9 Jan 2025 Anthony John PAINE · Prevention of Future Deaths report Oxfordshire
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Concerns raised 2 Potentially excessive 30 mph speed limit on a pedestrian-heavy town-centre road View source Obscured visibility of the pedestrian crossing for approaching vehicles View source
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Anthony John PAINE · 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
Anthony Paine died at the scene after being struck by a car while crossing the A361 in Banbury on 24 March 2023. Concerns were expressed that the 30 mph speed limit may be too high for the road’s characteristics and pedestrian volume, and that a slower vehicle speed might have allowed more time to react or reduced the severity of the impact.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oxfordshire County Council; that does not assign responsibility.
PFD Monitor interpretation Potentially excessive 30 mph speed limit on a pedestrian-heavy town-centre road
Wider context from the report “The speed limit on the A361 North Bar Street at the location of the collision is 30 mph. There was a concern expressed at the Inquest that this speed limit may be too high, given the characteristics of the road and the volume of pedestrian traffic in the area.
The A361 at this location is a long, straight, single carriageway with one lane in each direction. Travelling southbound, the pedestrian crossing is approached from a gradual rise in the road from Banbury Cross Roundabout, some 150 meters away. There is in the road obscures the view of the pedestrian crossing to approaching vehicles.
There are a number of pubs and restaurants on both sides of the road and a number of pedestrians in the area late into the evening.
The Forensic Collision Investigator concluded that in the short window of time in which Mr. Paine was likely visible to the driver, they failed to see him. The Investigator’s evidence was that even if the driver had seen Mr. Paine, there would have been insufficient time to react and avoid the collision. However, the Investigator’s evidence also stated that if the vehicle had been traveling at a slower speed, this may have provided the driver with sufficient time to react and either avoid the collision or reduce the severity of the impact.
In the opinion of the Forensic Collision Investigator, the speed of the driver’s vehicle was 32.6 mph ± 3.6 mph and was a contributing factor to the severity of the collision and that, as a general point, the slower the vehicle is travelling the less severe the effects of any impact.
It was further noted that other nearby town/city centres (eg Oxford) have introduced 20 mph speed limits on roads in the city centre.
” 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 Oxfordshire County Council; that does not assign responsibility.
PFD Monitor interpretation Obscured visibility of the pedestrian crossing for approaching vehicles
Wider context from the report “The speed limit on the A361 North Bar Street at the location of the collision is 30 mph. There was a concern expressed at the Inquest that this speed limit may be too high, given the characteristics of the road and the volume of pedestrian traffic in the area.
The A361 at this location is a long, straight, single carriageway with one lane in each direction. Travelling southbound, the pedestrian crossing is approached from a gradual rise in the road from Banbury Cross Roundabout, some 150 meters away. There is in the road obscures the view of the pedestrian crossing to approaching vehicles.
There are a number of pubs and restaurants on both sides of the road and a number of pedestrians in the area late into the evening.
The Forensic Collision Investigator concluded that in the short window of time in which Mr. Paine was likely visible to the driver, they failed to see him. The Investigator’s evidence was that even if the driver had seen Mr. Paine, there would have been insufficient time to react and avoid the collision. However, the Investigator’s evidence also stated that if the vehicle had been traveling at a slower speed, this may have provided the driver with sufficient time to react and either avoid the collision or reduce the severity of the impact.
In the opinion of the Forensic Collision Investigator, the speed of the driver’s vehicle was 32.6 mph ± 3.6 mph and was a contributing factor to the severity of the collision and that, as a general point, the slower the vehicle is travelling the less severe the effects of any impact.
It was further noted that other nearby town/city centres (eg Oxford) have introduced 20 mph speed limits on roads in the city centre.
” 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 Allocate funding through the 2025/26 Vision Zero road safety programme for proposed speed-limit improvement measures.
Verbatim wording from the response “That said, it should also be noted that following a community consultation, in line with our 20mph policy, an allocation has been made in the 2025/26 Vision Zero road safety programme for the design and implementation of improvement measures including (subject to consultation and subsequent approval) a 20mph speed limit at the location of the traffic collision resulting in the death of Mr Paine. If approved, the intention is that the scheme will be completed by the end of the 2025/26 financial year. Until this scheme is implemented there is no plan to change to the current and appropriate speed limit of 30mph.” Source location Response from Oxfordshire County Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Design and seek approval for a proposed 20mph speed limit at the collision location through the 2025/26 programme.
Verbatim wording from the response “That said, it should also be noted that following a community consultation, in line with our 20mph policy, an allocation has been made in the 2025/26 Vision Zero road safety programme for the design and implementation of improvement measures including (subject to consultation and subsequent approval) a 20mph speed limit at the location of the traffic collision resulting in the death of Mr Paine. If approved, the intention is that the scheme will be completed by the end of the 2025/26 financial year. Until this scheme is implemented there is no plan to change to the current and appropriate speed limit of 30mph.” Source location Response from Oxfordshire County Council
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PFD Monitor interpretation The current 30mph speed limit is considered appropriate and sufficient until any approved 20mph scheme is implemented.
Verbatim wording from the response “Thank you for your letter of 9 January and Regulation 28 Report to Prevent Future Deaths. In response to the matters of concern raised, I can confirm that the current speed limit (30mph), is in line with current national guidance and standards.” Source location Response from Oxfordshire County Council
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4 Nov 2024 Polly Mary Margaret Friedhoff · Prevention of Future Deaths report Oxfordshire
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Concerns raised 2 Insufficient path width for safe sharing by pedestrians and cyclists View source Failure to control cyclists’ use and speed in close proximity to pedestrians View source
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Polly Mary Margaret Friedhoff · Prevention of Future Deaths report
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Report summary
Polly Mary Margaret Friedhoff, aged 81, died at John Radcliffe Hospital on 2 December 2022 from injuries sustained after a collision with a pedal cyclist on the path beside the River Thames at Iffley Lock, Oxford. The principal concern was the safety of pedestrians using a narrow shared path that is frequently used by cyclists, including some travelling at significant speed, creating a risk of serious injury or death.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oxfordshire County Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient path width for safe sharing by pedestrians and cyclists
Wider context from the report “The concern relates to the safety of users, particularly pedestrians who appear to at greatest risk of injury as was the case with Mrs Friedhoff. Indeed, the speed of the cyclist was not excessive in this case but the injuries caused in the subsequent fall were serious. I understand this part of the path at the lock is popular with pedestrians and cyclists. It is a shared space, albeit strictly speaking it is a footpath and cyclists are not permitted to use it unless they have permission. In reality it is heavily used by cyclists for leisure and commuting and some cyclists travel at significant speed in close proximity to pedestrians. One of the main problems is that the path at the location of Mrs Friedhoff’s accident is only about 2 metres wide. A short distance before this the path is only 1.6 metres wide. I understand from ████████ that national guidance for such a path is 3.5 metres. Mrs Friedhoff’s sons are very familiar with the location and describe it as normal pavement width but with cyclists permitted to cycle on it, thereby creating an obvious accident risk. It is also noteworthy that the surface of the path has been upgraded in recent years which, in all probability, has encouraged its use by cyclists and enabled them to cycle faster.
I appreciate that OCC, and perhaps the Environment Agency, have given considerable thought to the safety issue and have not found a clear solution. It is not for me to make recommendations but I do request a further review to see if there are any mitigating measures, not least with clear signage reminding users, particularly cyclists, of the need to take care and slow down around pedestrians. At inquest, there was some evidence and discussion in relation to the following;
-A communications package, perhaps with a public consultation element.
-Stronger enforcement ( I understand the Environment Agency do not permit cyclists to cycle through locks and there are signs about this but do so nevertheless). I appreciate it is difficult to enforce this and the focus may necessarily be on speed.
-Gates or similar to slow cyclists.
-Segregation lines but the narrow width of the path no doubt makes this problematic .
-Reconfiguring so that the path is redirected through the small woods that are present at the location. This may afford the opportunity to have 2 separate paths at the location, one that is gated for pedestrians and one for cyclists.
In short, given my concern that accidents may continue to occur that could result in death, OCC are asked to carry out a safety review in conjunction with the Environment Agency and other stakeholders where appropriate.
” 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 Oxfordshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to control cyclists’ use and speed in close proximity to pedestrians
Wider context from the report “The concern relates to the safety of users, particularly pedestrians who appear to at greatest risk of injury as was the case with Mrs Friedhoff. Indeed, the speed of the cyclist was not excessive in this case but the injuries caused in the subsequent fall were serious. I understand this part of the path at the lock is popular with pedestrians and cyclists. It is a shared space, albeit strictly speaking it is a footpath and cyclists are not permitted to use it unless they have permission. In reality it is heavily used by cyclists for leisure and commuting and some cyclists travel at significant speed in close proximity to pedestrians. One of the main problems is that the path at the location of Mrs Friedhoff’s accident is only about 2 metres wide. A short distance before this the path is only 1.6 metres wide. I understand from ████████ that national guidance for such a path is 3.5 metres. Mrs Friedhoff’s sons are very familiar with the location and describe it as normal pavement width but with cyclists permitted to cycle on it, thereby creating an obvious accident risk. It is also noteworthy that the surface of the path has been upgraded in recent years which, in all probability, has encouraged its use by cyclists and enabled them to cycle faster.
I appreciate that OCC, and perhaps the Environment Agency, have given considerable thought to the safety issue and have not found a clear solution. It is not for me to make recommendations but I do request a further review to see if there are any mitigating measures, not least with clear signage reminding users, particularly cyclists, of the need to take care and slow down around pedestrians . At inquest, there was some evidence and discussion in relation to the following;
-A communications package, perhaps with a public consultation element.
-Stronger enforcement ( I understand the Environment Agency do not permit cyclists to cycle through locks and there are signs about this but do so nevertheless). I appreciate it is difficult to enforce this and the focus may necessarily be on speed.
-Gates or similar to slow cyclists.
-Segregation lines but the narrow width of the path no doubt makes this problematic.
-Reconfiguring so that the path is redirected through the small woods that are present at the location. This may afford the opportunity to have 2 separate paths at the location, one that is gated for pedestrians and one for cyclists.
In short, given my concern that accidents may continue to occur that could result in death, OCC are asked to carry out a safety review in conjunction with the Environment Agency and other stakeholders where appropriate.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undertake volunteer vegetation clearance around the Iffley Lock site.
Verbatim wording from the response “(2) Vegetation clearance – Whilst it is noted that the fatality took place in December when typically, overgrown trees/ vegetation may be less of a factor, both organisations appreciate that especially during summer months vegetation growth can restrict user space and visibility increasing the likelihood of conflict. Both the county council and” Source location Response from Oxfordshire County Council
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Organise promotional events with partners and user groups to highlight safe and responsible towpath use.
Verbatim wording from the response “Additionally, we are proposing to organise with partners and user groups a series of promotional events spread throughout the year would highlight safe and responsible use of the towpath. As an example, there are several annual high-profile rowing events along the river in the spring / summer period resulting in increased usage. It is proposed that promotional activity at events like these could provide a meaningful impact with a potentially large catchment of users. Similar events focusing on the councils Vision Zero programme have been held in Oxford over recent years and have had positive feedback. We consider this measure would have a beneficial relevance and reach to the wider towpath route including the Iffley lock site. We plan to commence this from spring 2025.” Source location Response from Oxfordshire County Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit and review existing towpath signage, including whether additional signs would benefit key entrance points.
Verbatim wording from the response “(3) Signage and promotion – It is noted that there is already various signage in the vicinity of the site and along the towpath. This said, a review of signage will be undertaken to give consideration for whether additional signage would be beneficial including at key entrance points along the towpath. We aim to carry out an audit of signage in winter/ early 2025 with implementation of any appropriate measures expected for the summer 2025.” Source location Response from Oxfordshire County Council
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2 Jul 2024 Caroline Diane Harris · Prevention of Future Deaths report Oxfordshire
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Concerns raised 3 Failure to share information regarding deterioration in mental health with the appropriate team View source Failure to inform the GP of declined attendance for medication View source Inability of Adult Social Care to directly refer to AMHT View source
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AI-generated summary
Caroline Diane Harris · 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
Caroline Diane Harris, who had a long-standing diagnosis of severe mental illness, was found deceased at home on 26 July 2023, and a medical cause of death could not be ascertained because of decomposition. Information about her declining mental health, refusal of medication and concerns raised by police was not shared with the Adult Mental Health Team, which limited its ability to supervise and follow her up. The principal concern was that important information was not shared between agencies and that appropriate interventions may consequently not have been made.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oxfordshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to share information regarding deterioration in mental health with the appropriate team
Wider context from the report “In March 2023, Thames Valley Police passed on a report about Caroline to the Mult-Agency Safeguarding Hub (MASH) which raised concerns about her behaviour and mental state and dishevelled appearance. The report stated that it was, ‘Shared in the interests of safeguarding as may be having relapse’.
MASH undertook a review of the report and concluded that Caroline was not at risk but may have needs for care and support from the local authority. The information was passed to the Council’s Adult Social Care Team who in turn passed the information onto Caroline’s GP. Evidence was given that the Adult Social Care Team were unable to directly refer to AMHT, even if they had considered it necessary. As the GP was not made aware that Caroline had declined to attend the clinic to receive her medication, she saw no need to refer the Police report to AMHT.
Evidence was given AMHT took a different view regarding the Police report and would have viewed the report as evidence of Caroline relapsing. AMHT’s view was that such a report met the criteria for being shared with them, with their knowledge of Caroline’s past history of self-neglect and non-compliance with taking medication, it ought to have been shared with them; and had it been done so it would have been followed up assertively and urgently including undertaking home visits and the possible use of compulsory powers under the Mental Health Act.
My concern is that important information regarding a deterioration in mental health was not shared with the appropriate Team who may have been able make appropriate interventions and to have taken steps to avoid a fatal outcome.
You should consider a review of how such information is assessed and shared between the respective agencies.
” 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 Oxfordshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to inform the GP of declined attendance for medication
Wider context from the report “In March 2023, Thames Valley Police passed on a report about Caroline to the Mult-Agency Safeguarding Hub (MASH) which raised concerns about her behaviour and mental state and dishevelled appearance. The report stated that it was, ‘Shared in the interests of safeguarding as may be having relapse’.
MASH undertook a review of the report and concluded that Caroline was not at risk but may have needs for care and support from the local authority. The information was passed to the Council’s Adult Social Care Team who in turn passed the information onto Caroline’s GP. Evidence was given that the Adult Social Care Team were unable to directly refer to AMHT, even if they had considered it necessary. As the GP was not made aware that Caroline had declined to attend the clinic to receive her medication, she saw no need to refer the Police report to AMHT.
Evidence was given AMHT took a different view regarding the Police report and would have viewed the report as evidence of Caroline relapsing. AMHT’s view was that such a report met the criteria for being shared with them, with their knowledge of Caroline’s past history of self-neglect and non-compliance with taking medication, it ought to have been shared with them; and had it been done so it would have been followed up assertively and urgently including undertaking home visits and the possible use of compulsory powers under the Mental Health Act.
My concern is that important information regarding a deterioration in mental health was not shared with the appropriate Team who may have been able make appropriate interventions and to have taken steps to avoid a fatal outcome.
You should consider a review of how such information is assessed and shared between the respective agencies.
” 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 Oxfordshire County Council; that does not assign responsibility.
PFD Monitor interpretation Inability of Adult Social Care to directly refer to AMHT
Wider context from the report “In March 2023, Thames Valley Police passed on a report about Caroline to the Mult-Agency Safeguarding Hub (MASH) which raised concerns about her behaviour and mental state and dishevelled appearance. The report stated that it was, ‘Shared in the interests of safeguarding as may be having relapse’.
MASH undertook a review of the report and concluded that Caroline was not at risk but may have needs for care and support from the local authority. The information was passed to the Council’s Adult Social Care Team who in turn passed the information onto Caroline’s GP. Evidence was given that the Adult Social Care Team were unable to directly refer to AMHT, even if they had considered it necessary. As the GP was not made aware that Caroline had declined to attend the clinic to receive her medication, she saw no need to refer the Police report to AMHT.
Evidence was given AMHT took a different view regarding the Police report and would have viewed the report as evidence of Caroline relapsing. AMHT’s view was that such a report met the criteria for being shared with them, with their knowledge of Caroline’s past history of self-neglect and non-compliance with taking medication, it ought to have been shared with them; and had it been done so it would have been followed up assertively and urgently including undertaking home visits and the possible use of compulsory powers under the Mental Health Act.
My concern is that important information regarding a deterioration in mental health was not shared with the appropriate Team who may have been able make appropriate interventions and to have taken steps to avoid a fatal outcome.
You should consider a review of how such information is assessed and shared between the respective agencies.
” Open source report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Email Adult Mental Health Teams when online records are unavailable, follow up until a decision is received, and escalate unsuccessful contact to team leaders.
Verbatim wording from the response “3. Where access to online records like RIO for mental health, is not possible the team must immediately email AMHT to check for mental health involvement before action is taken. The Social and Health Care Team will continue to follow up with AMHT until a response and decision is reached. In the unlikely event that contact cannot be made with AMHT, this is escalated to Team Leaders who will contact their counterparts in AMHT.” Source location Response from Oxfordshire County Council
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PFD Monitor interpretation Escalate urgent concerns by contacting GPs immediately or referring cases to the Professional Support Team for evaluation and decision.
Verbatim wording from the response “11. Where the situation appears to be urgent the team will either:” Source location Response from Oxfordshire County Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share qualifying mental-health reports with GPs, explain the reasons, and request follow-up and identification of social-care needs.
Verbatim wording from the response “10. The guidance issued to the Social and Health Care Team in August 2023, states that a report is shared with the person’s GP in the following circumstances.” Source location Response from Oxfordshire County Council
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2 Sep 2022 Jennifer Wong · Prevention of Future Deaths report Oxfordshire
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Concerns raised 4 Inadequate near-side and forward visibility safeguards for mobile cranes View source Unclear and inconsistent classification and application of regulations for mobile cranes View source Insufficient cycle-lane width View source Cycle lane layout failing to provide clear and safe positioning for cyclists crossing the junction View source See 1 more concern
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Jennifer Wong · Prevention of Future Deaths report
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Report summary
Jennifer Wong died at the scene of a road traffic accident on Headington Road, Oxford, on 26 September 2021, after a mobile crane turning left knocked her from her cycle and ran over her. The report identifies concerns about the crane driver's significant nearside blind spots and the lack of close-proximity mirrors or other visibility measures. It also raises concerns about the layout and width of the cycle lane, which may bring cyclists into conflict with vehicles turning left.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oxfordshire County Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate near-side and forward visibility safeguards for mobile cranes
Wider context from the report “It was apparent at inquest that the regulations concerning vehicles of this type are difficult to understand and to determine which regulations apply. The mobile crane in question was a Kato City Crane with a capacity of 22 tonnes, registration number P477 YHT. The odometer recorded 65,917 kilometres. According to the police Vehicle Examiner, it is classed as a mobile crane and operates outside of the Construction and Use regulations which governs HGV’s. It is said that it is governed by the Road Vehicles (Authorisation of Special Types) (General) Order 2003, otherwise known as STGO. I am further advised that under STGO it is likely to be classed a Cat B mobile crane. I understand it can also be regarded as a motor tractor/light locomotive/heavy locomotive under some regulations but at the same time it can also be classed as a road vehicle as it is intended for use on the road to get to site for example. Despite this, if I understand the position correctly, it is subject to reg 33 of the Construction and Use Regs and, for a vehicle first used after 1978 as this one was, it only requires a single offside mirror to be fitted.
According to paragraph 9.8 of the Collision Investigator’s report, it is categorised as ‘Engineering Plant’ (Department of Transport 2010) and does not fall within the requirements for close proximity mirrors (EU 2007, UN 2013).
1. It is immediately striking that the driver has virtually no view of the nearside of his vehicle or immediately in front of it . The crane is designed in such a way so that the boom/jib extends along the near side of the cab obliterating most of the view. It had one side mirror on each side but there were very significant blind spots . These appear to be worse than what one might have with a HGV or bus for example which, very often, have more mirrors and perhaps camera’s and audible warnings. It is also noteworthy that the crane did not have indicators which could be seen by someone alongside the crane as opposed to being behind or in front of it.
I refer you to the photographs in the report of the police collision investigator, ████████ ████████ and particularly from paragraph 9.10 and the figures which give a representation of the driver’s view.
Notwithstanding the above, it appears that the vehicle is only required by regulations to have one offside mirror and no close proximity mirrors which are designed to reduce the driver’s blind spots. The regulations are confusing but regardless of whether the vehicle is classed as engineering plant or some form of locomotive, the reality is that such vehicles are permitted to drive on the roads through towns and cities with next to no near side view . It is the second such case I have dealt with this year in Oxford. I understand there may be some separate and safer regulations that apply in London called the Transport for London Direct Vision Standard which would classify this vehicle with a star rating of zero and require the fitting of safe system measures.
” 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 Oxfordshire County Council; that does not assign responsibility.
PFD Monitor interpretation Unclear and inconsistent classification and application of regulations for mobile cranes
Wider context from the report “It was apparent at inquest that the regulations concerning vehicles of this type are difficult to understand and to determine which regulations apply . The mobile crane in question was a Kato City Crane with a capacity of 22 tonnes, registration number P477 YHT. The odometer recorded 65,917 kilometres. According to the police Vehicle Examiner, it is classed as a mobile crane and operates outside of the Construction and Use regulations which governs HGV’s. It is said that it is governed by the Road Vehicles (Authorisation of Special Types) (General) Order 2003, otherwise known as STGO. I am further advised that under STGO it is likely to be classed a Cat B mobile crane. I understand it can also be regarded as a motor tractor/light locomotive/heavy locomotive under some regulations but at the same time it can also be classed as a road vehicle as it is intended for use on the road to get to site for example. Despite this, if I understand the position correctly, it is subject to reg 33 of the Construction and Use Regs and, for a vehicle first used after 1978 as this one was, it only requires a single offside mirror to be fitted.
According to paragraph 9.8 of the Collision Investigator’s report, it is categorised as ‘Engineering Plant’ (Department of Transport 2010) and does not fall within the requirements for close proximity mirrors (EU 2007, UN 2013).
1. It is immediately striking that the driver has virtually no view of the nearside of his vehicle or immediately in front of it. The crane is designed in such a way so that the boom/jib extends along the near side of the cab obliterating most of the view. It had one side mirror on each side but there were very significant blind spots. These appear to be worse than what one might have with a HGV or bus for example which, very often, have more mirrors and perhaps camera’s and audible warnings. It is also noteworthy that the crane did not have indicators which could be seen by someone alongside the crane as opposed to being behind or in front of it.
I refer you to the photographs in the report of the police collision investigator, ████████ ████████ and particularly from paragraph 9.10 and the figures which give a representation of the driver’s view.
Notwithstanding the above, it appears that the vehicle is only required by regulations to have one offside mirror and no close proximity mirrors which are designed to reduce the driver’s blind spots. The regulations are confusing but regardless of whether the vehicle is classed as engineering plant or some form of locomotive, the reality is that such vehicles are permitted to drive on the roads through towns and cities with next to no near side view. It is the second such case I have dealt with this year in Oxford. I understand there may be some separate and safer regulations that apply in London called the Transport for London Direct Vision Standard which would classify this vehicle with a star rating of zero and require the fitting of safe system measures.
” 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 Oxfordshire County Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient cycle-lane width
Wider context from the report “The second concern relates to the width of the cycle lane . It is believed to be 0.95 metres wide at this location but the recommended width is 1.2m or perhaps 1.5m . I understand this is an issue which has already been raised following a site meeting. There may be valid reasons why the lane is the width it is but I would be grateful if this could be considered.
” 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 Oxfordshire County Council; that does not assign responsibility.
PFD Monitor interpretation Cycle lane layout failing to provide clear and safe positioning for cyclists crossing the junction
Wider context from the report “The first and main concern is in relation to the nearside cycle lane and what appeared to be an element of confusion or perhaps a dilemma for cyclists at this location intending to cycle straight across the junction. The cycle lane puts cyclists on the nearside of a lane that is specifically for vehicles turning right into Headley Way . There is the box/advanced stop line in front of the line of traffic in the lane but this requires the cyclist to decide to use it and, importantly, to have time to make it pass the nearside of the vehicles and into the box before the vehicles in the lane commence their right turn .
If there was no cycle lane, it appears more likely that a cyclist heading straight across would position themselves in lane 2 for vehicles also heading straight on. I believe that further consideration should be given to this issue and if improved signage has a part to play to mitigate the risks.
I appreciate of course that it is not possible to remove risk completely and cyclists will make different choices about where to position themselves at a junction such as this one. I anticipate that the junction is not dissimilar to many others in Oxford. The issue of cyclists in nearside blind spots, particularly involving large commercial vehicles with limited visibility, therefore presents a significant and ongoing risk .
” Open source report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Identify other city cycle-network sections that fall below current width standards.
Verbatim wording from the response “The original width of 0.95m was a legacy of a scheme that was installed some 10 plus years ago. The cycle widths are being amended to meet the current standards set out by the Department for Transport (1.2m minimum) and work is being undertaken by the council to establish where other sections of the city cycle network may be falling short of current standards. As mentioned previously, the amended designs and works will be completed by the end of November 2022.” Source location Response from Oxfordshire County Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Amend cycle-lane widths to meet the Department for Transport’s 1.2-metre minimum standard.
Verbatim wording from the response “The original width of 0.95m was a legacy of a scheme that was installed some 10 plus years ago. The cycle widths are being amended to meet the current standards set out by the Department for Transport (1.2m minimum) and work is being undertaken by the council to establish where other sections of the city cycle network may be falling short of current standards. As mentioned previously, the amended designs and works will be completed by the end of November 2022.” Source location Response from Oxfordshire County Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide a dropped kerb directing cyclists from London Road to the Headley Way shared-use path.
Verbatim wording from the response “The council has taken on board your concerns and several measures have already been put in place to improve the public highway for vulnerable road users at both the Headley way junction and at two other key sites within the city. The works that have been completed at Headley Way include: A 5 second advance green lights for cyclists heading east bound and a dropped kerb facility to bring cyclists off the London Road to turn left into Headley Way. We have also commissioned our highway maintenance contractors to undertake a series of road marking amendments to make it clearer for cyclists to utilise the junction. The redesign of the lane/cycle markings has been commissioned to specifically consider the concerns that you raised in your Matter of Concern point 1. The design and delivery of the works at the Headley junction are due to be completed by the end of November 2022.” Source location Response from Oxfordshire County Council
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Redesign and amend Headley Way road markings and cycle-lane markings to clarify cyclist movements through the junction.
Verbatim wording from the response “The council has taken on board your concerns and several measures have already been put in place to improve the public highway for vulnerable road users at both the Headley way junction and at two other key sites within the city. The works that have been completed at Headley Way include: A 5 second advance green lights for cyclists heading east bound and a dropped kerb facility to bring cyclists off the London Road to turn left into Headley Way. We have also commissioned our highway maintenance contractors to undertake a series of road marking amendments to make it clearer for cyclists to utilise the junction. The redesign of the lane/cycle markings has been commissioned to specifically consider the concerns that you raised in your Matter of Concern point 1. The design and delivery of the works at the Headley junction are due to be completed by the end of November 2022.” Source location Response from Oxfordshire 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 Review key junctions posing potential risks to vulnerable road users and develop short-, medium- and long-term mitigations.
Verbatim wording from the response “- The council has reviewed its key junctions that were deemed to be a potential risk to vulnerable road users with input from the cycle safety groups. These reviews have involved site meetings and virtual meetings to fully understand what is required to make the junctions as safe as is reasonably practicable with the resources that are available. In some locations these have been split into short, medium and long-term measures to enable some quick mitigations whilst having a more strategic overview of future developments in the area that will dramatically change the layout of some of the areas.” Source location Response from Oxfordshire 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 recommendations from the completed Stage 4 Road Safety Audit in proportion to the risks identified.
Verbatim wording from the response “- Stage 4 Road Safety Audit (RSA) – The RSA4 was completed in October 2022. The report is attached. The council is now ensuring that the recommendations are implemented in a timely manner that is proportionate to the risk posed by the measures being recommended for delivery.” Source location Response from Oxfordshire 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 Remove the stone planter at Headley Way to increase space for pedestrians and cyclists.
Verbatim wording from the response “- Dropped kerb – The council has now completed the dropped kerb facility at Headley way. We will also be removing the stone planter to increase the space for pedestrians and cyclist at this junction. This now means that cyclists are directed off the London Road before the Headley Way junction to afford them safe passage to the shared use cycle/footway on Headley way.” Source location Response from Oxfordshire 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 Provide cyclists with a five-second advance green signal at Headley Way.
Verbatim wording from the response “The council has taken on board your concerns and several measures have already been put in place to improve the public highway for vulnerable road users at both the Headley way junction and at two other key sites within the city. The works that have been completed at Headley Way include: A 5 second advance green lights for cyclists heading east bound and a dropped kerb facility to bring cyclists off the London Road to turn left into Headley Way. We have also commissioned our highway maintenance contractors to undertake a series of road marking amendments to make it clearer for cyclists to utilise the junction. The redesign of the lane/cycle markings has been commissioned to specifically consider the concerns that you raised in your Matter of Concern point 1. The design and delivery of the works at the Headley junction are due to be completed by the end of November 2022.” Source location Response from Oxfordshire 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 Commission and complete a Vulnerable Road Users audit of the relevant highway arrangements.
Verbatim wording from the response “- Vulnerable Road Users (VRU) Audit – following a request from the family, this was commissioned through our Highway maintenance provider on Friday 7 October 2022. There was slight delay in requesting this as we had to wait for the Stage 4 RSA to be completed to ensure a different team were used to undertake the additional assessment. This is to ensure the impartiality of both reports. The findings normally take a minimum of 31 days to be compiled into a report. This is the standard length of time that we would expect for such a report to be developed. The council will write to the coroner with the recommendations of this report upon receipt. The council can confirm that any further actions that are recommended within either the Stage 4 RSA or the VRU report will be actioned with immediate effect where it is a priority measure recommended.” Source location Response from Oxfordshire County Council
Open published response
19 Feb 2021 David Lewis · Prevention of Future Deaths report Oxfordshire
View report summary
Concerns raised 1 Danger of drivers failing to notice the roundabout in sufficient time View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
David Lewis · 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 Lewis died at the scene after his vehicle overshot the Vendee Drive roundabout in Bicester at speed on 16 July 2020. The report raised concern that, despite improved signage and reduced speed limits, drivers may still fail to notice the roundabout in sufficient time, particularly because it is approached around a bend or deflection. It identified possible need for further engineering measures, such as rumble strips or bars.
Read the report on judiciary.uk
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Oxfordshire County Council; that does not assign responsibility.
PFD Monitor interpretation Danger of drivers failing to notice the roundabout in sufficient time
Wider context from the report “(1) It will be seen from paragraph 18 of ████████ statement that a few days after this tragic accident there were amendments in the form of a reduction in the speed limit on approach to the roundabout. I understand these amendments were likely to be the result of a review which took place after a double fatality in June 2019. I am concerned that despite improved signage and reduced speed limits there is still the danger of drivers not noticing the roundabout in sufficient time . Importantly, it is noticed that the roundabout is approached from around a bend or deflection .
” 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 Extend the 40 mph speed limit, introduce a 50 mph transition buffer, and improve speed-limit sign conspicuity with reflective yellow backing boards.
Verbatim wording from the response “Since the incident the existing 40 mph limit has been extended along with a 50 mph limit introduced as a buffer transitioning between the national speed limit and 40 mph limit. As part of this work all speed limit signs were made more conspicuous using reflective yellow backing boards.” Source location 2021-0173-Response-from-Oxfordshire-County-Council-Redacted
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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 Remove the short third approach lane by painting hatched lines, reducing the approach to two lanes.
Verbatim wording from the response “the speed limit on the approach to the roundabout. In addition to this, it is proposed to remove the short third lane by painting hatched lines on it. This will reduce the approach to two lanes but should have minimal impact on the northbound capacity of the roundabout.” Source location 2021-0173-Response-from-Oxfordshire-County-Council-Redacted
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No amendments to the roundabout’s physical design were considered necessary because road safety audits identified no design issues.
Verbatim wording from the response “The Vendee Drive A41 roundabout is of a typical design and similar to many roundabouts across England. In order to encourage vehicles to reduce their speed before entering the lanes on the roundabout, a slight curve is built into the approach lanes. Road Safety audits were carried out throughout the project, these being on the design, once constructed, and after it had been operational for a short period. No design issues were identified at any stage and, as such, no proposals to amend the constructed physical build of the roundabout were identified.” Source location 2021-0173-Response-from-Oxfordshire-County-Council-Redacted
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Yellow bar markings cannot be used at this location because the Traffic Signs Regulations and General Directions 2016 guidance criteria are not met.
Verbatim wording from the response “The use of yellow bar markings as a visual deterrent was mentioned by Mr Wilson during the inquest and was subsequently referred to in the Regulation 28 report. This has been considered but unfortunately, due to the guidance for use criteria within the Traffic Signs Regulations and General Directions 2016, yellow markings would not be appropriate at this location.
However, consideration will be given to additional painted speed limit roundels on the lanes approaching the roundabout. These will serve as an even greater visual reminder of” Source location 2021-0173-Response-from-Oxfordshire-County-Council-Redacted
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations