28 Nov 2025 Gurkirat Singh · Prevention of Future Deaths report Black Country
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Concerns raised 4 Poor street lighting failing to provide adequate visibility for drivers View source Lack of central road markings View source Lack of pedestrian crossings on the High Street View source Obscured driver visibility from vehicles parked on either side of the road View source See 1 more concern
Responses linked to these concerns
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AI-generated summary
Gurkirat Singh · 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
Gurkirat Singh, a child, died after being struck by a single-decker bus on High Street, Tipton, on 6 December 2024. The report raises concerns about repeated incidents on the road, the absence of pedestrian crossings and central road markings, poor street lighting, and visibility being obscured by parked vehicles and building-line shadows.
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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 Sandwell Borough Council; that does not assign responsibility.
PFD Monitor interpretation Poor street lighting failing to provide adequate visibility for drivers
Wider context from the report “2. My concern is that in the last five years there have been six incidents including this fatality on this stretch of road and within half a mile approaching the roundabout. Evidence at the inquest emerged indicating there are no pedestrian crossings on this stretch of the High Street and visibility to drivers is obscured due to vehicles parked on either side.
3. In addition, there are no central road markings with poor street lighting resulting in the building line creating shadows on the footpath , which all add to the lack of visibility for drivers .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sandwell Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of central road markings
Wider context from the report “2. My concern is that in the last five years there have been six incidents including this fatality on this stretch of road and within half a mile approaching the roundabout. Evidence at the inquest emerged indicating there are no pedestrian crossings on this stretch of the High Street and visibility to drivers is obscured due to vehicles parked on either side.
3. In addition, there are no central road markings with poor street lighting resulting in the building line creating shadows on the footpath, which all add to the lack of visibility for drivers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sandwell Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of pedestrian crossings on the High Street
Wider context from the report “2. My concern is that in the last five years there have been six incidents including this fatality on this stretch of road and within half a mile approaching the roundabout. Evidence at the inquest emerged indicating there are no pedestrian crossings on this stretch of the High Street and visibility to drivers is obscured due to vehicles parked on either side.
3. In addition, there are no central road markings with poor street lighting resulting in the building line creating shadows on the footpath, which all add to the lack of visibility for drivers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sandwell Borough Council; that does not assign responsibility.
PFD Monitor interpretation Obscured driver visibility from vehicles parked on either side of the road
Wider context from the report “2. My concern is that in the last five years there have been six incidents including this fatality on this stretch of road and within half a mile approaching the roundabout. Evidence at the inquest emerged indicating there are no pedestrian crossings on this stretch of the High Street and visibility to drivers is obscured due to vehicles parked on either side .
3. In addition, there are no central road markings with poor street lighting resulting in the building line creating shadows on the footpath, which all add to the lack of visibility for drivers.
” 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 Introduce improved centre-line markings and parking bays on High Street where feasible.
Verbatim wording from the response “This will be further supported by the introduction of a new scheme incorporating improved centre-line markings and parking bays where feasible, and the introduction of a new 20mph zone for High Street and surrounding roads. This will complement the 20mph zone currently being implemented in the Owen Street area.” Source location Response from Sandwell Metropolitan Borough 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 Pursue introduction of a zebra crossing near the shop and café at High Street’s north-eastern end, subject to statutory consultation.
Verbatim wording from the response “In addition, it is proposed to pursue the introduction of a new zebra crossing in the vicinity of the shop and café at the north-eastern end of High Street. This proposal will be subject to statutory public consultation, as the installation of a crossing would require the displacement of some residential and business parking.” Source location Response from Sandwell Metropolitan Borough 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 Design and deliver enhanced street lighting and an improved lighting layout on High Street.
Verbatim wording from the response “Although existing street lighting levels have been assessed and are compliant with the standards in place at the time of installation, it has been identified that opportunities exist to enhance lighting to the next level of standard and to improve the overall layout. These improvements will now be designed and delivered as part of a wider package of safety measures for the area.” Source location Response from Sandwell Metropolitan Borough Council
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6 Dec 2019 Ms Safoora Alam · Prevention of Future Deaths report Black Country
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Concerns raised 7 Lack of information gathering before social worker visits View source Inconsistent sharing of documentation and case notes between agencies View source Lack of joint Mental Health Trust and social care packages for patients with complex physical health needs View source Lack of opportunities to convene multi-agency meetings View source Urgent referral mechanisms via safeguarding teams and GPs failing to work effectively View source Failure to contact the Mental Health Trust before social worker visits View source Failure to carry out an assessment before the visit View source See 4 more concerns
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AI-generated summary
Ms Safoora Alam · 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
Ms Safoora Alam had complex physical health problems, ongoing pain and mobility issues, and a history of impulsive overdoses and suicidal thoughts. On 28 January 2019, she set fire to her bed and herself, sustained burns to at least 80% of her body, and died later that day. The principal concerns were inconsistent sharing of documentation between agencies, inadequate joint working and information gathering, and a slow and ineffective urgent referral process when risks to her mental health escalated.
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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 Sandwell Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of information gathering before social worker visits
Wider context from the report “3. There was a lack of information gathering prior to the visit to see Ms Alam by the Social workers on the day she died. No contact was made with the Mental Health trust and no assessment took 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 Sandwell Borough Council; that does not assign responsibility.
PFD Monitor interpretation Inconsistent sharing of documentation and case notes between agencies
Wider context from the report “1. Evidence emerged during the inquest that there was inconsistent sharing of documentation and case notes between the agencies involved .
” 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 Sandwell Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of joint Mental Health Trust and social care packages for patients with complex physical health needs
Wider context from the report “2. There was a lack of a joint Mental Health Trust and social care packages for patients with complex physical health needs or opportunities to convene multi-agency meetings.
” 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 Sandwell Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of opportunities to convene multi-agency meetings
Wider context from the report “2. There was a lack of a joint Mental Health Trust and social care packages for patients with complex physical health needs or opportunities to convene multi-agency meetings.
” 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 Sandwell Borough Council; that does not assign responsibility.
PFD Monitor interpretation Urgent referral mechanisms via safeguarding teams and GPs failing to work effectively
Wider context from the report “4. The Local authority housing officers did recognise the escalating risk in her mental health state but the mechanism for urgent referral via the safeguarding team and GP was a slow and cumbersome process which didn’t 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 Sandwell Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to contact the Mental Health Trust before social worker visits
Wider context from the report “3. There was a lack of information gathering prior to the visit to see Ms Alam by the Social workers on the day she died. No contact was made with the Mental Health trust and no assessment took 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 Sandwell Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out an assessment before the visit
Wider context from the report “3. There was a lack of information gathering prior to the visit to see Ms Alam by the Social workers on the day she died. No contact was made with the Mental Health trust and no assessment took 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 Share lessons learned with all staff groups through team meetings.
Verbatim wording from the response “In relation to point 2, an action for Social Services to consider reviewing their training for social workers, obtaining accurate and up to date information prior to any visit. A review of our current practice guidance is being undertaken, and lessons learnt will be shared with all staff groups, through team meeting sessions.” Source location 2019-0426-Response-from-Sandwell-Metropolitan-Borough-Council-Redacted
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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 Review current practice guidance for social workers.
Verbatim wording from the response “In relation to point 2, an action for Social Services to consider reviewing their training for social workers, obtaining accurate and up to date information prior to any visit. A review of our current practice guidance is being undertaken, and lessons learnt will be shared with all staff groups, through team meeting sessions.” Source location 2019-0426-Response-from-Sandwell-Metropolitan-Borough-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 Review current joint agency protocols with the Urgent Care Manager and Mental Health Trust.
Verbatim wording from the response “In order to be assured of the robustness of our joint agency protocols. I can confirm the Service Manager of Social Work and Therapy has made contact with ████████ Urgent Care Manager, Mental Health Trust, and there are plans in place to undertake a review of our current protocols within the next four weeks.” Source location 2019-0426-Response-from-Sandwell-Metropolitan-Borough-Council-Redacted
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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 Develop a vulnerable adult risk management protocol through an operational group.
Verbatim wording from the response “In relation to our approaches to sharing information of risk. The Service Manager of Social Work and Therapy, and the Service Manager of Neighbourhoods have met and reviewed the identified concerns and actions within the report. As a result an operational group has been set up to explore and develop a vulnerable adult risk management protocol.” Source location 2019-0426-Response-from-Sandwell-Metropolitan-Borough-Council-Redacted
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1 Jun 2018 Imtiaz Mohammed · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1 Lack of monitoring and testing of taxi drivers for compliance with drug-driving limits 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
Imtiaz Mohammed · 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
Imtiaz Mohammed died in a serious road traffic collision in Birmingham on 17 December 2017, when a taxi was struck by an Audi travelling at between 94 and 100 mph. Toxicology showed the taxi driver was over the legal drug-driving limit for a cocaine metabolite, and concerns were raised that there was no system to monitor whether taxi drivers were over the drug limit while driving.
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 Sandwell Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of monitoring and testing of taxi drivers for compliance with drug-driving limits
Wider context from the report “1. Toxicology was obtained for the deceased who was driving the Taxi involved in the collision. This confirmed the following blood levels:
Cocaine 0.010mg/l
Benzoylecgonine (a cocaine metabolite) 0.40mg/l
Carboxy THC 0.10 mg/l
The level of the cocaine metabolite would have resulted in the deceased being over the legal drug driver limit. This did not contribute to this collision.
However the Midlands Police raised concerns at the inquest that there was presently no system in place to monitor and check whether taxi drivers are over the drug limit whilst driving . They confirmed in evidence that some sort of testing was required for the safety of passengers .
” Open source report
22 Jun 2017 Aston Soulsby · Prevention of Future Deaths report Black Country
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Concerns raised 1 Unsafe use of hatched road areas by pedestrians and vehicles View source
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AI-generated summary
Aston Soulsby · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 1 November 2016, schoolboy Aston Soulsby was struck by a bus while crossing Crankhall Lane, Wednesbury, after narrowly missing a Vauxhall Corsa. He sustained serious traumatic injuries and died in hospital on 7 November 2016. The inquest identified concern that pedestrians waiting in the hatched central area and vehicles passing parked vehicles there may cause confusion and pose risks to pedestrians and motorists.
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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 Sandwell Borough Council; that does not assign responsibility.
PFD Monitor interpretation Unsafe use of hatched road areas by pedestrians and vehicles
Wider context from the report “1. Evidence emerged during the inquest that pedestrians frequently wait in the hatch area whilst crossing the road and vehicles also pass parked vehicles in the road in the hatched area . This may lead to confusion and pose a risk for pedestrians and motorists .
” 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 Consider installing a formalised pedestrian crossing on Crankhall Lane, assessing location suitability against pedestrian desire lines, access, parking, servicing and usability.
Verbatim wording from the response “Nonetheless, it is accepted that it is not an ideal location for pedestrians to cross and as such to assist pedestrian movement, Sandwell MBC are considering the possibility of installing a formalised crossing point along this section of Crankhall Lane. It should be noted, however that this will be dependent upon a suitable location being identified with consideration given to desire lines, existing footway crossings, business accesses, parking bays, servicing to shops and usability.” Source location 2017-0204-Response-by-Sandwell-Metrolitan-Borough-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 Alter the existing carriageway markings and re-appropriate road space as necessary.
Verbatim wording from the response “In addition it has been noted the existing carriageway markings at this location are now considered to be an outdated layout and consequently these will be altered and road space re-appropriated as necessary.” Source location 2017-0204-Response-by-Sandwell-Metrolitan-Borough-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 Installing a formal crossing depends on identifying a suitable location that accommodates pedestrian movements, access, parking, servicing and usability.
Verbatim wording from the response “Nonetheless, it is accepted that it is not an ideal location for pedestrians to cross and as such to assist pedestrian movement, Sandwell MBC are considering the possibility of installing a formalised crossing point along this section of Crankhall Lane. It should be noted, however that this will be dependent upon a suitable location being identified with consideration given to desire lines, existing footway crossings, business accesses, parking bays, servicing to shops and usability.” Source location 2017-0204-Response-by-Sandwell-Metrolitan-Borough-Council
Open published response
12 Nov 2014 Lorraine Sheridan · Prevention of Future Deaths report Black Country
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Concerns raised 1 Lack of audible pedestrian phase indication on the opposing side of the carriageway 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
Lorraine Sheridan · 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
Lorraine Sheridan died following injuries sustained when she was struck by an articulated lorry while attempting to cross a pedestrian crossing on High Bullen Road, Wednesbury, on 30 May 2013. The report identified two documented collisions at the location and raised concern that the crossing lacked an audible indication to reinforce the pedestrian signal phase.
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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 Sandwell Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of audible pedestrian phase indication on the opposing side of the carriageway
Wider context from the report “(1) There have now been two documented collision’s at this location and in order to prevent similar collisions occurring in the future, the Police have suggested that an audible phase indication (red and green man) on the opposing side of the carriageway would reinforce the phase for pedestrians and make them far less likely to cross when it is unsafe to do so .
” Open source report
30 Apr 2014 Sukhir Singh RANA and Mandip SINGH · Prevention of Future Deaths report Black Country
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Concerns raised 1 Failure to set the road speed limit appropriately for its country-lane characteristics and bends 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
Sukhir Singh RANA and Mandip SINGH · 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
Sukhir Singh RANA and Mandip SINGH died following a road traffic collision on Park Lane, Handsworth, Birmingham, involving the car in which both men were travelling. The principal concerns were whether the 60-mile-per-hour speed limit was appropriate for a poorly lit, bend-filled country lane and whether the bend's theoretical maximum speed contributed to excessive speeds.
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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 Sandwell Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to set the road speed limit appropriately for its country-lane characteristics and bends
Wider context from the report “My concerns are that the speed limit for the road in question is 60 miles an hour . I write to enquire whether this is appropriate for what is largely a country lane with limited lighting and a number of bends . I appreciate of course, that if the speed limit were to be reduced it does not of itself prevent drivers exceeding the limit, but it may provide the appropriate signal to drivers. I also was concerned to note that the maximum theoretical speed for the bend where the collision occurred was around 60 miles per hour .
” 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