17 Apr 2018 Matthew James WILMOT · Prevention of Future Deaths report Bedfordshire and Luton
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Concerns raised 2 Insufficient consideration of unique-route risks in path risk assessments View source Pedestrian use of uniquely routed closed paths View source
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. 2
Action
Make the amended briefing mandatory in new-operative induction and refresh it for existing operatives every six months.
View source
Action
Amend the operative briefing to require assessment of alternative pedestrian routes and supervisory escalation for unsuitable routes at unique locations.
View source
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AI-generated summary
Matthew James WILMOT · 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 James WILMOT went out with friends to watch the FA Cup Final and was dropped off near his home at 00.45 hours on 28 May 2017. At 07:14, he was found upside down in an excavated hole on a closed path. The principal concern was that the risk assessment did not give enough consideration to the different risks of a unique route, where pedestrians may be more likely to use the shortest path despite barriers and closure signs.
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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 M & S Water Services (Utilities) Limited; that does not assign responsibility.
PFD Monitor interpretation Insufficient consideration of unique-route risks in path risk assessments
Wider context from the report “The accident happened on a path which had been excavated to find a stop cock. The excavation had been abandoned as a Deep Excavation Team was required. The path was closed by placing a sign at each end of the path stating that the path was closed. The hole and spoil were fenced off by using a metal railed fence which was alongside the path and 4 plastic yellow barriers which were secured to the metal fence. A risk assessment had taken place.
The evidence was that the risk assessment was in line with the Red Book and Industry Standards. The Red Book encourages a risk assessment based on the locality, footfall, etcetera. My concern is that not enough consideration was given to the nature of the path .
To all intents and purposes there are two types of paths. The most common is the path that runs parallel to a highway. If that path is closed, the pedestrian can be guided around the excavation or told to cross the road. It is unlikely that the pedestrian would walk through a barriered area in such circumstances as that would be slower than walking around it.
The second type of path is one that is unique in its journey from A to B, ie there is no road to the side. This particular path lead from the road to a row of houses, which were not accessible by road. The alternative route (which was not signposted) was 150 metres away, meaning a diversion of about 300 metres.
The path was not located in an area of risk.
However, my concern is that a route that is unique is always at risk as pedestrians will want to travel the shortest route. This is backed up by the evidence in the Inquest which recorded 9 pedestrians (including the deceased) travelling through the closed path in the 7 hours before the deceased was found. The excavators took photographs of the site just before they left it. Looking at those photographs, I would have risked walking down the closed path.
My concern is that there is not enough emphasis within the risk assessment process that a route that is unique has different risks to a path that is parallel .
” 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 M & S Water Services (Utilities) Limited; that does not assign responsibility.
PFD Monitor interpretation Pedestrian use of uniquely routed closed paths
Wider context from the report “The accident happened on a path which had been excavated to find a stop cock. The excavation had been abandoned as a Deep Excavation Team was required. The path was closed by placing a sign at each end of the path stating that the path was closed. The hole and spoil were fenced off by using a metal railed fence which was alongside the path and 4 plastic yellow barriers which were secured to the metal fence. A risk assessment had taken place.
The evidence was that the risk assessment was in line with the Red Book and Industry Standards. The Red Book encourages a risk assessment based on the locality, footfall, etcetera. My concern is that not enough consideration was given to the nature of the path.
To all intents and purposes there are two types of paths. The most common is the path that runs parallel to a highway. If that path is closed, the pedestrian can be guided around the excavation or told to cross the road. It is unlikely that the pedestrian would walk through a barriered area in such circumstances as that would be slower than walking around it.
The second type of path is one that is unique in its journey from A to B, ie there is no road to the side. This particular path lead from the road to a row of houses, which were not accessible by road. The alternative route (which was not signposted) was 150 metres away, meaning a diversion of about 300 metres.
The path was not located in an area of risk.
However, my concern is that a route that is unique is always at risk as pedestrians will want to travel the shortest route . This is backed up by the evidence in the Inquest which recorded 9 pedestrians (including the deceased) travelling through the closed path in the 7 hours before the deceased was found . The excavators took photographs of the site just before they left it. Looking at those photographs, I would have risked walking down the closed path.
My concern is that there is not enough emphasis within the risk assessment process that a route that is unique has different risks to a path that is parallel.
” 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 Make the amended briefing mandatory in new-operative induction and refresh it for existing operatives every six months.
Verbatim wording from the response “The briefing will be a mandatory part of the induction process for any new operatives and will be refreshed for all existing operatives at six monthly intervals.” Source location 2018-0107-Response-by-M-S-Water-Services
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 Amend the operative briefing to require assessment of alternative pedestrian routes and supervisory escalation for unsuitable routes at unique locations.
Verbatim wording from the response “It is submitted that the additional guidance given to operatives within three days of the accident on 28 May 2017 should assuage the concern regarding unique sites and whether or not there is sufficient focus in the risk assessment process on the likelihood of the public using the alternative route. It will be appreciated that on the Devon Road site the M&S operatives were required to complete the Amey Utility Services Limited risk assessment template.” Source location 2018-0107-Response-by-M-S-Water-Services
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 Additional operative guidance is considered sufficient to address concerns about unique sites and public use of alternative routes.
Verbatim wording from the response “It is submitted that the additional guidance given to operatives within three days of the accident on 28 May 2017 should assuage the concern regarding unique sites and whether or not there is sufficient focus in the risk assessment process on the likelihood of the public using the alternative route. It will be appreciated that on the Devon Road site the M&S operatives were required to complete the Amey Utility Services Limited risk assessment template.” Source location 2018-0107-Response-by-M-S-Water-Services
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 Job planning and identifying unique locations are assigned to the Job Initiator and Job Planner, not M&S.
Verbatim wording from the response “It is important to stress that M&S does not fulfil the role of the Job Initiator or Job Planner. The evidence of Amey (paragraph 4.5 of statement dated 14th December 2017) was that the Job Planner reviews the job for any special requirements based on the Job Initiator's comments. The process involves a visit to the site by the Customer Services Technician. To this extent there is also the opportunity within the planning / permitting process to identify any 'unique' locations.” Source location 2018-0107-Response-by-M-S-Water-Services
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations