29 Dec 2025 Brian Mitchell · Prevention of Future Deaths report East London
View report summary
Concerns raised 4 Lack of clear data demonstrating improved expedition and clarity of station staff communication in emergencies View source Lack of clear evidence that risks of fatal harm have been mitigated View source Lack of clear data demonstrating improved train-operator concentration and track observation during ATO operation View source Failure to implement technological measures detecting and alerting staff to persons on the tracks at Stratford station View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Brian Mitchell · 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
Brian Mitchell, aged 72, was struck by multiple trains after falling onto the tracks at platform 13 at Stratford Underground Station on 26 December 2023. The report identifies concerns that train operators failed to notice him or override automatic train operation, and that technological measures and training intended to mitigate similar risks had not been clearly implemented or shown to improve performance.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Transport for London; that does not assign responsibility.
PFD Monitor interpretation Lack of clear data demonstrating improved expedition and clarity of station staff communication in emergencies
Wider context from the report “4. No clear data is available to demonstrate that station staff training has improved expedition or clarity of communication in emergency circumstances.
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Lack of clear evidence that risks of fatal harm have been mitigated
Wider context from the report “1. In the two years that have elapsed since Brian’s death investigations have been conducted by the British Transport Police, The Rail Accident Investigation Branch (“RAIB”) and TFL into the circumstances that led to this incident. There is no clear evidence to demonstrate that risks of fatal harm have been mitigated.
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Lack of clear data demonstrating improved train-operator concentration and track observation during ATO operation
Wider context from the report “3. No clear data is available to demonstrate that training provided to train operators (drivers) to ensure that they concentrate and look at the tracks before them whilst operating trains using ATO has resulted in positive improvement in performance.
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Failure to implement technological measures detecting and alerting staff to persons on the tracks at Stratford station
Wider context from the report “2. Recommended technological measures to detect and alert staff to the presence of persons on the tracks have not been implemented at Stratford station.
” Open source report
25 Jul 2025 Robert Grey English · Prevention of Future Deaths report North London
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Concerns raised 2 Absence of suitable lights for locating people on or near railway lines at night View source Failure to provide distinct night-time protection for railway trespassers 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
Robert Grey English · 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
Robert Grey English, aged 32, was electrocuted after entering a railway track at night, and was subsequently run over by a train searching the track. The report identifies concerns about failures to follow the process for switching the rail power back on and about inadequate lighting and equipment for locating a person on the railway at night.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Transport for London; that does not assign responsibility.
PFD Monitor interpretation Absence of suitable lights for locating people on or near railway lines at night
Wider context from the report “The provision to protect a trespasser at night are the same as those during the day. The ability to locate a person close to or on the railway lines at night is made more difficult by the absence of suitable lights on the track or the train. In this case Mr English was not seen and run over by the train that has been asked to look for a person on the line.
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Failure to provide distinct night-time protection for railway trespassers
Wider context from the report “The provision to protect a trespasser at night are the same as those during the day. The ability to locate a person close to or on the railway lines at night is made more difficult by the absence of suitable lights on the track or the train. In this case Mr English was not seen and run over by the train that has been asked to look for a person on the line.
” 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 Test and risk-assess a high-output cab-mounted lighting rig for locating people on open-air track at night, identifying required improvements.
Verbatim wording from the response “You highlighted the need for more suitable lighting for locating a trespasser at night. We are actively assessing options for new equipment to provide additional lighting.” Source location Response from Transport for London
Open published response
16 Apr 2025 Sarah Alison CUNNINGHAM · Prevention of Future Deaths report Inner North London
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Concerns raised 2 Failure to translate investigation learning into a concrete plan View source Failure to incorporate the risk of passenger intoxication to individuals into corporate planning 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
Sarah Alison CUNNINGHAM · 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
Sarah Alison Cunningham jumped onto the northbound track at Chalk Farm London Underground Station while intoxicated by alcohol, cocaine and ketamine, and was killed by a train on 2 November 2024. The principal concern was that TfL’s corporate planning may not sufficiently address the risks posed to intoxicated passengers, with learning from its investigation described as aspirational and lacking a concrete plan.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Transport for London; that does not assign responsibility.
PFD Monitor interpretation Failure to translate investigation learning into a concrete plan
Wider context from the report “I heard evidence at inquest that London Underground passenger intoxication is recognised as a risk to London Underground staff. Extreme intoxication is also known to be a risk to the individual who is intoxicated. However, it struck me that the risk to the individual is not necessarily at the forefront of TfL corporate thinking.
Clearly, individuals have responsibility for their own drinking and/or drug taking and the consequences thereof. Intoxication carries additional risk whatever the activity.
However, public transport is encouraged for many good reasons. Not least, it is a matter of public policy that those who are or may become intoxicated should make travel plans that do not involve being in charge of a vehicle. The London Underground is an obvious alternative.
Realistically, some London Underground passengers will be intoxicated, and that has to inform TfL’s corporate planning. I heard that there was a TfL investigation following Sarah Cunningham’s death, but the learning from that appears at present to be somewhat aspirational, without a concrete plan .
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Failure to incorporate the risk of passenger intoxication to individuals into corporate planning
Wider context from the report “I heard evidence at inquest that London Underground passenger intoxication is recognised as a risk to London Underground staff. Extreme intoxication is also known to be a risk to the individual who is intoxicated. However, it struck me that the risk to the individual is not necessarily at the forefront of TfL corporate thinking .
Clearly, individuals have responsibility for their own drinking and/or drug taking and the consequences thereof. Intoxication carries additional risk whatever the activity.
However, public transport is encouraged for many good reasons. Not least, it is a matter of public policy that those who are or may become intoxicated should make travel plans that do not involve being in charge of a vehicle. The London Underground is an obvious alternative.
Realistically, some London Underground passengers will be intoxicated, and that has to inform TfL’s corporate planning . I heard that there was a TfL investigation following Sarah Cunningham’s death, but the learning from that appears at present to be somewhat aspirational, without a concrete plan.
” 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 Implement the revised process for managing Formal Incident Review recommendations, with accountable officers and directors developing actions to address identified risks.
Verbatim wording from the response “TfL has recently implemented a number of significant changes to the process around critical health and safety investigations, including changes to the management of recommendations arising from Formal Incident Reviews (FIRs). This new way of working means that the investigation team complete the investigation report with recommendations for the business.” Source location Response from Transport for London
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete a cross-mode safeguarding risk review and produce tailored action plans for protecting intoxicated and other vulnerable passengers.
Verbatim wording from the response “Our actions underway include:” Source location Response from Transport for London
Open published response
5 Nov 2024 Terence William Gillard · Prevention of Future Deaths report West London
View report summary
Concerns raised 2 Lack of certainty that the pedestrian crossing safety redesign will be implemented View source Absence of effective pedestrian crossing controls at Jersey Road View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Terence William Gillard · 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
Terence William Gillard was struck by a moving vehicle while crossing the A4 Great West Road at an uncontrolled pedestrian crossing on 11 September 2022. He suffered brain and multiple traumatic injuries and died in hospital on 18 September 2022 from a pulmonary embolism. The concern was that the crossing had no pedestrian traffic lights, demand button or sound signals, and that there was no certainty that proposed safety redesigns would be implemented.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Transport for London; that does not assign responsibility.
PFD Monitor interpretation Lack of certainty that the pedestrian crossing safety redesign will be implemented
Wider context from the report “The A4 Great West Road is a major route for vehicles of all types travelling in and out of west London. The crossing area, where Mr Gillard collided with the moving vehicle on 11 September 2022, is a designated uncontrolled crossing area across Jersey Road. There are no pedestrian traffic lights, no demand button, no sound signals. This pedestrian crossing area spans across a dual carriageway subject to a speed limit of 40mph. It has three lanes in both directions, separated by a raised central kerb. This crossing point also leads pedestrians into the cycling lane.
I understand that at no point during the normal use of the traffic light controlled junction does traffic cease to flow at the marked crossing area, making it difficult for pedestrian to judge when and from where the next vehicle would approach. This means that pedestrians will need to use their own judgment as to when it is safe to cross this road without the aid of pedestrian traffic lights.
I received evidence that there have been other accidents involving pedestrians and moving vehicles at this pedestrian crossing in the past.
I received evidence from the TFL of existing plans to re-design this pedestrian crossing to improve pedestrian safety. However, their implementation may not take place before the end of 2026 and it remains subject to the consent of the DFT and LBH, the outcome of any public consultation as well as funding considerations.
I am concerned that there appears to be no certainty that the redesign plans for the pedestrian crossing in question will be implemented .
I understand that the TFL, LBH and DFT are the organisations with the power to take the necessary actions to improve pedestrian safety at this junction.
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Absence of effective pedestrian crossing controls at Jersey Road
Wider context from the report “The A4 Great West Road is a major route for vehicles of all types travelling in and out of west London. The crossing area, where Mr Gillard collided with the moving vehicle on 11 September 2022, is a designated uncontrolled crossing area across Jersey Road. There are no pedestrian traffic lights, no demand button, no sound signals. This pedestrian crossing area spans across a dual carriageway subject to a speed limit of 40mph. It has three lanes in both directions, separated by a raised central kerb. This crossing point also leads pedestrians into the cycling lane.
I understand that at no point during the normal use of the traffic light controlled junction does traffic cease to flow at the marked crossing area , making it difficult for pedestrian to judge when and from where the next vehicle would approach. This means that pedestrians will need to use their own judgment as to when it is safe to cross this road without the aid of pedestrian traffic lights .
I received evidence that there have been other accidents involving pedestrians and moving vehicles at this pedestrian crossing in the past.
I received evidence from the TFL of existing plans to re-design this pedestrian crossing to improve pedestrian safety. However, their implementation may not take place before the end of 2026 and it remains subject to the consent of the DFT and LBH, the outcome of any public consultation as well as funding considerations.
I am concerned that there appears to be no certainty that the redesign plans for the pedestrian crossing in question will be implemented.
I understand that the TFL, LBH and DFT are the organisations with the power to take the necessary actions to improve pedestrian safety at this junction.
” 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 Review nearby pedestrian and vehicle collisions using historic collision data to identify additional collision-risk reductions.
Verbatim wording from the response “d. With regards to other collisions involving pedestrians and moving vehicles, we have undertaken a thorough review of the nearby collisions based on the historic collision data and will consider any other changes to the highway layout which may reduce collision risk in addition to changes to the crossing itself. For example, we are also proposing changes to the service road next to the crossing to make it easier for pedestrians and cyclists to access the crossing.” Source location Response from Transport for London
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 Develop a formal signalised crossing scheme across the A4 and both sections of Jersey Road, with associated highway-layout amendments.
Verbatim wording from the response “As previously advised at the inquest, we are developing a formal crossing proposal at this location. The proposals are as follows:” Source location Response from Transport for London
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 DfT consent is not required, and LBH consent is needed only for minor works on its road network.
Verbatim wording from the response “e. Finally, I turn to your concern that the implementation of TfL’s plans to redesign the pedestrian crossing will not be until 2026 and it remains subject to the consent of the DfT and LBH, the outcome of any public consultation as well as funding considerations. I explain above the steps which must be undertaken, and the timings involved with delivering appropriate and safe improvement works. In relation to consent from LBH, this is only necessary in relation to any minor works on their road network that may be required to facilitate delivery of the wider scheme. In addition, there is no requirement for consent or approvals to be obtained from the DfT.” Source location Response from Transport for London
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 Earlier implementation is constrained by required design, modelling, consultation, governance, contractor mobilisation and funding steps.
Verbatim wording from the response “As my colleague ████████ advised during the inquest, it is likely that delivery of the scheme will take place in 2026, to enable time for the completion of traffic modelling, public engagement, concept and detailed design and contractor mobilisation (including relocating any utility services that are required to be moved by statutory undertakers as part of scheme delivery).” Source location Response from Transport for London
Open published response
14 Dec 2022 Fatima Abukar · Prevention of Future Deaths report East London
View report summary
Concerns raised 3 Reduced legal enforcement of unlawful e-scooter use View source Failure to provide prominent written warnings about the illegal use of e-scooters View source Failure to require head protection for riders of legally authorised scooters 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
Fatima Abukar · 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
Fatima Abukar, a 14-year-old girl, died from catastrophic head injuries after the privately owned e-scooter she was riding entered the carriageway and struck a mini-bus. The concerns included e-scooter fatalities and enforcement, the absence of a requirement for riders of legally authorised scooters to wear head protection, and inconsistent or insufficiently prominent warnings about illegal e-scooter use.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Transport for London; that does not assign responsibility.
PFD Monitor interpretation Reduced legal enforcement of unlawful e-scooter use
Wider context from the report “1. Evidence in this inquest confirmed that since 2019 here have been 8 recorded fatalities involving e-scooters in London and 31 in the country at large. At the time of her death Ms Abukar was riding a privately owned e-scooter on a public highway. Despite the ubiquity of such devices on London’s streets, riding them on public roads is unlawful.
Whereas approximately 4000 unlawfully used scooters were seized by the Metropolitan Police Service in 2021, only 1100 were confiscated in 2022 . The reduction is attributable to a change in policy introduced in November 2021.
An inverse correlation exists between the rate of legal enforcement and the rate of deaths caused by e-scooters. The number of deaths in Q1 & 2 of 2022 is more than double that of Q1 & 2 of 2021.
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Failure to provide prominent written warnings about the illegal use of e-scooters
Wider context from the report “3. Some manufacturers and retailers of e-scooters in England and Wales provide consumers with written warnings about the illegal use of e-scooters, others do not. Where such warnings are present, often they are not prominent.
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Failure to require head protection for riders of legally authorised scooters
Wider context from the report “2. Ms Abukar died due to traumatic head injuries. Riders of legally authorised scooters (those hired from licenced operators) are not required to wear head protection.
” 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 Write to private e-scooter retailers and run a public communications campaign explaining that private e-scooter use is illegal.
Verbatim wording from the response “In addition, in the lead up to Christmas, with the expected increase in the sale of private e-scooters, ████████, London’s Walking and Cycling Commissioner, and Metropolitan Police Service (‘MPS’) Commander, ████████, jointly wrote to retailers to remind them of their duty to make customers aware of the law regarding the use of private e-scooters. TfL and the MPS have also jointly run a communications campaign to raise public awareness that private e-scooters are illegal.” Source location Response from Transport for London
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide rental e-scooter safety guidance and encourage riders to use protective equipment, including helmets.
Verbatim wording from the response “TfL and operators also provide safety guidance and tips on how to ride rental e-scooters safely and avoid serious injury to any road users. This includes encouraging all riders to use protective equipment while using e-scooters including wearing a helmet. The wearing of helmets is not required by DfT for the trials, however.” Source location Response from Transport for London
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 Continue working with the Metropolitan Police Service and City of London Police to engage private e-scooter users and support enforcement where necessary.
Verbatim wording from the response “TfL continues to work with the MPS, and City of London Police (‘CoLP’) to engage with users of privately-owned e-scooters and, where necessary, the MPS and CoLP will use their enforcement powers to help keep Londoners safe.” Source location Response from Transport for London
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 Enforcement concerning privately owned e-scooters is assigned to the Metropolitan Police Service and City of London Police using their enforcement powers.
Verbatim wording from the response “TfL continues to work with the MPS, and City of London Police (‘CoLP’) to engage with users of privately-owned e-scooters and, where necessary, the MPS and CoLP will use their enforcement powers to help keep Londoners safe.” Source location Response from Transport for London
Open published response
28 Nov 2022 Miriam BOULIA · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Unusually high number of similar collisions at the junction View source Insufficient pedestrian crossing signal timings at the junction 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
Miriam BOULIA · 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
Miriam Boulia was struck by a bus while crossing Great Eastern Street on a red pedestrian signal and sustained catastrophic, unsurvivable injuries; she was declared deceased at the scene. The report identified concerns that signal timings at the junction did not allow pedestrians enough time to cross safely, with a high number of similar collisions and improvements potentially taking two to four years.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Transport for London; that does not assign responsibility.
PFD Monitor interpretation Unusually high number of similar collisions at the junction
Wider context from the report “There have been 21 collisions involving injury at this junction over a recent three-year period, 9 of those involving injury to pedestrians. Of particular concern is that the number of collisions at this junction of a similar nature to that in which Ms Boulia died, is unusually high.
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Insufficient pedestrian crossing signal timings at the junction
Wider context from the report “The current timings of the signals, both at the pedestrian crossing where Ms Boulia died (at the North West side of Curtain Road, which I refer to as crossing 1) and the crossing over Great Eastern Street at the South East side of Curtain Road (by the Old Blue Last pub, which I refer to as crossing 2) do not allow enough time for pedestrians to cross the road safely.
The inter-green period (the period when the road traffic’s signals are not at green) at crossing 1 is only 10 seconds, made up of 6 seconds when the pedestrian signal is at green man and 4 seconds of “blackout” or “clearance” period. 10 seconds is insufficient time to allow pedestrians to cross the road safely before the road traffic’s signals change to green.
The green man for pedestrians is an invitation to cross, hence the blackout period should allow enough time for any pedestrians who step onto the crossing a moment before the green man goes out to cross the road safely. The current blackout period does not allow for this.
Although at crossing 1, the 10 second inter-green period extends to 16 seconds when there is no road traffic filtering from Curtain Road to Great Eastern Street, in practice this is rarely the case. There is no filtering traffic at crossing 2, but the inter-green period is still insufficient to allow pedestrians to cross safely.
PC ████████ observed that pedestrians routinely cross on the red man at the crossings at the junction of Great Eastern Street and Curtain Road, probably due to the inadequate inter-green periods.
” 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 Ask scheme designers to consider pedestrian safety options at Great Eastern Street/Curtain Road.
Verbatim wording from the response “22. Since August 2022, TfL has been meeting with the Department for Transport (‘DfT’) to discuss plans on spending the funding. TfL will now be progressing the scheme for the Safer Junction programme at Great Eastern Street/Shoreditch High Street/Commercial Street. As part of this, TfL will formally include the Great Eastern Street/Curtain Road junction within the scope of this scheme, subject to final approvals with the DfT. The scope of any briefing for the scheme will include asking the designers to consider the best options for pedestrians at this junction. The timescales for this scheme are 2-4 years, subject to funding.” Source location Response from Transport for London report
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 Undertake further vehicle-speed surveys to assess whether physical speed-reduction measures are required.
Verbatim wording from the response “32. In terms of instigating traffic calming measures on this stretch of road, such matters will also be considered as part of the wider scheme for this junction. TfL also reviews the speeds of vehicles on roads where speed limits have been changed. If speeds are not reducing or are not at the speed limit level, consideration can then be given to the use of physical measures to aid speed reduction. The most recent survey for Great Eastern Street shows a reduction in speed to 21mph which is within the category, below 24mph, that the DfT states signage and road markings can be used and that physical measures are not also required. We will undertake further surveys as part of the work highlighted in paragraph 22 to consider again if physical measures are required.” Source location Response from Transport for London report
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 Consider traffic-calming measures at the junction as part of the wider scheme.
Verbatim wording from the response “32. In terms of instigating traffic calming measures on this stretch of road, such matters will also be considered as part of the wider scheme for this junction. TfL also reviews the speeds of vehicles on roads where speed limits have been changed. If speeds are not reducing or are not at the speed limit level, consideration can then be given to the use of physical measures to aid speed reduction. The most recent survey for Great Eastern Street shows a reduction in speed to 21mph which is within the category, below 24mph, that the DfT states signage and road markings can be used and that physical measures are not also required. We will undertake further surveys as part of the work highlighted in paragraph 22 to consider again if physical measures are required.” Source location Response from Transport for London report
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 Progress the Safer Junction scheme and include Great Eastern Street/Curtain Road, subject to final Department for Transport approvals.
Verbatim wording from the response “21. On 30 August 2022, TfL reached a long-term agreement with the Government on funding until 31 March 2024. This has allowed TfL to recommence feasibility and design proposals for various schemes which were paused due to funding constraints during the pandemic.” Source location Response from Transport for London report
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 Consider restoring pedestrian guardrail at the junction as part of the wider scheme.
Verbatim wording from the response “31. Consideration of restoring PGR to this junction will be considered as part of the wider scheme for this junction referred to above.” Source location Response from Transport for London report
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 Arrange a site visit to assess urgent safety improvements proposed for the junction.
Verbatim wording from the response “38. TfL was made aware of the proposals in the MPS report on 31 October 2022. TfL is arranging a further site visit for early December 2022 to consider the proposals made in the MPS report and any findings made at the forthcoming inquest. The purpose of this site visit will be for TfL to consider any urgent safety improvements required at this junction.” Source location Response from Transport for London report
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 Consider modernising pedestrian signals, including possible countdown signals, as part of the junction scheme.
Verbatim wording from the response “a. Potential improvements to the signal timings;” Source location Response from Transport for London report
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 Undertake a design review of the Great Eastern Street/Curtain Road junction to identify ways to improve signal operation and provide additional pedestrian crossing time.
Verbatim wording from the response “It was observed that a number of pedestrians would cross in gaps against the red signal and therefore a planned review of the operational timings at the junction (see below) will seek to minimise the waiting time for pedestrians as much as practically possible. TfL’s own studies into pedestrian crossing behaviour have shown that compliance with the crossing signals reduces as wait time increases. The wait time at this junction is typical for a major central London junction with similar signal controls (a maximum of 89 seconds and an average of 45 seconds.)” Source location Response from Transport for London
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review operational timings and SCOOT settings across the Shoreditch Triangle to optimise movement phases, junction coordination and pedestrian waiting times.
Verbatim wording from the response “TfL will also conduct a review of the operational timings for all traffic signals within the Shoreditch triangle, which includes the location of this tragic fatality. The purpose of this review will be to optimise the green times each traffic, cycle or pedestrian movement (otherwise known as a ‘phases’) receives at each junction. The review will also consider how adjacent junctions are coordinated with each other (known as ‘offsets’) and the waiting times between each successive green signal (known as the ‘cycle time’). All of the signals in this network operate an adaptive signal control system, known as ‘SCOOT’ and TfL will review all of the settings for that system with an objective to minimise the pedestrian waiting times as much as reasonably possible. It is anticipated that this will commence at the start of March 2023.” Source location Response from Transport for London
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 Progress the Safer Junction scheme, including the Great Eastern Street/Curtain Road junction, through feasibility, design and construction.
Verbatim wording from the response “TfL provided a report to the Coroner to assist with his investigation (please find attached the report). TfL explained in the report that the proposed Safer Junction scheme at Great Eastern Street/Shoreditch High Street/Commercial Street will incorporate the Road Safety scheme at the junction at Great Eastern Street/Curtain Road. One proposal put forward was a new layout for this junction. This would seek to align and widen pedestrian crossings to the desire line and implement physical measures to slow speeds around this junction.” Source location Response from Transport for London
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 proposed junction safety schemes were paused because pandemic-related fare losses created funding constraints pending a long-term Government funding agreement.
Verbatim wording from the response “The onset of the Covid-19 pandemic in early 2020 and subsequent lockdowns devastated TfL’s fares income and meant TfL required emergency Government support to run its day-to-day transport services. Therefore, the proposals referred to above to investigate feasibility proposals for the junction at Great Eastern Street/Curtain Road, as well as the wider Safer Junction scheme, were paused pending a long-term funding deal.” Source location Response from Transport for London
Open published response
×
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 crossings’ existing signal timings are longer than reported and comply with Department for Transport and TfL standards and guidance.
Verbatim wording from the response “Period | Timing identified in PFD report (seconds) | Actual on street timing (seconds)
Green man | 6 | 6
Black Out | 4 | 5
All Red | 4 | 5
Starting Amber | 2 | 2
Total Intergreen | 10 | 12” Source location Response from Transport for London
Open published response
28 Sep 2021 Dane CHINNERY and 6 others · Prevention of Future Deaths report South London
View report summary
Concerns raised 1 Risk of under-reporting of incidents 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
Dane CHINNERY and 6 others · 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 9 November 2016, a tram travelling between Lloyd Park Station and Sandilands station derailed and overturned after the driver became disorientated and failed to brake before a tight curve; seven passengers were killed. The substantive concerns included inadequate risk assessment and mitigation, a lack of a just culture discouraging reporting of health and safety concerns, and the risk of under-reporting incidents.
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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Risk of under-reporting of incidents
Wider context from the report “The risk of under-reporting of incidents
” Open source report
20 Apr 2021 Ella Adoo-Kissi-Debrah · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 6 Insufficient undergraduate teaching on the health effects of air pollution View source Insufficient postgraduate education on the health effects of air pollution View source Insufficient detail and monitoring capacity for air quality information View source Insufficient professional guidance on communicating the health effects of air pollution View source Low public awareness of sources of national and local pollution information View source National Particulate Matter limits exceeding WHO guideline levels View source See 3 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
Ella Adoo-Kissi-Debrah · 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
Ella Adoo-Kissi-Debrah died aged 9 after an asthmatic episode led to cardiac arrest on 15 February 2013. The report states that air pollution, including exposure to nitrogen dioxide and particulate matter from traffic emissions, significantly contributed to her asthma and death. It also identifies concerns about pollution limits, public access to pollution information, and communication of air-pollution health risks by healthcare professionals.
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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Insufficient undergraduate teaching on the health effects of air pollution
Wider context from the report “(3) The adverse effects of air pollution on health are not being sufficiently communicated to patients and their carers by medical and nursing professionals. The evidence at the inquest was that this needs to be addressed at three levels:
a. Undergraduate. I am informed that undergraduate teaching is the responsibility of the GMC, Health Education England and the NMC.
b. Postgraduate. I am informed that postgraduate education is the responsibility of the Royal Colleges, in this case the Royal College of Physicians, the Royal College of Paediatrics and Child Health, the Royal College of General Practitioners, and the NMC.
c. Professional guidance. In this case relevant organisations are NICE and the British Thoracic Society.
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Insufficient postgraduate education on the health effects of air pollution
Wider context from the report “(3) The adverse effects of air pollution on health are not being sufficiently communicated to patients and their carers by medical and nursing professionals. The evidence at the inquest was that this needs to be addressed at three levels:
a. Undergraduate. I am informed that undergraduate teaching is the responsibility of the GMC, Health Education England and the NMC.
b. Postgraduate. I am informed that postgraduate education is the responsibility of the Royal Colleges, in this case the Royal College of Physicians, the Royal College of Paediatrics and Child Health, the Royal College of General Practitioners, and the NMC.
c. Professional guidance. In this case relevant organisations are NICE and the British Thoracic Society.
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Insufficient detail and monitoring capacity for air quality information
Wider context from the report “(2) There is a low public awareness of the sources of information (such as UK-Air website) about national and local pollution levels. Greater awareness would help individuals reduce their personal exposure to air pollution. It was clear from the evidence at the inquest that publicising this information is an issue that needs to be addressed by national as well as local government. The information must be sufficiently detailed and this is likely to require enlargement of the capacity to monitor air quality, for example by increasing the number of air quality sensors .
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Insufficient professional guidance on communicating the health effects of air pollution
Wider context from the report “(3) The adverse effects of air pollution on health are not being sufficiently communicated to patients and their carers by medical and nursing professionals. The evidence at the inquest was that this needs to be addressed at three levels:
a. Undergraduate. I am informed that undergraduate teaching is the responsibility of the GMC, Health Education England and the NMC.
b. Postgraduate. I am informed that postgraduate education is the responsibility of the Royal Colleges, in this case the Royal College of Physicians, the Royal College of Paediatrics and Child Health, the Royal College of General Practitioners, and the NMC.
c. Professional guidance. In this case relevant organisations are NICE and the British Thoracic Society.
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Low public awareness of sources of national and local pollution information
Wider context from the report “(2) There is a low public awareness of the sources of information (such as UK-Air website) about national and local pollution levels. Greater awareness would help individuals reduce their personal exposure to air pollution. It was clear from the evidence at the inquest that publicising this information is an issue that needs to be addressed by national as well as local government . The information must be sufficiently detailed and this is likely to require enlargement of the capacity to monitor air quality, for example by increasing the number of air quality sensors.
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation National Particulate Matter limits exceeding WHO guideline levels
Wider context from the report “(1) The national limits for Particulate Matter are set at a level far higher than the WHO guidelines. The evidence at the inquest was that there is no safe level for Particulate Matter and that the WHO guidelines should be seen as minimum requirements. Legally binding targets based on WHO guidelines would reduce the number of deaths from air pollution in the UK.
” Open source report
29 May 2020 Flora Shen · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 4 Dependence on multiple manual actions to activate the emergency brake View source Dependence on train passengers to notice hazards and contact the Passenger Services Agent in time View source Inability of the central CCTV monitoring system to watch all stations simultaneously View source Dependence on members of the public to notice hazards and activate alarms 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
Flora Shen · 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
Flora Shen died on 6 January 2020 at Lime House station after falling from the platform and being struck by a train. The report raised concerns about the reliance on members of the public to notice hazards and activate alarms, and about limited CCTV coverage and the response process on the driverless DLR system.
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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Dependence on multiple manual actions to activate the emergency brake
Wider context from the report “(1) If a member of the public on the train sees a person or hazard on the track ahead they have to go to one of the doorways to activate the passenger alarm. The Passenger Services Assistant then goes to the telephone which is accessed by a key to ask why the passenger alarm has been activated. In order to stop the train the Passenger Services Agent then needs to replace the phone, lock the phone compartment and use a key to activate the emergency brake.
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Dependence on train passengers to notice hazards and contact the Passenger Services Agent in time
Wider context from the report “(2) The ability to respond to a danger or hazard on the line seems sometimes to be dependent on this being noticed by a member of the public on a train and them being able to contact the Passenger Services Agent in time for the train to be stopped.
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Inability of the central CCTV monitoring system to watch all stations simultaneously
Wider context from the report “(3) The central DLR CCTV monitoring system cannot watch all stations at the same time and the safety of persons slipping, falling or collapsing on to a line on the DLR system seems to rely on ability of members of the public to notice the hazard and activate the alarm on either the platform or the train.
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Dependence on members of the public to notice hazards and activate alarms
Wider context from the report “(3) The central DLR CCTV monitoring system cannot watch all stations at the same time and the safety of persons slipping, falling or collapsing on to a line on the DLR system seems to rely on ability of members of the public to notice the hazard and activate the alarm on either the platform or the train.
” Open source report
×
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 Research and collaborate on CCTV and train-based hazard-detection technologies, including assessing potential options for a DLR trial.
Verbatim wording from the response “2. We will continue to research and collaborate with suppliers to identify potential solutions and improvements in the area of hazard/obstacle detection. We are currently exploring an emerging CCTV product that can detect persons and/or objects on the track, and have held preliminary discussions with its developer to assess its potential for testing on the DLR. We should know by December 2020 if a trial can be taken forward. However, this is partly dependent on the existing CCTV network being capable of supporting such a trial.” Source location 2020-0115-Response-from-TFL_Redacted.pdf
Open published response
×
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 Develop and roll out enhanced platform-alarm signage to improve passengers’ ability to locate alarms.
Verbatim wording from the response “1. Enhancing the signage on the platform alarms – the intention of this work is to give passengers a greater chance of locating the alarms on the platforms should they notify a hazard on the track. The timescale for completion is July 2021; the programme is now being developed and would be rolled out on a risk-basis.” Source location 2020-0115-Response-from-TFL_Redacted.pdf
Open published response
×
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 On-train and CCTV obstacle-detection technology is considered insufficiently mature for reliable operation on the DLR network.
Verbatim wording from the response “2. We will continue to research and collaborate with suppliers to identify potential solutions and improvements in the area of hazard/obstacle detection. We are currently exploring an emerging CCTV product that can detect persons and/or objects on the track, and have held preliminary discussions with its developer to assess its potential for testing on the DLR. We should know by December 2020 if a trial can be taken forward. However, this is partly dependent on the existing CCTV network being capable of supporting such a trial.” Source location 2020-0115-Response-from-TFL_Redacted.pdf
Open published response
17 Feb 2020 Liam Floyd SEAGER · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Delays in implementing a traffic management order prohibiting pedestrian crossing on the A12 View source Unavailability of a pedestrian crossing on the A12 at Wick Lane 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
Liam Floyd SEAGER · 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
Liam Floyd Seager was knocked over and killed by a transit van at approximately 3am on New Year’s Day 2019 while crossing the A12 southbound underpass. The concerns were the absence of a pedestrian crossing near the collision site, the delay before a traffic management order would prohibit pedestrians crossing there, and the need for preparatory work and a pedestrian crossing at Wick Lane.
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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Delays in implementing a traffic management order prohibiting pedestrian crossing on the A12
Wider context from the report “I heard at inquest that there is no pedestrian crossing on the A12 near the location of the collision.
1. Transport for London has indicated that it hopes to have a traffic management order in place by June 2020, which will prohibit pedestrians from crossing at this point. I am concerned that we are still four months away from this.
2. Once the traffic management order is in place, a pedestrian crossing is needed to make it easier for pedestrians to cross the top of the A12 at Wick Lane. Even before this, Tower Hamlets could undertake useful preparatory work to enable the build to proceed quickly following the TMO.
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a pedestrian crossing on the A12 at Wick Lane
Wider context from the report “I heard at inquest that there is no pedestrian crossing on the A12 near the location of the collision .
1. Transport for London has indicated that it hopes to have a traffic management order in place by June 2020, which will prohibit pedestrians from crossing at this point. I am concerned that we are still four months away from this.
2. Once the traffic management order is in place, a pedestrian crossing is needed to make it easier for pedestrians to cross the top of the A12 at Wick Lane . Even before this, Tower Hamlets could undertake useful preparatory work to enable the build to proceed quickly following the TMO.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a Traffic Regulation Order and install signage and supplementary measures prohibiting pedestrian access to the A12.
Verbatim wording from the response “Prohibiting pedestrian access to the A12” Source location Response from Transport for London
Open published response
×
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 Continue working with relevant London boroughs to identify and establish new or improved pedestrian crossings across the A12.
Verbatim wording from the response “As part of our longer-term strategic plans, we will continue working with the relevant London boroughs to identify and establish new and improved pedestrian crossing opportunities across the A12. These plans may include long term development proposals and are dependent on both the private and public sectors, as well as the use of land outside the highway boundary.” Source location Response from Transport for London
Open published response
×
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 LBTH is responsible for designing and constructing the new pedestrian crossing and providing wayfinding signs.
Verbatim wording from the response “Joint work between TfL and LBTH” Source location Response from Transport for London
Open published response
×
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 COVID-19 restrictions may prevent completion of the TRO’s remaining works until it is safe and government guidance permits them.
Verbatim wording from the response “However, due to the current health crisis caused by COVID-19 pandemic, we are following Government guidance in respect of the operations we can continue whilst following social distancing. As such and considering the pandemic, we may be unable to carry out the remaining activities to put in place the TRO. When it is safe to undertake the necessary works in respect of the TRO (and in accordance with guidance from the Department of Transport), this work will be a priority.” Source location Response from Transport for London
Open published response
29 Apr 2019 Alfonso Sinclair · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 4 Failure of station staff systems of work to position ticket-barrier monitoring where irregular passenger behaviour is more likely to be observed View source Lack of alarms at platform-end barriers View source Lack of ease of CCTV monitoring View source Lack of a system for staff to alert and track individuals of concern on CCTV View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Alfonso Sinclair · 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
Alfonso Sinclair entered the Victoria Line tunnel at Warren Street station on 31 August 2018 and was struck and killed by a train approximately 19.5 minutes later. The principal concerns were that staff did not identify or track his unusual behaviour on CCTV, that there were no alarms at the platform-end barriers, and that staff working systems and CCTV monitoring could be improved to help prevent similar 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Failure of station staff systems of work to position ticket-barrier monitoring where irregular passenger behaviour is more likely to be observed
Wider context from the report “4. That systems of work by station staff be reviewed to ensure monitoring of the ticket barriers a place where irregular behaviour by passengers is more likely to be observed .
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Lack of alarms at platform-end barriers
Wider context from the report “2. That there is no alarm at the barriers at the platform ends .
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Lack of ease of CCTV monitoring
Wider context from the report “5. That ease of monitoring of CCTV be facilitated .
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for staff to alert and track individuals of concern on CCTV
Wider context from the report “1. That there is no apparent system for staff to alert odd behaviour and then track an individual of concern on CCTV .
” Open source report
1 Apr 2019 Ozan Allen · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 4 Lack of pedestrian guard railing at the junction View source Failure of pedestrians to use staggered two-stage crossings as intended View source Impaired junction visibility from vehicles waiting to turn View source Pedestrian collision hazard near the junction 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
Ozan Allen · 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
Ozan Allen was hit by a car while crossing the junction of Mile End Road and Burdett Road on 16 August 2018 and died in hospital on 20 August 2018 from traumatic brain injury caused by the road traffic collision. Concerns included the junction’s complex layout, lack of pedestrian guard railing, impaired visibility, pedestrians not using staggered crossings as intended, and a history of collisions involving pedestrians.
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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Lack of pedestrian guard railing at the junction
Wider context from the report “(2) There is no pedestrian guard railing at the junction
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Failure of pedestrians to use staggered two-stage crossings as intended
Wider context from the report “(4) There are staggered two-stage crossings in place to enable pedestrians to cross the road. The investigator from the Metropolitan Police’s Road Engineering Unit, ████████ observed that pedestrians often do not use the crossings as intended .
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Impaired junction visibility from vehicles waiting to turn
Wider context from the report “(3) Visibility of the junction can be impaired by vehicles waiting to turn .
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Pedestrian collision hazard near the junction
Wider context from the report “(5) ████████ evidence was that in the three years to the end of 2017, there have been 36 reported personal injury collisions within 50 metres of the junction – 17 of which involved pedestrians .
(6) In addition, ████████ informed me that a collision study undertaken by TfL has identified that whilst collisions involving cyclists had decreased since the introduction of Cycle Superhighway 2, the proportion of collisions involving pedestrians had increased .
” 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 Complete a collision study examining recent recorded collision history to inform further cycling and walking improvements.
Verbatim wording from the response “The banned turns have been contentious with some local residents. The London Borough of Tower Hamlets has asked for these to be reviewed. In addition, as per your report, we acknowledge that monitoring of the changes made in 2016 shows that they have reduced the number of collisions affecting cyclists, but the number of collisions involving pedestrians has increased. This impact was not intended as part of that design. We sought to analyse reasons for this and commissioned a collision study that was completed in July 2018, prior to the death of Mr Allen, which involved a review of the recent recorded collision history. This informed a package of further proposals of cycling and walking improvements at this junction.” Source location 2019-0197-Response-by-Transport-for-London
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 Reintroduce the Burdett Road right turn into Mile End Road and ban the corresponding Mile End Road left turn.
Verbatim wording from the response “As outlined in our letter, we are proposing to re-introduce the right turn from Burdett Road (southern arm) to Mile End Road (eastern arm) but ban the corresponding left turn from Mile End Road (eastern arm) to Burdett Road (southern arm). This will allow us to decrease the overall wait times at the pedestrian crossings on all arms of the junction, as well as the adjacent staggered (two-part) crossing outside Mile End station that is co-ordinated with the operation of the junction.” Source location 2019-0197-Response-by-Transport-for-London
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 Investigate A11 approach measures, including bus-stop changes and relocating the Mile End station crossing, to reduce queuing and blocking back.
Verbatim wording from the response “We are also proposing to introduce a reduced speed limit of 20mph on the A11 corridor between Bow and Aldgate through the junction, and we are investigating measures on the A11 Mile End Road approaches such as changes to bus stop facilities and relocating the crossing outside Mile End station to reduce the risk of traffic queuing and blocking back into the junction. We have yet to consult on these additional proposals but plan to complete both further projects by 2024 subject to funding, resources, consultation, roadspace co-ordination for build, and due process.” Source location 2019-0197-Response-by-Transport-for-London
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement segregated cycle lanes, pedestrian islands and turn restrictions through the junction upgrade.
Verbatim wording from the response “As part of the upgrade of Cycle Superhighway 2 completed in 2016, changes were made at the junction including installing segregated cycle lanes on the Mile End Road approaches, and introducing a right turn ban from Mile End Road (western arm) into Burdett Road (southern arm) and a right turn ban from Burdett Road (southern arm) into Mile End Road (eastern arm). Prior to finalising this design, we considered straight-across crossing design options, but they were not feasible due to adverse impacts which included longer wait times for pedestrians, increased queue lengths for vehicles, and re-routing of traffic on local roads leading to ‘rat-running’.” Source location 2019-0197-Response-by-Transport-for-London
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 Reintroduce pedestrian guard railing on the junction’s north-west corner to direct pedestrians to formal crossings.
Verbatim wording from the response “We are proposing to re-introduce pedestrian guard railing on north-west corner of the junction to direct pedestrians to use the formal crossings provided. We are also investigating signal heads on green pedestrian signals to reduce the risk of ‘see-through’ problems (where two or more signals are close together and there are risks that road users look at the wrong set of signals), and removal of street furniture such as telephone kiosks to improve pedestrian visibility (subject to discussions with third parties).” Source location 2019-0197-Response-by-Transport-for-London
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a 20mph speed limit on the A11 corridor between Bow and Aldgate through the junction.
Verbatim wording from the response “We are also proposing to introduce a reduced speed limit of 20mph on the A11 corridor between Bow and Aldgate through the junction, and we are investigating measures on the A11 Mile End Road approaches such as changes to bus stop facilities and relocating the crossing outside Mile End station to reduce the risk of traffic queuing and blocking back into the junction. We have yet to consult on these additional proposals but plan to complete both further projects by 2024 subject to funding, resources, consultation, roadspace co-ordination for build, and due process.” Source location 2019-0197-Response-by-Transport-for-London
Open published response
×
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 Internal pedestrian islands will be retained because removing them would reduce capacity, increase congestion, and create additional risks.
Verbatim wording from the response “As part of the upgrade of Cycle Superhighway 2 completed in 2016, changes were made at the junction including installing segregated cycle lanes on the Mile End Road approaches, and introducing a right turn ban from Mile End Road (western arm) into Burdett Road (southern arm) and a right turn ban from Burdett Road (southern arm) into Mile End Road (eastern arm). Prior to finalising this design, we considered straight-across crossing design options, but they were not feasible due to adverse impacts which included longer wait times for pedestrians, increased queue lengths for vehicles, and re-routing of traffic on local roads leading to ‘rat-running’.” Source location 2019-0197-Response-by-Transport-for-London
Open published response
19 Dec 2018 Kurt Cochran and 5 others · Prevention of Future Deaths report London Inner (West)
View report summary
Concerns raised 18 Lack of consistent and up-to-date national protective security advice View source Failure of supervisory systems to audit ADAM System use View source Failure to record reasons for closing a Subject of Interest View source Lack of clear required intervals for officers to access the ADAM System View source Inadequate training for lone-actor and multi-actor marauding attacks View source Failure to provide revised Post Instructions directly to relevant officers View source Insufficient time for officers to access the ADAM System and review Post Instructions View source Failure to brief officers on the rationale for changes to Post Instructions View source Failure of Post Instructions to be clear and readily interpretable View source Inadequate coordinated training of AFOs, unarmed officers and security officers View source Lack of consistent pre-rental vehicle checks and enquiries View source Lack of regular supervisory audits of policing at the Palace of Westminster View source Lack of armed police protection at a vulnerable public entrance to the Parliamentary Estate View source Lack of periodic audit of Tactical Firearms Reviews View source Failure of Post Instructions to be consistent with tactical plans, orders and practices View source Lack of guidance on removing unconscious persons or bodies from navigable water View source Failure of officers to register for and access the ADAM System View source Insufficient facilities for officers to access the ADAM System View source See 15 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
Kurt Cochran and 5 others · 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 22 March 2017, Khalid Masood drove a vehicle across Westminster Bridge, fatally injuring Kurt Cochran, Leslie Rhodes, Aysha Frade and Andreea Cristea, before fatally stabbing PC Keith Palmer at the Palace of Westminster. The report raised concerns about the protection of public entrances, officers’ access to and understanding of Post Instructions, use of the ADAM System, supervision and training, and wider protective security measures.
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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent and up-to-date national protective security advice
Wider context from the report “MC14: I suggest that the Secretary of State for the Home Department asks the authorities responsible for preparing and delivering advice on protective security to consider whether any further work can usefully be done on this subject, particularly in preparing and delivering consistent and up-to-date national advice . I also suggest that TfL considers whether there is any further work it can do to improve protective security on major roadways and bridges in the capital, in response to national advice and known threats.
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Failure of supervisory systems to audit ADAM System use
Wider context from the report “MC6: It was a matter of concern that officers were unaware of their Post Instructions and that supervisory systems had not identified limited usage of the ADAM System . I therefore suggest that the MPS considers auditing use of the ADAM System periodically , by checks to confirm use at sufficiently regular intervals over the period.
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Failure to record reasons for closing a Subject of Interest
Wider context from the report “MC16: I suggest that the Security Service considers whether it would be practicable and beneficial to introduce a procedure whereby any decision to close a person as a Subject of Interest is recorded with brief reasons .
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Lack of clear required intervals for officers to access the ADAM System
Wider context from the report “MC2: I suggest that the MPS considers making it mandatory for officers on the Command to register for ADAM and to access it at specified intervals (perhaps supplemented by an instruction to confirm review of material on the system). I was concerned that a proportion of officers on the Command had not registered for the ADAM System despite it having been in use for six years. Furthermore, I heard evidence that officers were under instructions to access the system “regularly” but no definition of that term could be given . Given that the ADAM System is the repository for the authorised versions of Post Instructions, these were troubling features of the evidence. In short, a proportion of the officers had no means of accessing their instructions and officers generally had no clear guidance on how regularly they should be checking the system . Although the MPS has provided submissions referring to improvements in the ADAM System and improved systems of supervision, these would be relatively simple rules which would be readily enforceable through the disciplinary process.
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Inadequate training for lone-actor and multi-actor marauding attacks
Wider context from the report “MC9: I suggest that the MPS reviews the adequacy of training of officers stationed in the Parliamentary Estate to ensure it includes lone actor and multi-actor marauding attacks .
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Failure to provide revised Post Instructions directly to relevant officers
Wider context from the report “MC1: I suggest that the MPS gives consideration to providing revised Post Instructions to relevant groups by direct emails, in hard copy and/or via electronic devices (as well as their being accessible through ADAM) and to providing them in a way that requires the recipient to respond indicating safe receipt. I was concerned that, when Post Instructions were updated, they were apparently not emailed or provided in hard copy to relevant officers directly . The system relied upon officers’ use of the ADAM System, which was sporadic . I am aware from the submissions of the MPS that, since the attack, an update is sent to all relevant officers advising them of a revision of Post Instructions and telling them to view the new version on ADAM. The MPS has provided a copy of an example email, which was sent on 11 October 2018. However, it may be valuable for the MPS to go further than this by supplying revised instructions directly to the officers and in requiring an acknowledgement of safe receipt is sent back by the officers.
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Insufficient time for officers to access the ADAM System and review Post Instructions
Wider context from the report “MC3: Given the figures for usage of the ADAM System, it is a matter of concern whether officers have (a) adequate time to access the System regularly and review their Post Instructions and (b) adequate facilities to do so (e.g. ready access to computer terminals). I therefore suggest that the MPS considers the time and facilities available for officers to access the ADAM System and review their instructions.
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Failure to brief officers on the rationale for changes to Post Instructions
Wider context from the report “MC10: I suggest that the MPS considers the possibility of the firearms assessor / adviser briefing officers as to the rationale for any changes to their Post Instructions .
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Failure of Post Instructions to be clear and readily interpretable
Wider context from the report “MC4: I suggest that the MPS considers a periodic audit of all extant Post Instructions for the Parliamentary Estate to ensure their consistency and fitness for purpose. This might be part of the supervisory audit discussed at MC7 below, or separate from it. On the evidence I heard, Post Instructions are prepared after careful work by relevant experts within the MPS (firearms tactical assessors, in the case of AFO Post Instructions). Nevertheless, there were deficiencies in the expression of some Post Instructions , and some officers when presented with them found it difficult to interpret parts . It is important that each Post Instruction should be clear and internally consistent, and should be consistent with the broader tactical plan for the Estate. It was clear from the evidence of Commander Usher that Post Instructions should be followed precisely. They should not be subject to personal interpretation, since that would introduce inconsistent practice and would undermine the tactical rationale behind the instructions. Where the content of Post Instructions is ambiguous or not consistent with other orders or practices, security can be undermined.
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Inadequate coordinated training of AFOs, unarmed officers and security officers
Wider context from the report “MC8: I suggest that the MPS, with the Parliamentary Authorities, reviews the adequacy of training to ensure that it involves AFOs, unarmed officers and security officers and their co-ordination .
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent pre-rental vehicle checks and enquiries
Wider context from the report “MC18: I recommend that the Department for Transport and the British Vehicle Rental & Leasing Association consider introducing a Code of Practice (or at least guidance) on checks to be carried out and/or enquiries made before vehicles are rented .
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Lack of regular supervisory audits of policing at the Palace of Westminster
Wider context from the report “MC7: I suggest that the MPS considers instituting regular supervisory audits of policing at the Palace of Westminster (and perhaps other parts of the Parliamentary Estate), preferably by officers outside the PaDP Command.
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Lack of armed police protection at a vulnerable public entrance to the Parliamentary Estate
Wider context from the report “MC5: It was a matter of concern that, at the time of the attack, one of the most vulnerable and public entrances to the Parliamentary Estate was not protected by armed police . In my view, the MPS should consider (a) imposing a standing order that there should be armed officers stationed at all open public entry points to the Palace of Westminster (and possibly to some other buildings on the Parliamentary Estate) and (b) introducing a provision that this standing order may only be varied with the written approval of an officer of very senior rank.
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Lack of periodic audit of Tactical Firearms Reviews
Wider context from the report “MC11: I suggest that the MPS considers a periodic audit of Tactical Firearms Reviews .
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Failure of Post Instructions to be consistent with tactical plans, orders and practices
Wider context from the report “MC4: I suggest that the MPS considers a periodic audit of all extant Post Instructions for the Parliamentary Estate to ensure their consistency and fitness for purpose. This might be part of the supervisory audit discussed at MC7 below, or separate from it. On the evidence I heard, Post Instructions are prepared after careful work by relevant experts within the MPS (firearms tactical assessors, in the case of AFO Post Instructions). Nevertheless, there were deficiencies in the expression of some Post Instructions, and some officers when presented with them found it difficult to interpret parts. It is important that each Post Instruction should be clear and internally consistent, and should be consistent with the broader tactical plan for the Estate . It was clear from the evidence of Commander Usher that Post Instructions should be followed precisely. They should not be subject to personal interpretation, since that would introduce inconsistent practice and would undermine the tactical rationale behind the instructions. Where the content of Post Instructions is ambiguous or not consistent with other orders or practices , security can be undermined.
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on removing unconscious persons or bodies from navigable water
Wider context from the report “MC17: I suggest that the Maritime and Coastguard Agency considers whether it or some other body could provide guidance on the removal of unconscious persons or bodies from the water close to those operating on navigable rivers and canals .
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Failure of officers to register for and access the ADAM System
Wider context from the report “MC2: I suggest that the MPS considers making it mandatory for officers on the Command to register for ADAM and to access it at specified intervals (perhaps supplemented by an instruction to confirm review of material on the system). I was concerned that a proportion of officers on the Command had not registered for the ADAM System despite it having been in use for six years. Furthermore, I heard evidence that officers were under instructions to access the system “regularly” but no definition of that term could be given. Given that the ADAM System is the repository for the authorised versions of Post Instructions, these were troubling features of the evidence. In short, a proportion of the officers had no means of accessing their instructions and officers generally had no clear guidance on how regularly they should be checking the system. Although the MPS has provided submissions referring to improvements in the ADAM System and improved systems of supervision, these would be relatively simple rules which would be readily enforceable through the disciplinary process.
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Insufficient facilities for officers to access the ADAM System
Wider context from the report “MC3: Given the figures for usage of the ADAM System, it is a matter of concern whether officers have (a) adequate time to access the System regularly and review their Post Instructions and (b) adequate facilities to do so (e.g. ready access to computer terminals) . I therefore suggest that the MPS considers the time and facilities available for officers to access the ADAM System and review their instructions.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider and respond to updated national guidance on reducing risks in crowded highways, bridges and public spaces when issued.
Verbatim wording from the response “In relation to how TfL considers and responds to national advice, it is our understanding that the Office for Security and Counter-Terrorism (OSCT), NaCTSO in the Home Office and others are producing guidance on reducing risk in crowded spaces, such as highways, bridges and the public realm. TfL awaits with interest this updated guidance and will fully consider and respond to its recommendations when it is issued.” Source location 2018-0304-Response-by-Transport-for-London
Open published response
16 May 2018 Lucia CICCIOLI · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 6 Narrow road width placing cyclists in a vulnerable position View source Failure to repair dangerous road dip in LAVENDER HILL View source Inadequate cycle lane provision leading up to the traffic lights View source Yellow box preventing cyclists from legally stopping in the junction View source Inadequate protection for cyclists approaching the junction View source Lack of cycle lane provision in LAVENDER HILL immediately past the junction View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Lucia CICCIOLI · 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
Lucia CICCIOLI was cycling westbound through the junction of Latchmere Road and Elspeth Road towards Lavender Hill when she lost her balance after travelling over a dip in the road and collided with a MAN lorry. She sustained fatal injuries and died at the scene. The principal concerns were inadequate cycle-lane provision and protection, the junction layout and yellow box, the narrow road, and a dangerous dip in the road requiring urgent repair.
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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Narrow road width placing cyclists in a vulnerable position
Wider context from the report “5) The narrow aspect of LAVENDER HILL immediately past the said junction places cyclists a vulnerable position when they arrive in LAVENDER HILL from the said junction.
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Failure to repair dangerous road dip in LAVENDER HILL
Wider context from the report “6) The dip in the road in LAVENDER HILL (between position 4 and position 5 on the Reconstruction Plan) is dangerous and is in need of urgent repair .
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Inadequate cycle lane provision leading up to the traffic lights
Wider context from the report “1) There is an inadequate cycle lane leading up to the traffic lights leading up to the traffic lights at the junction of LATCHMERE ROAD and ELSPETH ROAD (the cycle lane is coloured pink on the Reconstruction Plan).
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Yellow box preventing cyclists from legally stopping in the junction
Wider context from the report “3) There is a yellow box in the middle of the said junction (situated between position 3 and 4 on The Reconstruction Plan) which causes concerns to cyclists when they are either proceeding straight through or turning right from the junction as they are prevented from legally stopping in the said yellow box .
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Inadequate protection for cyclists approaching the junction
Wider context from the report “2) There is inadequate protection generally for cyclists riding towards the junction with LATCHMERE ROAD and ELSPETH ROAD particularly for those cyclists that wish to go straight over the said junction towards LAVENDER HILL or for those cyclists that wish to turn right at that junction into LATCHMERE ROAD.
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Lack of cycle lane provision in LAVENDER HILL immediately past the junction
Wider context from the report “4) There is no cycle lane provision in LAVENDER HILL immediately past the said junction .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider providing an improved cycle feeder lane within the revised junction design, accounting for western-arm constraints.
Verbatim wording from the response “The provision of an improved cycle feeder lane will also be considered as part of the revised design, with consideration of the constraints on the western arm (see also response to points 4 and 5, below).” Source location 2018-0148-Response-by-Transport-for-London
Open published response
×
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 A cycle lane cannot currently be provided because insufficient carriageway space would require wider vehicles to enter it, creating a false sense of security.
Verbatim wording from the response “There is no existing cycle lane on the exit side of the western arm of Lavender Hill, because there is insufficient carriageway space given the need to accommodate general traffic progressing from the two existing straight-ahead lanes on the eastern arm of Lavender Hill.” Source location 2018-0148-Response-by-Transport-for-London
Open published response
×
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 yellow box should be retained because it prevents junction obstructions and reduces road danger from vehicles remaining in the junction.
Verbatim wording from the response “A yellow box has been provided at the junction to help prevent obstructions. All vehicles, including pedal cycles, may only enter a yellow box when the exit is clear. Our observations have indicated that the junction does potentially experience exit blocking from adjacent junctions. Without the yellow box facility, vehicles would remain in the centre of the junction at the end of each traffic light green stage. Vehicles entering the junction during the next traffic light green stage would then need to navigate around those vehicles already in the junction. This increases road danger, as inter-visibility between vehicles is reduced. For this reason, we consider that the yellow box should be retained.” Source location 2018-0148-Response-by-Transport-for-London
Open published response
Concerns raised 2 Reliance on driver self-reporting and recognition of unfitness to drive View source Lack of mandatory objective fitness testing before automatic licence renewal for older drivers 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
Evelyn Fisher · 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
Evelyn Fisher, aged 61, was struck by a vehicle that mounted the kerb while she was walking along a pavement in Paignton. She sustained a catastrophic head injury, never regained consciousness, and died from head injury. Concerns included the driver’s dementia and the reliance on self-reporting when renewing driving licences for older drivers, with no statutory requirement for objective testing before automatic renewal.
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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Reliance on driver self-reporting and recognition of unfitness to drive
Wider context from the report “(2) It was probable that ████████ had started to develop dementia before this incident but had not recognised it
(3) Despite ████████ renewing his licence in March 2015, as an over 70-year-old, this failed to prevent this incident as this scheme relies almost entirely on self reporting and further on a driver recognising that they may be unfit to drive .
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory objective fitness testing before automatic licence renewal for older drivers
Wider context from the report “(4) ████████ was 88 at the time of the incident and there is no statutory scheme to make it mandatory for drivers over 70 or 80 to be objectively tested before they have licenses automatically renewed .
” Open source report
28 Dec 2017 Mark Nicholas Welsh · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 3 Failure to consider proportionate pedestrian-crossing options at the junction View source Delays in delivering pedestrian safety improvements at the crossroads View source Failure to include overall collision incidence and reported near misses in traffic-control assessments View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mark Nicholas Welsh · 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
Mark Nicholas Welsh died after being knocked over by a lorry while crossing Duke’s Road at its junction with Euston Road in London on 6 July 2017. The report raised concerns about the prolonged delay in improving pedestrian safety at the crossroads, the decision not to install crossings, and the traffic-control statistics used by Transport for London, which did not account for all collisions or reported near misses.
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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Failure to consider proportionate pedestrian-crossing options at the junction
Wider context from the report “I heard at inquest that:
• Transport for London (TfL) made a decision in 2007 that it would not undertake any consideration of pedestrian crossings at that crossroads until after the completion of HS1;
• £50,000 was paid to TfL in 2009 by UNISON as part of planning permission to allow building on the opposite corner, £20,000 of which was used on a feasibility study in 2013, but TfL decided that traffic flow would be impeded by four pedestrian crossings, so none was installed and use was not made of the remaining £30,000;
• UNISON has made several complaints to Camden Council/TfL about the dangers of this particular crossroads, but TfL’s best expectation of delivery of any improvement is for the year 2020.
I appreciate that every decision about traffic control at one junction must be taken in the context of the whole network, but 13 years after the issue was first raised seems an inordinately long time to wait for some improvement at such a busy crossroads (about which there had been several complaints prior to this fatality).
Consideration of the junction was described to me as being based on four new crossings or none , which I did not quite understand.
The statistics upon which TfL decisions about traffic control are based, were described to me by TfL’s lead sponsor as only taking account of the proportion of collisions/accidents that result in serious injury or death, not taking into account the overall incidence of collisions/accidents (or even taking into account reported near misses). This seems an omission.
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Delays in delivering pedestrian safety improvements at the crossroads
Wider context from the report “I heard at inquest that:
• Transport for London (TfL) made a decision in 2007 that it would not undertake any consideration of pedestrian crossings at that crossroads until after the completion of HS1;
• £50,000 was paid to TfL in 2009 by UNISON as part of planning permission to allow building on the opposite corner, £20,000 of which was used on a feasibility study in 2013, but TfL decided that traffic flow would be impeded by four pedestrian crossings, so none was installed and use was not made of the remaining £30,000;
• UNISON has made several complaints to Camden Council/TfL about the dangers of this particular crossroads, but TfL’s best expectation of delivery of any improvement is for the year 2020 .
I appreciate that every decision about traffic control at one junction must be taken in the context of the whole network, but 13 years after the issue was first raised seems an inordinately long time to wait for some improvement at such a busy crossroads (about which there had been several complaints prior to this fatality).
Consideration of the junction was described to me as being based on four new crossings or none, which I did not quite understand.
The statistics upon which TfL decisions about traffic control are based, were described to me by TfL’s lead sponsor as only taking account of the proportion of collisions/accidents that result in serious injury or death, not taking into account the overall incidence of collisions/accidents (or even taking into account reported near misses). This seems an omission.
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Failure to include overall collision incidence and reported near misses in traffic-control assessments
Wider context from the report “I heard at inquest that:
• Transport for London (TfL) made a decision in 2007 that it would not undertake any consideration of pedestrian crossings at that crossroads until after the completion of HS1;
• £50,000 was paid to TfL in 2009 by UNISON as part of planning permission to allow building on the opposite corner, £20,000 of which was used on a feasibility study in 2013, but TfL decided that traffic flow would be impeded by four pedestrian crossings, so none was installed and use was not made of the remaining £30,000;
• UNISON has made several complaints to Camden Council/TfL about the dangers of this particular crossroads, but TfL’s best expectation of delivery of any improvement is for the year 2020.
I appreciate that every decision about traffic control at one junction must be taken in the context of the whole network, but 13 years after the issue was first raised seems an inordinately long time to wait for some improvement at such a busy crossroads (about which there had been several complaints prior to this fatality).
Consideration of the junction was described to me as being based on four new crossings or none, which I did not quite understand.
The statistics upon which TfL decisions about traffic control are based, were described to me by TfL’s lead sponsor as only taking account of the proportion of collisions/accidents that result in serious injury or death , not taking into account the overall incidence of collisions/accidents (or even taking into account reported near misses) . This seems an omission .
” Open source report
×
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 Continue working with Camden Council to develop designs enabling safer pedestrian and cycle facilities at the junction and nearby locations.
Verbatim wording from the response “We will continue working with Camden Council to develop a design for this junction and others in the near vicinity which will enable more and safer pedestrian and cycle facilities to be provided thereby encouraging people to walk, cycle or use public transport.” Source location 2017-0456-Response-by-Transport-for-Lonodn
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 Progress a banned turning movement and implement a signal-controlled pedestrian crossing on Dukes Road, subject to Camden Council agreement.
Verbatim wording from the response “Subject to Camden Council agreement, we intend to progress a banned turning movement in order to provide a signal controlled crossing on Dukes Road – to be implemented next year.” Source location 2017-0456-Response-by-Transport-for-Lonodn
Open published response
×
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 Network capacity and projected congestion impacts prevent TfL from introducing crossings that require holding traffic at the junction.
Verbatim wording from the response “We have been working closely with Camden Council to deliver a design for this junction that improves the safety for pedestrians and other vulnerable road users, and a history of our work on this was submitted to you as part of our evidence to the inquest. However, our decisions about traffic control and the use of signals must be coordinated with the surrounding road network to prevent excessive congestion, which is likely to have impacts both on safety and air pollution. The roads in this area are currently operating at the maximum level of capacity, and it has proved very difficult to find a solution for this junction which is acceptable both to us and Camden Council given potential local and wider traffic impacts, and does not have significant negative impacts elsewhere.” Source location 2017-0456-Response-by-Transport-for-Lonodn
Open published response
×
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 TfL relies on police-reported collision data and existing prioritisation methods because damage-only collisions and near misses cannot be recorded consistently.
Verbatim wording from the response “There is no consistent way of recording damage-only collisions, as the police don’t routinely attend site or require those involved to report the incident. A damage-only collision may be relatively trivial (i.e. scraping a wing mirror), and may not even be taken into account by insurance companies (who would be the other potential source of data). There is also no reasonable way of recording near misses, and it would be impossible to ensure consistency throughout the reporting.” Source location 2017-0456-Response-by-Transport-for-Lonodn
Open published response
28 Nov 2017 Sonia Elvira Stante · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 5 Confusing pedestrian crossing arrangement caused by two separate junctions View source Foreign visitors’ possible lack of understanding of the junction View source Lack of road markings indicating the direction pedestrians should look when crossing View source Green-man phasing failing to provide clear pedestrian crossing signals across each carriageway View source Missing louvre on the north-side green-man signal View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sonia Elvira Stante · 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
Sonia Elvira Stante was struck by a double-decker bus after stepping into the road in London on 10 July 2017, and died from her injuries on 21 July 2017. A review identified concerns about unclear pedestrian crossing arrangements, independently phased signals, missing louvre signage, and possible confusion for foreign visitors.
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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Confusing pedestrian crossing arrangement caused by two separate junctions
Wider context from the report “Following the incident ████████ Traffic Management Officer undertook a review of the road traffic layout at the scene. He met with TfL on site on 16 August 2017 and a number of findings were made:
(1) No road markings indicating the direction pedestrians should look when crossing
(2) Two separate junctions at that location make that crossing confusing for pedestrians
(3) The phasing of the green man operates for each carriageway independently so causing confusion for pedestrians who may look at the wrong phasing
(4) Missing louvre on the green man on the north side of the crossing making the green man more visible to pedestrians crossing from the south
(5) With the location being close to the Eurostar Terminal there are several hotels nearby and foreign visitors may not have a full understanding if the junction.
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Foreign visitors’ possible lack of understanding of the junction
Wider context from the report “Following the incident ████████ Traffic Management Officer undertook a review of the road traffic layout at the scene. He met with TfL on site on 16 August 2017 and a number of findings were made:
(1) No road markings indicating the direction pedestrians should look when crossing
(2) Two separate junctions at that location make that crossing confusing for pedestrians
(3) The phasing of the green man operates for each carriageway independently so causing confusion for pedestrians who may look at the wrong phasing
(4) Missing louvre on the green man on the north side of the crossing making the green man more visible to pedestrians crossing from the south
(5) With the location being close to the Eurostar Terminal there are several hotels nearby and foreign visitors may not have a full understanding if the junction .
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Lack of road markings indicating the direction pedestrians should look when crossing
Wider context from the report “Following the incident ████████ Traffic Management Officer undertook a review of the road traffic layout at the scene. He met with TfL on site on 16 August 2017 and a number of findings were made:
(1) No road markings indicating the direction pedestrians should look when crossing
(2) Two separate junctions at that location make that crossing confusing for pedestrians
(3) The phasing of the green man operates for each carriageway independently so causing confusion for pedestrians who may look at the wrong phasing
(4) Missing louvre on the green man on the north side of the crossing making the green man more visible to pedestrians crossing from the south
(5) With the location being close to the Eurostar Terminal there are several hotels nearby and foreign visitors may not have a full understanding if the junction.
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Green-man phasing failing to provide clear pedestrian crossing signals across each carriageway
Wider context from the report “Following the incident ████████ Traffic Management Officer undertook a review of the road traffic layout at the scene. He met with TfL on site on 16 August 2017 and a number of findings were made:
(1) No road markings indicating the direction pedestrians should look when crossing
(2) Two separate junctions at that location make that crossing confusing for pedestrians
(3) The phasing of the green man operates for each carriageway independently so causing confusion for pedestrians who may look at the wrong phasing
(4) Missing louvre on the green man on the north side of the crossing making the green man more visible to pedestrians crossing from the south
(5) With the location being close to the Eurostar Terminal there are several hotels nearby and foreign visitors may not have a full understanding if the junction.
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Missing louvre on the north-side green-man signal
Wider context from the report “Following the incident ████████ Traffic Management Officer undertook a review of the road traffic layout at the scene. He met with TfL on site on 16 August 2017 and a number of findings were made:
(1) No road markings indicating the direction pedestrians should look when crossing
(2) Two separate junctions at that location make that crossing confusing for pedestrians
(3) The phasing of the green man operates for each carriageway independently so causing confusion for pedestrians who may look at the wrong phasing
(4) Missing louvre on the green man on the north side of the crossing making the green man more visible to pedestrians crossing from the south
(5) With the location being close to the Eurostar Terminal there are several hotels nearby and foreign visitors may not have a full understanding if the junction.
” Open source report
×
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 Inspect the crossings and review their layout to identify changes that could further assist pedestrians.
Verbatim wording from the response “We inspected the crossings again on 11 September 2017 to review the layout and consider whether any changes could be made to assist pedestrians further. Subsequent to this visit, additional louvres were fitted on 13 October 2017 to two further green figure light aspects on the Pentonville Road crossing, including on the north side of the crossing (see Figure 2), to reduce the likelihood of pedestrians crossing when they were not invited to do so.” Source location 2017-0428-Response-by-Transport-for-London
Open published response
×
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 Fit additional louvres to two further pedestrian-signal aspects on the Pentonville Road crossing.
Verbatim wording from the response “We inspected the crossings again on 11 September 2017 to review the layout and consider whether any changes could be made to assist pedestrians further. Subsequent to this visit, additional louvres were fitted on 13 October 2017 to two further green figure light aspects on the Pentonville Road crossing, including on the north side of the crossing (see Figure 2), to reduce the likelihood of pedestrians crossing when they were not invited to do so.” Source location 2017-0428-Response-by-Transport-for-London
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 Install ‘Look left, Look right’ road markings at each pedestrian crossing at the junction.
Verbatim wording from the response “Road markings (‘matters of concern’ point 1)
The provision of ‘Look left, Look right’ markings is assessed by TfL on a site-by-site basis, in line with the national guidance. Following your report, these have been installed at each of the pedestrian crossings at this junction.” Source location 2017-0428-Response-by-Transport-for-London
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 pedestrian signals were functioning normally at the time of the collision, including the existing louvres intended to prevent confusion between crossings.
Verbatim wording from the response “Green figure ‘louvres’ on pedestrian signals (‘matters of concern’ point 4)
At the time of the collision, pedestrian signals at both crossings were functioning normally. This included louvres (a slatted cover designed to prevent confusion between the green figure light aspects of the separate crossings) on two of the green figure light aspects at the pedestrian crossings. These louvres were in place at the time of the site visit with the Metropolitan Police on 16 August 2017.” Source location 2017-0428-Response-by-Transport-for-London
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 staggered crossing arrangement is a common, efficient junction design that reduces pedestrian waiting and delays to other road users.
Verbatim wording from the response “Junction design and layout (‘matters of concern’ points 2 and 3)
The junction of Pentonville Road and King’s Cross Road operates as a single junction with two separately signalled pedestrian crossings. The crossing of King’s Cross Road is known as a ‘straight across’ crossing and the crossing on Pentonville Road as a ‘staggered’ crossing. This is a common arrangement and used throughout London. At a staggered crossing, a pedestrian must cross the road in two stages as each green figure light aspect will display independently of the other. Each green figure light aspect is sufficiently far apart to discourage pedestrians from looking at the other. This arrangement allows the junction to operate in the most efficient manner overall, reducing the time that pedestrians must wait before they are able to cross the road as well as delays to other road users.” Source location 2017-0428-Response-by-Transport-for-London
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 Although tourists use the area, the signs and highway design are clear and understandable for users regardless of their origins or familiarity.
Verbatim wording from the response “Understanding of the junction by foreign visitors (‘matters of concern’ point 5)
We take the safety of our highway extremely seriously and adopt an approach of continual improvement to reducing road danger. The measures we have undertaken at this junction will further enhance pedestrian safety at this location. There are hotels and tourists in the area, including those from outside the UK. This type of location, however, is not atypical in London and signs are designed and operate the highway so that it is clear and understandable for all users, regardless of their origins and familiarity of the area.” Source location 2017-0428-Response-by-Transport-for-London
Open published response
11 Aug 2017 Milan Dokic · Prevention of Future Deaths report London Inner (West)
View report summary
Concerns raised 2 Inadequate system for determining grip levels on London roads View source Failure to monitor grip values on London Cycle Super Highways View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Milan Dokic · 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
Milan Dokic was travelling by motorcycle on Battersea Park Road on 1 March 2016 in wet conditions when he lost control after entering a blue cycle lane, slid along the road and struck a bollard, sustaining fatal injuries at the scene. The report identified concerns about inadequate systems for determining and monitoring grip levels on Cycle Super Highways and other London roads, and about the effects of adjacent road surfaces with substantially different grip values.
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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Inadequate system for determining grip levels on London roads
Wider context from the report “1. There is an inadequate system of determining grip levels on CSH8 and on other Cycle Super Highways and on other roads in London.
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor grip values on London Cycle Super Highways
Wider context from the report “2. There has been a failure to monitor grip values on Cycle Super Highways in London.
” 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 Apply an updated skid-resistance monitoring policy specifying testing methods and frequencies for cycle superhighways.
Verbatim wording from the response “We have reviewed the approach to monitoring skid resistance on CSHs and our updated policy sets out the testing method and frequency of the regime for immediate application. All carriageway sections of the CSH have been SCRIM surveyed in the last 3 months to ensure TfL has the appropriate data to make decisions around the management of its cycle network. For segregated cycle-ways, a grip tester machine has been purchased by TfL and a testing regime is being implemented. A grip tester machine is a trailer based continuous surface friction measuring machine, which produces measurements that can be related to SCRIM data.” Source location 2017-0249-Response
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 Survey all carriageway sections of cycle superhighways using SCRIM to provide data for network-management decisions.
Verbatim wording from the response “We have reviewed the approach to monitoring skid resistance on CSHs and our updated policy sets out the testing method and frequency of the regime for immediate application. All carriageway sections of the CSH have been SCRIM surveyed in the last 3 months to ensure TfL has the appropriate data to make decisions around the management of its cycle network. For segregated cycle-ways, a grip tester machine has been purchased by TfL and a testing regime is being implemented. A grip tester machine is a trailer based continuous surface friction measuring machine, which produces measurements that can be related to SCRIM data.” Source location 2017-0249-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a grip-testing regime for segregated cycleways using a newly purchased grip tester.
Verbatim wording from the response “We have reviewed the approach to monitoring skid resistance on CSHs and our updated policy sets out the testing method and frequency of the regime for immediate application. All carriageway sections of the CSH have been SCRIM surveyed in the last 3 months to ensure TfL has the appropriate data to make decisions around the management of its cycle network. For segregated cycle-ways, a grip tester machine has been purchased by TfL and a testing regime is being implemented. A grip tester machine is a trailer based continuous surface friction measuring machine, which produces measurements that can be related to SCRIM data.” Source location 2017-0249-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Extend established grip-level determination methods to cycle superhighways.
Verbatim wording from the response “TfL has well established methods to determine grip levels across Transport for London’s Road Network (TLRN) and this is being extended to cover cycle superhighways. TfL implements and follows a comprehensive skid resistance policy which is based on proven industry best practice that is used by major highway authorities such as Highways England, and is supported by the Department for Transport. The policy describes in detail the approach to monitoring roads on the TLRN and identifying areas with a potential lack of grip, prioritising these identified sections for further investigation, and producing a risk rating of identified deficiencies for use in prioritising remedial works.” Source location 2017-0249-Response
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 Established grip-monitoring methods and a comprehensive skid-resistance policy adequately address determining grip levels on TfL roads and cycle superhighways.
Verbatim wording from the response “1. There is an inadequate procedure for determining grip levels on CSH8 and on other Cycle Superhighways and on other roads in London” Source location 2017-0249-Response
Open published response
20 Feb 2017 Esther HartSilver · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 4 Junction design permitting left-turning traffic from Lane 2 to cross straight-ahead traffic View source Lack of road-surface warning of turning-traffic conflict View source Failure of junction information to warn cyclists of vehicles turning across the bus lane View source Ambiguous road-surface indication of the bus-lane termination View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Esther HartSilver · 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
Esther HartSilver died after being seriously injured when an HGV lorry turning left at the junction of Denmark Hill and Orpheus Street collided with her bicycle as she cycled to work. The report raises concerns about the junction’s design, including the risk created by traffic turning across the bus lane, inadequate warning of potential conflicts, and a history of reported collisions and near misses involving vulnerable road users.
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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Junction design permitting left-turning traffic from Lane 2 to cross straight-ahead traffic
Wider context from the report “The junction predisposes itself to the very risk materialising that sadly caused Miss HartSilver’s death. Traffic wishing to turn left may, at the moment, turn left from Lane 2. This means that they cross a lane of traffic that may well be travelling straight ahead. Miss HartSilver was an experienced London cyclist and the HGV driver an experienced driver also. It is the junction that is unusual.
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Lack of road-surface warning of turning-traffic conflict
Wider context from the report “It may not be unusual for a lorry turning into a side road to have to cross a bus lane. The junction can be distinguished from this, however. This is a more major junction than it appears. It is a major because it feeds all the traffic that would have wanted to turn right as well as left, from a very busy road into what is effectively a side road. Further, it has a pedestrian crossing just before it. This means that although there is an early sign warning traffic of the banned right turn and to turn left instead, there are mandatory zig-zag lines on the road leading up to the junction and therefore there is no signage on the road surface warning any user of the potential for conflict.
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Failure of junction information to warn cyclists of vehicles turning across the bus lane
Wider context from the report “I am told if the bus lane were to end earlier there would still be a risk with larger vehicles needing to swing into lane 2, from lane 1, in turning the corner. It would not reduce the risk to zero. I understand all that. If I was cycling in that bus lane, even having seen the sign saying that there is a left turn for those wanting to turn right ahead, I would not be reminded of the risk of vehicles turning anything in the road layout. There is also a significant amount of traffic turning across a bus lane.
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Ambiguous road-surface indication of the bus-lane termination
Wider context from the report “The red coloured road surface that is present in the bus lane goes across this junction and will make vehicles think it is still a bus lane. Officially, the bus lane stops because the zig-zags take over as there is a pedestrian crossing present immediately before the turning on the left.
” 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 Progress the Camberwell Green junction safety scheme, including cyclist and pedestrian safety measures, through consultation, design updates and final road safety audit.
Verbatim wording from the response “The Orpheus Street junction is close to the junctions of Denmark Hill/Coldharbour Lane and Denmark Hill/Camberwell Church Street/Camberwell New Road junction adjacent to Camberwell Green and regularly referred to by that name. The latter Camberwell Green junction is part of the Transport for London Road Network (TLRN) for which TfL is the highway and traffic authority. It has the highest collision record in the area and is the 14th highest ranked junction in London based on recorded collisions for the 36 months to the end of December 2015. TfL has therefore been progressing with proposals to improve road safety at this junction, and as part of the design and approvals process recently received traffic management endorsement from TfL’s Road Space Performance Group on 16th March 2017 to proceed to public consultation.” Source location 2017-0052-Response-by-Transport-for-London
Open published response
17 Feb 2017 Mr Dokic · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 3 Potentially widespread dangerous areas of reduced-grip CSH road surface View source Failure to provide CSH road surfaces with increased grip for cyclists View source Road areas at junctions as a particular risk hazard 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
Mr Dokic · 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
Mr Dokic was travelling by motorcycle on Battersea Park Road on 1 March 2016 in wet conditions when he lost control after entering a blue cycle lane, struck a bollard and sustained fatal injuries. The principal concerns were that the cycle highway surface had reduced grip, potentially creating a hazard for cyclists and other vulnerable road users, particularly at junctions, and that similar dangerous areas might exist elsewhere.
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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Potentially widespread dangerous areas of reduced-grip CSH road surface
Wider context from the report “1. That the use of the road surface with reduced grip on the CSH compared to the usual road surface represents a hazard to road users making it more likely that they will lose control of their vehicles.
2. That the surface of the CSH with reduced grip may be widespread and as such other dangerous areas may exist .
3. That TfL should therefore undertake an urgent review of all areas treated with such road surface and replace it with the higher grip surface.
4. That the CSH should all have increased rather than reduced grip compared to the ordinary road surface since cyclists are vulnerable road users.
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Failure to provide CSH road surfaces with increased grip for cyclists
Wider context from the report “1. That the use of the road surface with reduced grip on the CSH compared to the usual road surface represents a hazard to road users making it more likely that they will lose control of their vehicles .
2. That the surface of the CSH with reduced grip may be widespread and as such other dangerous areas may exist.
3. That TfL should therefore undertake an urgent review of all areas treated with such road surface and replace it with the higher grip surface.
4. That the CSH should all have increased rather than reduced grip compared to the ordinary road surface since cyclists are vulnerable road users .
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Road areas at junctions as a particular risk hazard
Wider context from the report “5. That areas of road at junctions such as this junction between Battersea Park Road and Forrar Road are of particular concern from a risk perspective .
” Open source report
19 Aug 2016 Amanda Coppen · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 3 Road layout misleading pedestrians and motorists about traffic direction View source Potential risk to schoolchildren from increased pedestrian use of junction View source Presence of ordinary traffic in the dedicated busway 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
Amanda Coppen · 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
Amanda Coppen suffered fatal injuries when she was struck by a bus while crossing Pilot Busway on 4 January 2016. The inquest evidence indicated that she was crossing on a signal-controlled pedestrian crossing when the signal was red to pedestrians and green to traffic. Concerns included the unusual road layout potentially misleading pedestrians and motorists, and a possible increased risk to schoolchildren following the construction of a nearby school.
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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Road layout misleading pedestrians and motorists about traffic direction
Wider context from the report “The evidence at the inquest was that Ms Coppen was crossing the busway on a signal controlled pedestrian crossing while the signal was red to pedestrians and green to traffic. However, the evidence also suggested that the layout of Pilot Busway and the neighbouring road (West Parkside) is unusual: they run side by side; West Parkside consists of a single carriageway in each direction; Pilot Busway consists of a single dedicated bus lane in each direction . The evidence was that this layout could mislead road users (pedestrians and motorists) into believing that this is a standard dual carriageway . Ordinary traffic has been seen in the dedicated busway, and pedestrians could be misled into looking the wrong way when crossing the road .
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Potential risk to schoolchildren from increased pedestrian use of junction
Wider context from the report “I understand that a new school is shortly to be built close to this junction . This may increase the numbers of pedestrians using the junction and there is a potential risk to schoolchildren .
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Presence of ordinary traffic in the dedicated busway
Wider context from the report “The evidence at the inquest was that Ms Coppen was crossing the busway on a signal controlled pedestrian crossing while the signal was red to pedestrians and green to traffic. However, the evidence also suggested that the layout of Pilot Busway and the neighbouring road (West Parkside) is unusual: they run side by side; West Parkside consists of a single carriageway in each direction; Pilot Busway consists of a single dedicated bus lane in each direction. The evidence was that this layout could mislead road users (pedestrians and motorists) into believing that this is a standard dual carriageway. Ordinary traffic has been seen in the dedicated busway , and pedestrians could be misled into looking the wrong way when crossing the road.
” Open source report
6 Jun 2016 Ezh arul Islam · Prevention of Future Deaths report North London
View report summary
Concerns raised 1 Lack of a system to alert passengers that the bus is about to move View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ezh arul Islam · 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 23 October 2015, Ezh arul Islam fell and struck his head as a 191 bus moved away from a bus stop, possibly while he was sitting down. The principal concern was that there was no system to alert passengers that the bus was about to move; the inquest recorded a narrative conclusion and a medical cause of death involving aspiration pneumonia and treatment following chronic subdural haematoma.
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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Lack of a system to alert passengers that the bus is about to move
Wider context from the report “That there was no system to alert passengers that the 191 bus was about to move . In the past the signal that a bus was about to move would have been the conductor saying hold on tight and sounding a bell twice in rapid succession.
” 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 Develop the Bus Safety Standard for London Buses, including consideration of the recommendation for a passenger movement alert and other safety technologies and designs.
Verbatim wording from the response “TfL is also developing a Bus Safety Standard for London Buses which involves the consideration of a range of innovative and new technologies to continue to improve safety on buses. Such technologies could include collision avoidance systems which utilise sensors to warn bus drivers of potential dangers and trigger Automatic Emergency Braking systems, and Intelligent Speed Assistance. Other potential design innovations to be considered include improving wing mirror design and windscreen glazing to reduce the impact of any collision. Part of the work of the Bus Safety Standard for London involves” Source location 2016-0214-Response-by-Transport-for-London
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 bus conductor’s bell was not used to warn passengers that the bus was about to move.
Verbatim wording from the response “Your report refers to the past in which you say that the bus conductor signalled to customers when the bus was about to move by saying hold on tight and sounding a bell twice in rapid succession. The traditional role of a bus conductor was to collect fares, maintain the safety of the open platform and signal to the driver that it was safe to move away from the stop. The number of bus conductors significantly reduced during the 1990’s and early 2000’s as the use of the traditional routemaster was phased out of service. Bus conductors did not indicate to customers when the bus was to move and the use of the bell was to advise the driver that customers wishing to board or alight from the bus had done so. The bell was not used as a method of warning customers that the bus would be moving.” Source location 2016-0214-Response-by-Transport-for-London
Open published response
19 Jun 2015 Christopher Tandy · Prevention of Future Deaths report City of London
View report summary
Concerns raised 2 Lack of a separate lane for cyclists from vehicular and pedestrian traffic View source Lack of prominent signage communicating the 20 mph speed limit on London Bridge View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Christopher Tandy · 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
Christopher Tandy died after his bicycle veered across London Bridge and he was struck by a southbound motor car. Concerns included inadequate prominent signage for the 20 mph speed limit and the lack of a separate cycle lane on the bridge.
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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Lack of a separate lane for cyclists from vehicular and pedestrian traffic
Wider context from the report “Ideally, a separate lane for cyclists (e.g. as on Southwark Bridge) would separate them from vehicular and pedestrian traffic .
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Lack of prominent signage communicating the 20 mph speed limit on London Bridge
Wider context from the report “A review of the signage and road layout suggest that there is opportunity to take steps to try to prevent a recurrence of deaths in comparable circumstances. A driver unfamiliar with City roads, having been stuck in slow-moving traffic through the city, and on seeing the road over London Bridge open out from, first, one lane, to two lanes then to three lanes, is tempted to accelerate to a speed above the new statutory limit.
I suggest that some improved signage is desirable, to remind drivers that the speed limit on the bridge remains 20 mph. I was informed in evidence that there is no prominent speed limit signage at the commencement of the bridge and that in other places in the City only the smaller 20 mph repeater signs are displayed .
A driver travelling from south to north over Southwark Bridge will see a large 30mph speed limit sign at the north end. If the driver turns right onto Upper Thames Street and then goes under London Bridge and turns left into Fish Street Hill, then left onto Monument Street and then left onto London Bridge there is no prominent signage to make clear that the speed limit reduces from 30 to 20mph .
” 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 Publish proposals for improved traffic arrangements in the London Bridge area, including consideration of cyclist safety.
Verbatim wording from the response “In terms of the general road layout in the vicinity of London Bridge, there are a number of significant public and private developments currently in progress and others to be delivered in the near future, some of which have a temporary impact on road capacity and layout. In the longer term, TfL intends to publish proposals for improved traffic arrangements in the London Bridge area, intended to benefit road users in general, and cyclists in particular. The feasibility of a Cycle Superhighway across London Bridge is likely to begin in 2016, when various options such as full segregation will be investigated. Following this there will be full public consultation. Your concerns will also be taken into account in this process.” Source location 2015-0234-Response-by-Transport-for-London
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 Install an additional pair of 20 mph repeater signs on the north side of London Bridge.
Verbatim wording from the response “However, in view of your concerns, we will install an additional pair of repeater signs at the north side of the Bridge. The 20 mph scheme was introduced under an experimental Traffic Management Order. If it is to be retained on a permanent basis, there is scope for considering the spacing between the repeater signs along the entire route, and your concerns will be taken into account.” Source location 2015-0234-Response-by-Transport-for-London
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing repeater-sign arrangements comply with national standards and were considered sufficient to remind drivers that the speed limit remained 20mph.
Verbatim wording from the response “You refer to the prominence of signs at the commencement of London Bridge and that in other areas of the City, only smaller repeater signs are displayed. The 20mph limit does not commence at London Bridge, but continues over the Bridge. Larger terminal signs are used at the entry / exit points to the 20mph limit in Shoreditch High Street, and smaller repeater signs are used along the 20mph route into King William Street and across the Bridge, which is in accordance with national standards. It is considered that providing large terminal signs at the commencement of the Bridge travelling north to south could cause confusion. When the scheme was designed in 2014, the designers spaced repeater signs at the intervals that they believed would be sufficient to remind drivers that the speed limit remains at 20mph.” Source location 2015-0234-Response-by-Transport-for-London
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20 Feb 2015 Maria Nekrasova · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 4 Inadequate night-time lighting of the bridge carriageway View source Lack of prevention of pedestrian crossing of the bridge carriageway View source Failure to maintain driver visibility of pedestrians in the bridge carriageway during oncoming headlight glare View source Lack of protection for pedestrians in the middle of the bridge carriageway 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
Maria Nekrasova · 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
Maria Nekrasova was struck by a licensed taxi while standing in the hatched area in the middle of Westminster Bridge carriageway at about 1.50 am on 4 May 2014, sustaining a severe traumatic head injury from which she died. Concerns included the absence of pedestrian barriers or protection in the carriageway, low and contrasting street lighting, and vehicle headlight glare affecting drivers’ ability to see pedestrians.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Transport for London; that does not assign responsibility.
PFD Monitor interpretation Inadequate night-time lighting of the bridge carriageway
Wider context from the report “(2) At night the level of street lighting is low , the lamp standards producing pools of light which have the effect of leaving contrasting areas of the carriageway in relative 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Lack of prevention of pedestrian crossing of the bridge carriageway
Wider context from the report “(1) There is nothing to prevent pedestrians crossing the carriageway of the bridge (such as a central fence) and neither is there any protection for pedestrians who have reached the middle of the carriageway (such as a central reservation);
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain driver visibility of pedestrians in the bridge carriageway during oncoming headlight glare
Wider context from the report “(3) The glare of the headlights of oncoming vehicles makes it impossible for drivers of vehicles crossing the bridge to see pedestrians standing in the carriageway until it is too late to avoid hitting them.
” 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 Transport for London; that does not assign responsibility.
PFD Monitor interpretation Lack of protection for pedestrians in the middle of the bridge carriageway
Wider context from the report “(1) There is nothing to prevent pedestrians crossing the carriageway of the bridge (such as a central fence) and neither is there any protection for pedestrians who have reached the middle of the carriageway (such as a central reservation) ;
” Open source report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Carry out a detailed investigation of lighting levels and light distribution across Westminster Bridge by August 2015.
Verbatim wording from the response “The light output from each of the ‘heritage’ lighting points on the bridge is similar to that provided from conventional street lights. However, TfL will be carrying out a detailed investigation of the lighting levels and the distribution of light over the bridge by August 2015. Following the outcome of the investigation, we will consider what alterations might be appropriate or possible, taking into account the physical constraints of providing additional lighting points across the bridge deck and in such a historic location.” Source location 2015-0141-Response-by-Transport-for-London
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider appropriate or possible alterations to Westminster Bridge lighting after completing the lighting investigation.
Verbatim wording from the response “The light output from each of the ‘heritage’ lighting points on the bridge is similar to that provided from conventional street lights. However, TfL will be carrying out a detailed investigation of the lighting levels and the distribution of light over the bridge by August 2015. Following the outcome of the investigation, we will consider what alterations might be appropriate or possible, taking into account the physical constraints of providing additional lighting points across the bridge deck and in such a historic location.” Source location 2015-0141-Response-by-Transport-for-London
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Pedestrian barriers will not be erected because they could isolate pedestrians and create a safety hazard.
Verbatim wording from the response “TfL’s policy is a presumption against the provision of pedestrian guardrail, except where there is a proven safety requirement. Having considered this location, and the possible physical segregation of pedestrians from vehicular traffic, the erection of a barrier could potentially create a safety hazard for pedestrians, joggers or cyclists who could become isolated on the wrong side of the barrier. For this reason, no barriers will be erected. Central reservations are usually provided to separate the flow of opposing high speed traffic, to prevent overtaking on the approaches to junctions or at designated pedestrian crossing points.” Source location 2015-0141-Response-by-Transport-for-London
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Headlight glare is not addressed because it is outside the respondent’s ability to influence or control.
Verbatim wording from the response “Glare from headlights is not a matter that TfL has any ability to influence or control, and no further comment is made in this respect.” Source location 2015-0141-Response-by-Transport-for-London
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A central reserve is not considered appropriate because the bridge has a 30mph limit and no locations justify a pedestrian crossing.
Verbatim wording from the response “Given that Westminster Bridge is subject to a 30mph speed limit and that there are no junctions or locations across the bridge which justify the provision of a pedestrian crossing, the provision of a central reserve would be inconsistent with other urban locations and TfL do not feel it would be appropriate to install one.” Source location 2015-0141-Response-by-Transport-for-London
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations