5 Nov 2024 Terence William Gillard · Prevention of Future Deaths report West London
View report summary
Concerns raised 2 Lack of certainty that the pedestrian crossing safety redesign will be implemented View source Absence of effective pedestrian crossing controls at Jersey Road View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Terence William Gillard · 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
Terence William Gillard was struck by a moving vehicle while crossing the A4 Great West Road at an uncontrolled pedestrian crossing on 11 September 2022. He suffered brain and multiple traumatic injuries and died in hospital on 18 September 2022 from a pulmonary embolism. The concern was that the crossing had no pedestrian traffic lights, demand button or sound signals, and that there was no certainty that proposed safety redesigns would be implemented.
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 London Borough of Hounslow; that does not assign responsibility.
PFD Monitor interpretation Lack of certainty that the pedestrian crossing safety redesign will be implemented
Wider context from the report “The A4 Great West Road is a major route for vehicles of all types travelling in and out of west London. The crossing area, where Mr Gillard collided with the moving vehicle on 11 September 2022, is a designated uncontrolled crossing area across Jersey Road. There are no pedestrian traffic lights, no demand button, no sound signals. This pedestrian crossing area spans across a dual carriageway subject to a speed limit of 40mph. It has three lanes in both directions, separated by a raised central kerb. This crossing point also leads pedestrians into the cycling lane.
I understand that at no point during the normal use of the traffic light controlled junction does traffic cease to flow at the marked crossing area, making it difficult for pedestrian to judge when and from where the next vehicle would approach. This means that pedestrians will need to use their own judgment as to when it is safe to cross this road without the aid of pedestrian traffic lights.
I received evidence that there have been other accidents involving pedestrians and moving vehicles at this pedestrian crossing in the past.
I received evidence from the TFL of existing plans to re-design this pedestrian crossing to improve pedestrian safety. However, their implementation may not take place before the end of 2026 and it remains subject to the consent of the DFT and LBH, the outcome of any public consultation as well as funding considerations.
I am concerned that there appears to be no certainty that the redesign plans for the pedestrian crossing in question will be implemented .
I understand that the TFL, LBH and DFT are the organisations with the power to take the necessary actions to improve pedestrian safety at this junction.
” 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 London Borough of Hounslow; that does not assign responsibility.
PFD Monitor interpretation Absence of effective pedestrian crossing controls at Jersey Road
Wider context from the report “The A4 Great West Road is a major route for vehicles of all types travelling in and out of west London. The crossing area, where Mr Gillard collided with the moving vehicle on 11 September 2022, is a designated uncontrolled crossing area across Jersey Road. There are no pedestrian traffic lights, no demand button, no sound signals. This pedestrian crossing area spans across a dual carriageway subject to a speed limit of 40mph. It has three lanes in both directions, separated by a raised central kerb. This crossing point also leads pedestrians into the cycling lane.
I understand that at no point during the normal use of the traffic light controlled junction does traffic cease to flow at the marked crossing area , making it difficult for pedestrian to judge when and from where the next vehicle would approach. This means that pedestrians will need to use their own judgment as to when it is safe to cross this road without the aid of pedestrian traffic lights .
I received evidence that there have been other accidents involving pedestrians and moving vehicles at this pedestrian crossing in the past.
I received evidence from the TFL of existing plans to re-design this pedestrian crossing to improve pedestrian safety. However, their implementation may not take place before the end of 2026 and it remains subject to the consent of the DFT and LBH, the outcome of any public consultation as well as funding considerations.
I am concerned that there appears to be no certainty that the redesign plans for the pedestrian crossing in question will be implemented.
I understand that the TFL, LBH and DFT are the organisations with the power to take the necessary actions to improve pedestrian safety at this junction.
” 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 Conduct discussions and site meetings with TfL to improve A4 traffic conditions for vulnerable road users.
Verbatim wording from the response “Following the incident, we have had a number of discussions and site meetings with TfL to improve traffic conditions in the A4 especially for the vulnerable road users. We understand that TfL has undertaken a detailed study of the collision data in the area and is now reviewing the junction with a view to provide a formal pedestrian crossing facility at this location.” Source location Response from London Borough of Hounslow
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with TfL and stakeholders to secure priority implementation of the proposed pedestrian and cyclist crossing safety measures.
Verbatim wording from the response “- a signal-controlled crossing for pedestrian and cyclists across the A4,” Source location Response from London Borough of Hounslow
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 Consult on TfL’s proposed crossing designs and ensure they are technically sound and aligned with local users’ needs.
Verbatim wording from the response “The proposals being considered are amending the existing design to accommodate improvements as follows.” Source location Response from London Borough of Hounslow
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with TfL to facilitate interim temporary pedestrian warning signs at the crossing location.
Verbatim wording from the response “We are also working with TfL to facilitate some interim temporary measures such as additional signs to warn pedestrians to take care when crossing the road at this location.” Source location Response from London Borough of Hounslow
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 TfL is responsible for safety, maintenance, signs and signals on the A4, while the borough’s highway authority role is limited to Jersey Road.
Verbatim wording from the response “The incident took place on A4 which is part of the Transport for London Road Network (TLRN) and TfL is the Highways and Traffic Authority for roads that falls under this network. Similarly, TfL is responsible for road maintenance, traffic signs, traffic signals and road safety of TLRN. LBH is the Highway Authority for Jersey Road which forms a junction with the A4.” Source location Response from London Borough of Hounslow
Open published response
27 Sep 2017 Mrs Pamela Craigie · Prevention of Future Deaths report West London
View report summary
Concerns raised 4 Failure to make urgent 1:1 care funding referrals when criteria are met View source Lack of clear criteria and timing for referrals for 1:1 care funding View source Delays in urgent multi-disciplinary team assessments for 1:1 care View source Lack of effective interim management of residents at high risk of falls pending 1:1 care View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mrs Pamela Craigie · 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
Mrs Pamela Craigie died on 19 March 2017 after falling at Cloisters Nursing Home on 24 February 2017 and sustaining an acute subdural haematoma and head injury. The report raised concerns about inconsistent supervision and adherence to her care plan, unclear criteria and processes for referring residents for urgent 1:1 care, delays in urgent assessments, and how residents’ safety was managed while awaiting additional care.
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 London Borough of Hounslow; that does not assign responsibility.
PFD Monitor interpretation Failure to make urgent 1:1 care funding referrals when criteria are met
Wider context from the report “2. That it is 'very difficult' to get funding from the local authority for 1:1 care. I am concerned that applications to the local authority for urgent 1:1 care are not being made, because the Home feel that they have been refused before and that a future application will not be successful . The Home should ensure that where the criteria for 1:1 care is met, that a referral for funding is always made.
” 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 London Borough of Hounslow; that does not assign responsibility.
PFD Monitor interpretation Lack of clear criteria and timing for referrals for 1:1 care funding
Wider context from the report “1. A resident would only be likely to warrant funding for 1:1 care if they were falling "almost every day, or every week". There is no set number of times they would be required to fall. However, it is not clear from the staff who gave evidence, when a referral for funding for 1:1 care should be made to the local authority, and based on what criteria . The Home should ensure that the criteria for 1:1 care is clear to staff.
” 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 London Borough of Hounslow; that does not assign responsibility.
PFD Monitor interpretation Delays in urgent multi-disciplinary team assessments for 1:1 care
Wider context from the report “3. If the Home does consider that a resident needs urgent 1:1 care e.g. because of a very high risk of falls, the Home sends a referral form to the London Borough of Hounslow. In their experience it takes two, or two-and-a-half weeks, for the urgent multi-disciplinary team (MDT) meeting to occur . This seems to be a very long time for an urgent 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 London Borough of Hounslow; that does not assign responsibility.
PFD Monitor interpretation Lack of effective interim management of residents at high risk of falls pending 1:1 care
Wider context from the report “4. Following the above, in the interim, the Home informs the family that the resident is a high risk of falls, but it is not clear how the high risk is managed effectively until 1:1 care is put in place (or until the MDT meeting) . The Home should ensure that steps are taken to ensure the safety of the resident in the interim.
” Open source report
3 Oct 2016 Amy El-Keria · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 5 Failure to assess and provide support for family contact when children are placed far from home View source Inadequate staffing levels for one-to-one care in inpatient CAMHS units View source Shortage of acute mental health beds near young people's homes View source Failure to maintain an ongoing welfare-support role for children placed at external facilities View source Lack of national staffing guidance for inpatient CAMHS units View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Amy El-Keria · 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
Amy El-Keria, aged 14, died on 13 November 2012 after tying a ligature around her neck and suspending herself from a radiator while receiving inpatient mental health care. The inquest identified concerns about staffing levels being insufficient to provide the one-to-one support in her care plan and the shortage of acute mental health beds for young people close to home, limiting family support.
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 London Borough of Hounslow; that does not assign responsibility.
PFD Monitor interpretation Failure to assess and provide support for family contact when children are placed far from home
Wider context from the report “(2) Social Services clearly have a vital role to play in ensuring family contact where a child is placed far from their family home where difficulties arise. There was no assessment carried out to assess whether there was any need to provide support to a child in need under Section 17 Children Act 1989 even when Amy’s mother had specifically raised the difficulties she was having with contact with Amy, including the cost of travel, with her support worker .
” 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 London Borough of Hounslow; that does not assign responsibility.
PFD Monitor interpretation Inadequate staffing levels for one-to-one care in inpatient CAMHS units
Wider context from the report “(1) The Jury in this Inquest found that the staffing levels, which were in line with the ONIC staffing ratio, were inadequate to give Amy sufficient one to one time in accordance with her care plan . It is understood that in December 2014 the Department of Health tasked NICE with developing guidance on staffing levels for inpatient CAMHS units but this appears to have been discontinued. There is currently no national guidance on staffing levels for inpatient CAHMS
” 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 London Borough of Hounslow; that does not assign responsibility.
PFD Monitor interpretation Shortage of acute mental health beds near young people's homes
Wider context from the report “(2) There continues to be a shortage of acute mental health beds for young people close to where they live . This means that families have to travel long distances to visit their child and they are unable to provide the necessary day to day support to their child. Family support can play a very significant role in managing risk of suicide by avoiding and mitigating distress.
” 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 London Borough of Hounslow; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain an ongoing welfare-support role for children placed at external facilities
Wider context from the report “(1) The evidence given at the Inquest showed that there was a clear misapprehension by Hounslow Social Services as to their role in supporting Amy whilst at Ticehurst . It appears that Social services did not appreciate their important ongoing role to ensure Amy’s welfare whilst placed at Ticehurst████████ the Court expert, gave evidence that Hounslow may have seen this as a health funded placement as a stand-alone intervention that did not require their input.
” 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 London Borough of Hounslow; that does not assign responsibility.
PFD Monitor interpretation Lack of national staffing guidance for inpatient CAMHS units
Wider context from the report “(1) The Jury in this Inquest found that the staffing levels, which were in line with the ONIC staffing ratio, were inadequate to give Amy sufficient one to one time in accordance with her care plan. It is understood that in December 2014 the Department of Health tasked NICE with developing guidance on staffing levels for inpatient CAMHS units but this appears to have been discontinued . There is currently no national guidance on staffing levels for inpatient CAHMS
” Open source report
17 Aug 2015 Ian David Morley · Prevention of Future Deaths report West London
View report summary
Concerns raised 2 Failure to conduct a fresh risk assessment following deterioration in condition View source Inadequate fire risk management 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
Ian David Morley · 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
Ian David Morley, a wheelchair-bound resident in supported accommodation with multiple sclerosis, died after being found alight in his wheelchair, apparently after a cigarette fell onto a towel covering the seat. Concerns included the absence of a fresh risk assessment after his condition deteriorated and inadequate fire risk management at Greenrod Place.
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 London Borough of Hounslow; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct a fresh risk assessment following deterioration in condition
Wider context from the report “1. The multiple sclerosis nurse who had been working with the deceased noted that his condition had deteriorated shortly before his death. This should have prompted a fresh risk assessment but it was not evident that it did, in fact, do so .
” 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 London Borough of Hounslow; that does not assign responsibility.
PFD Monitor interpretation Inadequate fire risk management
Wider context from the report “2. There was inadequate fire risk management at Greenrod Place
” Open source report
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations