29 Jul 2024 Lamarah Grace Scarlett · Prevention of Future Deaths report Gloucestershire
View report summary
Concerns raised 9 Lack of a requirement for transport crew to be qualified first aiders View source Lack of a comprehensive schedule for inspection of transport operators View source Lack of mandatory training or forums for transport operators to receive cascaded information View source Inadequacy of the passenger assessment test View source Fragmented access to organisations causing confusion and inconsistency for transport operators View source Failure of transport crew to read and understand patient safety plans View source Failure to conduct contractually required home visits between passengers and transport crew View source Failure to notify the local authority of transport crew personnel changes View source Failure to understand the need for proper handovers at drop-off and pick-up View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Lamarah Grace Scarlett · 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
Lamarah Grace Scarlett, a 12-year-old girl with alternating hemiplegia of childhood, became distressed and experienced breathing difficulties while being transported home from school on 24 September 2021. Her head became hyperextended, obstructing her airway; she arrived home unresponsive and was pronounced deceased despite resuscitation efforts. Concerns included the regulation, training, safety-plan compliance, handovers, first-aid qualifications, assessment, and oversight of operators providing home-to-school transport for children with special educational needs.
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 Traffic Commissioners for Great Britain; that does not assign responsibility.
PFD Monitor interpretation Lack of a requirement for transport crew to be qualified first aiders
Wider context from the report “Whether there is sufficient regulation of transport operators who provide category 1 home to school transport services to Special Educational Needs children?
The following specific issues were identified:
• The patient safety plans are not always read and understood by transport crew,
• Home visits between passenger and transport crew often do not occur when contractually required,
• The local authority are often not notified of personnel changes in the transport crew,
• The need for proper handovers at drop off and pick up is not understood
• There is no requirement for transport crew to be qualified first aiders ,
• The passenger assessment test requires further improvement,
• There is no comprehensive schedule for inspection of transport operators,
• There is no mandatory training or forums for operators to attend where information can be cascaded to them.
• Operators have to approach multiple organisations which leads to confusion and inconsistency.
” 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 Traffic Commissioners for Great Britain; that does not assign responsibility.
PFD Monitor interpretation Lack of a comprehensive schedule for inspection of transport operators
Wider context from the report “Whether there is sufficient regulation of transport operators who provide category 1 home to school transport services to Special Educational Needs children?
The following specific issues were identified:
• The patient safety plans are not always read and understood by transport crew,
• Home visits between passenger and transport crew often do not occur when contractually required,
• The local authority are often not notified of personnel changes in the transport crew,
• The need for proper handovers at drop off and pick up is not understood
• There is no requirement for transport crew to be qualified first aiders,
• The passenger assessment test requires further improvement,
• There is no comprehensive schedule for inspection of transport operators ,
• There is no mandatory training or forums for operators to attend where information can be cascaded to them.
• Operators have to approach multiple organisations which leads to confusion and inconsistency.
” 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 Traffic Commissioners for Great Britain; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory training or forums for transport operators to receive cascaded information
Wider context from the report “Whether there is sufficient regulation of transport operators who provide category 1 home to school transport services to Special Educational Needs children?
The following specific issues were identified:
• The patient safety plans are not always read and understood by transport crew,
• Home visits between passenger and transport crew often do not occur when contractually required,
• The local authority are often not notified of personnel changes in the transport crew,
• The need for proper handovers at drop off and pick up is not understood
• There is no requirement for transport crew to be qualified first aiders,
• The passenger assessment test requires further improvement,
• There is no comprehensive schedule for inspection of transport operators,
• There is no mandatory training or forums for operators to attend where information can be cascaded to them.
• Operators have to approach multiple organisations which leads to confusion and inconsistency.
” 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 Traffic Commissioners for Great Britain; that does not assign responsibility.
PFD Monitor interpretation Inadequacy of the passenger assessment test
Wider context from the report “Whether there is sufficient regulation of transport operators who provide category 1 home to school transport services to Special Educational Needs children?
The following specific issues were identified:
• The patient safety plans are not always read and understood by transport crew,
• Home visits between passenger and transport crew often do not occur when contractually required,
• The local authority are often not notified of personnel changes in the transport crew,
• The need for proper handovers at drop off and pick up is not understood
• There is no requirement for transport crew to be qualified first aiders,
• The passenger assessment test requires further improvement ,
• There is no comprehensive schedule for inspection of transport operators,
• There is no mandatory training or forums for operators to attend where information can be cascaded to them.
• Operators have to approach multiple organisations which leads to confusion and inconsistency.
” 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 Traffic Commissioners for Great Britain; that does not assign responsibility.
PFD Monitor interpretation Fragmented access to organisations causing confusion and inconsistency for transport operators
Wider context from the report “Whether there is sufficient regulation of transport operators who provide category 1 home to school transport services to Special Educational Needs children?
The following specific issues were identified:
• The patient safety plans are not always read and understood by transport crew,
• Home visits between passenger and transport crew often do not occur when contractually required,
• The local authority are often not notified of personnel changes in the transport crew,
• The need for proper handovers at drop off and pick up is not understood
• There is no requirement for transport crew to be qualified first aiders,
• The passenger assessment test requires further improvement,
• There is no comprehensive schedule for inspection of transport operators,
• There is no mandatory training or forums for operators to attend where information can be cascaded to them.
• Operators have to approach multiple organisations which leads to confusion and inconsistency.
” 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 Traffic Commissioners for Great Britain; that does not assign responsibility.
PFD Monitor interpretation Failure of transport crew to read and understand patient safety plans
Wider context from the report “Whether there is sufficient regulation of transport operators who provide category 1 home to school transport services to Special Educational Needs children?
The following specific issues were identified:
• The patient safety plans are not always read and understood by transport crew ,
• Home visits between passenger and transport crew often do not occur when contractually required,
• The local authority are often not notified of personnel changes in the transport crew,
• The need for proper handovers at drop off and pick up is not understood
• There is no requirement for transport crew to be qualified first aiders,
• The passenger assessment test requires further improvement,
• There is no comprehensive schedule for inspection of transport operators,
• There is no mandatory training or forums for operators to attend where information can be cascaded to them.
• Operators have to approach multiple organisations which leads to confusion and inconsistency.
” 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 Traffic Commissioners for Great Britain; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct contractually required home visits between passengers and transport crew
Wider context from the report “Whether there is sufficient regulation of transport operators who provide category 1 home to school transport services to Special Educational Needs children?
The following specific issues were identified:
• The patient safety plans are not always read and understood by transport crew,
• Home visits between passenger and transport crew often do not occur when contractually required ,
• The local authority are often not notified of personnel changes in the transport crew,
• The need for proper handovers at drop off and pick up is not understood
• There is no requirement for transport crew to be qualified first aiders,
• The passenger assessment test requires further improvement,
• There is no comprehensive schedule for inspection of transport operators,
• There is no mandatory training or forums for operators to attend where information can be cascaded to them.
• Operators have to approach multiple organisations which leads to confusion and inconsistency.
” 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 Traffic Commissioners for Great Britain; that does not assign responsibility.
PFD Monitor interpretation Failure to notify the local authority of transport crew personnel changes
Wider context from the report “Whether there is sufficient regulation of transport operators who provide category 1 home to school transport services to Special Educational Needs children?
The following specific issues were identified:
• The patient safety plans are not always read and understood by transport crew,
• Home visits between passenger and transport crew often do not occur when contractually required,
• The local authority are often not notified of personnel changes in the transport crew ,
• The need for proper handovers at drop off and pick up is not understood
• There is no requirement for transport crew to be qualified first aiders,
• The passenger assessment test requires further improvement,
• There is no comprehensive schedule for inspection of transport operators,
• There is no mandatory training or forums for operators to attend where information can be cascaded to them.
• Operators have to approach multiple organisations which leads to confusion and inconsistency.
” 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 Traffic Commissioners for Great Britain; that does not assign responsibility.
PFD Monitor interpretation Failure to understand the need for proper handovers at drop-off and pick-up
Wider context from the report “Whether there is sufficient regulation of transport operators who provide category 1 home to school transport services to Special Educational Needs children?
The following specific issues were identified:
• The patient safety plans are not always read and understood by transport crew,
• Home visits between passenger and transport crew often do not occur when contractually required,
• The local authority are often not notified of personnel changes in the transport crew,
• The need for proper handovers at drop off and pick up is not understood
• There is no requirement for transport crew to be qualified first aiders,
• The passenger assessment test requires further improvement,
• There is no comprehensive schedule for inspection of transport operators,
• There is no mandatory training or forums for operators to attend where information can be cascaded to them.
• Operators have to approach multiple organisations which leads to confusion and inconsistency.
” Open source report
17 Sep 2019 Dr Jonathan Edward Ball · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 4 Failure of HGV rear hazard warning lights to remain working and sufficiently conspicuous View source Failure to train or instruct HGV drivers to report stranded vehicles to emergency services View source Lack of an HGV warning device for alerting approaching motorists to a stranded vehicle View source Lack of duplicate rear indicator and hazard warning lights on HGVs View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Dr Jonathan Edward Ball · 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 24 November 2018, Dr Jonathan Edward Ball died after his Skoda collided with a stationary 32-ton HGV on the A647 Stanningley bypass near Pudsey, Leeds. The substantive concerns related to the absence of advance warning equipment and emergency-service notification for the stranded HGV, and the limited visibility or resilience of its rear hazard warning lights.
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 Traffic Commissioners for Great Britain; that does not assign responsibility.
PFD Monitor interpretation Failure of HGV rear hazard warning lights to remain working and sufficiently conspicuous
Wider context from the report “(3) The evidence of the other motorists on the A647 at the material time indicated that the rear offside hazard warning light was hard to see (or thought not to be working) thus giving the impression that the HGV was indicating to turn left (and thereby potentially confusing approaching motorists). In such circumstances there was no added resilience to the lights displayed, such as would have been provided by having duplicate indicator/hazard lights on the rear corners of the HGV. Given the arduous work of such vehicles and the propensity for the light to become dirty at the end of a working day , concern was expressed at the Inquest as to the danger which might be created in the event (a) the HGV broke down in a hazardous location and (b) the rear lights were not working or insufficiently conspicuous .
” 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 Traffic Commissioners for Great Britain; that does not assign responsibility.
PFD Monitor interpretation Failure to train or instruct HGV drivers to report stranded vehicles to emergency services
Wider context from the report “(2) The HGV driver had not been trained or instructed to contact the emergency services to report the foreseeable hazard created by his stranded HGV on a dual carriageway at night. The HGV was there for some 41 minutes before the fatal collision occurred (although the Inquest heard evidence there were several near misses before then). It was likely that when a mechanic did arrive at the scene the HGV would have been there for a further period before it was repaired or could have been towed to a safe location. In consequence, the police had no opportunity to guard the scene, position safety barrier or warning signs to alert approaching motorists of the hazard.
” 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 Traffic Commissioners for Great Britain; that does not assign responsibility.
PFD Monitor interpretation Lack of an HGV warning device for alerting approaching motorists to a stranded vehicle
Wider context from the report “(1) The HGV was not equipped with a device (such as a warning triangle) which the driver could have positioned some way before his stranded vehicle to warn oncoming motorists of the hazard presented by a stranded 32 ton HGV blocking one lane of a dual carriageway in darkness.
” 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 Traffic Commissioners for Great Britain; that does not assign responsibility.
PFD Monitor interpretation Lack of duplicate rear indicator and hazard warning lights on HGVs
Wider context from the report “(3) The evidence of the other motorists on the A647 at the material time indicated that the rear offside hazard warning light was hard to see (or thought not to be working) thus giving the impression that the HGV was indicating to turn left (and thereby potentially confusing approaching motorists). In such circumstances there was no added resilience to the lights displayed , such as would have been provided by having duplicate indicator/hazard lights on the rear corners of the HGV . Given the arduous work of such vehicles and the propensity for the light to become dirty at the end of a working day, concern was expressed at the Inquest as to the danger which might be created in the event (a) the HGV broke down in a hazardous location and (b) the rear lights were not working or insufficiently conspicuous.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Department for Transport is responsible for considering vehicle-design legislation and mandatory warning-triangle requirements.
Verbatim wording from the response “The Senior Traffic Commissioner was concerned to learn of the events leading to Dr Ball’s death and of course shares your desire to prevent similar circumstances arising in the future. You will appreciate that it is the role of Government, through the Department for Transport, to consider the need to legislate on the matters relating to vehicle design or to impose a mandatory requirement for warning triangles to be deployed at a time of a breakdown. To assist you we have identified the relevant section of the Department for Transport, namely the Freight, Operator Licensing and Roadworthiness Division at:” Source location 2019-0507-Response-from-the-Office-of-the-Traffic-Commissioner-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 The DVSA administers periodic driver training and may work with training providers to include safety training in available modules.
Verbatim wording from the response “You may be aware that, in addition to the general health and safety duties and those relating to the assessment of risk on operators, that there is a requirement under European legislation for holders of vocational entitlements to undertake periodic training under the umbrella of the Driver’s Certificate of Professional Competence. The DVSA administer this scheme and may be able to work with and provide advice to training providers on the inclusion of safety training into the modules available to drivers. The DVSA can be contacted at:” Source location 2019-0507-Response-from-the-Office-of-the-Traffic-Commissioner-Redacted
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations