Concerns raised 1 Failure to provide pedestrian guardrails at a primary informal crossing 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
Charlotte Marie SAUNDERS · 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
Charlotte Marie Saunders was struck by a tipper lorry while crossing Christchurch Way in Stone, Staffordshire, on 27 August 2024, sustaining multiple injuries and a severe traumatic brain injury that resulted in prolonged disorder of consciousness and 24-hour care. She died on 13 January 2026; the principal concern was that the road layout, including gaps in pedestrian guardrails between a supermarket and the town centre, encouraged pedestrians to cross at an unsafe location near a busy bypass despite nearby controlled crossings.
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 National Highways; that does not assign responsibility.
PFD Monitor interpretation Failure to provide pedestrian guardrails at a primary informal crossing location
Wider context from the report “I have concern that there is a risk of future deaths as a result of the current layout of this location, given the following:
1. The ring road is a busy road with heavy, consistent traffic flow, this being a bypass around the town centre
2. There is a busy supermarket with a large car park on one side of the ring road and the town centre on the other
3. There is a purpose-built pedestrian walkway leading to the pavement on the outer side of the carriageway and an alleyway leading directly into the town centre on the other side
4. There are no pedestrian guardrails either side of the carriageway at what appears to be a primary location used by people for their speed and convenience, to avoid the need to walk further to use the pedestrian crossings
” Open source report
12 Feb 2026 Rita Margaret Thomas and Christine Dale · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 1 Failure to set a speed limit that provides sufficient reaction time at the A684 junction View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Rita Margaret Thomas and Christine Dale · 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
On 19 September 2024, Rita Thomas was driving and Christine Dale was a passenger when their vehicle collided with a bus on the M6 Junction 37 exit ramp, causing both to sustain life-ending injuries. The principal concern was that the national speed limit on the A684, together with the junction design, may give drivers insufficient time to react when a vehicle crosses their path.
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 National Highways; that does not assign responsibility.
PFD Monitor interpretation Failure to set a speed limit that provides sufficient reaction time at the A684 junction
Wider context from the report “(1) The exit ramps at Junction 37 of the M6 are recognised to be 'high harm' spots. Several very serious collisions have occurred at the same location. Significant efforts have been made to address this, including by placing stop signs, increasing the visibility of signs, and improving driver awareness. However, the A684 remains the subject of the National Speed Limit. I was informed that no speed limit was imposed because previous investigation 'did not highlight a speeding problem'. The evidence I heard included an observation by the driver of the bus that: "At the point where I first saw the car, I was only a few metres away from the top of the slip road. The dark car was travelling up the slip road from my left-hand side. I must have only been aware of its presence for a matter of one or two seconds...I did not have any time to react or take any evasive action. As far as I recall I did not have time to brake or steer to try and avoid the collision."
For the avoidance of doubt, the evidence indicates that the bus was being driven at less than the national speed limit.
I am concerned that this indicates that the speed at which vehicles are permitted to drive on the A684, taken with the design of the junction, gives drivers insufficient time to react in the event that a vehicle crosses into their path.
” 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 Upgrade approach signing and install STOP signs, approach lane delineation markings, and transverse yellow markings at the junction.
Verbatim wording from the response “As a direct result, the already substantial, approach signing has been upgraded and improved, ‘STOP’ signing and approach lane delineation markings have been installed” Source location 2026-0093 - Response from National Highways
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 Changes to the National Speed Limit on the A684 are the responsibility of Westmorland and Furness Council, not National Highways.
Verbatim wording from the response “To clarify, any changes to the current National Speed Limit along this section of the A684 would be the responsibility of Westmorland and Furness Council and not National Highways.” Source location 2026-0093 - Response from National Highways
Open published response
Concerns raised 4 Hazardous road layout requiring right-turning vehicles to cross multiple traffic-control areas View source Ambiguity in legal guidance on right turns across double solid white lines View source Lack of left-turn-only signage at the Moss Farm Shop exit View source Failure of road markings to prevent prohibited overtaking and right turns View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Nathan Thomas CYSTER · 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
Nathan Thomas Cyster died at the scene on 29 March 2025 after his motorcycle collided with a BMW X5 on the A5 Watling Street. The report identifies concerns about the hazardous right-turn layout at the Moss Farm Shop exit, the absence of left-turn-only signage, ineffective road markings against prohibited overtaking, and ambiguity in legal guidance about right turns across double white lines.
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 National Highways; that does not assign responsibility.
PFD Monitor interpretation Hazardous road layout requiring right-turning vehicles to cross multiple traffic-control areas
Wider context from the report “1. Hazardous Right-Turn Manoeuvre Across Multiple Lanes and Road Markings
Vehicles exiting Moss Farm Shop are currently required to cross a lane of traffic approaching from their right, traverse double solid white lines, and pass through a right-turn filter lane before entering the main carriageway. This configuration necessitates crossing areas specifically marked to restrict overtaking and protect turning movements, creating a complex and potentially hazardous manoeuvre for drivers.
” 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 National Highways; that does not assign responsibility.
PFD Monitor interpretation Ambiguity in legal guidance on right turns across double solid white lines
Wider context from the report “4. Ambiguity in Legal Guidance Regarding Right Turns Across Double White Lines
The inquest was told that there is ambiguity and contradiction in the guidance regarding the legality of turning right out of premises across double solid white lines at the location of Moss Farm Shop. As per the police report:
“It would appear that the rules surrounding crossing double white lines to enter and exit junctions and premises is a little more ambiguous. The Highway Code mentioning only entry into, whilst a government website states entry and exit. ”
This contradiction may lead to different drivers having different understandings of the law and whether they would anticipate vehicles turning right out of the farm shop across double white lines.
” 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 National Highways; that does not assign responsibility.
PFD Monitor interpretation Lack of left-turn-only signage at the Moss Farm Shop exit
Wider context from the report “2. Absence of Left-Turn Only Signage at Moss Farm Shop
There is no “left turn only” signage—either in the form of a mandatory highway sign or an advisory sign positioned by the Farm itself—at the Moss Farm Shop exit. This is in contrast to other nearby businesses along the A5, which display such signage to discourage or prohibit right turns across the carriageway.
” 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 National Highways; that does not assign responsibility.
PFD Monitor interpretation Failure of road markings to prevent prohibited overtaking and right turns
Wider context from the report “3. Ineffectiveness of Road Markings in Preventing Prohibited Overtaking
Although the road markings at this location—including double solid white lines and hatched areas—are intended to prohibit overtaking by vehicles (including motorcycles) travelling from Cannock and the Turf Island towards the Moss Farm junction, available evidence demonstrates that these markings are not effective in practice.
CCTV analysis from the day of the collision and a separate 3-hour review period revealed that, within that window, 31 vehicles (28% of all vehicles exiting) turned right out of the Moss Farm Shop, and 7 motorcycles and 1 car overtook on the prohibited section prior to the 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 a site visit and discuss observed traffic movements and overtaking at the A5 location.
Verbatim wording from the response “3. Road markings on the A5 All Purpose Trunk Road (APTR) – National Highways Road Safety engineers conducted a site visit to this location on 9th February 2026 to observe traffic movements, particularly any occurrences of overtaking in contravention of the double white line system. Further to this site visit engineers have undertaken an initial discussion of the results of the site observations on the 10th February 2026.” Source location Response from National Highways
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 Investigate road markings, signing and carriageway layout on the A5 within National Highways’ jurisdiction to identify potential overtaking mitigation measures.
Verbatim wording from the response “We will investigate the location to establish if any measures can be identified to reduce the occurrence of injudicious overtaking by drivers in contravention of the double white line system. This investigation will be restricted to the A5 within our jurisdiction and will cover road markings, signing and carriageway layout.” Source location Response from National Highways
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 Staffordshire Police is responsible for enforcing the double white line system.
Verbatim wording from the response “The responsibility for enforcement of the double white line system sits with Staffordshire Police.” Source location Response from National Highways
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 Department for Transport is responsible for guidance on traffic signs regulations and the Highway Code.
Verbatim wording from the response “4. Legal guidance regarding right turns across double white lines - To be answered by the Department for Transport. National Highways is not responsible for the Traffic Signs Regulations and General Directions (TSRGD) traffic signs guidance or the Highway Code.” Source location Response from National Highways
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 Moss Farm Shop is responsible for controlling traffic and providing signage within its private premises.
Verbatim wording from the response “1. Right turn manoeuvre exiting Moss Farm Shop - To be answered by Moss Farm Shop. National Highways is not responsible for the control of traffic exiting a private business and is therefore unable to assist on this point.” Source location Response from National Highways
Open published response
9 Jan 2026 Ayan SEDIQI · Prevention of Future Deaths report Greater Lincolnshire
View report summary
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.
×
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.
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 National Highways; 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
×
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 Establish a 24/7 team to handle contacts received through National Highways’ X channels.
Verbatim wording from the response “Social Media Channels” Source location Response from National Highways Limited
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 Provide emergency-reporting guidance through the Customer Contact Centre’s front-end message.
Verbatim wording from the response “National Highways Customer Contact Centre” Source location Response from National Highways Limited
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 Raise with motorway service-area operators how to promote contacting National Highways.
Verbatim wording from the response “Motorway Service Areas (MSAs)” Source location Response from National Highways Limited
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 Launch a redesigned website to improve visibility and access to the Defect Reporting Tool.
Verbatim wording from the response “During 2026/27 we plan to launch a new version of the National Highways website that is designed on optimising how users find the DRT and making it visible on multiple pages for increased ease of access.” Source location Response from National Highways Limited
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 Provide Traffic Officers and Highways Inspectors with information to explain when and how to contact National Highways.
Verbatim wording from the response “Traffic Officers and Highways Inspectors” Source location Response from National Highways Limited
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 Explore use of variable message signs to increase awareness of contacting National Highways, subject to safety and operational requirements.
Verbatim wording from the response “Roadside Infrastructure” Source location Response from National Highways Limited
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate the Defect Reporting Tool with emergency prompts and automatic routing of local-road reports to the relevant local highway authority.
Verbatim wording from the response “National Highways Website – Defect Reporting” Source location Response from National Highways Limited
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 Display the National Highways Customer Contact Centre number on black-on-yellow signs at major roadwork scheme ends.
Verbatim wording from the response “Road Improvement Schemes” Source location Response from National Highways Limited
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 Provide the engagement van with promotional material explaining when and how the public can contact National Highways.
Verbatim wording from the response “Engagement Van” Source location Response from National Highways Limited
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 Extend website-address livery to newly commissioned National Highways vehicles as the fleet is replaced.
Verbatim wording from the response “Fleet Livery” Source location Response from National Highways Limited
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 Ensure relevant communications activities include information on contacting National Highways.
Verbatim wording from the response “4 DETAILS OF FURTHER ACTION PROPOSED” Source location Response from National Highways Limited
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 Discuss with wayfinder service providers opportunities to inform users who operates and maintains the road.
Verbatim wording from the response “Wayfinder Services” Source location Response from National Highways Limited
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 Investigate whether black-on-yellow roadside signs could guide users to report immediate-danger situations.
Verbatim wording from the response “At the same time, we will also investigate if hard plate signage (black on yellow signs) with appropriate messaging, might guide road users to reporting situations they consider present a risk of immediate danger to road users.” Source location Response from National Highways Limited
Open published response
Concerns raised 4 Inadequate warning signage for known flood risks View source Failure to maintain drainage gullies regularly View source Known flood risk in the area View source Surface water on the road View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
James Alexander SCOTT · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
James Alexander Scott died at the scene after his Vauxhall Corsa lost control on standing water during a road traffic collision on the A33 on 5 July 2024. The standing water was identified as a contributory factor, with concerns about the known flood risk, blocked drainage gullies, maintenance frequency, and the presence of only a temporary warning sign.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Highways; that does not assign responsibility.
PFD Monitor interpretation Inadequate warning signage for known flood risks
Wider context from the report “(3) The fact that only a Temporary Sign was in place in an area known for years to be a flood risk
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Highways; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain drainage gullies regularly
Wider context from the report “(2) Whilst the precise cause of the flooding is unknown, a more regular maintenance schedule may have prevented the buildup of vegetation within the gullies and therefore assisted in the drainage of the heavy rainfall experienced that day thus reducing the amount of surface water present on the road
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Highways; that does not assign responsibility.
PFD Monitor interpretation Known flood risk in the area
Wider context from the report “(1) The area is a known flood risk
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Highways; that does not assign responsibility.
PFD Monitor interpretation Surface water on the road
Wider context from the report “(4) The surface water was a contributory factor in this death
” Open source report
×
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 Establish M3 Junction 9 scheme responsibility for cyclic maintenance and add regular driven drainage-defect checks by a Traffic Safety Control Officer.
Verbatim wording from the response “The location of the incident has now been taken under the management of the NH M3 Junction 9 (J9) major improvement scheme to improve congestion and traffic flow in the wider area. The scheme is being delivered by our supply chain and overseen by ourselves. In circumstances like this we invoke a Detailed Local Operating Agreement (DLOA) which sets out whether the scheme or normal operations is responsible for the maintenance and inspection activity in the area. The M3 J9 major improvement scheme has now taken responsibility for cyclic maintenance in this area until completion of their scheme scheduled for March 2028. Safety inspections will remain with our NH Inspectors but with the addition of regular driven site checks by the scheme Traffic Safety Control Officer (TSCO) who will identify and act on any defects that arise.” Source location Response from National Highway Agency
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 Reinstate and retain the “Road liable to flooding” sign until drainage actions and monitoring are complete, subject to drainage-engineer consent.
Verbatim wording from the response “At the first site visit on 28 August 2025, it was noted that the sign had been laid down on the verge, this was reinstated by NH that day. The M3 J9 scheme has been instructed to ensure the sign remains in place until instructed to be removed by the NH Operations Directorate South East Drainage team upon completion of the actions proposed and a suitable period of monitoring.” Source location Response from National Highway Agency
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 Repair or replace three National Highways-owned gullies by 31 December 2025.
Verbatim wording from the response “5. Repair or replace eight gullies and locate outfalls in the ditch on the southbound verge between Kings Worthy House and London Road pedestrian crossing. [This action required HCC collaboration to clarify ownership].” Source location Response from National Highway Agency
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 resurfacing extents and assess drainage improvements to remove the rolling-crown flat spot and improve flow into gullies.
Verbatim wording from the response “8. A review of resurfacing extents within the M3 J9 scheme as the program currently stops approximately 25 metres short of the current NH boundary and an extension will avoid a double joint in a short distance.” Source location Response from National Highway Agency
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 Complete flood-risk drainage maintenance, including vegetation and detritus clearance, gully jetting, sweeping, inlet checks and overburden removal.
Verbatim wording from the response “The first drainage flood risk site visit of financial year 1 April 2024 to 31 March 2025 was ordered on 23 April 2024 with a six-month window for completion. The work was completed on 31 August 2024. The drainage flood risk site visit prior to this was carried out on 23 November 2023 which was flood risk site visit two for the previous financial year.” Source location Response from National Highway Agency
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 HCC is responsible for repairing, cleaning and investigating the relevant drainage system and ditch, with scheme support where possible.
Verbatim wording from the response “2. Further works to be considered by M3 J9 scheme on the central reserve due to the pedestrian crossing being moved out slightly to narrow the lane. HCC to repair defective gullies at Itchen Abbas Road.” Source location Response from National Highway Agency
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 No further signage action is currently required because extensive M3 J9 traffic management and signage are in place.
Verbatim wording from the response “No further signage action required at present due to extensive M3 J9 scheme traffic management and signage now in place. M3 J9 scheme to ensure that “Road liable to flooding” sign is not removed without prior consent of NH drainage engineers.” Source location Response from National Highway Agency
Open published response
18 Jul 2025 Darren Christopher Reilly and Tyler Cox · Prevention of Future Deaths report Hertfordshire
View report summary
Concerns raised 1 Gap in the safety barrier on the M1 southbound View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Darren Christopher Reilly and Tyler Cox · 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
On 1 April 2024, Darren Christopher Reilly and Tyler Cox sustained fatal injuries when the Range Rover in which they were travelling left the M1 carriageway and collided with trees. The principal concern was the unexplained gap in the safety barrier at the collision location, creating a risk that future vehicles could leave the carriageway and occupants could suffer serious or fatal injuries.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Highways; that does not assign responsibility.
PFD Monitor interpretation Gap in the safety barrier on the M1 southbound
Wider context from the report “I heard evidence that along this section of the M1 southbound there are safety barriers to the nearside of the carriageway. It was explained to me that if a vehicle loses control, the safety barrier is designed to prevent a vehicle from leaving the carriageway – the idea being that a vehicle that has lost control will continue along the safety barrier before coming to a more controlled stop, thereby minimising the risk of serious injury of death to passengers.
It was further explained to me that this is particularly important when a high-speed carriageway (such as a motorway) is lined with established trees, as is the case here. This is because any vehicle that has lost control and leaves the carriageway is likely to do so at high speed and collide with these established trees. This would likely lead to a very sharp and sudden deceleration, and may cause the vehicle to overturn, which significantly increases the likelihood of serious injury and death to passengers.
In this case, I was shown images of the collision scene which depict the presence of safety barriers shortly before and shortly after the collision site. Whilst I heard evidence that, in general, gaps are sometimes inserted in the safety barrier for the purposes of access or due to the presence of other safety measures (e.g. a grassed bank), the witnesses from the Roads Policing Unit could not offer any explanation for why there is a gap in the safety barrier at this location.
Consequently, I am concerned that there is a gap in the safety barrier at this location, which for the reasons outlined above gives rise to a risk that future deaths may occur.
” 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 Clear trees within 5 metres of the carriageway edge along this section of the M1.
Verbatim wording from the response “Where vegetation is the only potential hazard in the verge, the risk of vehicles colliding with trees is managed through a programme of tree removal work. Where there is no VRS present we remove any tree within 5m of the carriageway edge. There is a cyclical programme of verge tree clearance that aims to ensure that trees close to the carriageway are regularly removed. Prior to the incident on 1 April 2024, trees at this location were last cleared on 19 February 2024.” Source location Response from National Highways Agency
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 Undertake the Road Restraint Risk Assessment Process to assess the need for vehicle restraint systems or other mitigations at this location.
Verbatim wording from the response “We will undertake the Road Restraint Risk Assessment Process (RRRAP) in accordance with the requirements of CD 377 to assess the need for VRS, or other mitigations such as additional tree clearance, at this location based on the current technical standards.” Source location Response from National Highways Agency
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 Existing tree clearance and network safety monitoring are relied upon instead of upgrading vehicle restraint systems as a matter of course.
Verbatim wording from the response “Where vegetation is the only potential hazard in the verge, the risk of vehicles colliding with trees is managed through a programme of tree removal work. Where there is no VRS present we remove any tree within 5m of the carriageway edge. There is a cyclical programme of verge tree clearance that aims to ensure that trees close to the carriageway are regularly removed. Prior to the incident on 1 April 2024, trees at this location were last cleared on 19 February 2024.” Source location Response from National Highways Agency
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 260-metre barrier gap need not be closed because current CD 377 requirements apply only to gaps shorter than 100 metres.
Verbatim wording from the response “The standard sets out a risk-based approach to the provision of VRS using an analysis tool known as the Road Restraint Risk Assessment Process (RRRAP).” Source location Response from National Highways Agency
Open published response
29 Jun 2025 Leigh NARDELLI · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 1 Failure to replace hazardous P1 terminals with safer bifurcated systems View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Leigh NARDELLI · 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
Leigh Nardelli died in a road traffic collision on the A5 Southbound in Milton Keynes after his vehicle aquaplaned in torrential rain, struck barriers and hit a concrete support. The principal concern was that a known hazardous P1 terminal had not been replaced with a safer system for financial reasons and continues to present a significant risk.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Highways; that does not assign responsibility.
PFD Monitor interpretation Failure to replace hazardous P1 terminals with safer bifurcated systems
Wider context from the report “The hazard posed by the design of the P1 terminal was known by National Highways and it was due for replacement at the site of the collision in 2022. It presented and continues to present a significant risk and was not replaced for financial reasons . There is a gradual roll out programme across National Highways to replace P1 terminals with a safer bifurcated system but I consider the implications of the financial limitations represents an ongoing safety concern for vehicles approaching them on designated roads .
” 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 Develop a design to remove the material-location P1 terminal and replace it with a compliant bifurcated barrier.
Verbatim wording from the response “A design was developed ready for implementation in around 2022 to remove the P1 terminal at the material location and replace it with a bifurcation as set out above, but lack of resources and road space constraints meant the renewal could not be delivered at the end of the financial year. The renewal was only considered to be delivered at that time due to budget availability in the East region and was considered against other renewal opportunities elsewhere in the region.” Source location Response from National Highways
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 Start a design brief to remove six ramped-end terminals along the A5 and replace them with CD 377-compliant bifurcations.
Verbatim wording from the response “Date | Action
Mid-August 2025 | Survey work of the central reserve barrier provision to start
Late 2025 | Subject to overall network need, barrier condition along the route and current funding levels, design brief to be started to remove the six ramped end terminals within the central reserve along this length of the A5 (between the junction with the A508 (Old Stratford) and Kelly’s Kitchen) and replace them with bifurcations compliant with CD 377.” Source location Response from National Highways
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 Survey central-reserve barrier provision and condition along the A5 between Old Stratford and Kelly’s Kitchen.
Verbatim wording from the response “Formal survey work” Source location Response from National Highways
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 barrier condition is considered adequate to perform its intended function, so renewal was not considered urgent.
Verbatim wording from the response “The central reserve safety barrier renewal on the material section of the A5 was identified for renewal in 2020 mainly based on its age. It is over 25 years old and so nearing its expected end of serviceable life. However visual condition inspections are also done to assess the urgency or priority of the timing of a renewal intervention and due to its condition, this section was not considered to be urgent.” Source location Response from National Highways
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 Barrier renewal could not be delivered at the planned time because of insufficient resources and road-space constraints.
Verbatim wording from the response “A design was developed ready for implementation in around 2022 to remove the P1 terminal at the material location and replace it with a bifurcation as set out above, but lack of resources and road space constraints meant the renewal could not be delivered at the end of the financial year. The renewal was only considered to be delivered at that time due to budget availability in the East region and was considered against other renewal opportunities elsewhere in the region.” Source location Response from National Highways
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 Renewal programming beyond 2025/26 cannot be committed until Central Government confirms the next multi-year funding settlement.
Verbatim wording from the response “Central Government awards funding to National Highways in multi-year settlements (usually 5-year cycles). National Highways then determines how much of the funding is assigned to different assets in each region. The indicative next allocation of funding did not assign a high level of funding to the East region for the renewal of VRS. The funding that is available will be targeted to the poorest condition assets across the East region. The condition of the VRS asset on the material section of the A5 is expected to warrant an intervention in the next 5 years so is currently earmarked for renewal in that period. However, if its condition proves not to be deteriorating as much as expected and other sections of barrier in the East region are a higher priority, then a decision may have to be made to reassign funding to those other VRS renewals.” Source location Response from National Highways
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 barrier standards will not be applied retrospectively because doing so is not considered proportionate or an effective use of public resources.
Verbatim wording from the response “When a new standard is produced, it only applies to new works/designs and therefore TD 19/06 and CD 377 would not be applied retrospectively to existing barrier systems, nor would it be a proportionate and effective use of public resources to do so.” Source location Response from National Highways
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 Fatal incidents involving ramped terminals and bridge piers are considered uncommon on the Strategic Road Network.
Verbatim wording from the response “A review of fatal incidents on the whole of the SRN in England has been undertaken to identify any other incidents where a vehicle has impacted a ramped end terminal in the central reserve and subsequently impacted a bridge pier. This search has been limited to fatal incidents as there is typically insufficient detail available for serious, slight and damage-only incidents in order to make a detailed assessment of the circumstances of the incident.” Source location Response from National Highways
Open published response
Concerns raised 1 Continuing hazard from a mound of earth on a motorway central reservation View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Patrick Anthony MONGAN · 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
Patrick Anthony MONGAN, an 18-year-old male, died after a road traffic collision on the M18 on 7 September 2024. The vehicle struck a mound of earth on the central reservation, became airborne, and Patrick was ejected; he was pronounced dead at 03:10 hours. The concern identified was that the mound remained a hazard capable of causing vehicles to lose control and putting road users at risk of death.
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 National Highways; that does not assign responsibility.
PFD Monitor interpretation Continuing hazard from a mound of earth on a motorway central reservation
Wider context from the report “The Forensic Collision Investigator advised that the aforementioned mound of earth creates a continuing hazard to motorway users and any vehicle which might have legitimate cause to veer to the central reservation and in doing so strikes the mound, even when travelling within the speed limit, would be subjected to the same effect on the vehicle (in that control of the vehicle would be lost) with potentially catastrophic effects . The continued presence of this hazard (the mound of earth on a tarmac construction) places road users at risk of death
” 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 Level the central reservation to eliminate the level difference between the running lanes and central reservation.
Verbatim wording from the response “i) Levelled the central reservation in this specific location so that there is no deviation in level between the carriageway running lanes and the central reservation” Source location Response from National Highways Agency
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 No other safety actions are considered necessary at this location.
Verbatim wording from the response “There are no other actions to be carried out at this location.” Source location Response from National Highways Agency
Open published response
16 Apr 2025 Freddie SLATER · Prevention of Future Deaths report North West Kent
View report summary
Concerns raised 1 Lack of physical barriers on the grass verge between the M20 and M25/M20 slip road View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Freddie SLATER · 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
On 16 October 2024, Freddie Slater died at the scene after his Smart car collided with two other vehicles on the M20 and an adjoining slip road in Kent. The report raised concerns that the grass verge separating the roads had no physical barriers, allowing an uncontrolled vehicle to cross into traffic travelling in the opposite carriageway and creating a risk of high-speed collisions and fatalities.
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 National Highways; that does not assign responsibility.
PFD Monitor interpretation Lack of physical barriers on the grass verge between the M20 and M25/M20 slip road
Wider context from the report “(1) The grass verge which separates the M20 and M25/ M20 slip road does not have erected upon it any physical barriers to prevent traffic crossing the verge from either of the 2 roads referred to and entering a parallel lane the opposite side of the verge.
(2) The evidence received from National Highways confirmed that under the present policy guidance, barriers would not normally be required as there are no features such as an incline on the slip road, bridge supports or trees requiring physical protection between the two merging roads of traffic travelling at similar speeds in the same direction.
(3) The facts of the present case illustrate that in the event of a loss of control of a vehicle travelling on either the M20 or in the slip road there is the potential for that vehicle, without any warning to drivers travelling at or about the same area in the coastbound direction, cross the grass verge to their side and enter their lane of travel. As both the material roads are subject to the same national speed limit of 70MPH, the risk of a high speed collision and fatality arises.
” 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 Assess the barrier provision against current road restraint requirements using the Road Restraint Risk Assessment Process.
Verbatim wording from the response “A review of the current barrier provision at this locality with reference to current requirements” Source location Response from National Highways
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 No further action or direct CD 377 amendment is intended because similar incidents are uncommon and changes must address safety and value for money.
Verbatim wording from the response “A review of fatal incidents on the whole of the SRN in England has been undertaken to identify any other incidents where a vehicle has crossed over a strip at the end of the nosing at an on-slip road and impacted a vehicle on the adjacent slip road. This search has been limited to fatal incidents as there is typically insufficient detail available for serious, slight and damage-only incidents in order to make a detailed assessment of the circumstances of the incident.” Source location Response from National Highways
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 merge arrangements do not constitute a barrier-requiring hazard because traffic travels in the same direction.
Verbatim wording from the response “As identified in paragraph 5(2) of the Regulation 28 report, current design requirements would not require a barrier to be erected within the grassed medium between the M25 link and the M20 link.” Source location Response from National Highways
Open published response
6 Feb 2025 Jane BENNETT · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 1 Hazardous difficulty manoeuvring at the junction of St Johns Road, Tiffield and the A43 Northamptonshire View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jane BENNETT · 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 Bennett was involved in a road traffic collision at the junction of St Johns Road, Tiffield and the A43 on 13 March 2024 and was later confirmed deceased on 15 March 2024. The report raises concern that the junction is very difficult to manoeuvre and that, without changes, further accidents or fatalities are likely.
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 National Highways; that does not assign responsibility.
PFD Monitor interpretation Hazardous difficulty manoeuvring at the junction of St Johns Road, Tiffield and the A43 Northamptonshire
Wider context from the report “The junction of St Johns Road, Tiffield and the A43 Northamptonshire is very difficult to manoeuvre. Witnesses who attended at the inquest gave evidence to the effect that unless some changes are made there are likely to be further accidents/or fatalities. I concur with this view.
” 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 Develop and construct the 2026 A43 renewals scheme, including carriageway resurfacing, line-marking repainting and replacement reflective road studs through to St John’s Road junction.
Verbatim wording from the response “National Highways currently have a renewals scheme programmed for 2026/2027 which includes resurfacing, road markings, road studs, vegetation clearance, and drainage for sections of the A43 including St John’s junction.” Source location Response from National Highways
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 Carry out planned summer 2025 minor surfacing works, including refreshed eastbound road markings and reflective road studs through the junction.
Verbatim wording from the response “In advance of the 2026/2027 planned carriageway renewals scheme, National Highways is planning minor surfacing works for Summer 2025. This will include refreshing road markings and reflective road studs on the A43 eastbound mainline through the junction. We are currently investigating the possibility of including the vegetation clearance in these works.” Source location Response from National Highways
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 Investigate including vegetation clearance in the summer 2025 works to improve visibility at the junction.
Verbatim wording from the response “In advance of the 2026/2027 planned carriageway renewals scheme, National Highways is planning minor surfacing works for Summer 2025. This will include refreshing road markings and reflective road studs on the A43 eastbound mainline through the junction. We are currently investigating the possibility of including the vegetation clearance in these works.” Source location Response from National Highways
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 Investigate potential junction improvements, such as signage, as part of the A43 renewals scheme scoping.
Verbatim wording from the response “The A43 renewals scheme is currently being developed and scheduled for construction in the later part of 2026. This scheme involves resurfacing of the A43 eastbound and westbound carriageway, repainting of the line markings and replacing the reflective road studs from the M1 motorway through to St John’s Road junction. While the physical layout of the junction will not change, as part of our scoping we are investigating potential improvements for the junction of St John’s Road, such as signage.” Source location Response from National Highways
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 junction does not rank highly as a safety problem location, so detailed investigations for a potential safety improvement scheme have not been prioritised.
Verbatim wording from the response “Following the fatal incident National Highways has referred to this assessment list and the junction of the A43 / St John’s Road does not appear within the top 100 sites in the Midlands. Although this data does not include the recent fatality it does reveal that this junction has a relatively good safety record in relation to the Midlands trunk and motorway network, with only two ‘slight’ injury collisions recorded here within that 5 year period. Based on this, the junction of the A43 and St John’s Road does not rank highly as a safety problem location, and for this reason we have not prioritised this junction as a location to undertake detailed investigations for a potential safety improvement scheme.” Source location Response from National Highways
Open published response
16 Jan 2025 Alexander Charles Edward Thomas · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Failure to prevent access to the eastbound motorway crash barrier via a fixed metal ladder View source Lack of fencing preventing access over the eastbound motorway crash barrier View source Failure to prevent access from the pedestrian walkway to the eastbound motorway crash barrier via a ramp-like structure View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Alexander Charles Edward Thomas · 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
Alexander Charles Edward Thomas died on 14 August 2024 after entering the eastbound carriageway of the M56 motorway and being struck by a heavy goods vehicle. Concerns included accessible routes from a pedestrian walkway and track to the motorway's crash barrier, and a lack of fencing to prevent access onto the motorway along that stretch.
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 National Highways; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent access to the eastbound motorway crash barrier via a fixed metal ladder
Wider context from the report “1. During the inquest, I heard that ████████ is a pedestrian walkway running underneath the M56 motorway. On the northern side of the motorway (eastbound carriageway side) the entrance to the walkway tunnel is constructed so that the buttress walls form a ramp-like structure which has a shallow gradient topped with a waist-high railing which provides an easily accessible and walkable route from the footpath to the Armco crash barrier bordering the hard shoulder of the eastbound motorway carriageway.
2. Also leading from ████████ is an established track through undergrowth running west parallel to the motorway. That path leads directly to a fixed bespoke metal ladder which appears to be specifically positioned so as to enable a person to climb up to the Armco crash barrier bordering the hard shoulder of the eastbound carriageway .
3. There is no fencing to prevent access over the Armco crash barrier onto the motorway itself along this stretch of the eastbound carriageway, in contrast to the substantial fencing positioned behind the Armco crash barrier along the opposite stretch of the westbound carriageway.
” 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 National Highways; that does not assign responsibility.
PFD Monitor interpretation Lack of fencing preventing access over the eastbound motorway crash barrier
Wider context from the report “1. During the inquest, I heard that ████████ is a pedestrian walkway running underneath the M56 motorway. On the northern side of the motorway (eastbound carriageway side) the entrance to the walkway tunnel is constructed so that the buttress walls form a ramp-like structure which has a shallow gradient topped with a waist-high railing which provides an easily accessible and walkable route from the footpath to the Armco crash barrier bordering the hard shoulder of the eastbound motorway carriageway.
2. Also leading from ████████ is an established track through undergrowth running west parallel to the motorway. That path leads directly to a fixed bespoke metal ladder which appears to be specifically positioned so as to enable a person to climb up to the Armco crash barrier bordering the hard shoulder of the eastbound carriageway.
3. There is no fencing to prevent access over the Armco crash barrier onto the motorway itself along this stretch of the eastbound carriageway , in contrast to the substantial fencing positioned behind the Armco crash barrier along the opposite stretch of the westbound carriageway.
” 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 National Highways; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent access from the pedestrian walkway to the eastbound motorway crash barrier via a ramp-like structure
Wider context from the report “1. During the inquest, I heard that ████████ is a pedestrian walkway running underneath the M56 motorway. On the northern side of the motorway (eastbound carriageway side) the entrance to the walkway tunnel is constructed so that the buttress walls form a ramp-like structure which has a shallow gradient topped with a waist-high railing which provides an easily accessible and walkable route from the footpath to the Armco crash barrier bordering the hard shoulder of the eastbound motorway carriageway .
2. Also leading from ████████ is an established track through undergrowth running west parallel to the motorway. That path leads directly to a fixed bespoke metal ladder which appears to be specifically positioned so as to enable a person to climb up to the Armco crash barrier bordering the hard shoulder of the eastbound carriageway.
3. There is no fencing to prevent access over the Armco crash barrier onto the motorway itself along this stretch of the eastbound carriageway, in contrast to the substantial fencing positioned behind the Armco crash barrier along the opposite stretch of the westbound carriageway.
” 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 Repair and extend boundary fencing around the hotel car park, Hasty Lane and the structure’s wing walls to reduce access to the carriageway.
Verbatim wording from the response “We will repair the boundary fence both at the edge of the hotel car park and Hasty Lane, extending this to cover the wing walls of the structure to increase the security and reduce access to the area along the carriageway. This work will be completed by the 30 June 2025.” Source location Response from National Highways
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 Assess with electrical and maintenance teams whether remote cabinet access is feasible, whether carriageway ladder access is essential, and what health and safety requirements apply.
Verbatim wording from the response “In addition, we are in discussion with our Electrical team and Maintenance contractors to establish if it is feasible to maintain a more remote access to the electrical cabinets and whether direct access from the mainline carriageway, via the ladder, is essential. This includes the relevant health and safety requirements and if this can be resolved we will take steps to remove the ladder from the retaining wall. Again, if this is feasible the work will be completed by 30 June 2025.” Source location Response from National Highways
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 Completely preventing determined pedestrian access to the Strategic Road Network is impossible, although fencing and compliant design provide deterrence and security.
Verbatim wording from the response “The M56 motorway at this point spans Hasty Lane which forms an underpass to facilitate access by cyclists and pedestrians. The structural supports and cast concrete wing walls mirror the profile of the embankments on either side of the motorway and are located within the highway boundary. This design of ‘bridge’ complies with the design requirements outlined within the Design Manual for Roads and Bridges and includes tubular railings to protect against falls from the structure. It is accepted that this type of design does not deter determined attempts by pedestrians to gain access to the motorway but when combined with timber boundary fence provides some deterrence and security. By the very nature of the Strategic Road Network, it is impossible to fully deny access.” Source location Response from National Highways
Open published response
Concerns raised 2 Higher proportion of road traffic collisions on the A38 stretch between Carkeel and Trerulefoot roundabouts View source Failure to secure funding for the developed average-speed-camera safety scheme View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
NIGEL WILLIAM SWEET · 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
Nigel William Sweet, aged 63, died on 7 March 2024 on the A38 after losing control of his motorcycle while attempting to overtake in wet conditions and being struck by an oncoming vehicle. Concerns included the higher proportion of collisions on this stretch of road, associated with its single-carriageway layout and occasional creeper lanes, and the absence of approved funding for a proposed average-speed-camera safety scheme.
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 National Highways; that does not assign responsibility.
PFD Monitor interpretation Higher proportion of road traffic collisions on the A38 stretch between Carkeel and Trerulefoot roundabouts
Wider context from the report “(1) The court found that this stretch of the A38 from Carkeel roundabout to Trerulefoot roundabout has a history of a higher proportion of road traffic collisions compared to equivalent roads . This is because of the nature of the A38 over this stretch which features predominantly single carriageway layout with occasional creeper lanes .
(2) The court heard evidence that a safety scheme had been developed to introduce average speed cameras for this stretch of the A38 but that funding had not yet been approved. The safety scheme was specifically designed to reduce the higher proportion of collisions on this stretch of road.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Highways; that does not assign responsibility.
PFD Monitor interpretation Failure to secure funding for the developed average-speed-camera safety scheme
Wider context from the report “(1) The court found that this stretch of the A38 from Carkeel roundabout to Trerulefoot roundabout has a history of a higher proportion of road traffic collisions compared to equivalent roads. This is because of the nature of the A38 over this stretch which features predominantly single carriageway layout with occasional creeper lanes.
(2) The court heard evidence that a safety scheme had been developed to introduce average speed cameras for this stretch of the A38 but that funding had not yet been approved . The safety scheme was specifically designed to reduce the higher proportion of collisions on this stretch of road.
” 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 Reduce the speed limit through Landrake and Tideford villages to 30 mph.
Verbatim wording from the response “Our current plan is to implement an Average Speed Camera Systems (ASCS) between Carkeel and Trerulefoot and to reduce the speed limit through the villages of Landrake and Tideford to 30 mph. We aim to publish the notice for the Traffic Regulation Order (TRO) in March 2025 and begin implementation of the ASCS and signs in May of financial year 2025/2026.” Source location Response from National Highways
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 Complete the A38 Carkeel-to-Trerulefoot pipeline study and select online safety interventions for further development.
Verbatim wording from the response “Although this data demonstrates there are other similar roads with greater need, we completed a pipeline study ‘A38 Carkeel to Trerulefoot’ in 2022. The study considered many options for interventions ranging from providing a dual carriageway around the villages, widening the A38, to small targeted interventions. The outcome of this study found that the extensive engineering required to dual or widen the A38 within the existing topography was unaffordable at the time and a proposal largely focused on several online interventions was selected. Following the Secretary of State’s Written Ministerial Statement published on 9 March 2023 that the pipeline schemes, which included the A38 Carkeel to Trerulefoot scheme, previously earmarked for RIS3 (2025-30) would continue to be developed and considered for inclusion within RIS4 (2030-35).” Source location Response from National Highways
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 an Average Speed Camera System between Carkeel and Trerulefoot to improve speed-limit compliance and reduce collisions.
Verbatim wording from the response “Following deferral of any major improvement scheme, as a member of the external South West Vision Zero Road Safety Partnership, National Highways has been working closely with Cornwall Council, Devon and Cornwall Police and other external partners to identify interventions that could reduce the number of collisions on this section of the A38 and improve the safety of residents in Landrake and Tideford.” Source location Response from National Highways
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 wide single 2+1 layout will not be removed because it enables safer overtaking and reduces congestion-related dangerous overtaking.
Verbatim wording from the response “As wide single 2 + 1 road layouts help prevent congestion, which could result in road users performing injudicious overtakes in undesirable locations, we have no plans to remove this layout from the DMRB Standards or at this location.” Source location Response from National Highways
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 Extensive engineering to dual or widen the A38 was unaffordable at the time because of the route’s constrained topography.
Verbatim wording from the response “Although this data demonstrates there are other similar roads with greater need, we completed a pipeline study ‘A38 Carkeel to Trerulefoot’ in 2022. The study considered many options for interventions ranging from providing a dual carriageway around the villages, widening the A38, to small targeted interventions. The outcome of this study found that the extensive engineering required to dual or widen the A38 within the existing topography was unaffordable at the time and a proposal largely focused on several online interventions was selected. Following the Secretary of State’s Written Ministerial Statement published on 9 March 2023 that the pipeline schemes, which included the A38 Carkeel to Trerulefoot scheme, previously earmarked for RIS3 (2025-30) would continue to be developed and considered for inclusion within RIS4 (2030-35).” Source location Response from National Highways
Open published response
3 Dec 2024 Gary Stephen DUNN · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 2 Insufficient road signage for navigating the roundabout View source Inappropriate signage informing cyclists of the available alternative route 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
Gary Stephen DUNN · 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
Gary Stephen DUNN died instantly after his bicycle collided with a left-turning LGV while he was cycling through the Stoneferry Road/Ferry Lane roundabout in Kingston Upon Hull. Concerns were raised about insufficient signage explaining the changed lane arrangements and inadequate signage informing cyclists of an alternative shared pedestrian and cycle path and Toucan Crossing.
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 National Highways; that does not assign responsibility.
PFD Monitor interpretation Insufficient road signage for navigating the roundabout
Wider context from the report “I appreciate it has been almost a year before this inquest was concluded so the change in road layout may now be more known to regular drivers, however people unfamiliar with the road may also need to navigate the roundabout. The Officer in the Case, an experienced Serious Collision Investigation Officer, raised concerns regarding the signage of 2 aspects of this area of road:
• Firstly, although the road markings which indicate the centre lane can also be used for left hand turning vehicles was regarded as clear, the officer felt there was insufficient actual road signage to assist road users in how the roundabout can be navigated . This was of particular concern as this is a busy roundabout with a build up of traffic and so markings on the road are often obscured .
• Secondly, there is a dual use path for both pedestrians and cyclists as well as the availability of a Toucan Crossing. This provides cyclists with an alternative to using the road. Again, evidence was heard that there was inappropriate signage to instruct cyclists that this route was available.
” 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 National Highways; that does not assign responsibility.
PFD Monitor interpretation Inappropriate signage informing cyclists of the available alternative route
Wider context from the report “I appreciate it has been almost a year before this inquest was concluded so the change in road layout may now be more known to regular drivers, however people unfamiliar with the road may also need to navigate the roundabout. The Officer in the Case, an experienced Serious Collision Investigation Officer, raised concerns regarding the signage of 2 aspects of this area of road:
• Firstly, although the road markings which indicate the centre lane can also be used for left hand turning vehicles was regarded as clear, the officer felt there was insufficient actual road signage to assist road users in how the roundabout can be navigated. This was of particular concern as this is a busy roundabout with a build up of traffic and so markings on the road are often obscured.
• Secondly, there is a dual use path for both pedestrians and cyclists as well as the availability of a Toucan Crossing. This provides cyclists with an alternative to using the road. Again, evidence was heard that there was inappropriate signage to instruct cyclists that this route was available .
” Open source report
11 Sep 2024 Emma Victoria HARPER · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 3 Failure to prevent continued use of an unsafe foot bridge as an alternative route View source Failure to provide bridge barriers preventing pedestrians from easily climbing over and falling from the bridge View source Failure to apply a clear basis for including foot bridges in barrier safety works View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Emma Victoria HARPER · 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
Emma Victoria HARPER died on 4 May 2024 after falling from a footbridge onto a crash barrier beside the M602 motorway; the inquest concluded that her death was suicide. Concerns were raised that the bridge had not been included in works to increase barrier heights or otherwise prevent people at risk from falling onto the motorway, and that the basis for its exclusion was unclear.
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 National Highways; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent continued use of an unsafe foot bridge as an alternative route
Wider context from the report “1. During the course of evidence it was stated that the foot bridge which the deceased fell from had not been considered suitable for amendments to be made to the level of barrier which would prevent a pedestrian crossing the bridge from easily climbing over and falling onto the highway below.
2. Other bridges in the locality were considered and selected for an increase in the height of the barrier or other works to prevent the risk of falling from the bridge onto the M602 motorway.
3. It was unclear on what basis the foot bridge that the deceased fell from has been excluded from such works and there is a risk that this bridge may still be accessed by people who may be at risk of falling as an alternative to other bridges were works had been undertaken in the locality .
” 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 National Highways; that does not assign responsibility.
PFD Monitor interpretation Failure to provide bridge barriers preventing pedestrians from easily climbing over and falling from the bridge
Wider context from the report “1. During the course of evidence it was stated that the foot bridge which the deceased fell from had not been considered suitable for amendments to be made to the level of barrier which would prevent a pedestrian crossing the bridge from easily climbing over and falling onto the highway below .
2. Other bridges in the locality were considered and selected for an increase in the height of the barrier or other works to prevent the risk of falling from the bridge onto the M602 motorway.
3. It was unclear on what basis the foot bridge that the deceased fell from has been excluded from such works and there is a risk that this bridge may still be accessed by people who may be at risk of falling as an alternative to other bridges were works had been undertaken in the locality.
” 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 National Highways; that does not assign responsibility.
PFD Monitor interpretation Failure to apply a clear basis for including foot bridges in barrier safety works
Wider context from the report “1. During the course of evidence it was stated that the foot bridge which the deceased fell from had not been considered suitable for amendments to be made to the level of barrier which would prevent a pedestrian crossing the bridge from easily climbing over and falling onto the highway below.
2. Other bridges in the locality were considered and selected for an increase in the height of the barrier or other works to prevent the risk of falling from the bridge onto the M602 motorway.
3. It was unclear on what basis the foot bridge that the deceased fell from has been excluded from such works and there is a risk that this bridge may still be accessed by people who may be at risk of falling as an alternative to other bridges were works had been undertaken in the locality.
” 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 Complete a study of suicide-related issues at bridges and structures along the M602 route.
Verbatim wording from the response “In relation to the M602 a study of suicide related issues along the route was undertaken in 2022, specifically in relation to the number of incidents occurring at bridges and structures spanning the route. The ████████ footbridge that you have raised as a concern was one of eight structures included in this assessment. It was identified that an increase in parapet fence height from the standard 1 metre to 1.8 metres was a potential intervention but noted that the boundary is difficult to effectively secure around the bridge itself. The footpaths along ████████ and ████████ which run for several hundred metres alongside and above the M602 have concrete boundary walls of approximately the same height as the existing bridge parapet fence.” Source location Response from National Highways
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 Increase parapet fence heights to 1.8 metres at six bridges with the highest numbers of suicide-related incidents.
Verbatim wording from the response “During the current road investment period (2020-25) in the North West region we have increased parapet fence heights to 1.8 metres at six of our bridges with the highest number of suicide related incidents. These are ████████ and ████████ over the M60 in ████████, ████████ and ████████ at Junction █ of the M60, and ████████ and ████████ over the M56 in Wythenshawe.” Source location Response from National Highways
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 Available funding and achievable benefits constrain parapet upgrades, so locations with the highest number of incidents are prioritised.
Verbatim wording from the response “Increasing the parapet fence height from the standard 1 metre to 1.8 metres can cost up to £1m per bridge. In addressing concerns surrounding these sites we are constrained by the available funding and the benefits that can be achieved. We therefore prioritise locations with the highest number of suicide related incidents. This is the reason that some bridges have already received upgraded parapets, as historically they have exhibited a far higher level of risk. An example in this area is ████████ which crosses the M602 adjacent to ████████.” Source location Response from National Highways
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 No parapet-height increase is currently proposed because the footbridge recorded three incidents, none causing injury or fatality, during the assessment period.
Verbatim wording from the response “When assessing the available information relating to suicide related incidents along the M602, there were three recorded at the ████████ footbridge during the five-year study assessment period from 2017 to 2021, none of which had resulted in an injury or fatality. We therefore currently have no proposals to increase the parapet fence height at ████████ footbridge.” Source location Response from National Highways
Open published response
27 Aug 2024 Mason John Portman · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 2 Lack of road markings advising on appropriate speed or road curvature ahead View source Lack of signs advising on appropriate speed or road curvature ahead View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mason John Portman · 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
Mason John Portman was the sole occupant and driver of a vehicle that lost control on 17 December 2023, collided with several objects and vehicles, and came to rest after tumbling across the A672, causing fatal injuries. The principal concern was the absence of road markings and signs advising on appropriate speed or road curvature at the location, with a request to review the road conditions and consider appropriate signage and markings.
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 National Highways; that does not assign responsibility.
PFD Monitor interpretation Lack of road markings advising on appropriate speed or road curvature ahead
Wider context from the report “During the inquest I heard that Mason approached the location of the collision via the slip road that there were no road markings or signs displayed to advise on appropriate speed or road curvature ahead.
” 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 National Highways; that does not assign responsibility.
PFD Monitor interpretation Lack of signs advising on appropriate speed or road curvature ahead
Wider context from the report “During the inquest I heard that Mason approached the location of the collision via the slip road that there were no road markings or signs displayed to advise on appropriate speed or road curvature ahead .
” Open source report
×
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 Calderdale Council is responsible for the A672 carriageway and immediate slip-road interface beyond National Highways’ boundary, including associated signs and markings.
Verbatim wording from the response “I can confirm that National Highways is the Highway Authority for the M62 motorway and the exit slip roads at junction 22. This extends up to the marked timber boundary fence and cattle grid at the interface with the A672. Beyond this point Calderdale Council is the relevant highway authority, including the A672 carriageway and immediate slip road interface.” Source location Response from National Highways
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 junction layout and signing adequately convey alignment and junction details; therefore no alterations to the layout or slip-road speed limit are proposed.
Verbatim wording from the response “In examining and assessing the current situation, we believe that the current layout and signing strategy adequately conveys the necessary and appropriate information regarding alignment and detail of the junction in order to enable the slip road and junction to be approached at an appropriate speed. We therefore do not propose any alterations to the current junction layout or speed limit along the slip road.” Source location Response from National Highways
Open published response
23 Aug 2024 Amal Mohamed AHMED · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 5 Inadequate positioning and visibility of No Entry signage for wrong-way slip-road entry View source Frequent wrong-way driving down the slip road into oncoming traffic View source Slip-road geometry allowing wrong-way vehicles to enter and build up considerable speed View source Failure to maintain adequate visibility of road-surface No Entry markings at the slip-road junction View source Failure of commonly used satnav applications to provide unambiguous verbal directions at the junction View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Amal Mohamed AHMED · 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
Amal Mohamed Ahmed died at the scene after entering the A5 southbound off slip road in the wrong direction and colliding head-on with another vehicle. The other vehicle’s driver later died in hospital, and a passenger suffered life-threatening injuries. The principal concern was that inadequate, poorly positioned and poorly visible signage and the unlit, wide junction allowed drivers to enter the slip road incorrectly; other drivers were observed making the same manoeuvre.
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 National Highways; that does not assign responsibility.
PFD Monitor interpretation Inadequate positioning and visibility of No Entry signage for wrong-way slip-road entry
Wider context from the report “The exit point of the A5 "off" slip road at the Little Brickhill junction is wide. The signage indicating No Entry appears to be inadequate as there are two No Entry signs which are widely spaced at the junction. One is positioned to appear to forbid entry to the road over the bridge leading over the A5 and does not obviously relate to the slip road. The second is positioned such that it obliquely faces the road over the bridge and would not be visible to a driver turning right onto the slip road until they had completed the manoeuvre placing them at risk. There is a No Right Turn sign as the junction is approached. There is also No Entry in large white letters at the mouth of the slip road junction, however, this may be (1) obscured by vehicles leaving the slip road and (2) the junction is unlit and was said by a witness as being "pitch black". After the collision attention police officers saw three further vehicles perform exactly the same manoeuvre as Ms Ahmed and attempt to travel down the slip road in the wrong direction. Local residents have contacted police and claimed that it is a very common occurrence for drivers to mistakenly travel down the slip road in the wrong direction. The slip road is long and allows for the build up of considerable speed in turn facilitating what the police describe as a high energy impact. Following the collision, large temporary No Entry signs were positioned at the slip road junction. They were quickly removed apparently because the original signs were deemed to comply with necessary regulations. That seems wholly irrelevant to me because drivers are clearly commonly not seeing the signs because of the large numbers who mistakenly drive the wrong way onto the slip road. In my opinion, consideration should be given to alternative arrangements to prevent vehicles entering and travelling along the slip road in the wrong direction.
” 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 National Highways; that does not assign responsibility.
PFD Monitor interpretation Frequent wrong-way driving down the slip road into oncoming traffic
Wider context from the report “I have made observations regarding the slip road at this junction in my initial pre-Inquest Report To Prevent Future Deaths dated the 21st December 2023.
National Highways undertook a number of immediate remedial measures to try to prevent drivers turning and travelling the wrong way down this slip road, including narrowing the "mouth" of the slip road to one lane, placement of very large temporary "No Entry" signs and placement of signs indicating "Do Not Use Satnav" at the site. CCTV monitoring of driver behaviour was commenced. Police activity and monitoring by National Highways showed that despite these measures, drivers were still turning early and attempting to drive the wrong way down the slip road . Further enquiries by the police and information volunteered by members of the public who made the same incorrect manoeuvre led to the finding that while the visual map display on commonly used satnav applications at this junction displayed the correct information, the verbal commands gave information likely to confuse and direct drivers down the wrong slip road into the path of oncoming traffic . This was observed to happen frequently.
” 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 National Highways; that does not assign responsibility.
PFD Monitor interpretation Slip-road geometry allowing wrong-way vehicles to enter and build up considerable speed
Wider context from the report “The exit point of the A5 "off" slip road at the Little Brickhill junction is wide. The signage indicating No Entry appears to be inadequate as there are two No Entry signs which are widely spaced at the junction. One is positioned to appear to forbid entry to the road over the bridge leading over the A5 and does not obviously relate to the slip road. The second is positioned such that it obliquely faces the road over the bridge and would not be visible to a driver turning right onto the slip road until they had completed the manoeuvre placing them at risk. There is a No Right Turn sign as the junction is approached. There is also No Entry in large white letters at the mouth of the slip road junction, however, this may be (1) obscured by vehicles leaving the slip road and (2) the junction is unlit and was said by a witness as being "pitch black". After the collision attention police officers saw three further vehicles perform exactly the same manoeuvre as Ms Ahmed and attempt to travel down the slip road in the wrong direction. Local residents have contacted police and claimed that it is a very common occurrence for drivers to mistakenly travel down the slip road in the wrong direction. The slip road is long and allows for the build up of considerable speed in turn facilitating what the police describe as a high energy impact. Following the collision, large temporary No Entry signs were positioned at the slip road junction. They were quickly removed apparently because the original signs were deemed to comply with necessary regulations. That seems wholly irrelevant to me because drivers are clearly commonly not seeing the signs because of the large numbers who mistakenly drive the wrong way onto the slip road. In my opinion, consideration should be given to alternative arrangements to prevent vehicles entering and travelling along the slip road in the wrong direction.
” 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 National Highways; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain adequate visibility of road-surface No Entry markings at the slip-road junction
Wider context from the report “The exit point of the A5 "off" slip road at the Little Brickhill junction is wide. The signage indicating No Entry appears to be inadequate as there are two No Entry signs which are widely spaced at the junction. One is positioned to appear to forbid entry to the road over the bridge leading over the A5 and does not obviously relate to the slip road. The second is positioned such that it obliquely faces the road over the bridge and would not be visible to a driver turning right onto the slip road until they had completed the manoeuvre placing them at risk. There is a No Right Turn sign as the junction is approached. There is also No Entry in large white letters at the mouth of the slip road junction, however, this may be (1) obscured by vehicles leaving the slip road and (2) the junction is unlit and was said by a witness as being "pitch black". After the collision attention police officers saw three further vehicles perform exactly the same manoeuvre as Ms Ahmed and attempt to travel down the slip road in the wrong direction. Local residents have contacted police and claimed that it is a very common occurrence for drivers to mistakenly travel down the slip road in the wrong direction. The slip road is long and allows for the build up of considerable speed in turn facilitating what the police describe as a high energy impact. Following the collision, large temporary No Entry signs were positioned at the slip road junction. They were quickly removed apparently because the original signs were deemed to comply with necessary regulations. That seems wholly irrelevant to me because drivers are clearly commonly not seeing the signs because of the large numbers who mistakenly drive the wrong way onto the slip road. In my opinion, consideration should be given to alternative arrangements to prevent vehicles entering and travelling along the slip road in the wrong direction.
” 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 National Highways; that does not assign responsibility.
PFD Monitor interpretation Failure of commonly used satnav applications to provide unambiguous verbal directions at the junction
Wider context from the report “I have made observations regarding the slip road at this junction in my initial pre-Inquest Report To Prevent Future Deaths dated the 21st December 2023.
National Highways undertook a number of immediate remedial measures to try to prevent drivers turning and travelling the wrong way down this slip road, including narrowing the "mouth" of the slip road to one lane, placement of very large temporary "No Entry" signs and placement of signs indicating "Do Not Use Satnav" at the site. CCTV monitoring of driver behaviour was commenced. Police activity and monitoring by National Highways showed that despite these measures, drivers were still turning early and attempting to drive the wrong way down the slip road. Further enquiries by the police and information volunteered by members of the public who made the same incorrect manoeuvre led to the finding that while the visual map display on commonly used satnav applications at this junction displayed the correct information, the verbal commands gave information likely to confuse and direct drivers down the wrong slip road into the path of oncoming traffic . This was observed to happen frequently.
” 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 Undertake further work to assess junction capacity and whether the A5 off-slip bell-mouth width can be reduced with hatched markings.
Verbatim wording from the response “○ Width of the junction bell mouth at the end of the A5 off slip – the A5 off slip and junction bell mouth is two lanes wide. The bell mouth is effectively widened by the concrete overrun area along the eastern edge of the bell mouth. Reducing the width of the junction with hatched road markings may increase the conspicuity of the ‘No Entry’ measures. Further work will be undertaken to understand the capacity of the junction and whether the junction width can be reduced.” Source location Response from Highways
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 developing enhanced A5 off-slip mitigation options and establish which measures will be progressed, including improved signage and road markings.
Verbatim wording from the response “• The site assessment has established that, when measured against the Wrong Way Driving Toolkit, the junction has all the required ‘standard’ mitigation measures in place. However, potential improvements to road markings and signage on both National Highways and Milton Keynes City Council’s network have been identified.” Source location Response from Highways
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 Complete a full safety review of the junction against the current Wrong Way Driving: Mitigation Toolkit.
Verbatim wording from the response “The site visit has informed a full safety review of the junction, including an assessment of the junction against the latest version of National Highways’ Wrong Way Driving: Mitigation Toolkit (v1.2 January 2021). The junction had previously been assessed against the previous version of the toolkit (first issued in 2017).” Source location Response from Highways
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 temporary large No Entry signs on A-frames at both sides of the A5 off-slip exit.
Verbatim wording from the response “Further temporary signing has been put in place at the exit point of the A5 off slip at the Little Brickhill junction in the form of two large 1200mm ‘No Entry’ signs on A-frames on each side of the carriageway (Traffic Signs Regulations and General Directions (TSRGD), Diagram 616 No entry for vehicular traffic). These signs are intended to provide mitigation against further wrong way driving incidents while a full safety review of the junction has been undertaken.” Source location Response from Highways
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 junction already has all standard wrong-way-driving mitigation measures required by the current toolkit.
Verbatim wording from the response “• The site assessment has established that, when measured against the Wrong Way Driving Toolkit, the junction has all the required ‘standard’ mitigation measures in place. However, potential improvements to road markings and signage on both National Highways and Milton Keynes City Council’s network have been identified.” Source location Response from Highways
Open published response
22 Aug 2024 Tracey Julie HAYBITTLE · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 2 Failure of commonly used satnav applications to provide safe verbal directions at the junction View source Frequent wrong-way driving on the slip road 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. 10
Action
Deploy temporary ‘Do not follow Sat Nav’ and customer-information signs at the junction.
Stated completedThe respondent said that this action was complete when they made their response on 30 August 2024. View source
Action
Restore and maintain the temporary and fixed No-Entry signing, including correcting sign orientation, removing graffiti and repairing sign-related defects.
Stated in progressThe respondent said that this action was in progress when they made their response on 30 August 2024. View source
Action
Install additional temporary No-Entry signs at the A5 off-slip exit to mitigate wrong-way driving.
Stated completedThe respondent said that this action was complete when they made their response on 30 August 2024. View source
Action
Carry out detailed design and programme implementation of permanent junction works for the 2025/26 financial year.
Stated plannedThe respondent said that this action was planned when they made their response on 30 August 2024. View source
Action
Investigate Sat Nav routing and liaise with Google Maps, Apple Maps and WAZE regarding potentially confusing audible instructions.
Stated in progressThe respondent said that this action was in progress when they made their response on 30 August 2024. View source
Action
Commission and complete consultant feasibility assessments of permanent junction options, including safety risk, effectiveness, cost, engineering difficulty and lighting appraisal.
Stated completedThe respondent said that this action was complete when they made their response on 30 August 2024. View source
Action
Undertake seven-day, 24-hour CCTV monitoring to measure the effectiveness of the temporary layout.
Stated plannedThe respondent said that this action was planned when they made their response on 30 August 2024. View source
Action
Review feasibility outcomes with consultants and develop the preferred permanent option through a workshop, outline design, cost estimate and Stage 1 road-safety-audit documents.
Stated plannedThe respondent said that this action was planned when they made their response on 30 August 2024. View source
Action
Operate daily inspections of the temporary signing and cones to monitor their condition and alignment.
Stated completedThe respondent said that this action was complete when they made their response on 30 August 2024. View source
Action
Close the offside slip-road lane and reposition the temporary No-Entry signs closer together to reduce apparent two-way-road movements.
Stated completedThe respondent said that this action was complete when they made their response on 30 August 2024. View source See 7 more actions
×
AI-generated summary
Tracey Julie HAYBITTLE · 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
Tracey Julie Haybittle died at the John Radcliffe Hospital after a head-on collision when another driver entered the wrong slip road at the Little Brickhill junction. The report raised concerns that verbal commands from commonly used satnav applications could confuse and direct drivers down the wrong slip road into oncoming traffic, and that this occurred frequently despite remedial measures.
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 National Highways; that does not assign responsibility.
PFD Monitor interpretation Failure of commonly used satnav applications to provide safe verbal directions at the junction
Wider context from the report “I have made observations regarding the slip road at this junction in my initial pre-Inquest Report To Prevent Future Deaths dated the 21st December 2023 in respect of the linked case of Amal Mohamed Ahmood.
National Highways undertook a number of immediate remedial measures to try to prevent drivers turning and travelling the wrong way down this slip road, including narrowing the "mouth" of the slip road to one lane, placement of very large temporary "No Entry" signs and placement of signs indicating "Do Not Use Satnav" at the site. CCTV monitoring of driver behaviour was commenced. Police activity and monitoring by National Highways showed that despite these measures, drivers were still turning early and attempting to drive the wrong way down the slip road. Further enquiries by the police and information volunteered by members of the public who made the same incorrect manoeuvre led to the finding that while the visual map display on commonly used satnav applications at this junction displayed the correct information, the verbal commands gave information likely to confuse and direct drivers down the wrong slip road into the path of oncoming traffic . This was observed to happen frequently.
” 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 National Highways; that does not assign responsibility.
PFD Monitor interpretation Frequent wrong-way driving on the slip road
Wider context from the report “I have made observations regarding the slip road at this junction in my initial pre-Inquest Report To Prevent Future Deaths dated the 21st December 2023 in respect of the linked case of Amal Mohamed Ahmood.
National Highways undertook a number of immediate remedial measures to try to prevent drivers turning and travelling the wrong way down this slip road, including narrowing the "mouth" of the slip road to one lane, placement of very large temporary "No Entry" signs and placement of signs indicating "Do Not Use Satnav" at the site. CCTV monitoring of driver behaviour was commenced. Police activity and monitoring by National Highways showed that despite these measures, drivers were still turning early and attempting to drive the wrong way down the slip road . Further enquiries by the police and information volunteered by members of the public who made the same incorrect manoeuvre led to the finding that while the visual map display on commonly used satnav applications at this junction displayed the correct information, the verbal commands gave information likely to confuse and direct drivers down the wrong slip road into the path of oncoming traffic. This was observed to happen frequently .
” 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 Deploy temporary ‘Do not follow Sat Nav’ and customer-information signs at the junction.
Verbatim wording from the response “Again, on the 29 April 2024, the location was visited by National Highways and Thames Valley Police (Traffic Management Officer). During the site visit, a vehicle was observed to attempt to turn right into the slip road against the No-Entry signing. The driver was flagged down and aborted the turn. On speaking to the driver, they said that the Sat Nav app said to turn right. This raised concerns that Sat Nav instructions may have been leading to driver confusion.” Source location Response from National Highways
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 Restore and maintain the temporary and fixed No-Entry signing, including correcting sign orientation, removing graffiti and repairing sign-related defects.
Verbatim wording from the response “Following a site inspection on 24 April 2024, it was observed that the offside fixed (permanent) No-Entry sign had been rotated to face westwards (facing the Little Brickhill approach). This alteration had not been instructed or carried out by National Highways.” Source location Response from National Highways
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 additional temporary No-Entry signs at the A5 off-slip exit to mitigate wrong-way driving.
Verbatim wording from the response “Additional temporary signing has been put in place at the exit point of the A5 off slip at the Little Brickhill junction in the form of two large 1200mm ‘No Entry’ signs on A-frames on each side of the carriageway (Traffic Signs Regulations and General Directions (TSRGD), Diagram 616 No entry for vehicular traffic). These signs are intended to provide mitigation against further wrong way driving incidents while a full safety review of the junction has been undertaken.” Source location Response from National Highways
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 Carry out detailed design and programme implementation of permanent junction works for the 2025/26 financial year.
Verbatim wording from the response “Following completion of above actions, detailed design will be carried out and implementation programmed for the 2025/26 financial year.” Source location Response from National Highways
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 Investigate Sat Nav routing and liaise with Google Maps, Apple Maps and WAZE regarding potentially confusing audible instructions.
Verbatim wording from the response “Investigations have been undertaken to understand the potential influence Sat Nav instructions are having on driver behaviour. Route drives were undertaken using various Sat Nav apps (Google Maps, Apple Maps and WAZE) to review route guidance given to drivers.” Source location Response from National Highways
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission and complete consultant feasibility assessments of permanent junction options, including safety risk, effectiveness, cost, engineering difficulty and lighting appraisal.
Verbatim wording from the response “Following receipt of the Regulation 28 Report to Prevent future Deaths, we commissioned our external design consultant (WSP) to carry out feasibility work to determine and recommend appropriate permanent changes at the junction, including the following key activities:” Source location Response from National Highways
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 Undertake seven-day, 24-hour CCTV monitoring to measure the effectiveness of the temporary layout.
Verbatim wording from the response “As part of continued monitoring of the junction, we are planning to undertake CCTV monitoring, initially for 24hours a day for a period of 7 days, to measure the effectiveness of the temporary layout.” Source location Response from National Highways
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 feasibility outcomes with consultants and develop the preferred permanent option through a workshop, outline design, cost estimate and Stage 1 road-safety-audit documents.
Verbatim wording from the response “Details of the external design consultants’ initial assessment and options were submitted to National Highways on 14 June 2024, and we are currently reviewing the outcomes and planning the next steps, which include:” Source location Response from National Highways
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate daily inspections of the temporary signing and cones to monitor their condition and alignment.
Verbatim wording from the response “These works were undertaken on the night of the 24 April 2024. A daily inspection regime was put in place to monitor the signs and cones, and this is ongoing.” Source location Response from National Highways
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 Close the offside slip-road lane and reposition the temporary No-Entry signs closer together to reduce apparent two-way-road movements.
Verbatim wording from the response “These further changes involved closing the offside lane of the slip road to remove the potential ‘appearance’ of a two-way road. This also enabled the two large diameter No-Entry signs to be positioned closer together, see images below:” Source location Response from National Highways
Open published response
Concerns raised 2 Lack of stopping areas between refuse areas on all lanes open motorways View source Failure to monitor all lanes open motorways View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Kevin O'Reilly · 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
Kevin John O'Reilly was injured in a motorway collision on 29 June 2023 after his vehicle ran out of petrol and stopped in lane three. He later developed sepsis and pneumonia, followed by a large intracranial bleed, and died on 6 February 2024 from a traumatic intracranial haemorrhage. The concerns included the lack of stopping areas between designated refuse areas on the all-lanes-open motorway and the absence of monitoring of such motorways.
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 National Highways; that does not assign responsibility.
PFD Monitor interpretation Lack of stopping areas between refuse areas on all lanes open motorways
Wider context from the report “i. It was accepted at inquest that Mr O’Reilly was on an all lanes open motorway. This type of motorway has all lanes open for vehicles to use, and areas for vehicles to stop every 1.6 miles, but not areas in between.
ii. It was accepted that there was no area for vehicles to stop should they need to, unless they were near to the refuse areas spaced 1.6 miles apart , and the all lanes open motorways were not monitored.
” 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 National Highways; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor all lanes open motorways
Wider context from the report “i. It was accepted at inquest that Mr O’Reilly was on an all lanes open motorway. This type of motorway has all lanes open for vehicles to use, and areas for vehicles to stop every 1.6 miles, but not areas in between.
ii. It was accepted that there was no area for vehicles to stop should they need to, unless they were near to the refuse areas spaced 1.6 miles apart, and the all lanes open motorways were not monitored .
” 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 Complete the nationwide programme constructing and installing more than 150 additional emergency areas on all-lane-running motorways.
Verbatim wording from the response “Over the last 2 years, National Highways has been adding additional emergency areas to some ALR sections of motorway. We recently completed a nationwide programme to construct and install more than 150 additional emergency areas². We prioritised locations where emergency areas could make the most difference and bring benefits to drivers. The M6 junction 10a to 13 was not included as one of the locations for additional emergency areas because after looking at the frequency of live lane stops alongside safety data, other locations were determined to be higher priority as emergency areas could make the most difference and bring benefits to drivers as soon as possible.” Source location Response from National Highways
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 New emergency-area standards are not retrospectively funded for the existing Strategic Road Network.
Verbatim wording from the response “When a new standard is produced, National Highways is not funded to retrofit the Strategic Road Network (SRN) but to apply the new standard in any new works/designs. Currently, there are no plans for the addition of more emergency areas to this section of the M6 motorway.” Source location Response from National Highways
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 M6 section’s emergency areas were spaced 1.2 miles apart, within the applicable 1.6-mile design maximum.
Verbatim wording from the response “This location complied with the design standards at the time (IAN/161) which required places to stop in an emergency at a maximum spacing of 2.5km (1.6 miles).” Source location Response from National Highways
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 No additional emergency areas were planned because safety data identified higher-priority locations where they would provide greater immediate benefit.
Verbatim wording from the response “Over the last 2 years, National Highways has been adding additional emergency areas to some ALR sections of motorway. We recently completed a nationwide programme to construct and install more than 150 additional emergency areas². We prioritised locations where emergency areas could make the most difference and bring benefits to drivers. The M6 junction 10a to 13 was not included as one of the locations for additional emergency areas because after looking at the frequency of live lane stops alongside safety data, other locations were determined to be higher priority as emergency areas could make the most difference and bring benefits to drivers as soon as possible.” Source location Response from National Highways
Open published response
26 Jan 2024 PAUL ANDREW FREAR · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 1 Lack of clear and visible pedestrian crossing indications at the junction 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
PAUL ANDREW FREAR · 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
Paul Andrew Frear died at Queen Elizabeth Hospital, Birmingham, from injuries sustained when he entered the carriageway at a pedestrian crossing during a red pedestrian signal and collided with a vehicle. The report raises concern that the junction layout and pedestrian signals were confusing, particularly because indications were positioned only to the pedestrian’s left and were not visible on the opposite side, creating a risk of further deaths.
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 National Highways; that does not assign responsibility.
PFD Monitor interpretation Lack of clear and visible pedestrian crossing indications at the junction
Wider context from the report “5. My concern is that the design of this junction means that it is not obvious to a pedestrian that the only place to look for indications as to whether it is safe to cross the road is to their left . There are no such indicators on the opposite side of the carriageway which is ordinarily where a pedestrian would be looking . The signals were situated immediately to the left of where Mr Frear was stood/where any pedestrian would be standing.
6. Within the police report the collision investigator (who visited the scene) states as follows; I do however find the layout very confusing with the right turn filter lane (lane 3) not being separated from the main carriageway a pedestrian is faced with stationary traffic. If a pedestrian chose to look up to their right they would be presented with a red traffic light and the only indication that it is still not safe to cross is the pedestrian controls to their immediate left. The green light for lanes 1 and 2 is not visible to pedestrians and there is no pedestrian light indication on the opposite side .’ I share this concern.
7. Coroner understands from the police that there were two previous incidents at this location which occurred prior to the changes resulting in the current road layout. Coroner also understands Sandwell Highways have completed safety reviews and processes throughout the design, implementation and post installation of the junction design.
8. Whilst the current road layout may be legal, the death of Mr Frear highlights the safety issue for pedestrians present at this junction crossing from BOTH sides and highlights that the signage for pedestrians in not clear enough and there is a risk of further deaths now and in the future.
” Open source report
8 Jan 2024 Walter FAULDER · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 1 Risk of further accidents at a busy pedestrian crossing 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
Walter FAULDER · 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
Walter Faulder, aged 88, was struck by a vehicle while crossing the A595 at Orton Grange on 13 December 2022 and was pronounced deceased at the scene. Concerns included his apparent misunderstanding of the crossing arrangements and the safety of the busy crossing point, particularly for schoolchildren and older people, with a concern that further accidents and fatalities could occur without safety alterations.
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 National Highways; that does not assign responsibility.
PFD Monitor interpretation Risk of further accidents at a busy pedestrian crossing
Wider context from the report “(1) Walter seems to have believed that as a pedestrian he had right of way, he may have been a bit confused having forgotten his wallet however the day before the collision be referred to the illuminated pole in the central refuge as a Belisha Beacon.
(2) I heard that this is a busy crossing point, schoolchildren cross morning and evening for busses too and from school. There are also an increasing number of older people living in nearby developments.
(3) I am concerned that without safety alterations further accidents and possible fatalities may occur. Is there a case for lights to be installed?
” Open source report
16 Aug 2023 Absolom Adolphus Abraham Zephaniah DUFFY · Prevention of Future Deaths report Lincolnshire
View report summary
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.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
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.
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 National Highways; 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
18 Apr 2023 David Levett · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 1 Absence of a safe stopping place on all-lane-running smart motorways View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
David Levett · 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 Levett was a rear-seat passenger in a vehicle struck by a lorry on an all-lane-running smart motorway on 28 January 2018. He sustained severe head and chest injuries, was taken to hospital, and was confirmed deceased on 24 February 2018; evidence at the inquest raised concern that there was nowhere for the driver of the first vehicle to park safely, such as on a hard shoulder.
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 National Highways; that does not assign responsibility.
PFD Monitor interpretation Absence of a safe stopping place on all-lane-running smart motorways
Wider context from the report “DURING THE COURSE OF THE INQUEST, EVIDENCE WAS GIVEN THAT THE LOCATION OF THE COLLISION WAS ON AN ALL LANE RUNNING SMART MOTORWAY. THERE WAS NOWHERE FOR THE DRIVER OF THE FIRST VEHICLE TO PARK SAFELY e.g.. ON A HARD SHOULDER.
” 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 Install over 150 additional emergency areas on operational and construction all-lane-running motorways, subject to governance.
Verbatim wording from the response “In taking forward the 2021 TSC recommendations, the government announced in January 2022 it was committing £390 million to install over 150 additional emergency areas during the second Road Investment Period (2020-2025) on ALR motorways in operation and construction. This means drivers will have more places to stop if they get into difficulty. In comparison to January 2022 this will be around 50% more emergency areas, giving drivers added reassurance.” Source location Response from National Highways
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 Consider retrofitting further emergency areas when formulating the 2025–30 Road Investment Strategy, based on evidence of potential benefits.
Verbatim wording from the response “Retrofitting more emergency areas across the remainder of ALR motorways will be considered when formulating the 2025-30 Road Investment Strategy. This will be based on evidence of the potential benefits and considering whether the additional emergency areas help drivers to feel safer.” Source location Response from National Highways
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A hard shoulder would not eliminate collision risk; emergency areas provide a safer relative place to stop during emergencies.
Verbatim wording from the response “The concern raised focuses on the lack of a hard shoulder on an ALR motorway, and the subsequent question of where a driver can safely stop in an emergency. Hard shoulders do not eliminate the risk of collision, and 1 in 14 of all deaths on motorways happen on hard shoulders (based on 2016-2020 data). The hard shoulder is perceived to be a place of safety, but in reality it does not provide a completely safe place to stop.” Source location Response from National Highways
Open published response
14 Apr 2023 Benjamin James TEAGUE · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 1 Poor road condition with potholes View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Benjamin James TEAGUE · 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
Benjamin James Teague died at the scene after his BMW crossed onto the incorrect side of the A5 and collided head-on with an approaching car on 2 August 2021. Evidence at the inquest raised concern about the poor condition of the road, including potholes, which had reportedly deteriorated after repairs.
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 National Highways; that does not assign responsibility.
PFD Monitor interpretation Poor road condition with potholes
Wider context from the report “During the course of the inquest, evidence was given that the A5 between Pottersbury and Paulesbury (scene of the collision) is in a very poor state with potholes . I understand that a repair was carried out shortly after the road traffic collision but has since deteriorated . I believe that this matter should be looked at by National Highways,
” 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 Carry out the seven-phase resurfacing programme to renew targeted A5 running-surface sections between south Northamptonshire and Attherstone.
Verbatim wording from the response “• Commenced work on an extensive seven-phase road resurfacing scheme to renew targeted sections of the running surface along the A5 between south Northamptonshire and Attherstone. This work commenced on 20 February 2023. The link to the A5 press release can” Source location Response from National Highways
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 Make defects identified during inspections safe and complete temporary repairs within risk-based timescales until resurfacing is complete.
Verbatim wording from the response “• Increased the safety inspection regime from once every week to twice weekly to identify any immediate safety concerns in December 2022. Defects identified were made safe and repaired within risk based timescales set out in National Highways defect prioritisation guidance notes. Repair timescale is typically within 24 hours for defects which could impact safety and within 28 days for those defects with a high potential of deteriorating to a condition that could impact on safety.” Source location Response from National Highways
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 Increase safety inspections on the affected A5 stretch to twice weekly until resurfacing is complete.
Verbatim wording from the response “• Increased the safety inspection regime from once every week to twice weekly to identify any immediate safety concerns in December 2022. Defects identified were made safe and repaired within risk based timescales set out in National Highways defect prioritisation guidance notes. Repair timescale is typically within 24 hours for defects which could impact safety and within 28 days for those defects with a high potential of deteriorating to a condition that could impact on safety.” Source location Response from National Highways
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 Complete localized patch repairs over approximately two miles of the A5 between Pottersbury and Towcester.
Verbatim wording from the response “• Carried out localised repair work of patches of between 7m to 160m in length over a 2-mile section of carriageway between Pottersbury and Towcester between 9 and 10 January 2023.” Source location Response from National Highways
Open published response
13 Feb 2023 Steven Easdale · Prevention of Future Deaths report Hertfordshire
View report summary
Concerns raised 1 Lack of working lights on a pedestrian refuge 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
Steven Easdale · 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
Steven Easdale was struck by a car while crossing the B197 Digswell Hill on 5 November 2021 and died at Addenbrookes Hospital on 12 December 2021 from injuries sustained in the collision. The principal concern was that an unlit pedestrian refuge and nearby streetlamp posed a danger to road users and pedestrians; the coroner considered that illumination may have helped the driver see Mr Easdale earlier and avoid the collision.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Highways; that does not assign responsibility.
PFD Monitor interpretation Lack of working lights on a pedestrian refuge
Wider context from the report “(1) That the lack of working lights on the pedestrian refuge on the B197 Digswell Hill (near the Red Lion Public House) poses a danger to road users and pedestrians. Specifically that neither the illuminated bollard nor the streetlamp are in working order .
” Open source report
8 Feb 2023 Stephen Robert Wood · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 1 Lack of knowledge and/or understanding of when to report road obstructions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Stephen Robert Wood · 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
On 30 May 2021, Stephen Robert Wood was riding his motorcycle when it entered a 60-metre stretch of grass covering the carriageway, causing him to fall into the path of an oncoming car. He sustained numerous significant and unsurvivable injuries and died. The principal concern was a lack of knowledge about when road obstructions should be reported, meaning hazards may not be removed or warnings provided to other road users.
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 National Highways; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge and/or understanding of when to report road obstructions
Wider context from the report “2. I have concerns with regard to the following:
i. That there is a lack of knowledge and/or understanding as to when people should report an obstruction in the road. I would request that consideration is given to making all road users aware of the dangers of obstructions in the road and to encourage them to report any hazards to the local Police force or Local Authority so that it can be removed as soon as possible, or at least other road users be warned of the hazard to prevent a future death.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local highway authorities are responsible for local roads, including addressing hazards and obstructions on Coombe Road.
Verbatim wording from the response “I note that the collision occurred on Coombe Road, Winterbourne Steepleton, Dorchester, Dorset. For clarity, National Highways is the Government-owned company, sponsored by the Department for Transport (DfT), charged with operating, maintaining and improving England's motorways and major A-roads. Responsibility for local roads, including Coombe Road, rests with local highway authorities (not National Highways), and the road network in other parts of the UK rests with the devolved administrations.” Source location Response from National Highways Agency
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 Responsibility for local roads, including Coombe Road, lies outside National Highways’ remit.
Verbatim wording from the response “I note that the collision occurred on Coombe Road, Winterbourne Steepleton, Dorchester, Dorset. For clarity, National Highways is the Government-owned company, sponsored by the Department for Transport (DfT), charged with operating, maintaining and improving England's motorways and major A-roads. Responsibility for local roads, including Coombe Road, rests with local highway authorities (not National Highways), and the road network in other parts of the UK rests with the devolved administrations.” Source location Response from National Highways Agency
Open published response
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations