Concerns raised 2 Failure to provide adequate warning signage for pedestrians crossing near the car park View source Lack of assistance for pedestrians crossing the road View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Phillip Tetley · 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
Phillip Tetley died on 1 December 2025 after being struck by vehicles while crossing the A620 Straight Mile in Ranby. The report raised concerns about the lack of provision to assist people crossing the road, the increased use of the overflow carpark, and incomplete warning signage that might leave drivers unaware of the risks.
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 Nottinghamshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequate warning signage for pedestrians crossing near the car park
Wider context from the report “The court heard evidence that the possibility of a crossing is being considered by the council. The overflow carpark to the south of the A620 has been increased in size and there is an increase in the number of people crossing the road to get to the prison estate. Many of those crossing expressed concern about crossing the road safely. The court is concerned that if nothing is done to assist those crossing the road there is a risk of future deaths.
The court also received initial evidence from VIA in the form of a written statement that warning signs had been installed on the approach to the carpark, but then heard evidence that only “SLOW” signage had been installed, and planned “PEDESTRIANS IN THE ROAD/CROSSING” signage had not . As a result, drivers may be unaware of the risks posed at the car park location .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of assistance for pedestrians crossing the road
Wider context from the report “The court heard evidence that the possibility of a crossing is being considered by the council. The overflow carpark to the south of the A620 has been increased in size and there is an increase in the number of people crossing the road to get to the prison estate. Many of those crossing expressed concern about crossing the road safely. The court is concerned that if nothing is done to assist those crossing the road there is a risk of future deaths.
The court also received initial evidence from VIA in the form of a written statement that warning signs had been installed on the approach to the carpark, but then heard evidence that only “SLOW” signage had been installed, and planned “PEDESTRIANS IN THE ROAD/CROSSING” signage had not. As a result, drivers may be unaware of the risks posed at the car park location.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete pedestrian-movement, road-safety and feasibility investigations identifying a preferred location for a signal-controlled puffin crossing.
Verbatim wording from the response “Following the fatal collision on 1 December 2025, Nottinghamshire County Council commissioned a review of pedestrian movements and road safety conditions on the A620 Straight Mile adjacent to HMP Ranby.” Source location Response from Nottingham County Council
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Progress detailed design, statutory consultation, approvals, procurement and construction of a signal-controlled pedestrian crossing adjacent to the prison overflow car park.
Verbatim wording from the response “As a result, the Council has instructed Via East Midlands to progress the detailed design and delivery of a signal-controlled pedestrian crossing at this location. The current anticipated programme is as follows:” Source location Response from Nottingham County Council
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement monitoring and verification of highway safety measures commissioned following collision investigations.
Verbatim wording from the response “The Council and Via East Midlands acknowledge that the intended signage should have been installed earlier and regret that this did not occur. The matter has been reviewed internally and steps have been taken to ensure that highway safety measures commissioned in response to collision investigations are appropriately monitored and verified following instruction and implementation.” Source location Response from Nottingham County Council
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Install two pedestrian warning signs on approaches to HMP Ranby alongside existing slow-warning signs.
Verbatim wording from the response “Following notification of the fatal collision by Nottinghamshire Police on 3 December 2025, Via East Midlands commissioned the installation of temporary warning signage consisting of both "SLOW" signs and "Pedestrians in Road" warning signs on the approaches to HMP Ranby.” Source location Response from Nottingham County Council
Open published response
4 Oct 2023 Janet Irene SPENCER · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 3 Failure to ensure all involved have the information required to contribute effectively to the transfer process View source Failure to ensure smooth transitions between care facilities during discharge or transfer View source Failure to ensure adequate and up-to-date risk assessments and care plans during discharge or transfer between care facilities View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Janet Irene SPENCER · 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
Janet Irene Spencer suffered an unwitnessed fall in her assisted living accommodation on 30 August 2022, sustaining a traumatic acute subdural haematoma. She was treated in hospital and placed on end-of-life care, but did not recover and died some 13 days later; underlying ischaemic heart disease contributed to, but did not directly cause, her death. The report identified concerns about inadequate and outdated risk assessments and care plans during discharge or transfer, and insufficient information-sharing to support smooth transfers between care facilities.
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 Nottinghamshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure all involved have the information required to contribute effectively to the transfer process
Wider context from the report “2. The systems in place in respect of discharge to assess patients do not appear to ensure a smooth transition between care facilities, especially when transfers are arranged at pace. In particular, they do not appear to ensure that all involved have the information they require to contribute effectively to the transfer process .
” 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 Nottinghamshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure smooth transitions between care facilities during discharge or transfer
Wider context from the report “2. The systems in place in respect of discharge to assess patients do not appear to ensure a smooth transition between care facilities, especially when transfers are arranged at pace . In particular, they do not appear to ensure that all involved have the information they require to contribute effectively to the transfer process.
” 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 Nottinghamshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure adequate and up-to-date risk assessments and care plans during discharge or transfer between care facilities
Wider context from the report “1. The systems in place in respect of discharge to assess patients do not appear to ensure patients are discharged or transferred between care facilities with an adequate and up to date risk assessment and care plan in place .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement and use a referral and assessment process for Assessment Flat admissions, recording care needs, risks and medical information and sharing them with providers.
Verbatim wording from the response “11. The LA recognises that improvements have been required in the clear and accurate sharing of up-to-date information for admission to the Assessment Flats, as illustrated by Mrs Spencer’s situation. To ensure that the risk of any future breakdown in communication is mitigated, a new process and referral / assessment form has been implemented for all people moving into Assessment Flat accommodation. This process is for hospital and community admissions into” Source location Response from Nottinghamshire County Council
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold weekly Transfer of Care Hub audits and reflective discussions about hospital discharges and required improvements.
Verbatim wording from the response “9. At a more operational level, the Transfer of Care Hubs hold weekly audits and reflective discussions of hospital discharges that have gone well or where improvements are required.” Source location Response from Nottinghamshire County Council
Open published response
14 Oct 2021 Mr Murray Hyslop · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 4 Failure of senior staff to openly consider and learn from adverse care events View source Lack of expectation for staff to take a broader view when identifying residents in need of medical attention View source Failure to provide sufficiently responsive review of pressure-damage prevention needs View source Failure to effectively cascade medical-assessment training to frontline care staff View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Mr Murray Hyslop · 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
Mr Murray Hyslop developed Covid-19, reduced fluid intake and appetite, and became dehydrated, malnourished and affected by acute kidney injury. He was admitted to hospital on 24 December 2020 but did not recover and died from natural disease on 16 January 2021. Concerns included inadequate prevention of pressure damage, failure to identify when he needed medical attention, and a lack of openness about learning from adverse events.
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 Nottinghamshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure of senior staff to openly consider and learn from adverse care events
Wider context from the report “(3) Learning from adverse events – the culture within senior staff of obfuscation and denial when issues regarding care are raised was of significant concern to me as it is hard to have confidence that, as they said to me, “lessons will be learned”. It was appropriate for the senior management to be supportive of their frontline staff who, as set out above, worked hard when the care home was understaffed. They were not, however, open minded to consider areas where significant changes in practice and culture needed to take place .
” 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 Nottinghamshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of expectation for staff to take a broader view when identifying residents in need of medical attention
Wider context from the report “(2) Identifying a resident in need of medical attention – some of the difficulties in Mr Hyslop’s care were exacerbated by the outbreak of Covid-19, but there was no evidence of any expectation upon any members of staff to consider a broader view of Mr Hyslop’s presentation than how he was on a particular day . The witnesses did not seek to suggest that they usually did this but were unable to during the outbreak and so I consider that it is likely that this was an issue was existed both before and after the outbreak. I was more reassured in this area by “Restore 2” materials and training which provide very clear and helpful guidance to carers. It is not clear to me how this training, which has been completed by the registered manager, has been effectively cascaded to frontline care staff and their evidence to me suggested that this has not happened to date;
” 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 Nottinghamshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide sufficiently responsive review of pressure-damage prevention needs
Wider context from the report “(1) Prevention of pressure damage – there was a lack of appreciation of the need to consider Mr Hyslop’s extreme vulnerability to pressure damage when he was very unwell, dehydrated, malnourished and largely immobile. Policies and practices supported only monthly review of his needs and that is insufficiently responsive in order to appropriately prevent damage from occurring ;
” 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 Nottinghamshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to effectively cascade medical-assessment training to frontline care staff
Wider context from the report “(2) Identifying a resident in need of medical attention – some of the difficulties in Mr Hyslop’s care were exacerbated by the outbreak of Covid-19, but there was no evidence of any expectation upon any members of staff to consider a broader view of Mr Hyslop’s presentation than how he was on a particular day. The witnesses did not seek to suggest that they usually did this but were unable to during the outbreak and so I consider that it is likely that this was an issue was existed both before and after the outbreak. I was more reassured in this area by “Restore 2” materials and training which provide very clear and helpful guidance to carers. It is not clear to me how this training, which has been completed by the registered manager, has been effectively cascaded to frontline care staff and their evidence to me suggested that this has not happened to date ;
” Open source report
23 Jun 2021 Heather Frances Page · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 5 Railway track with multiple easy access points near a popular beauty spot increasing suicide risk View source Pedestrian crossings requiring people to walk on railway tracks View source Dependence on local authority support for closing or rationalising crossings View source Failure to reduce or rationalise the number of crossings View source High fatality rate along the section of track 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
Heather Frances Page · 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 7 October 2020, Heather Frances Page stepped in front of a train and died in the resulting collision. The report identified concerns about pedestrian crossings requiring people to walk on the tracks, a high number of fatalities, ease of access to the track, and difficulties reducing or rationalising crossings because of local authority opposition.
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 Nottinghamshire County Council; that does not assign responsibility.
PFD Monitor interpretation Railway track with multiple easy access points near a popular beauty spot increasing suicide risk
Wider context from the report “Evidence was heard regarding the section of track adjacent to the Attenborough Nature Reserve. I noted the following issues of concern in relation to this section of track:-
(1) There are a number of pedestrian crossings along this short stretch of track which involve pedestrians having to walk on the tracks to cross to the other side.
(2) There has been a high number of fatalities along this short section of track (seven in as many years).
(3) The nature of that section of track is such that it increases the risks of completed suicide due to the ease of access at multiple points and its proximity to a very popular beauty spot .
(4) Efforts by Network Rail to reduce / rationalise the number of crossings along that stretch have failed due, in part, to opposition from the relevant local authorities.
(5) Support or opposition from local authorities and councils will respectively increase or reduce the prospects of the risks inherent in that stretch of track being reduced. In the absence of support from local authorities and councils, Network Rail will be less likely to make an application to close or rationalise crossings along this section of track, given the known opposition from some persons living near, or using, the crossings. If an application is made, it will be less likely to be granted in the absence of support from the relevant local authorities and councils.
” 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 Nottinghamshire County Council; that does not assign responsibility.
PFD Monitor interpretation Pedestrian crossings requiring people to walk on railway tracks
Wider context from the report “Evidence was heard regarding the section of track adjacent to the Attenborough Nature Reserve. I noted the following issues of concern in relation to this section of track:-
(1) There are a number of pedestrian crossings along this short stretch of track which involve pedestrians having to walk on the tracks to cross to the other side.
(2) There has been a high number of fatalities along this short section of track (seven in as many years).
(3) The nature of that section of track is such that it increases the risks of completed suicide due to the ease of access at multiple points and its proximity to a very popular beauty spot.
(4) Efforts by Network Rail to reduce / rationalise the number of crossings along that stretch have failed due, in part, to opposition from the relevant local authorities.
(5) Support or opposition from local authorities and councils will respectively increase or reduce the prospects of the risks inherent in that stretch of track being reduced. In the absence of support from local authorities and councils, Network Rail will be less likely to make an application to close or rationalise crossings along this section of track, given the known opposition from some persons living near, or using, the crossings. If an application is made, it will be less likely to be granted in the absence of support from the relevant local authorities and councils.
” 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 Nottinghamshire County Council; that does not assign responsibility.
PFD Monitor interpretation Dependence on local authority support for closing or rationalising crossings
Wider context from the report “Evidence was heard regarding the section of track adjacent to the Attenborough Nature Reserve. I noted the following issues of concern in relation to this section of track:-
(1) There are a number of pedestrian crossings along this short stretch of track which involve pedestrians having to walk on the tracks to cross to the other side.
(2) There has been a high number of fatalities along this short section of track (seven in as many years).
(3) The nature of that section of track is such that it increases the risks of completed suicide due to the ease of access at multiple points and its proximity to a very popular beauty spot.
(4) Efforts by Network Rail to reduce / rationalise the number of crossings along that stretch have failed due, in part, to opposition from the relevant local authorities.
(5) Support or opposition from local authorities and councils will respectively increase or reduce the prospects of the risks inherent in that stretch of track being reduced. In the absence of support from local authorities and councils, Network Rail will be less likely to make an application to close or rationalise crossings along this section of track , given the known opposition from some persons living near, or using, the crossings. If an application is made, it will be less likely to be granted in the absence of support from the relevant local authorities and councils.
” 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 Nottinghamshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to reduce or rationalise the number of crossings
Wider context from the report “Evidence was heard regarding the section of track adjacent to the Attenborough Nature Reserve. I noted the following issues of concern in relation to this section of track:-
(1) There are a number of pedestrian crossings along this short stretch of track which involve pedestrians having to walk on the tracks to cross to the other side.
(2) There has been a high number of fatalities along this short section of track (seven in as many years).
(3) The nature of that section of track is such that it increases the risks of completed suicide due to the ease of access at multiple points and its proximity to a very popular beauty spot.
(4) Efforts by Network Rail to reduce / rationalise the number of crossings along that stretch have failed due, in part, to opposition from the relevant local authorities.
(5) Support or opposition from local authorities and councils will respectively increase or reduce the prospects of the risks inherent in that stretch of track being reduced. In the absence of support from local authorities and councils, Network Rail will be less likely to make an application to close or rationalise crossings along this section of track, given the known opposition from some persons living near, or using, the crossings. If an application is made, it will be less likely to be granted in the absence of support from the relevant local authorities and councils.
” 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 Nottinghamshire County Council; that does not assign responsibility.
PFD Monitor interpretation High fatality rate along the section of track
Wider context from the report “Evidence was heard regarding the section of track adjacent to the Attenborough Nature Reserve. I noted the following issues of concern in relation to this section of track:-
(1) There are a number of pedestrian crossings along this short stretch of track which involve pedestrians having to walk on the tracks to cross to the other side.
(2) There has been a high number of fatalities along this short section of track (seven in as many years).
(3) The nature of that section of track is such that it increases the risks of completed suicide due to the ease of access at multiple points and its proximity to a very popular beauty spot.
(4) Efforts by Network Rail to reduce / rationalise the number of crossings along that stretch have failed due, in part, to opposition from the relevant local authorities.
(5) Support or opposition from local authorities and councils will respectively increase or reduce the prospects of the risks inherent in that stretch of track being reduced. In the absence of support from local authorities and councils, Network Rail will be less likely to make an application to close or rationalise crossings along this section of track, given the known opposition from some persons living near, or using, the crossings. If an application is made, it will be less likely to be granted in the absence of support from the relevant local authorities and councils.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Meet with Public Health Authority officers to discuss Network Rail deaths and near misses.
Verbatim wording from the response “10. Additionally, officers of NCC in its capacity as Local Highway Authority are to meet with officers of NCC in its capacity as Public Health Authority next week to discuss ‘Network Rail Deaths and Near Misses’, which it is understood is specifically in relation to work by the British Transport Police, Network Rail and Public Health colleagues regarding suicides on the railway.” Source location 2021-0213-Response-from-Nottinghamshire-County-Council_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Divert public rights of way at specified Nottinghamshire crossings to remove or avoid at-grade railway crossings.
Verbatim wording from the response “8. Notwithstanding the above, it has been possible to obtain public support to take forward a number of safety improvements in recent years, and several crossings in Nottinghamshire have been diverted by NCC and bridged by Network Rail to remove at grade crossings over operational lines. For example:” Source location 2021-0213-Response-from-Nottinghamshire-County-Council_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide temporary emergency closure of Burton Joyce Footpath No.6 to prevent public access during Network Rail emergency safety works.
Verbatim wording from the response “9. Separate to the above, NCC continues to work closely with Network Rail’s Level Crossing Managers in order to help manage public safety at level crossings. For example, NCC recently provided a temporary emergency closure on Burton Joyce Footpath No.6 (Chestnut Grove) following a near-miss incident which prevented public access while Network Rail undertook some emergency improvement works.” Source location 2021-0213-Response-from-Nottinghamshire-County-Council_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue Countryside Access Team contact and collaboration with Network Rail’s Liabilities Team on public-highway rights across railway land.
Verbatim wording from the response “7. NCC’s Countryside Access Team has regular contact and a good working relationship with Network Rail’s Liabilities Team; this being the team within Network Rail with responsibility for the stopping up and diversion of public highway rights across railway lines and operational property. As part of this, NCC are currently discussing a number of at grade crossings in the County regarding their future management, as well as discussing opportunities for access on their non-operational land, which would increase public safety. Any proposals arising from this would, however, be subject to the formal legally prescribed consultation referred to above and thus may potentially be unable to be taken forward due to objections from highway users.” Source location 2021-0213-Response-from-Nottinghamshire-County-Council_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain regular dialogue with Network Rail about level-crossing diversions, bridges, future management and safer access to non-operational land.
Verbatim wording from the response “6. Additional to the above, NCC and Network Rail are in regular dialogue regarding level” Source location 2021-0213-Response-from-Nottinghamshire-County-Council_Published
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Network Rail is responsible for operating, maintaining and improving the safety of the national rail network, including level crossings.
Verbatim wording from the response “B. The operation, maintenance and improvement of a safe national rail network (including level crossings), is the responsibility of Network Rail, with oversight and funding specifically provided to them by the Office of Rail and Road for improving safety at such crossings.” Source location 2021-0213-Response-from-Nottinghamshire-County-Council_Published
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The assertion that local authorities opposed Network Rail’s efforts to rationalise crossings is incorrect in respect of Nottinghamshire County Council.
Verbatim wording from the response “1. NCC is grateful for sight of the Assistant Coroner’s report relating to Heather Frances PAGE and would be happy to attend any future inquests if it can provide information of assistance to the coroner. NCC is concerned that, in the report, it is stated that evidence was heard that “(4) Efforts by Network Rail to reduce / rationalise the number of crossings along that stretch have failed due, in part, to opposition from the relevant local authorities”. As the Assistant Coroner will be aware, NCC was not invited to be an interested party at the inquest and was provided with no opportunity to answer this assertion which is, for the reasons set out below, incorrect.” Source location 2021-0213-Response-from-Nottinghamshire-County-Council_Published
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Authority cannot unilaterally close or rationalise crossings because statutory consultation and objection procedures restrict its available powers.
Verbatim wording from the response “3. Closure of level crossings can be achieved under 4 separate Acts of Parliament¹, with only the Highways Act powers available to the Local Highway Authority. The prescribed process which Highway Authorities must follow in order to divert or extinguish certain minor public highways² involve the making of an Order and formal public consultation. Should objections be received and maintained to the diversion or extinguishment, an Order cannot be brought into effect but must be referred to the Secretary of State for determination which often necessitates the holding of a local public inquiry, though it is possible, at the Secretary of State’s discretion, for such an Order to be determined following a hearing or, rarely, to be dealt with by an exchange of written representations.” Source location 2021-0213-Response-from-Nottinghamshire-County-Council_Published
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Where a person intends suicide, no measures can prevent it, and widespread crossing closures would face overwhelming public resistance.
Verbatim wording from the response “a. as with the highways network, it is inevitably the case that where a person intends to take their own life, there are no measures that can be put in place to prevent it (and widespread closure of all such crossings would meet with overwhelming public resistance due to the level of interference that would represent with people’s enjoyment of such routes); and” Source location 2021-0213-Response-from-Nottinghamshire-County-Council_Published
Open published response
25 Mar 2021 Sean Daniel FEGAN · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 7 Failure to account for autistic presentation when understanding mental health needs View source Failure to establish informed agreement before withdrawing mental health services View source Failure to proactively engage with family members and receive their concerns when services withdraw View source Unavailability of services for patients with dual diagnosis and significant drugs misuse problems View source Failure to provide access to needed mental health treatment View source Failure to make secondary mental health care decisions using adequate information and assessment View source Overriding care plans without assessment by decision-makers and review of the risk assessment View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Sean Daniel FEGAN · 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
Sean Daniel Fegan, who had autism, complex mental health conditions and drug misuse, died from toxicity after taking a combination of prescribed and illicit substances on or before 26 April 2020. The report raised concerns about decisions regarding secondary mental health care, access to treatment, dual diagnosis services, liaison with family members, implementation of care plans and autism awareness.
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 Nottinghamshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to account for autistic presentation when understanding mental health needs
Wider context from the report “6. Autism awareness – I was concerned that Mr Fegan’s presentation acted as a barrier to a proper understanding of his mental health needs . In line with his autism diagnosis, he did not present in a socially typical way of expressing his feelings and emotions in a demonstrative manner, but rather ‘jumped’ to his view about what treatment he required, namely prescriptions. This was misunderstood by professionals on more than one occasion .
” 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 Nottinghamshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to establish informed agreement before withdrawing mental health services
Wider context from the report “5. Implementation of care plans – a care plan was devised by the liaison nurse and psychiatrist, only to be overruled by persons who had not themselves assessed Mr Fegan, on an incorrect basis, and without a review of the risk assessment justifying that decision. Mr Fegan was called and invited to agree to the withdrawal of services. Such a practice runs the significant risk that patients who are less assertive or who have poor insight into their mental health needs will be said to have ‘agreed’ that a service is no longer required .
” 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 Nottinghamshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to proactively engage with family members and receive their concerns when services withdraw
Wider context from the report “4. Liaison with family members – there was no evidence of proactive attempts to engage with family members, even when services withdrew . When a family member sought to share concerns, these were rebuffed .
” 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 Nottinghamshire County Council; that does not assign responsibility.
PFD Monitor interpretation Unavailability of services for patients with dual diagnosis and significant drugs misuse problems
Wider context from the report “3. Dual diagnosis – it was acknowledged that there was a ‘gap’ within the services in relation to dual diagnosis patients . There was evidence of a resistance to agreeing to provide a service to patients with significant drugs misuse problems .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide access to needed mental health treatment
Wider context from the report “2. Access to mental health treatment – Mr Fegan had complex mental health conditions and experienced very high levels of distress and anxiety as a consequence. He was declined mental health treatment on two occasions by the Trust . Mr Fegan took an overdose due to his frustration at not being able to access mental health services which he needed . Whilst this was not the cause of Mr Fegan’s death, it created a dangerous state of affairs .
” 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 Nottinghamshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to make secondary mental health care decisions using adequate information and assessment
Wider context from the report “1. Decision making surrounding the need for secondary mental health care – as set out above, a decision was taken in December 2019 that Mr Fegan did not require mental health treatment at all in the absence of adequate information or assessment and for reasons which appeared incorrect .
” 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 Nottinghamshire County Council; that does not assign responsibility.
PFD Monitor interpretation Overriding care plans without assessment by decision-makers and review of the risk assessment
Wider context from the report “5. Implementation of care plans – a care plan was devised by the liaison nurse and psychiatrist, only to be overruled by persons who had not themselves assessed Mr Fegan , on an incorrect basis, and without a review of the risk assessment justifying that decision . Mr Fegan was called and invited to agree to the withdrawal of services. Such a practice runs the significant risk that patients who are less assertive or who have poor insight into their mental health needs will be said to have ‘agreed’ that a service is no longer required.
” Open source report
27 Dec 2019 Enid Baber · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 3 Failure to routinely assess whether people with significant restrictions on liberty in their own homes are deprived of their liberty View source Lack of training in deprivation of liberty assessment View source Lack of adequate safeguards and safety attention for people potentially deprived of liberty in their own homes 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
Enid Baber · 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
Enid Baber, who was cognitively impaired, died suddenly after getting into or falling backwards into a bath late at night or in the early hours of the morning. The report raised concerns that people living in their own homes with significant restrictions on their liberty might be unlawfully deprived of liberty without adequate safeguards, partly because relevant social workers were not required or prompted to assess this and had not received specific training.
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 Nottinghamshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely assess whether people with significant restrictions on liberty in their own homes are deprived of their liberty
Wider context from the report “Enid Baber was not free to leave her property. This was a fact which was well known to Nottinghamshire County Council who had been involved in coordinating her package of care. She was also under a measure of supervision and control during the day. I concluded, after hearing evidence on the point, that although in my finding she was not being deprived of her liberty, this was a very finely balanced decision.
I was advised that Nottinghamshire County Council has a team which deals with deprivation of liberty (‘DOL’) in community settings although the evidence I received was that the team dealing with dementia cases did not routinely or actively carry out an assessment as to whether or not persons in Mrs Baber’s situation are deprived of their liberty . They have not received specific training on this difficult assessment process.
In this case, Mrs Baber’s circumstances fell only narrowly short of a deprivation of liberty and only minor changes would have resulted in a different conclusion. There was no mechanism by which the social workers working with Mrs Baber were required or prompted to consider the issue of deprivation of liberty and they had not been trained to do so.
Had Mrs Baber been deprived of her liberty then she has a human right for that detention to be kept under review and I remained concerned that this particular class of persons, that is, persons who remain in their own home but who have significant restrictions on their liberty, may be unlawfully deprived of their liberty without adequate safeguards being in place and that this may potentially become unsafe by, for example, insufficient attention to the safety implications of being locked in your own home.
” 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 Nottinghamshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of training in deprivation of liberty assessment
Wider context from the report “Enid Baber was not free to leave her property. This was a fact which was well known to Nottinghamshire County Council who had been involved in coordinating her package of care. She was also under a measure of supervision and control during the day. I concluded, after hearing evidence on the point, that although in my finding she was not being deprived of her liberty, this was a very finely balanced decision.
I was advised that Nottinghamshire County Council has a team which deals with deprivation of liberty (‘DOL’) in community settings although the evidence I received was that the team dealing with dementia cases did not routinely or actively carry out an assessment as to whether or not persons in Mrs Baber’s situation are deprived of their liberty. They have not received specific training on this difficult assessment process.
In this case, Mrs Baber’s circumstances fell only narrowly short of a deprivation of liberty and only minor changes would have resulted in a different conclusion. There was no mechanism by which the social workers working with Mrs Baber were required or prompted to consider the issue of deprivation of liberty and they had not been trained to do so .
Had Mrs Baber been deprived of her liberty then she has a human right for that detention to be kept under review and I remained concerned that this particular class of persons, that is, persons who remain in their own home but who have significant restrictions on their liberty, may be unlawfully deprived of their liberty without adequate safeguards being in place and that this may potentially become unsafe by, for example, insufficient attention to the safety implications of being locked in your own home.
” 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 Nottinghamshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate safeguards and safety attention for people potentially deprived of liberty in their own homes
Wider context from the report “Enid Baber was not free to leave her property. This was a fact which was well known to Nottinghamshire County Council who had been involved in coordinating her package of care. She was also under a measure of supervision and control during the day. I concluded, after hearing evidence on the point, that although in my finding she was not being deprived of her liberty, this was a very finely balanced decision.
I was advised that Nottinghamshire County Council has a team which deals with deprivation of liberty (‘DOL’) in community settings although the evidence I received was that the team dealing with dementia cases did not routinely or actively carry out an assessment as to whether or not persons in Mrs Baber’s situation are deprived of their liberty. They have not received specific training on this difficult assessment process.
In this case, Mrs Baber’s circumstances fell only narrowly short of a deprivation of liberty and only minor changes would have resulted in a different conclusion. There was no mechanism by which the social workers working with Mrs Baber were required or prompted to consider the issue of deprivation of liberty and they had not been trained to do so.
Had Mrs Baber been deprived of her liberty then she has a human right for that detention to be kept under review and I remained concerned that this particular class of persons, that is, persons who remain in their own home but who have significant restrictions on their liberty, may be unlawfully deprived of their liberty without adequate safeguards being in place and that this may potentially become unsafe by, for example, insufficient attention to the safety implications of being locked in your own home .
” Open source report
21 Feb 2018 Molly Jean Mills · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 5 Inadequate visibility of oncoming traffic for vehicles waiting or turning at the junction View source Failure of junction warning signs to identify the Home Farm junction View source Risk of shunt-type collisions for vehicles waiting to turn right View source Road layout requiring a sharp-angled right turn into Home Farm View source Lack of clear right-of-way and manoeuvre rules for opposing right turns View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Molly Jean Mills · 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
Molly Jean Mills, known as Jean, was involved in a collision with a lorry while turning right on the A6006 near Stanford on Soar on 6 June 2017. She died in hospital on 17 July 2017 after contracting bronchopneumonia associated with rib fractures sustained in the collision. The report identified concerns that the junction layout, incline, obstructed visibility, unclear manoeuvring arrangements and inadequate warnings increased the risk of future collisions and 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 Nottinghamshire County Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate visibility of oncoming traffic for vehicles waiting or turning at the junction
Wider context from the report “1. There is a significant incline on this road (in the direction the lorry was travelling). This makes the visibility issues referred to below much more significant.
2. If there are vehicles in the central carriageway waiting to turn right into both the DNRC and Home Farm, as here, there is a risk of them having an inadequate view of oncoming traffic on the A6006 , before making their turning manoeuvres.
3. This is the case in both directions, but particularly for vehicles travelling in the direction towards Rempstone, because of the incline of the road .
4. The evidence of the lorry driver was that he did not see Jean’s car until she turned in front of his vehicle.
5. The evidence of the Forensic Collision Investigation Unit officer was that Jean’s view would have been largely or completely blocked by vehicles waiting to turn right into DNRC until 2.93 seconds before impact.
6. Witness evidence suggested that the right turn into DNRC is often backed up, resulting in queues in this central lane, making visibility worse . It was suggested this may be partly because of a security barrier in the DNRC grounds, which causes traffic to back up. This is likely to remain a busy junction when the DNRC opens.
7. If the oncoming vehicle (coming up the incline towards Rempstone) was a standard vehicle, rather than a lorry, visibility would be even worse , given that the cab of a lorry is higher up.
8. Similarly, if the vehicles waiting to turn right (into Home Farm and DNRC) were lorries or other large vehicles, such as ambulances, then visibility concerns would be heightened further .
9. There is an element of uncertainty at the junction – where both vehicles are turning right – there is no clear indication of who has right of way or how the vehicles should make their manoeuvres.
10. There is a solid double white line on the road just before the turning into Home Farm. This requires a driver turning right to make a sharp-angled turn.
11. The signs on either side of the junction warn oncoming traffic of the DNRC junction, but not the Home Farm junction. The fact that the Home Farm road is a private road should not reduce the need for adequate safety warnings to drivers.
12. I have been provided with a Nottinghamshire County Council Road Safety Audit regarding this junction, which is dated 21.9.15. This contains the following extract :
During the site visit we were approached by a member of the public (apparently the owner) from Home Farm, opposite the Stanford Hall Access. He brought to our attention an issue which he felt had safety implications. Drivers intending to turn right into the Home Farm access have to wait on their side of the A6006 centre line to give way to oncoming traffic, as previously. They then have to turn across both the right turn lane and the Eastbound A6006 traffic lane. If a number of vehicles were occupying the right turn lane, he felt there would be potential to mask oncoming A6006 vehicles from view . Although the existing situation requires a right turner to wait in the westbound lane of the A6006, he also felt that he would be at greater risk of shunt type accidents than previously.
13. Sadly, this appears to have been the very risk that played a part in this collision.
” 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 Nottinghamshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure of junction warning signs to identify the Home Farm junction
Wider context from the report “1. There is a significant incline on this road (in the direction the lorry was travelling). This makes the visibility issues referred to below much more significant.
2. If there are vehicles in the central carriageway waiting to turn right into both the DNRC and Home Farm, as here, there is a risk of them having an inadequate view of oncoming traffic on the A6006, before making their turning manoeuvres.
3. This is the case in both directions, but particularly for vehicles travelling in the direction towards Rempstone, because of the incline of the road.
4. The evidence of the lorry driver was that he did not see Jean’s car until she turned in front of his vehicle.
5. The evidence of the Forensic Collision Investigation Unit officer was that Jean’s view would have been largely or completely blocked by vehicles waiting to turn right into DNRC until 2.93 seconds before impact.
6. Witness evidence suggested that the right turn into DNRC is often backed up, resulting in queues in this central lane, making visibility worse. It was suggested this may be partly because of a security barrier in the DNRC grounds, which causes traffic to back up. This is likely to remain a busy junction when the DNRC opens.
7. If the oncoming vehicle (coming up the incline towards Rempstone) was a standard vehicle, rather than a lorry, visibility would be even worse, given that the cab of a lorry is higher up.
8. Similarly, if the vehicles waiting to turn right (into Home Farm and DNRC) were lorries or other large vehicles, such as ambulances, then visibility concerns would be heightened further.
9. There is an element of uncertainty at the junction – where both vehicles are turning right – there is no clear indication of who has right of way or how the vehicles should make their manoeuvres.
10. There is a solid double white line on the road just before the turning into Home Farm. This requires a driver turning right to make a sharp-angled turn.
11. The signs on either side of the junction warn oncoming traffic of the DNRC junction, but not the Home Farm junction . The fact that the Home Farm road is a private road should not reduce the need for adequate safety warnings to drivers .
12. I have been provided with a Nottinghamshire County Council Road Safety Audit regarding this junction, which is dated 21.9.15. This contains the following extract :
During the site visit we were approached by a member of the public (apparently the owner) from Home Farm, opposite the Stanford Hall Access. He brought to our attention an issue which he felt had safety implications. Drivers intending to turn right into the Home Farm access have to wait on their side of the A6006 centre line to give way to oncoming traffic, as previously. They then have to turn across both the right turn lane and the Eastbound A6006 traffic lane. If a number of vehicles were occupying the right turn lane, he felt there would be potential to mask oncoming A6006 vehicles from view. Although the existing situation requires a right turner to wait in the westbound lane of the A6006, he also felt that he would be at greater risk of shunt type accidents than previously.
13. Sadly, this appears to have been the very risk that played a part in this collision.
” 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 Nottinghamshire County Council; that does not assign responsibility.
PFD Monitor interpretation Risk of shunt-type collisions for vehicles waiting to turn right
Wider context from the report “1. There is a significant incline on this road (in the direction the lorry was travelling). This makes the visibility issues referred to below much more significant.
2. If there are vehicles in the central carriageway waiting to turn right into both the DNRC and Home Farm, as here, there is a risk of them having an inadequate view of oncoming traffic on the A6006, before making their turning manoeuvres.
3. This is the case in both directions, but particularly for vehicles travelling in the direction towards Rempstone, because of the incline of the road.
4. The evidence of the lorry driver was that he did not see Jean’s car until she turned in front of his vehicle.
5. The evidence of the Forensic Collision Investigation Unit officer was that Jean’s view would have been largely or completely blocked by vehicles waiting to turn right into DNRC until 2.93 seconds before impact.
6. Witness evidence suggested that the right turn into DNRC is often backed up, resulting in queues in this central lane, making visibility worse. It was suggested this may be partly because of a security barrier in the DNRC grounds, which causes traffic to back up. This is likely to remain a busy junction when the DNRC opens.
7. If the oncoming vehicle (coming up the incline towards Rempstone) was a standard vehicle, rather than a lorry, visibility would be even worse, given that the cab of a lorry is higher up.
8. Similarly, if the vehicles waiting to turn right (into Home Farm and DNRC) were lorries or other large vehicles, such as ambulances, then visibility concerns would be heightened further.
9. There is an element of uncertainty at the junction – where both vehicles are turning right – there is no clear indication of who has right of way or how the vehicles should make their manoeuvres.
10. There is a solid double white line on the road just before the turning into Home Farm. This requires a driver turning right to make a sharp-angled turn.
11. The signs on either side of the junction warn oncoming traffic of the DNRC junction, but not the Home Farm junction. The fact that the Home Farm road is a private road should not reduce the need for adequate safety warnings to drivers.
12. I have been provided with a Nottinghamshire County Council Road Safety Audit regarding this junction, which is dated 21.9.15. This contains the following extract :
During the site visit we were approached by a member of the public (apparently the owner) from Home Farm, opposite the Stanford Hall Access. He brought to our attention an issue which he felt had safety implications. Drivers intending to turn right into the Home Farm access have to wait on their side of the A6006 centre line to give way to oncoming traffic, as previously. They then have to turn across both the right turn lane and the Eastbound A6006 traffic lane. If a number of vehicles were occupying the right turn lane, he felt there would be potential to mask oncoming A6006 vehicles from view. Although the existing situation requires a right turner to wait in the westbound lane of the A6006, he also felt that he would be at greater risk of shunt type accidents than previously .
13. Sadly, this appears to have been the very risk that played a part in this collision.
” 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 Nottinghamshire County Council; that does not assign responsibility.
PFD Monitor interpretation Road layout requiring a sharp-angled right turn into Home Farm
Wider context from the report “1. There is a significant incline on this road (in the direction the lorry was travelling). This makes the visibility issues referred to below much more significant.
2. If there are vehicles in the central carriageway waiting to turn right into both the DNRC and Home Farm, as here, there is a risk of them having an inadequate view of oncoming traffic on the A6006, before making their turning manoeuvres.
3. This is the case in both directions, but particularly for vehicles travelling in the direction towards Rempstone, because of the incline of the road.
4. The evidence of the lorry driver was that he did not see Jean’s car until she turned in front of his vehicle.
5. The evidence of the Forensic Collision Investigation Unit officer was that Jean’s view would have been largely or completely blocked by vehicles waiting to turn right into DNRC until 2.93 seconds before impact.
6. Witness evidence suggested that the right turn into DNRC is often backed up, resulting in queues in this central lane, making visibility worse. It was suggested this may be partly because of a security barrier in the DNRC grounds, which causes traffic to back up. This is likely to remain a busy junction when the DNRC opens.
7. If the oncoming vehicle (coming up the incline towards Rempstone) was a standard vehicle, rather than a lorry, visibility would be even worse, given that the cab of a lorry is higher up.
8. Similarly, if the vehicles waiting to turn right (into Home Farm and DNRC) were lorries or other large vehicles, such as ambulances, then visibility concerns would be heightened further.
9. There is an element of uncertainty at the junction – where both vehicles are turning right – there is no clear indication of who has right of way or how the vehicles should make their manoeuvres.
10. There is a solid double white line on the road just before the turning into Home Farm. This requires a driver turning right to make a sharp-angled turn.
11. The signs on either side of the junction warn oncoming traffic of the DNRC junction, but not the Home Farm junction. The fact that the Home Farm road is a private road should not reduce the need for adequate safety warnings to drivers.
12. I have been provided with a Nottinghamshire County Council Road Safety Audit regarding this junction, which is dated 21.9.15. This contains the following extract :
During the site visit we were approached by a member of the public (apparently the owner) from Home Farm, opposite the Stanford Hall Access. He brought to our attention an issue which he felt had safety implications. Drivers intending to turn right into the Home Farm access have to wait on their side of the A6006 centre line to give way to oncoming traffic, as previously. They then have to turn across both the right turn lane and the Eastbound A6006 traffic lane. If a number of vehicles were occupying the right turn lane, he felt there would be potential to mask oncoming A6006 vehicles from view. Although the existing situation requires a right turner to wait in the westbound lane of the A6006, he also felt that he would be at greater risk of shunt type accidents than previously.
13. Sadly, this appears to have been the very risk that played a part in this collision.
” 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 Nottinghamshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of clear right-of-way and manoeuvre rules for opposing right turns
Wider context from the report “1. There is a significant incline on this road (in the direction the lorry was travelling). This makes the visibility issues referred to below much more significant.
2. If there are vehicles in the central carriageway waiting to turn right into both the DNRC and Home Farm, as here, there is a risk of them having an inadequate view of oncoming traffic on the A6006, before making their turning manoeuvres.
3. This is the case in both directions, but particularly for vehicles travelling in the direction towards Rempstone, because of the incline of the road.
4. The evidence of the lorry driver was that he did not see Jean’s car until she turned in front of his vehicle.
5. The evidence of the Forensic Collision Investigation Unit officer was that Jean’s view would have been largely or completely blocked by vehicles waiting to turn right into DNRC until 2.93 seconds before impact.
6. Witness evidence suggested that the right turn into DNRC is often backed up, resulting in queues in this central lane, making visibility worse. It was suggested this may be partly because of a security barrier in the DNRC grounds, which causes traffic to back up. This is likely to remain a busy junction when the DNRC opens.
7. If the oncoming vehicle (coming up the incline towards Rempstone) was a standard vehicle, rather than a lorry, visibility would be even worse, given that the cab of a lorry is higher up.
8. Similarly, if the vehicles waiting to turn right (into Home Farm and DNRC) were lorries or other large vehicles, such as ambulances, then visibility concerns would be heightened further.
9. There is an element of uncertainty at the junction – where both vehicles are turning right – there is no clear indication of who has right of way or how the vehicles should make their manoeuvres .
10. There is a solid double white line on the road just before the turning into Home Farm. This requires a driver turning right to make a sharp-angled turn.
11. The signs on either side of the junction warn oncoming traffic of the DNRC junction, but not the Home Farm junction. The fact that the Home Farm road is a private road should not reduce the need for adequate safety warnings to drivers.
12. I have been provided with a Nottinghamshire County Council Road Safety Audit regarding this junction, which is dated 21.9.15. This contains the following extract :
During the site visit we were approached by a member of the public (apparently the owner) from Home Farm, opposite the Stanford Hall Access. He brought to our attention an issue which he felt had safety implications. Drivers intending to turn right into the Home Farm access have to wait on their side of the A6006 centre line to give way to oncoming traffic, as previously. They then have to turn across both the right turn lane and the Eastbound A6006 traffic lane. If a number of vehicles were occupying the right turn lane, he felt there would be potential to mask oncoming A6006 vehicles from view. Although the existing situation requires a right turner to wait in the westbound lane of the A6006, he also felt that he would be at greater risk of shunt type accidents than previously.
13. Sadly, this appears to have been the very risk that played a part in this collision.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assess permanent closure of the Home Farm access and consult affected parties.
Verbatim wording from the response “I can confirm that we are already considering a number of highway improvement measures at this location. The inclusion of this work in the 2018/19 Highways Programme was recently approved by the Council’s Communities and Place Committee. However there is some investigatory work to be carried out before we can finalise our proposals.” Source location 2018-0051-Response-by-Nottingham-County-Council
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 Develop alternative junction measures, including revisions to the central traffic island and associated road markings, if closure is not pursued.
Verbatim wording from the response “Should it not prove possible or desirable to close the access, we are considering a package of alternative measures to assist drivers attempting to turn right at that location. This includes revisions to the position of the existing central traffic island, and its associated road markings, to make it easier for vehicles to gain access to the right-turn lane when approaching from the east. This should allow drivers to position their vehicles where they can wait more comfortably for a safe gap in the oncoming traffic.” Source location 2018-0051-Response-by-Nottingham-County-Council
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Permanent closure of the Home Farm access may not be possible without specific Secretary of State authorisation if objections are received.
Verbatim wording from the response “Firstly we need to consider if the access to Home Farm can be closed on a permanent basis. We are obliged to explore this option as the most obvious and effective solution, since it would remove the opportunity for the right-turn manoeuvre that Jean attempted, and therefore almost guarantee that a similar collision would not occur in the future. This would require consultation with the various parties affected. Should we receive objections then this closure may not prove possible without specific authorisation from the Secretary of State.” Source location 2018-0051-Response-by-Nottingham-County-Council
Open published response
6 Nov 2017 RYAN JAMES VOUT · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 4 Inability to pre-arrange ambulance attendance during execution of a s.135 (1) MHA Act 1983 warrant View source Failure to inform family before discharge View source Failure of hospital and community professionals to liaise before discharge View source Lack of a formal briefing or risk assessment before entry under a s.135 (1) MHA Act 1983 warrant View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
RYAN JAMES VOUT · 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
Ryan James Vout, who had paranoid schizophrenia and was apparently unmedicated, stabbed himself in the chest during an attempt by police officers to execute a section 135 warrant on 10 August 2016. He died despite emergency first aid and hospital treatment. The principal concerns were inadequate coordination before his discharge from psychiatric care, the inability to pre-arrange an ambulance for section 135 warrant attendances, and the lack of a formal briefing or risk assessment before officers entered the premises.
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 Nottinghamshire County Council; that does not assign responsibility.
PFD Monitor interpretation Inability to pre-arrange ambulance attendance during execution of a s.135 (1) MHA Act 1983 warrant
Wider context from the report “(2) The inability to pre-arrange attendance of an ambulance when police officers exercise a s.135 (1) MHA Act 1983 warrant;
” 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 Nottinghamshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to inform family before discharge
Wider context from the report “(1) The lack of a co-ordinated discharge from in-patient psychiatric care into the community, in particular the failure of appropriate professionals from hospital and community to liaise and for family to be informed as a pre-requisite for discharge ;
” 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 Nottinghamshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure of hospital and community professionals to liaise before discharge
Wider context from the report “(1) The lack of a co-ordinated discharge from in-patient psychiatric care into the community, in particular the failure of appropriate professionals from hospital and community to liaise and for family to be informed as a pre-requisite for discharge;
” 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 Nottinghamshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a formal briefing or risk assessment before entry under a s.135 (1) MHA Act 1983 warrant
Wider context from the report “(3) The lack of a formality to the ‘briefing’ or risk assessment exercise before officers enter premises with a view to exercising a s.135 (1) MHA Act 1983 warrant.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a more robust joint process for communicating demographic and essential risk information between AMHPs and police before s135 warrant execution.
Verbatim wording from the response “A more robust process for communicating demographics and essential risk information in relation to the s135 (1) warrant between AMHPs and the Police has been developed jointly.” Source location 2017-0376-Response-by-Nottinghamshire-County-Council
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a typewritten s135 information document for magistrate completion and electronic transmission to police, including recent risk assessments and environmental factors.
Verbatim wording from the response “This will include a typewritten document that is completed initially for the magistrate and then sent electronically by the AMHP when requesting police assistance under s.135 (1). This will ensure that clear communication to all agencies including recent risk assessments and environmental factors are taken in to account with regard to the specifics of the situation.” Source location 2017-0376-Response-by-Nottinghamshire-County-Council
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Established multidisciplinary referral and assessment processes are considered sufficient to support coordinated discharge and community aftercare.
Verbatim wording from the response “(1) The lack of a co-ordinated discharge from in-patient psychiatric care into the community, in particular the failure of appropriate professionals from hospital and community to liaise and for family to be informed as a pre-requisite for discharge;” Source location 2017-0376-Response-by-Nottinghamshire-County-Council
Open published response
13 May 2016 Harold James Davies · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 3 Delays in approval and commencement of remedial junction safety work View source Repeated fatal collisions at the junction involving vehicles emerging from Station Road View source 60mph speed limit on the Station Road approach to the junction for unfamiliar drivers View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Harold James Davies · 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
Harold James Davies, aged 91, died in a road traffic collision on the evening of 8 November 2015 after his Volvo collided with a Jaguar at the junction of Station Road and the A.46 in Nottinghamshire. The principal concern was that this was the third fatality at the junction since 2010, with concerns about the absence of a date for funding or commencing proposed remedial safety work and the potential need for additional warning signs and a lower speed limit.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire County Council; that does not assign responsibility.
PFD Monitor interpretation Delays in approval and commencement of remedial junction safety work
Wider context from the report “2. Highways England and their maintenance contractor A-One+ have undertaken an extensive risk assessment of the junction and there is a proposal to undertake the following remedial safety work:
(a) vehicle activated signs on both carriageways of the A.46 to alert oncoming traffic of the presence of vehicles at the junction waiting to join or cross the carriageways
(b) the installation of slim line bollards at the Station Road junction
(c) appropriate demarcation of the central reservation/turning area.
3. Evidence was given at the inquest that there is no date for the approval of funding or the commencement of the remedial safety work .
” 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 Nottinghamshire County Council; that does not assign responsibility.
PFD Monitor interpretation Repeated fatal collisions at the junction involving vehicles emerging from Station Road
Wider context from the report “1. Although the current road layout and existing safety provisions did not cause or contribute to the particular circumstances of this collision, I am concerned that this is the 3rd fatality at this junction since 2010 . The 2 most recent fatalities in January 2014 and November 2015 involving, vehicles emerging from Station Road into the northbound 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 Nottinghamshire County Council; that does not assign responsibility.
PFD Monitor interpretation 60mph speed limit on the Station Road approach to the junction for unfamiliar drivers
Wider context from the report “4. The national speed limit on Station Road on its approach to the junction with the A.46 is 60mph . The SCIO gave evidence that additional warning signs and a possible reduction in speed limit on the approach would provide additional safety for drivers who were unfamiliar with the Station Road and its approach to the junction . Nottinghamshire Police has offered to meet with Nottinghamshire County Council, the authority responsible for the maintenance of Station Road, and undertake a risk assessment.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation There is no evidence that excessive approach speed contributes significantly to these accidents, and lowering the speed limit would be ineffective.
Verbatim wording from the response “Station Road is derestricted, that is, its speed limit is 60mph which is the national speed limit for such roads in the absence of any other posted limit. The situation is very common there are many thousands of miles of these derestricted roads in rural areas. The 60mph is an absolute upper limit, and drivers have to adapt their speed to suit the road layout and conditions as they find them throughout their journey. Therefore when approaching the junction with the A46, drivers on Station Road will slow and adapt their speed to allow them to negotiate the bend on the approach, and slow appropriately for the junction. We have no evidence that excessive high speed is occurring on this approach, or that it is leading to reports of injury accidents on Station Road. We also understand that approach speed is not a significant contributory factor in the accidents at the A46 junction.” Source location Response from Nottinghamshire County Council
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Highways England is responsible for investigating accidents and developing safety measures on the A46.
Verbatim wording from the response “The fatal accident and two previous fatal accidents occurred at the junction of the Trunk Road A46 and Station Road Collingham. Since the incidents happened on the Trunk Road, which are the responsibility of Highways England, the County Council has not carried out investigations on these individual incidents, or the group of accidents.” Source location Response from Nottinghamshire County Council
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Investigating accidents on the A46 falls outside the Council’s responsibility because it is a trunk road.
Verbatim wording from the response “The fatal accident and two previous fatal accidents occurred at the junction of the Trunk Road A46 and Station Road Collingham. Since the incidents happened on the Trunk Road, which are the responsibility of Highways England, the County Council has not carried out investigations on these individual incidents, or the group of accidents.” Source location Response from Nottinghamshire County Council
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Side-road approach measures are not usually effective for restart accidents; main-road measures are considered more appropriate.
Verbatim wording from the response “It is understood that the two accidents were most likely restarts, Mr Davies was apparently indicating to turn right, suggesting he knew he was approaching the junction. It is not usually effective to try to affect this type of accident by measures on the side road approach. The measures proposed by Highways England on the main road A46 are more appropriate.” Source location Response from Nottinghamshire County Council
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A lower speed limit is not considered appropriate because legal procedures, implementation costs and delay could outweigh its arguable benefits.
Verbatim wording from the response “A lowered speed limit would require a legal order to be brought into force, which would involve amongst other things a lengthy consultation process. The consequent delay in progressing the proposed Highways England improvement scheme, and the costs of signing and implementation of a speed limit, are therefore not appropriate given the arguable benefits.” Source location Response from Nottinghamshire County Council
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations