant agencies, to ensure that the heightened risks posed by such patients are drawn to the attention of LFRS at the earliest opportunity.
(VII) Evidence was also given at Inquest that the availability of such safety equipment is not well known, and that by increased publicity to the relevant agencies in relation to their availability, there may be a wider distribution of such material with a consequential saving of lives.
” 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 Lincolnshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness among relevant agencies of available safety equipment for high-risk patients
Wider context from the report “(I) Mr Spring was identified at the initial hospital assessment as being at high risk by virtue of his use of Home Oxygen and also by virtue of his smoking habit. There was no mechanism in place whereby such risk could be notified directly to LFRS notwithstanding that Mr Spring had expressly consented to his personal information being shared with them. Such reporting was deferred to Air Liquide.
(II) The fact that Mr Spring, as a smoker, was considered to be high risk was confirmed by risk assessments undertaken by representatives of Air Liquide, the Home Oxygen supplier, upon the installation of the Home Oxygen on 27 March 2013 and upon subsequent service visits undertaken on 19 June 2013 and 8 January 2014.
(III) Although a mechanism existed for the communication of that increased risk to LFRS by Air Liquide, a facet of their system, designed to prevent duplicate notifications being delivered, operated to prevent notification of his status as a smoker and LFRS were notified only that Mr Spring was a user of Home Oxygen.
(IV) Evidence was given at Inquest that LFRS have available, free of charge, a variety of safety equipment for those most at risk of such incidents. Such equipment comprises both smoke and carbon monoxide alarms, flame retardant bedding and portable “misting systems”.
(V) The absence of full notification to LFRS meant that the extent of the risk to which Mr Spring was exposed was not identified. As a consequence, he was not assessed by LFRS for the provision of the safety equipment described above.
(VI) Whilst a number of Properly Interested Persons have already met to discuss the concerns raised by this death, and whilst Air Liquide have already taken steps to ensure that their internal systems are more robust, there remains a need to put in place more extensive lines of communication between all relevant agencies, to ensure that the heightened risks posed by such patients are drawn to the attention of LFRS at the earliest opportunity.
(VII) Evidence was also given at Inquest that the availability of such safety equipment is not well known , and that by increased publicity to the relevant agencies in relation to their availability, there may be a wider distribution of such material with a consequential saving of lives.
” Open source report
16 Mar 2015 Joshua David Booth · Prevention of Future Deaths report Central Lincolnshire
View report summary
Concerns raised 3 Failure to provide appropriately located and informative warning signage for road subsidence View source Failure to provide suitable roadside protection at the foot of the bank View source Failure to maintain the road in a safe condition following subsidence 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
Joshua David Booth · 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
Joshua David Booth sustained fatal injuries after his vehicle lost control on a heavily subsided section of road, collided with a wooden post and entered Fodder Drain. The report identified the road subsidence, inadequate warning signage and the posts at the foot of the bank as serious dangers to motorists and contributory concerns relating to the death.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lincolnshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide appropriately located and informative warning signage for road subsidence
Wider context from the report “(II) Appropriate signage needs to be erected to warn of the imminent danger of the road subsidence . The signage needs to be closer to the section of road in question and should include an appropriate advisory speed limit .
” 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 Lincolnshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide suitable roadside protection at the foot of the bank
Wider context from the report “(III) The posts at the foot of the bank constitute a serious danger to vehicles leaving this section of road . An Armco barrier should be erected along this section of the road to provide security to passing motorists.
” 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 Lincolnshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain the road in a safe condition following subsidence
Wider context from the report “(I) The subsided section of road is seriously substandard and a danger to passing motorists and formed a contributory factor to Mr Booth's death. The section of road requires immediate repair.
” 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 Provide and sign an advisory 40 mph speed limit on Fodderdyke Bank.
Verbatim wording from the response “3. Following an earlier review there is an advisory speed limit of 40 mph on Fodderdyke Bank which is signed accordingly.” Source location 2015-0125-Response-by-Lincolnshire-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 Level the subsided road section with bituminous material to provide a more regular public surface.
Verbatim wording from the response “1. The discrete section of road identified in your report which had been subject to subsidence has now been levelled with bituminous material to provide a more regular surface for the public.” Source location 2015-0125-Response-by-Lincolnshire-County-Council
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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 Erect and retain temporary uneven-road signage, with regular inspection and review.
Verbatim wording from the response “2. Signage exists at regular intervals along the section of Fodderdyke Bank between Stickney and Friskney. Temporary signage was erected which includes the area which has now been repaired. This signage advising of uneven road surface has been left in place and supplements the existing permanent signs. The "uneven road" signage in the area is subject to regular inspection and review.” Source location 2015-0125-Response-by-Lincolnshire-County-Council
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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 Safety barriers cannot be erected without significant structural works because the embankment lacks sufficient strength.
Verbatim wording from the response “Due to the nature of the embankments (constructed from a mixture of clay, peat and silts in general) there is not enough strength to enable safety barriers to be erected without significant structural works to support the barrier.” Source location 2015-0125-Response-by-Lincolnshire-County-Council
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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 Providing safety barriers would be excessively costly and divert limited resources from repairing other county road defects.
Verbatim wording from the response “The cost of providing barriers would be excessive and divert resources from repairing the defects and failings in the road construction throughout the County and would not be best use of limited resources.” Source location 2015-0125-Response-by-Lincolnshire-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