2 Oct 2024 Michael Sean Heath · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 7 Failure to ensure carers are informed of Mental Health Act admissions within 24 hours View source Failure to establish agreed communication means and maintain relevant patient information in an accessible central repository View source Failure to provide mental health patients with access to an independent mental health advocate View source Failure to ensure officers are trained to assess mental health-related calls and associated immediate risks View source Failure to determine when police are the appropriate agency for mental health-related enquiries View source Lack of connectivity between overseas and UK mental health services during repatriation of an ill patient View source Failure to consider wider circumstances and likely follow-on care before removing out-of-area patients from GP practice lists View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Michael Sean Heath · 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
Michael Sean Heath died on 25 August 2023 in an apartment from injuries involving his pericardial sac. The inquest jury determined that he died by taking his own life while suffering an acute mental health crisis. Principal concerns included police and mental health service responses, inter-agency communication, continuity of care after his return from Gibraltar, and access to appropriate mental health support.
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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure carers are informed of Mental Health Act admissions within 24 hours
Wider context from the report “In relation to the management of mental health patients that their carers are made aware of any admission under the Mental Health Act within 24 hours and those patients are supported with access to an independent mental health advocate;
” 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to establish agreed communication means and maintain relevant patient information in an accessible central repository
Wider context from the report “The means of communication is known and agreed between all mental health agencies to ensure all relevant patient information is held in an accessible central repository .
” 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide mental health patients with access to an independent mental health advocate
Wider context from the report “In relation to the management of mental health patients that their carers are made aware of any admission under the Mental Health Act within 24 hours and those patients are supported with access to an independent mental health advocate ;
” 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure officers are trained to assess mental health-related calls and associated immediate risks
Wider context from the report “In relation to Policing is the extent to which all officers are trained to assess the increasing number of calls to the police which are of a mental health nature , the risks associated with the consequences of not making the right assessment where there may be an immediate risk to life and when to accept that the police are the right agency to be involved in mental health related enquiries due to their powers of entry;
” 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to determine when police are the appropriate agency for mental health-related enquiries
Wider context from the report “In relation to Policing is the extent to which all officers are trained to assess the increasing number of calls to the police which are of a mental health nature, the risks associated with the consequences of not making the right assessment where there may be an immediate risk to life and when to accept that the police are the right agency to be involved in mental health related enquiries due to their powers of entry ;
” 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of connectivity between overseas and UK mental health services during repatriation of an ill patient
Wider context from the report “The apparent lack of connectivity between mental health services abroad and the UK upon repatriation whilst the patient remains ill ;
” 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to consider wider circumstances and likely follow-on care before removing out-of-area patients from GP practice lists
Wider context from the report “That there is a risk to patients generated by a decision to remove a patient from a GP practice list where the patient resides out of geographical area for that GP practice without considering the wider circumstances and the likely follow on care ; and
” 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 Policing, mental health management, cross-service collaboration and GP decision-making do not concern Trafford Council’s actions or decisions, so it cannot address them.
Verbatim wording from the response “Within your listed matters, you have raised over-arching concerns regarding Policing, the management of mental health patients, the quality of collaboration between mental health services both abroad and in the UK upon repatriation whilst the patient remains ill and GP decision-making – and I note that there is no specific reference to the actions of Trafford Council within those listed concerns. As these concerns do not relate to the actions nor decision-making of Trafford Council, you will appreciate that I am unable to specifically address these with a respective timetable for action.” Source location Response from Trafford Council
Open published response
18 Nov 2020 Alfie Gildea · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 22 Limited police recognition and use of Claire's Law in domestic abuse cases View source Unqualified staff making key MARAT decisions View source Inconsistent definitions and thresholds for serious or serial domestic abuse perpetrators View source Lack of police understanding of policy and required actions for serial or serious domestic abuse perpetrators View source Poor information sharing and joint risk recognition across statutory agencies View source Limited police training and capability to identify coercive and controlling behaviour View source Insufficient health visitor capacity for safeguarding and interagency work View source Failure to ensure serial and serious domestic abuse perpetrator information is recorded and accessible View source Reduced specialist support and oversight for low and medium risk domestic abuse cases View source Failure to share complete relevant information between police and CPS View source Failure of CPS decision makers to follow guidance and document prosecution assessments View source Limited health visitor understanding of coercive and controlling behaviour View source Failure to provide a clear and effective system for notifying alleged victims of DVPNs and DVPOs View source Failure to share perpetrator risk information with alleged victims View source Failure to place domestic abuse suspects on protective bail conditions during further investigation View source Failure to provide safe opportunities for domestic abuse disclosure View source Failure to pursue further enquiries supporting victimless domestic abuse prosecutions View source Failure to routinely document police and CPS case discussions View source Failure to use the MARAC framework when appropriate View source Limited police training in domestic abuse risk evaluation and scoring View source Insufficient resourcing of the MARAT frontline service View source Failure to conduct required health visiting conversations face to face View source See 19 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Alfie Gildea · 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
Alfie Gildea sustained catastrophic injuries consistent with being shaken with force while in his father's care on 12 September 2018 and died from his injuries on 14 September 2018. The report identifies concerns about failures by police, children's services, health visiting services and the CPS to recognise, assess, share and act on domestic abuse risks, including coercive and controlling behaviour.
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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Limited police recognition and use of Claire's Law in domestic abuse cases
Wider context from the report “7. Recognition of when and how Claire's Law should be used and the understanding of its importance in DA cases was limited amongst the officers giving evidence.
” 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Unqualified staff making key MARAT decisions
Wider context from the report “15. The inquest was told that at the time the MARAT – front line service – was significantly under resourced. This was confirmed via an OFSTED inspection shortly after Alfie's death. As a result staff were stretched and staff who were not qualified social workers were making key decisions . Trafford Local Authority have increased resourcing but it was unclear if the lessons learnt by Trafford as a result of Alfie's death had been shared nationally.
” 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Inconsistent definitions and thresholds for serious or serial domestic abuse perpetrators
Wider context from the report “2. The inquest was told that the GMP/CPS definitions of a serious/serial domestic abuser perpetrator were different . It was unclear why that was the case. However as a result there are different points at which an offender's background triggers the requirement to treat the suspect as a serial/serious DA perpetrator .
” 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of police understanding of policy and required actions for serial or serious domestic abuse perpetrators
Wider context from the report “4. There was a lack of understanding amongst police witnesses about the GMP policy in relation to serial/serious DA perpetrators and the actions that were required under GMPs policy .
” 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Poor information sharing and joint risk recognition across statutory agencies
Wider context from the report “12. Information sharing between all of the statutory agencies in particular health; Local Authority and Police was poor . As a result there was no holistic overview of the situation or shared recognition of the risk posed by the perpetrator . Opportunities to use the MARAC framework were not taken.
” 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Limited police training and capability to identify coercive and controlling behaviour
Wider context from the report “5. Evidence at the inquest suggested that the majority of officers had received very limited training in relation to DA and in particular coercive and controlling behaviour . Understanding of how coercive and controlling behaviour in a relationship could be identified was limited .
” 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient health visitor capacity for safeguarding and interagency work
Wider context from the report “14. The inquest was told that Health Visitor numbers were reducing due to national funding arrangements . As a result the service was becoming increasingly stretched which decreased the ability of health visitors to support vulnerable families, identify risk, build relationships or engage with other 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure serial and serious domestic abuse perpetrator information is recorded and accessible
Wider context from the report “3. It is unclear where the information that an individual met the criteria for a serial and serious DA Perpetrator should or did sit in GMPs systems . Officers giving evidence did not understand how such information could be accessed or recorded .
” 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Reduced specialist support and oversight for low and medium risk domestic abuse cases
Wider context from the report “9. The inquest heard that since the death of Alfie GMP had restructured and removed the PPIU units. However the inquest heard that as a result the limited specialist support and oversight offered to neighbourhood/response officers had further reduced in low/medium risk DA cases .
” 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to share complete relevant information between police and CPS
Wider context from the report “10. The evidence to the inquest was that although there is a clear policy regarding information sharing between the CPS and Police that was not followed . The file that was submitted omitted key information available to GMP that would have been important to the decision maker . The CPS decision maker did not follow CPS guidance, set an action plan or document any detailed assessment of proceeding without the direct evidence of the victim. The inquest was told it was likely that there was a conversation between the Officer and CPS decision maker. This was not documented by either of them and there was no evidence that such conversations are routinely documented despite the fact that they may contain key information.
” 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure of CPS decision makers to follow guidance and document prosecution assessments
Wider context from the report “10. The evidence to the inquest was that although there is a clear policy regarding information sharing between the CPS and Police that was not followed. The file that was submitted omitted key information available to GMP that would have been important to the decision maker. The CPS decision maker did not follow CPS guidance, set an action plan or document any detailed assessment of proceeding without the direct evidence of the victim . The inquest was told it was likely that there was a conversation between the Officer and CPS decision maker. This was not documented by either of them and there was no evidence that such conversations are routinely documented despite the fact that they may contain key information.
” 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Limited health visitor understanding of coercive and controlling behaviour
Wider context from the report “13. The health visiting service had limited understanding of how coercive and controlling behaviour could manifest itself . Conversations took place via telephone although their policy dictated they should be face to face. The health visiting service did not share with the alleged victim the risk the perpetrator posed particularly post the reported strangulation incident. Questions about whether the victim was being subjected to DA took place when the perpetrator was in close proximity and allowed little real opportunity for disclosure.
” 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a clear and effective system for notifying alleged victims of DVPNs and DVPOs
Wider context from the report “11. The GMP policy on notification of DVPN/DVPOs to alleged victims was not followed . There was no evidence of a clear and effective system of notification on the Trafford Division of GMP .
” 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to share perpetrator risk information with alleged victims
Wider context from the report “13. The health visiting service had limited understanding of how coercive and controlling behaviour could manifest itself. Conversations took place via telephone although their policy dictated they should be face to face. The health visiting service did not share with the alleged victim the risk the perpetrator posed particularly post the reported strangulation incident. Questions about whether the victim was being subjected to DA took place when the perpetrator was in close proximity and allowed little real opportunity for disclosure.
” 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to place domestic abuse suspects on protective bail conditions during further investigation
Wider context from the report “1. The inquest was told that at the time of the allegation of assault in July 2018 suspects in domestic abuse cases were not placed on bail with conditions, to protect alleged victims, where further investigation was required . Instead they were placed under investigation.
” 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide safe opportunities for domestic abuse disclosure
Wider context from the report “13. The health visiting service had limited understanding of how coercive and controlling behaviour could manifest itself. Conversations took place via telephone although their policy dictated they should be face to face. The health visiting service did not share with the alleged victim the risk the perpetrator posed particularly post the reported strangulation incident. Questions about whether the victim was being subjected to DA took place when the perpetrator was in close proximity and allowed little real opportunity for disclosure .
” 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to pursue further enquiries supporting victimless domestic abuse prosecutions
Wider context from the report “8. The limited training and understanding of GMP officers meant that lines of further enquiry that would allow for a victimless prosecution were not followed .
” 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely document police and CPS case discussions
Wider context from the report “10. The evidence to the inquest was that although there is a clear policy regarding information sharing between the CPS and Police that was not followed. The file that was submitted omitted key information available to GMP that would have been important to the decision maker. The CPS decision maker did not follow CPS guidance, set an action plan or document any detailed assessment of proceeding without the direct evidence of the victim. The inquest was told it was likely that there was a conversation between the Officer and CPS decision maker. This was not documented by either of them and there was no evidence that such conversations are routinely documented despite the fact that they may contain key information .
” 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to use the MARAC framework when appropriate
Wider context from the report “12. Information sharing between all of the statutory agencies in particular health; Local Authority and Police was poor. As a result there was no holistic overview of the situation or shared recognition of the risk posed by the perpetrator. Opportunities to use the MARAC framework were not taken .
” 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Limited police training in domestic abuse risk evaluation and scoring
Wider context from the report “6. The inquest was told that the DASH risk assessment is a national tool. However training of GMP officers on understanding how to evaluate risk and score risk was limited .
” 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient resourcing of the MARAT frontline service
Wider context from the report “15. The inquest was told that at the time the MARAT – front line service – was significantly under resourced . This was confirmed via an OFSTED inspection shortly after Alfie's death. As a result staff were stretched and staff who were not qualified social workers were making key decisions. Trafford Local Authority have increased resourcing but it was unclear if the lessons learnt by Trafford as a result of Alfie's death had been shared nationally.
” 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct required health visiting conversations face to face
Wider context from the report “13. The health visiting service had limited understanding of how coercive and controlling behaviour could manifest itself. Conversations took place via telephone although their policy dictated they should be face to face . The health visiting service did not share with the alleged victim the risk the perpetrator posed particularly post the reported strangulation incident. Questions about whether the victim was being subjected to DA took place when the perpetrator was in close proximity and allowed little real opportunity for disclosure.
” 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 Improve children’s services policies and procedures in response to identified concerns.
Verbatim wording from the response “As was confirmed and accepted at the inquest, the Council has made significant improvements to its policies and procedures since 2018. The full details of these changes and improvements were set out in detail in the Council’s evidence to the inquest such that you were able to confirm that you did not have any specific further concerns relating to the Council. In relation to the possible national issue identified in point 15 of your listed concerns, our understanding was that it was your intention to write to central government, specifically the Department for Education.” Source location 2020-0242-Response-from-Childrens-Services-Trafford-Council-Redacted.pdf
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 possible national issue was for central government, specifically the Department for Education, to address.
Verbatim wording from the response “As was confirmed and accepted at the inquest, the Council has made significant improvements to its policies and procedures since 2018. The full details of these changes and improvements were set out in detail in the Council’s evidence to the inquest such that you were able to confirm that you did not have any specific further concerns relating to the Council. In relation to the possible national issue identified in point 15 of your listed concerns, our understanding was that it was your intention to write to central government, specifically the Department for Education.” Source location 2020-0242-Response-from-Childrens-Services-Trafford-Council-Redacted.pdf
Open published response
10 Feb 2020 Christine Rosemary Neild · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Failure to provide reliable overnight detection of residents getting up and wandering View source Failure to escalate incidents involving residents putting non-food items in their mouths and undertake further risk assessment View source Failure to restrict access to gloves for residents who may place items in their mouths 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
Christine Rosemary Neild · 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
Christine Rosemary Neild had significant learning difficulties, dysphagia, and required feeding support. She became very unwell and died at Meade Close on 31 January 2020; the medical cause of death was a sub-acute bowel obstruction associated with an incisional hernia. Concerns included accessible gloves and other non-food items, a failure to escalate an earlier ingestion incident or undertake further risk assessment, and the lack of regular sensors to alert staff when residents got up at night.
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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide reliable overnight detection of residents getting up and wandering
Wider context from the report “3. The inquest heard that in care settings such as this one for those with learning disabilities there was no regular use of sensors to alert night staff of a resident getting up and wandering . Staff relied on hearing a resident getting up despite this being difficult if they were delivering personal care onto another resident .
” 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate incidents involving residents putting non-food items in their mouths and undertake further risk assessment
Wider context from the report “2. There had been an earlier incident when Christine Neild had put non-food items in her mouth. The carer did not escalate this and there was no further risk assessment .
” 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to restrict access to gloves for residents who may place items in their mouths
Wider context from the report “1. During the course of the inquest evidence was heard that gloves were in open and easily accessible locations throughout the home including in rooms and the kitchen area . The inquest was told that this is standard practice in care settings for people with learning disabilities even where residents do not have insight into what items can safely be placed in their mouths .
” Open source report
21 Dec 2018 Richard John Whale · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 5 Failure of club stewards to comply with the steward code of conduct View source Lack of guidance on steward placement to keep handrail access clear View source Lack of regular audits of steward compliance with the Code of Conduct View source Failure of staircase width standards to account for steward deployment View source Lack of mechanisms for discussing and monitoring implementation of recommendations View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Richard John Whale · 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
Richard John Whale died at Salford Royal Hospital after suffering a head injury in a fall down the exit stairs at Old Trafford football ground. The concerns included stewards impeding the exit and obstructing access to handrails, inadequate guidance on steward placement, non-compliance with the stewards’ code of conduct, and a lack of evidence of regular audits. There was also no mechanism to discuss or monitor whether recommendations issued after his death had been followed.
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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure of club stewards to comply with the steward code of conduct
Wider context from the report “4. It was accepted by MUFC that the club stewards were not complying with the code of conduct relating to stewards although one was trained and one was undergoing training. A supervisor was also supervising them. There was no evidence of regular audits of stewards and their compliance with the Code of Conduct.
” 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on steward placement to keep handrail access clear
Wider context from the report “3. The green guide does not give guidance as to placement of stewards or suggest best practice to avoid stewards blocking access to the handrails. It was accepted during the course of the inquest that the role and placement of stewards was vital to ensuring the safety of the public at football matches.
” 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of regular audits of steward compliance with the Code of Conduct
Wider context from the report “4. It was accepted by MUFC that the club stewards were not complying with the code of conduct relating to stewards although one was trained and one was undergoing training. A supervisor was also supervising them. There was no evidence of regular audits of stewards and their compliance with the Code of Conduct.
” 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure of staircase width standards to account for steward deployment
Wider context from the report “2. The widths of the staircases (“vomitories”) is set in the Green Guide. Those widths take into account the handrails but not the inevitable reduction in width that takes place when stewards are deployed into them. In effect, the vomitories are significantly narrower at points than the suggested widths.
” 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of mechanisms for discussing and monitoring implementation of recommendations
Wider context from the report “1. The Local Authority had issued a list of recommendations to the club after the death of Mr Whale. There was no mechanism in place for discussion of those recommendations or to ensure that they had been followed or if not followed discussion for reasons.
” 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 Require the Club to respond to future recommendations or requests within specified timescales and review actions where necessary.
Verbatim wording from the response “In addition, the Council have now requested that the Club responds to any future recommendations or requests within a specified time frame with a review of all actions where it is considered necessary. This positive approach has been welcomed by the Club and has been implemented with immediate effect.” Source location 2018-0404-Response-by-Trafford-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 Include observations of the Club’s monitoring of stewarding behaviour in future match-day safety audits.
Verbatim wording from the response “Following the conclusion of the inquest, Council Officers and the regional Sports Ground Safety Authority Inspector have met with the Club to discuss the concerns raised during the inquest. During these discussions, the Club explained the actions they have taken to address the recommendations highlighted in the letter from the Council, and they have also explained that they are undertaking additional awareness training for stewards and monitoring of stewards' behaviour whilst carrying out their duties at the stadium. Council officers undertaking future match-day audits at the Club will include observations of the monitoring of stewarding behaviour by the Club.” Source location 2018-0404-Response-by-Trafford-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 Responsibility for deciding whether to implement the informal recommendations rested with the Club.
Verbatim wording from the response “the Club, and it did not stipulate any legal contraventions which the Club should action or that any action should be taken within a specified timescale. The responsibility, therefore, was with the Club as to whether or not the recommendations were implemented.” Source location 2018-0404-Response-by-Trafford-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 Existing club safety arrangements and Council engagement mechanisms were considered sufficient to address the recommendations.
Verbatim wording from the response “It was within this remit that the Council undertook an investigation into the accident to Richard John Whale. The investigation found that the Club had satisfactory arrangements in place at the time of the accident in relation to maintaining the safety of spectators at the ground, and that there was no evidence available which would warrant any formal action under the Health and Safety at Work etc Act 1974.” Source location 2018-0404-Response-by-Trafford-Council
Open published response
3 Apr 2018 Casper Blackburn · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Lack of CCTV coverage in the area View source Extremely poor lighting in the canal area 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
Casper Blackburn · 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
Casper Blackburn died in the early hours of 1 October 2017 after entering the Bridgewater canal in unclear circumstances; the medical cause of death was drowning. Concern was raised that extremely poor lighting, and the absence of CCTV, made the canal difficult to distinguish from the surrounding grass verge and path, creating a risk of future deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of CCTV coverage in the area
Wider context from the report “The lighting in the area where Casper likely accidentally entered the canal was extremely poor. There is no CCTV in the area and therefore what precisely happened on the morning of Casper’s death is unclear. Evidence was heard that police attended the scene at night on a date following Casper’s death. The area was so dark that it was very difficult to discern the canal from the grass verge or the path. I am concerned that future deaths might occur if action is not taken to address this.
” 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Extremely poor lighting in the canal area
Wider context from the report “The lighting in the area where Casper likely accidentally entered the canal was extremely poor. There is no CCTV in the area and therefore what precisely happened on the morning of Casper’s death is unclear. Evidence was heard that police attended the scene at night on a date following Casper’s death. The area was so dark that it was very difficult to discern the canal from the grass verge or the path. I am concerned that future deaths might occur if action is not taken to address this.
” 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 Council has limited ability to act because it neither owns the canal path nor controls the public right of way.
Verbatim wording from the response “Unfortunately, the Council has a very limited ability to take direct action as it is not the relevant landowner in respect of the path which runs alongside the canal, nor is it responsible for the public right of way which runs over that path. In both instances the responsible party is the Bridgewater Canal Company Limited. However, the Council has approached the Bridgewater Canal Company to seek to find a resolution to improve the safety of the users of the path and to improve safety measures.” Source location 2018-0094-Responses_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 Responsibility for the canal path and public right of way rests with Bridgewater Canal Company Limited.
Verbatim wording from the response “Unfortunately, the Council has a very limited ability to take direct action as it is not the relevant landowner in respect of the path which runs alongside the canal, nor is it responsible for the public right of way which runs over that path. In both instances the responsible party is the Bridgewater Canal Company Limited. However, the Council has approached the Bridgewater Canal Company to seek to find a resolution to improve the safety of the users of the path and to improve safety measures.” Source location 2018-0094-Responses_Redacted
Open published response
30 Dec 2016 Raymond David SHEPHERD · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 7 Failure to identify deterioration and make appropriate primary health care referrals View source Poor standard of record keeping in the Home Care Support Service User comment book View source Failure to undertake both daily care visits View source Failure to undertake or arrange review of a mental capacity assessment View source Failure to update and review the Home Care Support Customer file View source Failure to respond to indicators of self-neglect and inadequate nutrition View source Failure to notify the GP or ambulance service after reported or observed falls View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Raymond David SHEPHERD · 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
Raymond David SHEPHERD had chronic ill health, severely limited mobility and a high risk of falls and self-neglect. In January 2016, care records noted repeated falls, poor appetite and a deterioration in his condition, but referrals to a GP or ambulance service were not made; he later sustained a femur fracture after a further fall and died in hospital on 30 January 2016. The principal concerns were poor care record-keeping, missed care visits, failure to escalate reported or observed falls and deterioration, and the absence of a mental capacity assessment.
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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to identify deterioration and make appropriate primary health care referrals
Wider context from the report “6. Over a period of some days there seems to have been a deterioration in his condition which could have been identified and steps taken to stop it by appropriate referrals to primary health care services . In the event it had led him to having a further significant fall in which he fractured a femur as well as sustaining other injuries. This in turn led to a hospital admission but he was not fit enough to undergo surgery and died.
” 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Poor standard of record keeping in the Home Care Support Service User comment book
Wider context from the report “1. The standard and detail of the record keeping in the Home Care Support Service User comment book was of very poor standard .
” 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake both daily care visits
Wider context from the report “3. On some occasions both daily visits were not undertaken .
” 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake or arrange review of a mental capacity assessment
Wider context from the report “7. There was no mental capacity assessment undertaken or a review of this arranged .
” 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to update and review the Home Care Support Customer file
Wider context from the report “2. The Home Care Support Customer file does not seem to have been updated and reviewed .
” 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to respond to indicators of self-neglect and inadequate nutrition
Wider context from the report “5. The deceased was a service user with chronic health problems which affected his mobility and was at high risk of suffering a fall as well as self-neglect . He reported not wishing to eat anything over a period of days which again should have triggered some concern .
” 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to notify the GP or ambulance service after reported or observed falls
Wider context from the report “4. From 18 January 2016 there were at least three occasions when the deceased had either reported a fall or been found having after fallen, but no action was taken to notify the GP or ambulance service .
” Open source report
12 Apr 2016 Dennis Bennett · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 5 Lack of understanding that DOLS are place specific View source Lack of understanding of the outcome of urgent DOLS applications View source Failure to provide consistent information about DOLS applications View source Failure to distinguish urgent DOLS applications from detention under Section 3 of the Mental Health Act View source Failure to consider whether DOLS are necessary when patients are compliant with treatment View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Dennis Bennett · 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
Dennis Bennett had dementia and was admitted under the Mental Health Act before receiving end-stage palliative care on a mental health ward, where he died of natural causes on 7 February 2016. Concerns included an urgent deprivation of liberty application made while he was already detained under Section 3, uncertainty about the application’s continuation, confusion about place-specific authorisations, and limited consideration of whether the application was needed while he was compliant and receiving palliative care.
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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding that DOLS are place specific
Wider context from the report “1. The Trust staff completed an application for an urgent DOLS at the same time as the deceased was already subject to detention under Section 3 of the Mental Health Act.
2. There was a lack of understanding as to what occurred at the conclusion of the urgent application and conflicting evidence was heard from two employees of Trafford Council.
3. The decision to apply for a DOLS was initially made at a time when the decision was for him to be moved to nursing home care. Indeed the evidence provided by the family was that a DOLS application was necessary so that he could be moved to the nursing home. There appears to be a lack of understanding as to the fact that DOLS are place specific .
4. The deceased was then on end stage palliative care and entirely compliant with treatment there was little consideration as to why a DOLS was applied for as opposed to treating the deceased in his best interests.
Whilst in this case the application did not impact on his care or treatment there is a concern that a lack of understanding and differing information may and could impact on other patients.
” 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of the outcome of urgent DOLS applications
Wider context from the report “1. The Trust staff completed an application for an urgent DOLS at the same time as the deceased was already subject to detention under Section 3 of the Mental Health Act.
2. There was a lack of understanding as to what occurred at the conclusion of the urgent application and conflicting evidence was heard from two employees of Trafford Council.
3. The decision to apply for a DOLS was initially made at a time when the decision was for him to be moved to nursing home care. Indeed the evidence provided by the family was that a DOLS application was necessary so that he could be moved to the nursing home. There appears to be a lack of understanding as to the fact that DOLS are place specific.
4. The deceased was then on end stage palliative care and entirely compliant with treatment there was little consideration as to why a DOLS was applied for as opposed to treating the deceased in his best interests.
Whilst in this case the application did not impact on his care or treatment there is a concern that a lack of understanding and differing information may and could impact on other patients.
” 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide consistent information about DOLS applications
Wider context from the report “1. The Trust staff completed an application for an urgent DOLS at the same time as the deceased was already subject to detention under Section 3 of the Mental Health Act.
2. There was a lack of understanding as to what occurred at the conclusion of the urgent application and conflicting evidence was heard from two employees of Trafford Council .
3. The decision to apply for a DOLS was initially made at a time when the decision was for him to be moved to nursing home care. Indeed the evidence provided by the family was that a DOLS application was necessary so that he could be moved to the nursing home. There appears to be a lack of understanding as to the fact that DOLS are place specific.
4. The deceased was then on end stage palliative care and entirely compliant with treatment there was little consideration as to why a DOLS was applied for as opposed to treating the deceased in his best interests.
Whilst in this case the application did not impact on his care or treatment there is a concern that a lack of understanding and differing information may and could impact on other patients.
” 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to distinguish urgent DOLS applications from detention under Section 3 of the Mental Health Act
Wider context from the report “1. The Trust staff completed an application for an urgent DOLS at the same time as the deceased was already subject to detention under Section 3 of the Mental Health Act .
2. There was a lack of understanding as to what occurred at the conclusion of the urgent application and conflicting evidence was heard from two employees of Trafford Council.
3. The decision to apply for a DOLS was initially made at a time when the decision was for him to be moved to nursing home care. Indeed the evidence provided by the family was that a DOLS application was necessary so that he could be moved to the nursing home. There appears to be a lack of understanding as to the fact that DOLS are place specific.
4. The deceased was then on end stage palliative care and entirely compliant with treatment there was little consideration as to why a DOLS was applied for as opposed to treating the deceased in his best interests.
Whilst in this case the application did not impact on his care or treatment there is a concern that a lack of understanding and differing information may and could impact on other patients.
” 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to consider whether DOLS are necessary when patients are compliant with treatment
Wider context from the report “1. The Trust staff completed an application for an urgent DOLS at the same time as the deceased was already subject to detention under Section 3 of the Mental Health Act.
2. There was a lack of understanding as to what occurred at the conclusion of the urgent application and conflicting evidence was heard from two employees of Trafford Council.
3. The decision to apply for a DOLS was initially made at a time when the decision was for him to be moved to nursing home care. Indeed the evidence provided by the family was that a DOLS application was necessary so that he could be moved to the nursing home. There appears to be a lack of understanding as to the fact that DOLS are place specific.
4. The deceased was then on end stage palliative care and entirely compliant with treatment there was little consideration as to why a DOLS was applied for as opposed to treating the deceased in his best interests .
Whilst in this case the application did not impact on his care or treatment there is a concern that a lack of understanding and differing information may and could impact on other patients.
” Open source report
15 Sep 2015 Karen Clayton · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 5 Pedestrian crossing route through a cycle path created by road layout View source Unclear and potentially confusing signage in the immediate area View source Confusing and dangerous contra-flow cycle lane on a predominantly one-way route View source Weak guidance discouraging pedestrians from walking in cycle paths View source Insufficient segregation of pedestrian, bicycle and motor traffic View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Karen Clayton · 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 2 January 2015, Karen Clayton collided with a pedestrian while cycling in a designated cycle lane in Altrincham and sustained fatal head injuries. The concerns identified included inadequate segregation of pedestrians, cyclists and motor traffic, a confusing contra-flow cycle lane, unclear signage, and weak guidance on pedestrians using cycle paths.
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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Pedestrian crossing route through a cycle path created by road layout
Wider context from the report “4. Because of the location of the Supermarket and the lay out of the road, there is an obvious crossing-place via the cycle path . Not to use this route by pedestrians intending to walk to the railway station would involve them in crossing the road twice .(Trafford)
” 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Unclear and potentially confusing signage in the immediate area
Wider context from the report “3. The signage in the immediate area is unclear and possibly confusing (Trafford)
” 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Confusing and dangerous contra-flow cycle lane on a predominantly one-way route
Wider context from the report “2. Although this is a “one way” route for most traffic, the cycle lane allows for bicycles to travel in a contra flow . This is inherently confusing and dangerous for the cyclists and other road users .(Trafford)
” 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Weak guidance discouraging pedestrians from walking in cycle paths
Wider context from the report “5. The guidance in the “Highway Code” and elsewhere relating to the fact that pedestrians should not walk in a cycle path, is weak and needs to be re-written and reinforced. (Secretary of State for Transport)
” 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient segregation of pedestrian, bicycle and motor traffic
Wider context from the report “1. At this location there is mixed traffic, being pedestrian, bicycle and motor. There is insufficient room for all these different forms of traffic to be effectively segregated .(Trafford)
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation There is sufficient room to segregate cyclists, vehicles and pedestrians effectively on this section of Moss Lane.
Verbatim wording from the response “The current layout of the section of Moss Lane between Manor Road and Stamford New Road was designed in accordance with the Department of Transport guidance, namely ‘Traffic Advisory Leaflet 6/98 September 1998’ for Contraflow cycling and was constructed in November 2002. Physical segregation of cyclists and vehicular traffic was provided at the entry and exit from the one way street because there was sufficient room to do so and the route is lined and signed in accordance with this document. This layout also corresponds with ‘Transport for Greater Manchester’s current ‘Greater Manchester Cycling Design Guidance’ document. The Council does not concur that there is insufficient room for the three forms of traffic to be effectively segregated on this road.” Source location 2015-0388-Response-by-Trafford-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 The Council considers the existing road layout, crossings and related arrangements adequate, so no improvements are required in this instance.
Verbatim wording from the response “The current layout of the section of Moss Lane between Manor Road and Stamford New Road was designed in accordance with the Department of Transport guidance, namely ‘Traffic Advisory Leaflet 6/98 September 1998’ for Contraflow cycling and was constructed in November 2002. Physical segregation of cyclists and vehicular traffic was provided at the entry and exit from the one way street because there was sufficient room to do so and the route is lined and signed in accordance with this document. This layout also corresponds with ‘Transport for Greater Manchester’s current ‘Greater Manchester Cycling Design Guidance’ document. The Council does not concur that there is insufficient room for the three forms of traffic to be effectively segregated on this road.” Source location 2015-0388-Response-by-Trafford-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 The current layout is not confusing, and pedestrians use the mandatory cycle lane knowingly to shorten their journeys.
Verbatim wording from the response “Following its introduction no recorded injury accidents had taken place on this link until the accident in question and there haven’t been any recorded accidents to date since. It is the Councils opinion that the current layout is not confusing and pedestrians who walk along the mandatory cycle lane do so knowingly to shorten their journey.” Source location 2015-0388-Response-by-Trafford-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 Pedestrians travelling between the railway station and Tesco do not need to cross Moss Lane twice because controlled crossings are available at both ends.
Verbatim wording from the response “There are controlled crossings on Moss Lane at the traffic signals junctions at either end of its one way section and the Council does not consider that pedestrians travelling between the railway station and the Tesco Supermarket have to cross the road twice to reach their destination.” Source location 2015-0388-Response-by-Trafford-Council
Open published response
20 Aug 2015 Joyce Plested · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Unsafe positioning of the pedestrian crossing adjacent to the mini roundabout View source Lack of pedestrian barriers protecting the footpath by the mini roundabout View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Joyce Plested · 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
Joyce Plested was riding her mobility scooter near a Sainsbury store when she was struck by a car while crossing Curzon Road, sustaining an injury that later led to her death. The report raised concerns about the crossing’s position near a busy mini roundabout and suggested that moving it and protecting the footpath with barriers would create a safer environment.
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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Unsafe positioning of the pedestrian crossing adjacent to the mini roundabout
Wider context from the report “Immediately outside the doors to the store, there is a mini roundabout and across two of the exit roads therefrom there are “Zebra Crossings”. This makes this a very ‘busy’ junction and there are numerous matters to which both drivers and pedestrians have to give their full attention.
In evidence at the inquest, the expert “Crash reconstruction” Police Officer confirmed that if the crossing which traverses Curzon Road were to be positioned further away from the mini roundabout and the footpath by the roundabout to be protected by pedestrian barriers, this would be a much safer environment.
The current position means that the crossing is on land owned by Sainsbury PLC whereas if it were moved further down it would be on the public highway maintained by Trafford MBC.
It therefore seems to me that it would be a relatively simple and hugely beneficial solution, simply to move the crossing to the suggested safer position.
” 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 Trafford Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of pedestrian barriers protecting the footpath by the mini roundabout
Wider context from the report “Immediately outside the doors to the store, there is a mini roundabout and across two of the exit roads therefrom there are “Zebra Crossings”. This makes this a very ‘busy’ junction and there are numerous matters to which both drivers and pedestrians have to give their full attention.
In evidence at the inquest, the expert “Crash reconstruction” Police Officer confirmed that if the crossing which traverses Curzon Road were to be positioned further away from the mini roundabout and the footpath by the roundabout to be protected by pedestrian barriers , this would be a much safer environment.
The current position means that the crossing is on land owned by Sainsbury PLC whereas if it were moved further down it would be on the public highway maintained by Trafford MBC.
It therefore seems to me that it would be a relatively simple and hugely beneficial solution, simply to move the crossing to the suggested safer position.
” 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