Concerns raised 3 Mature trees obstructing safe pedestrian and mobility-aid access along the pavement View source Roadside mature trees creating an immediate vehicle-collision hazard View source Lack of formal risk assessment and evaluation of safety concerns relating to roadside trees 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
JAY STUART WHITING · 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
Jay Whiting, aged 21, died on 7 January 2023 after sustaining fatal injuries when the vehicle he was driving left the road and collided with a mature tree in Plymouth. The report raises safety concerns about mature trees positioned immediately beside Embankment Road, including their potential danger to vehicles and obstruction of pavement users, and notes that Plymouth City Council had not formally assessed the risks or whether action was warranted.
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 Plymouth City Council; that does not assign responsibility.
PFD Monitor interpretation Mature trees obstructing safe pedestrian and mobility-aid access along the pavement
Wider context from the report “Although the determinations at the inquest found there to be a number of relevant factors which contributed to the fatal road traffic collision and, therefore, to Jay Whiting’s death (as set out in paragraph 4, above), one such contributing factor was that the vehicle being driven by Jay Whiting left the road and immediately collided with a mature tree (one of many such trees which line Embankment Road, Plymouth). Embankment Road (or at least this particular stretch) is a dual carriageway and a main route into the city centre of Plymouth.
As part of the investigation and inquest process, photos were taken of the scene by forensic collision investigating officers, and these showed the large trees to be adjacent to the dual carriageway, situated on a pavement only a matter of inches from the kerb. It is clear from these photos that, firstly, any vehicle that, in whatever situation, has cause to leave the road and mount the kerb is very likely to immediately collide with one of the mature trees and, secondly, the size of the trees (the circumference of their trunks) make it difficult for pedestrians, or those using mobility aides, to safely walk/move along the pavement without having to step into the road .
Evidence was heard at the inquest from Motor Police Constable ████████ road casualty reduction officer for the Plymouth area (employed by Devon and Cornwall Police). MPC ████████’s unequivocal opinion was that the presence of these mature trees at this location (both on the northbound and southbound carriageways on Embankment Road, but particularly the stretch of trees at the location of this fatal incident on the northbound carriageway) is frankly dangerous from a road safety perspective. MPC ████████ stated that, in addition to this fatal accident in 2023, there was a fatal accident in 2008, where a vehicle collided with one of the trees along the same stretch of the northbound carriageway, resulting in the deaths of two occupants of the vehicle. MPC ████████ was therefore concerned that there had been three deaths arising in very similar circumstances at the same location, involving trauma brought about by vehicular collision with one of the mature trees. MPC ████████ stated that he was not aware of any other location in Plymouth where trees lining the road had been considered a contributory factor in a fatal vehicle collision. Owing to these concerns, MPC ████████ made a request that consideration is given by Plymouth City Council to removing the trees at this location.
Evidence was also heard at the inquest from ████████ senior traffic engineer for street services (employed by Plymouth City Council). ████████ stated that he was aware of the concerns held by Devon and Cornwall Police regarding the mature trees and that, personally, he would also like the trees to be removed. ████████ stated that the removal of trees in Plymouth was currently ‘a political topic’ and, for the trees on Embankment Road to be removed, a decision would need to be taken justifying the use of scarce local authority public funding. ████████ accepted that there had, thus far, been no formal risk assessment or evaluation carried out by Plymouth City Council as to whether the safety concerns identified warranted resources being used to remove the trees. ████████ further accepted that this process should now take place and that he had been waiting for the outcome of this inquest before deciding upon appropriate next steps.
Owing to there being clear safety concerns regarding the continued presence of these mature trees on Embankment Road, Plymouth, in my view these need to be formally considered (it is for Plymouth City Council to consider issues of risk and cost/benefit analysis of any proposed action/inaction) with a view to determining what, if anything, should happen to the trees.
” 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 Plymouth City Council; that does not assign responsibility.
PFD Monitor interpretation Roadside mature trees creating an immediate vehicle-collision hazard
Wider context from the report “Although the determinations at the inquest found there to be a number of relevant factors which contributed to the fatal road traffic collision and, therefore, to Jay Whiting’s death (as set out in paragraph 4, above), one such contributing factor was that the vehicle being driven by Jay Whiting left the road and immediately collided with a mature tree (one of many such trees which line Embankment Road, Plymouth). Embankment Road (or at least this particular stretch) is a dual carriageway and a main route into the city centre of Plymouth.
As part of the investigation and inquest process, photos were taken of the scene by forensic collision investigating officers, and these showed the large trees to be adjacent to the dual carriageway, situated on a pavement only a matter of inches from the kerb. It is clear from these photos that, firstly, any vehicle that, in whatever situation, has cause to leave the road and mount the kerb is very likely to immediately collide with one of the mature trees and, secondly, the size of the trees (the circumference of their trunks) make it difficult for pedestrians, or those using mobility aides, to safely walk/move along the pavement without having to step into the road.
Evidence was heard at the inquest from Motor Police Constable ████████ road casualty reduction officer for the Plymouth area (employed by Devon and Cornwall Police). MPC ████████’s unequivocal opinion was that the presence of these mature trees at this location (both on the northbound and southbound carriageways on Embankment Road, but particularly the stretch of trees at the location of this fatal incident on the northbound carriageway) is frankly dangerous from a road safety perspective . MPC ████████ stated that, in addition to this fatal accident in 2023, there was a fatal accident in 2008, where a vehicle collided with one of the trees along the same stretch of the northbound carriageway, resulting in the deaths of two occupants of the vehicle. MPC ████████ was therefore concerned that there had been three deaths arising in very similar circumstances at the same location, involving trauma brought about by vehicular collision with one of the mature trees. MPC ████████ stated that he was not aware of any other location in Plymouth where trees lining the road had been considered a contributory factor in a fatal vehicle collision. Owing to these concerns, MPC ████████ made a request that consideration is given by Plymouth City Council to removing the trees at this location.
Evidence was also heard at the inquest from ████████ senior traffic engineer for street services (employed by Plymouth City Council). ████████ stated that he was aware of the concerns held by Devon and Cornwall Police regarding the mature trees and that, personally, he would also like the trees to be removed. ████████ stated that the removal of trees in Plymouth was currently ‘a political topic’ and, for the trees on Embankment Road to be removed, a decision would need to be taken justifying the use of scarce local authority public funding. ████████ accepted that there had, thus far, been no formal risk assessment or evaluation carried out by Plymouth City Council as to whether the safety concerns identified warranted resources being used to remove the trees. ████████ further accepted that this process should now take place and that he had been waiting for the outcome of this inquest before deciding upon appropriate next steps.
Owing to there being clear safety concerns regarding the continued presence of these mature trees on Embankment Road, Plymouth, in my view these need to be formally considered (it is for Plymouth City Council to consider issues of risk and cost/benefit analysis of any proposed action/inaction) with a view to determining what, if anything, should happen to the trees.
” 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 Plymouth City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of formal risk assessment and evaluation of safety concerns relating to roadside trees
Wider context from the report “Although the determinations at the inquest found there to be a number of relevant factors which contributed to the fatal road traffic collision and, therefore, to Jay Whiting’s death (as set out in paragraph 4, above), one such contributing factor was that the vehicle being driven by Jay Whiting left the road and immediately collided with a mature tree (one of many such trees which line Embankment Road, Plymouth). Embankment Road (or at least this particular stretch) is a dual carriageway and a main route into the city centre of Plymouth.
As part of the investigation and inquest process, photos were taken of the scene by forensic collision investigating officers, and these showed the large trees to be adjacent to the dual carriageway, situated on a pavement only a matter of inches from the kerb. It is clear from these photos that, firstly, any vehicle that, in whatever situation, has cause to leave the road and mount the kerb is very likely to immediately collide with one of the mature trees and, secondly, the size of the trees (the circumference of their trunks) make it difficult for pedestrians, or those using mobility aides, to safely walk/move along the pavement without having to step into the road.
Evidence was heard at the inquest from Motor Police Constable ████████ road casualty reduction officer for the Plymouth area (employed by Devon and Cornwall Police). MPC ████████’s unequivocal opinion was that the presence of these mature trees at this location (both on the northbound and southbound carriageways on Embankment Road, but particularly the stretch of trees at the location of this fatal incident on the northbound carriageway) is frankly dangerous from a road safety perspective. MPC ████████ stated that, in addition to this fatal accident in 2023, there was a fatal accident in 2008, where a vehicle collided with one of the trees along the same stretch of the northbound carriageway, resulting in the deaths of two occupants of the vehicle. MPC ████████ was therefore concerned that there had been three deaths arising in very similar circumstances at the same location, involving trauma brought about by vehicular collision with one of the mature trees. MPC ████████ stated that he was not aware of any other location in Plymouth where trees lining the road had been considered a contributory factor in a fatal vehicle collision. Owing to these concerns, MPC ████████ made a request that consideration is given by Plymouth City Council to removing the trees at this location.
Evidence was also heard at the inquest from ████████ senior traffic engineer for street services (employed by Plymouth City Council). ████████ stated that he was aware of the concerns held by Devon and Cornwall Police regarding the mature trees and that, personally, he would also like the trees to be removed. ████████ stated that the removal of trees in Plymouth was currently ‘a political topic’ and, for the trees on Embankment Road to be removed, a decision would need to be taken justifying the use of scarce local authority public funding. ████████ accepted that there had, thus far, been no formal risk assessment or evaluation carried out by Plymouth City Council as to whether the safety concerns identified warranted resources being used to remove the trees . ████████ further accepted that this process should now take place and that he had been waiting for the outcome of this inquest before deciding upon appropriate next steps.
Owing to there being clear safety concerns regarding the continued presence of these mature trees on Embankment Road, Plymouth, in my view these need to be formally considered (it is for Plymouth City Council to consider issues of risk and cost/benefit analysis of any proposed action/inaction) with a view to determining what, if anything, should happen to the trees.
” 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 Initiate the statutory process to extend the 30mph speed limit along approximately 800 metres of the A374 Embankment Road.
Verbatim wording from the response “1. Implementation of a process to extend the 30mph Speed Limit on both sides of the A374 Embankment Road from its current terminal north-east of Stanley place to a point north-east of the Rowing Club, approximately 800 metres. This will involve the introduction of a Traffic Regulation Order (“TRO”) and as such will be subject to a statutory process which will include a statutory consultation followed by a formal decision to be taken in accordance with the Council’s constitution. If following this process the TRO is agreed, it is envisaged that the lower speed limit will be introduced at the beginning of April 2025.” Source location Response from Plymouth City 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 specified trees beside the north-east carriageway and reconstruct approximately 450 metres of the carriageway and footway.
Verbatim wording from the response “2. We plan to remove a number of trees adjacent to the north-east bound carriageway between the Glendinning Depot and Arnold’s Point. The works for tree” Source location Response from Plymouth City Council
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 Trees on the south-west carriageway are not considered a significant collision risk because of existing lower speeds, junction conditions and a safety camera.
Verbatim wording from the response “As part of this process, the City Council has considered removal of the trees sited on the south-west bound carriageway. These trees have no history of involvement in collisions with vehicles and are also planted in a way which does not block the adjacent footway/cycleway. This section of road is in-bound towards the City Centre and currently has lower traffic speeds due to the junction with Lanhydrock Rd and the presence of a Safety Camera in advance of the junction. As the speed limit will now be dropped to 30mph with a Speed Camera in place, it is not considered that the trees on this side of the road present a significant risk and will therefore remain in place. Given the constraint on Council budgets, work on which present a significant risk of collisions must be prioritised.” Source location Response from Plymouth City Council
Open published response
Concerns raised 2 Sun glare hazard impairing driver visibility at the junction View source Failure to prevent vehicles cutting the corner onto the incorrect side of 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
Harry Edward Simmons · 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
Harry Edward Simmons, aged 87, was struck by a car while crossing Montpellier Road in Plymouth and later died in hospital from his injuries. The report raised concerns about drivers cutting the junction, the effect of sun on visibility, and the risk of further collisions at the junction; three collisions had occurred there in the previous five years.
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 Plymouth City Council; that does not assign responsibility.
PFD Monitor interpretation Sun glare hazard impairing driver visibility at the junction
Wider context from the report “(1) Acting Police Inspector ████████ gave evidence to the inquest as follows:
1. In his opinion as Mr Simmons was at least ½ way across the road if the driver had not turned into the junction on the incorrect side of the road, he would have most likely avoided him.
2. The sun is a particular hazard at that junction and would have had an effect on the ability of the driver to see Mr Simmons .
3. Double yellow lines in his opinion would not prevent a further accident of this nature.
4. A pedestrian refuge in the centre of the road on the junction of Montpellier Road and Beacon Park Road together with a keep left sign would prevent vehicles cutting the corner and causing a similar accident again.
5. There have been 3 collisions on this junction in the last 5 years, 2 of which have cited the sun as a contributory factor .
6. There is local knowledge to suggest that drivers cutting this corner is a commonplace occurrence as the sharp turn right to the correct side of the road is a more difficult manoeuvre to make.
” 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 Plymouth City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent vehicles cutting the corner onto the incorrect side of the road
Wider context from the report “(1) Acting Police Inspector ████████ gave evidence to the inquest as follows:
1. In his opinion as Mr Simmons was at least ½ way across the road if the driver had not turned into the junction on the incorrect side of the road , he would have most likely avoided him.
2. The sun is a particular hazard at that junction and would have had an effect on the ability of the driver to see Mr Simmons.
3. Double yellow lines in his opinion would not prevent a further accident of this nature.
4. A pedestrian refuge in the centre of the road on the junction of Montpellier Road and Beacon Park Road together with a keep left sign would prevent vehicles cutting the corner and causing a similar accident again.
5. There have been 3 collisions on this junction in the last 5 years, 2 of which have cited the sun as a contributory factor.
6. There is local knowledge to suggest that drivers cutting this corner is a commonplace occurrence as the sharp turn right to the correct side of the road is a more difficult manoeuvre to make .
” 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 Bid for funding to enable construction of the proposed highway safety scheme.
Verbatim wording from the response “The scheme is estimated to cost in the region of £70,000 and I am currently bidding for funding to enable construction to go ahead.” Source location Response from Plymouth City 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 a scheme design addressing the identified highway safety issues.
Verbatim wording from the response “The City Council have undertaken a study into the circumstances leading to the collision and have commissioned a scheme design to deal with the identified highway issues involved.” Source location Response from Plymouth City 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 Complete a study into the circumstances leading to the collision.
Verbatim wording from the response “The City Council have undertaken a study into the circumstances leading to the collision and have commissioned a scheme design to deal with the identified highway issues involved.” Source location Response from Plymouth City Council
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 Road humps and parking restrictions cannot be predetermined because they require statutory public consultation.
Verbatim wording from the response “* Introduction of both road humps and waiting restrictions is subject to a statutory consultation process which cannot be predetermined.” Source location Response from Plymouth City Council
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 Construction depends on securing funding, so the safety scheme cannot proceed unless budget becomes available.
Verbatim wording from the response “The scheme is estimated to cost in the region of £70,000 and I am currently bidding for funding to enable construction to go ahead.” Source location Response from Plymouth City Council
Open published response
Concerns raised 4 Unsuitable accommodation View source Self-neglect View source Failure to maintain clean bedding View source Inappropriate care package 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
Gordon Eric Atkinson · 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
Gordon Eric Atkinson lived alone in a poor-condition caravan and had numerous falls, including an unwitnessed fall that caused burns. He was later admitted to a care home, nursing home and hospital, where he died on 6 February 2015. The concerns included unsuitable accommodation, self-neglect, and an inappropriate care package.
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 Plymouth City Council; that does not assign responsibility.
PFD Monitor interpretation Unsuitable accommodation
Wider context from the report “(1) The deceased appeared to be living in accommodation that was unsuitable .
” 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 Plymouth City Council; that does not assign responsibility.
PFD Monitor interpretation Self-neglect
Wider context from the report “(2) On the evidence it was clear that the deceased was neglecting himself . In particular, his sister pointed out that his bed was soiled with faeces and remained unchanged.
” 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 Plymouth City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain clean bedding
Wider context from the report “(2) On the evidence it was clear that the deceased was neglecting himself. In particular, his sister pointed out that his bed was soiled with faeces and remained unchanged .
” 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 Plymouth City Council; that does not assign responsibility.
PFD Monitor interpretation Inappropriate care package
Wider context from the report “(3) It appeared from the evidence at the Inquest that his care package was inappropriate
” Open source report
Concerns raised 1 Failure to ensure clear information sharing for vulnerable adults at risk of self-neglect when their primary carer is outside the Clinical Commissioning Group 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.
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AI-generated summary
Andrew John Nickolls · 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
Andrew John Nickolls was discharged from Torbay Hospital on 12 September 2013 and was later found by police officers in his flat after concerns were raised. The report identified concerns about information sharing and continuity of primary care for a vulnerable adult who may have been neglecting himself; the medical cause of death was unascertained and the inquest conclusion was open.
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 Plymouth City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure clear information sharing for vulnerable adults at risk of self-neglect when their primary carer is outside the Clinical Commissioning Group
Wider context from the report “The principal learning point is to be that there is an advantage in a patient being looked after by a primary carer (i.e. a GP) within the Clinical Commissioning Group. If this is not the case, then it is imperative that there is clear information sharing, particularly where there is a vulnerable adult and there is a possibility they are neglecting themselves.
” Open source report
Concerns raised 1 Risk of drug-related death among future inhabitants of the property 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.
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AI-generated summary
Daniel COLLINS · 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
Daniel COLLINS occupied a flat in a property in Devonport, Plymouth, and died within one week of another occupant in the same property. The inquest concluded that his death was drug-related, and concern was raised about a history of drug abuse at the property and the risk of future drug-related deaths among its inhabitants.
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 Plymouth City Council; that does not assign responsibility.
PFD Monitor interpretation Risk of drug-related death among future inhabitants of the property
Wider context from the report “1. ████████ appears to be a property in multiple occupation having several flats in the property. The occupants clearly associate and are on speaking terms with one another. It appears there is a history of drug abuse at the property. I am concerned that future inhabitants of that property may suffer a drug related death.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations