7 Apr 2026 Matilda Rose Davis · Prevention of Future Deaths report Warwickshire
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Concerns raised 3 Failure to signpost people with possible suicidal thoughts to crisis support services View source Failure to directly ask about suicidal ideation when suicidal thoughts are indicated in referral information View source Lack of mandatory suicide prevention training for frontline practitioners and staff View source
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Matilda Rose Davis · 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
Matilda was found deceased at her home shortly after an urgent safeguarding visit concerning her mental health and the welfare of her children. The inquest identified concerns that suicide prevention training was not mandatory for frontline practitioners, that she was not asked directly about suicidal ideation, and that she was not signposted to crisis support services.
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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 Warwickshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to signpost people with possible suicidal thoughts to crisis support services
Wider context from the report “Evidence heard during the inquest confirmed that suicide prevention training is not mandatory for frontline practitioners and staff within Warwickshire Children’s Services. The social worker and support worker who visited Matilda had not received suicide prevention training, although such training was available within the organisation.
In the absence of mandatory suicide prevention training, Matilda was not asked directly about suicidal ideation during the visit, where reference was made to suicidal thoughts within the referral context. It was also noted that she was not signposted to crisis support services at that time.
The non-mandatory nature of suicide prevention training may give rise to variability in practice when practitioners are required to explore, record, or respond to indications of possible self harm or suicidal thoughts.
” 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 Warwickshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to directly ask about suicidal ideation when suicidal thoughts are indicated in referral information
Wider context from the report “Evidence heard during the inquest confirmed that suicide prevention training is not mandatory for frontline practitioners and staff within Warwickshire Children’s Services. The social worker and support worker who visited Matilda had not received suicide prevention training, although such training was available within the organisation.
In the absence of mandatory suicide prevention training, Matilda was not asked directly about suicidal ideation during the visit, where reference was made to suicidal thoughts within the referral context. It was also noted that she was not signposted to crisis support services at that time.
The non-mandatory nature of suicide prevention training may give rise to variability in practice when practitioners are required to explore, record, or respond to indications of possible self harm or suicidal thoughts.
” 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 Warwickshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory suicide prevention training for frontline practitioners and staff
Wider context from the report “Evidence heard during the inquest confirmed that suicide prevention training is not mandatory for frontline practitioners and staff within Warwickshire Children’s Services . The social worker and support worker who visited Matilda had not received suicide prevention training, although such training was available within the organisation.
In the absence of mandatory suicide prevention training, Matilda was not asked directly about suicidal ideation during the visit, where reference was made to suicidal thoughts within the referral context. It was also noted that she was not signposted to crisis support services at that time.
The non-mandatory nature of suicide prevention training may give rise to variability in practice when practitioners are required to explore, record, or respond to indications of possible self harm or suicidal thoughts.
” 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 Commission Tier 2 practitioner suicide prevention training through a formal competitive procurement process.
Verbatim wording from the response “Due to the scale of investment, commissioning of Tier 2 training will be subject to a formal procurement tender process in line with organisational requirements. As such options will be finalised following a competitive tendering exercise. In person and online options will be considered with the preference to be for frontline staff who hold cases to have in person training. Commencing Autumn 2026.” Source location Response from Warwickshire County Council
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver mandatory Tier 1 suicide prevention awareness training to all Children and Families frontline staff within three months.
Verbatim wording from the response “Tier 1 – Universal awareness (mandatory)
This tier establishes a baseline for all staff. It focuses on:” Source location Response from Warwickshire County Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a refreshed central suicide prevention intranet resource hub supporting access to guidance, training materials and support pathways.
Verbatim wording from the response “Delivery will be through the updated 2024 e-learning programme, ensuring content is aligned with current best practice in suicide prevention, supported by a single, accessible intranet resource hub which signposts to additional resources and pathways for support (including Dear Life). A refreshed and regularly reviewed suicide prevention intranet page will act as the central resource hub, building on the existing WCC Suicide Prevention page and ensuring consistent access to guidance and training materials, as well as signposting resources.” Source location Response from Warwickshire County Council
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver phased, mandatory Tier 2 practitioner training to identified Children and Families staff, with refreshers and ongoing training for new starters.
Verbatim wording from the response “Tier 2 – Practitioner response (mandatory)
This tier is designed for staff working directly with individuals at risk, including social workers, family practitioners, and personal advisors.
The focus is on developing applied skills and confidence in:” Source location Response from Warwickshire County Council
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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 Tier 2 practitioner training will be phased over three years because financial considerations and workforce capacity constrain faster implementation.
Verbatim wording from the response “Tier 2 Delivery Model and Timescale
Delivery of Tier 2 training will follow a phased three-year implementation model, reflecting both financial considerations and workforce capacity.” Source location Response from Warwickshire County Council
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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 Expansion of suicide-prevention training to wider workforce groups is subject to funding agreement.
Verbatim wording from the response “Following initial rollout, delivery will transition into a business-as-usual model permitting funding, including:” Source location Response from Warwickshire County Council
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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 Mandatory completion of universal suicide-awareness training across the Council remains subject to further corporate agreement.
Verbatim wording from the response “Delivery will be through the updated 2024 e-learning programme, ensuring content is aligned with current best practice in suicide prevention, supported by a single, accessible intranet resource hub which signposts to additional resources and pathways for support (including Dear Life). A refreshed and regularly reviewed suicide prevention intranet page will act as the central resource hub, building on the existing WCC Suicide Prevention page and ensuring consistent access to guidance and training materials, as well as signposting resources.” Source location Response from Warwickshire County Council
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Tier 2 training commissioning and delivery options cannot be finalised until a competitive procurement tender is completed.
Verbatim wording from the response “Due to the scale of investment, commissioning of Tier 2 training will be subject to a formal procurement tender process in line with organisational requirements. As such options will be finalised following a competitive tendering exercise. In person and online options will be considered with the preference to be for frontline staff who hold cases to have in person training. Commencing Autumn 2026.” Source location Response from Warwickshire County Council
Open published response
10 Nov 2023 Master Mason Williams · Prevention of Future Deaths report Warwickshire
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Concerns raised 1 Unavailability of street lighting due to underground cabling faults 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
Master Mason Williams · 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
Mason Williams was struck by a car while crossing Trinity Road, Piccadilly, in darkness on 30 November 2022 and died in hospital three days later. The substantive concern was that the street lighting was not illuminated because of a fault with underground cabling, which may have been damaged in an earlier road traffic collision.
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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 Warwickshire County Council; that does not assign responsibility.
PFD Monitor interpretation Unavailability of street lighting due to underground cabling faults
Wider context from the report “i. The street lighting along Trinity Road, Piccadilly, nr Kingsbury was not illuminated at the time of the Road Traffic Collision due to a fault. I am told the fault was with the underground cabling which was affecting lamp posts 16 to 21 along Trinity Road .
ii. I am aware that the cabling may have been damaged from a previous Road Traffic Collision that occurred on 20 October 2022.
” Open source report
13 Sep 2018 Laila Habibi and Danial Ghafuri · Prevention of Future Deaths report Warwickshire
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Concerns raised 3 Absence of an illuminated single-carriageway warning sign View source Periodic large volumes of traffic on the road View source Road traffic incidents on the road, including fatalities 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
Laila Habibi and Danial Ghafuri · 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
Laila Habibi and her two-year-old son, Danial Ghafuri, were passengers in a car diverted from the M1 motorway when it entered the wrong carriageway on the A426 Lutterworth Road and collided with an oncoming HGV; both died at the scene on 17 February 2018. The concerns included previous road traffic incidents and fatalities on the road, its use as a regular M1 diversion route carrying large volumes of traffic, and the absence of an illuminated single-carriageway warning sign.
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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 Warwickshire County Council; that does not assign responsibility.
PFD Monitor interpretation Absence of an illuminated single-carriageway warning sign
Wider context from the report “(3) an absence of an illuminated ‘single carriageway’ warning sign
” 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 Warwickshire County Council; that does not assign responsibility.
PFD Monitor interpretation Periodic large volumes of traffic on the road
Wider context from the report “(2) that this road is a regular diversion route from the M1 motorway hence periodically, receives usually large volumes of 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 Warwickshire County Council; that does not assign responsibility.
PFD Monitor interpretation Road traffic incidents on the road, including fatalities
Wider context from the report “(1) that there had been a number of road traffic incidents on this road including fatalities ,
” Open source report
25 May 2018 Neil JONES · Prevention of Future Deaths report Warwickshire
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Concerns raised 1 Fatal road traffic collision hazard at the site despite a 50 mph speed limit View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Neil JONES · 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
Neil Jones was ejected from the Bel Air nightclub at the Belfry Resort because he was intoxicated and was subsequently hit by a vehicle at about 1.30am on the A446 outside the resort. The report raised concern about four fatal road traffic collisions at the site over 10 years, despite a reduction in the speed limit, and noted that a casualty reduction scheme was being considered.
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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 Warwickshire County Council; that does not assign responsibility.
PFD Monitor interpretation Fatal road traffic collision hazard at the site despite a 50 mph speed limit
Wider context from the report “(1) There have been 4 (four) fatal road traffic collisions at this site over 10 years despite a reduction in the speed limit to 50 mph. in 2008. I am aware that the site is being considered as a casualty reduction scheme although I understand no final decision has been made.
” 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 prioritisation and short-listing of casualty-reduction schemes for the A446 site and decide the outcome by the end of September.
Verbatim wording from the response “The death of Mr Jones increases the number of casualties on this length of the A444 and thus will affect the prioritisation of schemes. However, until we have completed our scheme short listing process it is not possible to commit to any scheme. Given that the resources available are finite, any decision to implement one scheme will mean that one or more other schemes cannot be implemented elsewhere. Therefore, it is important that the prioritisation process is adhered to before committing funds to a scheme. We are currently undertaking this process and would expect to make a decision by the end of September at which point we will be able to confirm the outcome.” Source location Response from Warwickshire County Council
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No immediate highway safety actions were considered necessary following the post-collision site inspection.
Verbatim wording from the response “The purpose of the site visit is to ascertain whether for safety reasons there are any immediate actions that need to be taken in respect to the highway and any possible defects and/or improvements that should be remedied or carried out without delay. At the time of the inspection officers attending agreed there were no immediate actions that needed to be undertaken.” Source location Response from Warwickshire County Council
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Finite casualty-reduction funding and prioritisation requirements prevent commitment to a scheme before the shortlisting process is complete.
Verbatim wording from the response “The County Council addresses road safety in a number of ways. In the case of this length of road, the relevant programme is the casualty reduction programme. We undertake an annual review of all collision cluster sites and routes across the County in order to identify those with the worst collision records and where there is a pattern of causes which can be addressed by engineering measures. The number of possible schemes considered each year across the County exceeds the annual funding available for the programme and, therefore, it is necessary to prioritise schemes according to objective criteria. The criteria identify those schemes which will deliver the greatest reduction in casualties for the money spent.” Source location Response from Warwickshire County Council
Open published response
28 Sep 2017 Katherine Tracey Vanloo · Prevention of Future Deaths report Warwickshire
View report summary
Concerns raised 5 Lack of formal auditing of pothole repair completion and quality View source Delays in raising and transmitting pothole repair works orders View source Delays in completing pothole repairs View source Failure to ensure repair of the identified pothole View source Lack of tracking of outstanding pothole repair works orders View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Katherine Tracey Vanloo · 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
Katherine Tracey Vanloo died on 3 January 2016 from catastrophic injuries after falling from her bicycle when it hit an unrepaired pothole and being struck by a car. The report identified delays in repairing the pothole and a lack of systems to track outstanding works and audit whether repairs had been completed and were of adequate quality.
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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 Warwickshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of formal auditing of pothole repair completion and quality
Wider context from the report “(1) The pothole was first identified on 23rd March 2015 as a category 2 defect with a target of 28 days within which such defects should be repaired.
(2) The works order to carry out the repair was only raised by Warwickshire County Council 3 months later on 5th June 2015. This was sent to Balfour Beatty Living Places who had entered into a contract with Warwickshire County Council to repair road surfaces in Warwickshire. They in turn subcontracted the road repair work, which included pothole repair work, to CR MacDonald. The works order was received by CR MacDonald on 19th June 2015.
(3) The work to repair the pothole was not undertaken by an employee of CR MacDonald until 2nd November 2015, albeit that the wrong pothole was repaired on that day.
(4) There was a delay of over 7 months between the identification of the pothole and the time it was supposedly repaired on 2nd November 2015.
(5) At the time of the incident Warwickshire County Council did not have a system in place to track with Balfour Beatty Living Places or CR MacDonald the progress of works orders, i.e. when outstanding works had been completed, nor any formal programme of auditing to check if the work has been done and to check the quality of the work.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Warwickshire County Council; that does not assign responsibility.
PFD Monitor interpretation Delays in raising and transmitting pothole repair works orders
Wider context from the report “(1) The pothole was first identified on 23rd March 2015 as a category 2 defect with a target of 28 days within which such defects should be repaired.
(2) The works order to carry out the repair was only raised by Warwickshire County Council 3 months later on 5th June 2015. This was sent to Balfour Beatty Living Places who had entered into a contract with Warwickshire County Council to repair road surfaces in Warwickshire. They in turn subcontracted the road repair work, which included pothole repair work, to CR MacDonald. The works order was received by CR MacDonald on 19th June 2015.
(3) The work to repair the pothole was not undertaken by an employee of CR MacDonald until 2nd November 2015, albeit that the wrong pothole was repaired on that day.
(4) There was a delay of over 7 months between the identification of the pothole and the time it was supposedly repaired on 2nd November 2015.
(5) At the time of the incident Warwickshire County Council did not have a system in place to track with Balfour Beatty Living Places or CR MacDonald the progress of works orders, i.e. when outstanding works had been completed, nor any formal programme of auditing to check if the work has been done and to check the quality of the work.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Warwickshire County Council; that does not assign responsibility.
PFD Monitor interpretation Delays in completing pothole repairs
Wider context from the report “(1) The pothole was first identified on 23rd March 2015 as a category 2 defect with a target of 28 days within which such defects should be repaired.
(2) The works order to carry out the repair was only raised by Warwickshire County Council 3 months later on 5th June 2015. This was sent to Balfour Beatty Living Places who had entered into a contract with Warwickshire County Council to repair road surfaces in Warwickshire. They in turn subcontracted the road repair work, which included pothole repair work, to CR MacDonald. The works order was received by CR MacDonald on 19th June 2015.
(3) The work to repair the pothole was not undertaken by an employee of CR MacDonald until 2nd November 2015 , albeit that the wrong pothole was repaired on that day.
(4) There was a delay of over 7 months between the identification of the pothole and the time it was supposedly repaired on 2nd November 2015.
(5) At the time of the incident Warwickshire County Council did not have a system in place to track with Balfour Beatty Living Places or CR MacDonald the progress of works orders, i.e. when outstanding works had been completed, nor any formal programme of auditing to check if the work has been done and to check the quality of the work.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Warwickshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure repair of the identified pothole
Wider context from the report “(1) The pothole was first identified on 23rd March 2015 as a category 2 defect with a target of 28 days within which such defects should be repaired.
(2) The works order to carry out the repair was only raised by Warwickshire County Council 3 months later on 5th June 2015. This was sent to Balfour Beatty Living Places who had entered into a contract with Warwickshire County Council to repair road surfaces in Warwickshire. They in turn subcontracted the road repair work, which included pothole repair work, to CR MacDonald. The works order was received by CR MacDonald on 19th June 2015.
(3) The work to repair the pothole was not undertaken by an employee of CR MacDonald until 2nd November 2015, albeit that the wrong pothole was repaired on that day.
(4) There was a delay of over 7 months between the identification of the pothole and the time it was supposedly repaired on 2nd November 2015.
(5) At the time of the incident Warwickshire County Council did not have a system in place to track with Balfour Beatty Living Places or CR MacDonald the progress of works orders, i.e. when outstanding works had been completed, nor any formal programme of auditing to check if the work has been done and to check the quality of the work.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Warwickshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of tracking of outstanding pothole repair works orders
Wider context from the report “(1) The pothole was first identified on 23rd March 2015 as a category 2 defect with a target of 28 days within which such defects should be repaired.
(2) The works order to carry out the repair was only raised by Warwickshire County Council 3 months later on 5th June 2015. This was sent to Balfour Beatty Living Places who had entered into a contract with Warwickshire County Council to repair road surfaces in Warwickshire. They in turn subcontracted the road repair work, which included pothole repair work, to CR MacDonald. The works order was received by CR MacDonald on 19th June 2015.
(3) The work to repair the pothole was not undertaken by an employee of CR MacDonald until 2nd November 2015, albeit that the wrong pothole was repaired on that day.
(4) There was a delay of over 7 months between the identification of the pothole and the time it was supposedly repaired on 2nd November 2015.
(5) At the time of the incident Warwickshire County Council did not have a system in place to track with Balfour Beatty Living Places or CR MacDonald the progress of works orders, i.e. when outstanding works had been completed , nor any formal programme of auditing to check if the work has been done and to check the quality of the work.
” Open source report
1 Mar 2016 Peter Embra · Prevention of Future Deaths report Warwickshire
View report summary
Concerns raised 1 Failure to act promptly on urgent referrals for assessment 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
Peter Embra · 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
Peter Embra’s death was investigated, with the inquest concluding with a Narrative Verdict. The principal concern was that the local authority failed to act on an urgent referral from a GP, resulting in an approximately seven-week delay before a social worker visited him.
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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 Warwickshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to act promptly on urgent referrals for assessment
Wider context from the report “The local authority failed to act on an urgent referral from a GP.
████████(GP) visited Mr Embra at his home on 9 March 2015 and contacted the local authority asking for an urgent assessment . On 16 March he made a written referral to the local authority asking for an urgent assessment preferably that day . There was an approximately 7 week delay before a Social Worker visited Mr Embra.
” Open source report
1 May 2015 Julius CATACHANAS · Prevention of Future Deaths report Warwickshire
View report summary
Concerns raised 1 Absence of street lighting 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
Julius CATACHANAS · 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
Julius Catachanas, aged 25, died following a road traffic collision while driving at night on Campden Road, where his car collided with a lorry at the junction with the Fosseway. Concerns were raised about the absence of street lighting and whether the junction should be staggered to prevent vehicles crossing the Fosseway straight through.
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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 Warwickshire County Council; that does not assign responsibility.
PFD Monitor interpretation Absence of street lighting at the junction
Wider context from the report “(1) I was concerned that street lighting was not present 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 Implement a street-lighting scheme to improve junction visibility at night.
Verbatim wording from the response “• In view of the number of injury collisions that occurred in the hours of darkness, a street lighting scheme will be implemented to make the junction more visible at night;” Source location Response from Warwickshire County Council
Open published response
9 Jan 2015 Mark Burdett · Prevention of Future Deaths report Warwickshire
View report summary
Concerns raised 1 Lack of signage warning motorists of a concealed entrance 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
Mark Burdett · 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 Burdett was riding his motorcycle along Blythe Road, Coleshill, on 10 July 2014 when he collided with a car exiting from Blythe Hall. The concern was the lack of a warning sign for the concealed entrance, particularly for traffic travelling from the Coleshill direction.
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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 Warwickshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of signage warning motorists of a concealed entrance
Wider context from the report “(1) the lack of a sign warning motorists of the concealed entrance -- this particularly applied to traffic coming from the Coleshill direction
” Open source report
24 Mar 2014 Sean Andrew Morley · Prevention of Future Deaths report Warwickshire
View report summary
Concerns raised 4 Lack of street lighting on the road View source Exposure of pedestrians and cyclists to vehicular traffic on the A444 View source Lack of warning signs for pedestrians and cyclists using the road View source Lack of barriers or other protective features separating vehicular traffic from pedestrians 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
Sean Andrew Morley · 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
Sean Andrew Morley was struck and killed by a motor vehicle while crossing the A444 Bedworth By-pass on foot between 3am and 4am on 2 September 2012. The report raised concerns that the road was regularly used by pedestrians and cyclists despite having no warning signs, street lighting, barriers, or other protective features, and that these conditions created a risk of further fatal collisions.
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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 Warwickshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of street lighting on the road
Wider context from the report “(1) I heard evidence that the stretch of the A444 where Sean died is regularly used by pedestrians and cyclists, who walk or ride on the grass verge at the side of the carriageway or on the edge of the carriageway itself.
(2) Since Sean’s death, there has been a further incident on the same stretch of road where a pedestrian was struck by a car. Fortunately, the injuries were not fatal.
(3) There are no signs warning pedestrians or cyclists of the dangers of using the road. There are no street lights . The speed limit on the road is 70mph. There is no barrier or other protective features between the vehicular traffic and pedestrians.
(4) These factors strongly suggest that there is a risk of further fatal collisions between vehicles and other 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 Warwickshire County Council; that does not assign responsibility.
PFD Monitor interpretation Exposure of pedestrians and cyclists to vehicular traffic on the A444
Wider context from the report “(1) I heard evidence that the stretch of the A444 where Sean died is regularly used by pedestrians and cyclists, who walk or ride on the grass verge at the side of the carriageway or on the edge of the carriageway itself .
(2) Since Sean’s death, there has been a further incident on the same stretch of road where a pedestrian was struck by a car. Fortunately, the injuries were not fatal.
(3) There are no signs warning pedestrians or cyclists of the dangers of using the road. There are no street lights. The speed limit on the road is 70mph. There is no barrier or other protective features between the vehicular traffic and pedestrians.
(4) These factors strongly suggest that there is a risk of further fatal collisions between vehicles and other 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 Warwickshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of warning signs for pedestrians and cyclists using the road
Wider context from the report “(1) I heard evidence that the stretch of the A444 where Sean died is regularly used by pedestrians and cyclists, who walk or ride on the grass verge at the side of the carriageway or on the edge of the carriageway itself.
(2) Since Sean’s death, there has been a further incident on the same stretch of road where a pedestrian was struck by a car. Fortunately, the injuries were not fatal.
(3) There are no signs warning pedestrians or cyclists of the dangers of using the road . There are no street lights. The speed limit on the road is 70mph. There is no barrier or other protective features between the vehicular traffic and pedestrians.
(4) These factors strongly suggest that there is a risk of further fatal collisions between vehicles and other 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 Warwickshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of barriers or other protective features separating vehicular traffic from pedestrians
Wider context from the report “(1) I heard evidence that the stretch of the A444 where Sean died is regularly used by pedestrians and cyclists, who walk or ride on the grass verge at the side of the carriageway or on the edge of the carriageway itself.
(2) Since Sean’s death, there has been a further incident on the same stretch of road where a pedestrian was struck by a car. Fortunately, the injuries were not fatal.
(3) There are no signs warning pedestrians or cyclists of the dangers of using the road. There are no street lights. The speed limit on the road is 70mph. There is no barrier or other protective features between the vehicular traffic and pedestrians .
(4) These factors strongly suggest that there is a risk of further fatal collisions between vehicles and other road users.
” 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 Carry out a feasibility study for a separated footpath between Walsingham Drive and Sutherland Drive, including costs, benefits, speed limits and lighting.
Verbatim wording from the response “4. Evidence was also given that proposals to introduce a footpath to enable pedestrians to walk between Walsingham Drive and Sutherland Drive, separated from the fast moving traffic would need to be properly investigated through a feasibility study. A feasibility study is to be carried out by consultants on behalf of the County Council and the level of footfall provided by the CCTV survey will feed into this study, giving a clear understanding of the level of usage such a facility would attract. This study will consider the cost and benefit of the introduction of a footpath, given the limitations of the road safety budget. Included in the study will be the speed limit for the road and other factors such as street lighting etc. The feasibility study is expected to be completed by the end of September 2014.” Source location Response from Warwickshire County Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assess the layby’s usage and viability, including whether removing it would prevent pedestrians crossing the A444.
Verbatim wording from the response “6. The location and usage of the layby raise other concerns. It is apparent that there are people being picked up or dropped off from vehicles in this layby, who subsequently walk across the A444 to or from premises off Sutherland Drive. This location is also to be assessed to determine if it would be advisable to remove the layby, in order to prevent the pedestrian movements across the A444 in this location. A CCTV survey has been conducted, the results of which will be analysed and an assessment made of the layby and its viability.” Source location Response from Warwickshire County Council
Open published response
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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 Install barrier railings and introduce warning signs directing vulnerable road users to alternative routes and warning of dual-carriageway dangers.
Verbatim wording from the response “7. At the inquest, the lack of warning signs to deter pedestrians from using this route was discussed. The Traffic Signs, Regulations and General Directions 2002 which prescribe the types of sign permitted to be used on the highway, do not include signs for this purpose, that are approved for use on the highway. However, Warwickshire County Council has made a commitment to introduce barrier railings, to be positioned at locations where the footway around the roundabout at Walsingham Drive terminates; and warning signs that are designed to inform pedestrians and other vulnerable road users that alternative routes are available, and to advise them of the dangers posed by walking or cycling along a dual carriageway with a 70mph speed limit.” Source location Response from Warwickshire County Council
Open published response
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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 Analyse CCTV footage to determine pedestrian and cyclist usage and inform safety assessments.
Verbatim wording from the response “3. It is accepted that during the course of the investigations into the circumstances leading to Mr Morley's death, it became apparent that there is evidence of pedestrian footfall along the A444, in the form of a welltrodden path in the verge. At the inquest into Mr Morley's death, evidence was given by a Road Safety Engineer on behalf of the County Council that a CCTV survey had been commissioned to determine the level of pedestrian and cyclist use. Analysis of this footage and the direction of travel of pedestrians is still to be carried out.” Source location Response from Warwickshire County Council
Open published response
7 Feb 2014 John William GROOBY · Prevention of Future Deaths report Warwickshire
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Concerns raised 1 Lack of signage warning motorists of deer use of the area as a game track View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
John William GROOBY · 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
John William Grooby, a motorcyclist, died after being struck by a deer on the A3400 between Tredington and Shipston on Stour on 24 October 2013. The substantive concern was the lack of signage warning motorists that deer use the area as a “game track”.
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 Warwickshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of signage warning motorists of deer use of the area as a game track
Wider context from the report “(1) Lack of any signage to warn motorists that deer use this area as a “game track”.
” 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 evidence on deer collisions and assess the case for warning signs at the A3400 location.
Verbatim wording from the response “PC ████████ was notified by a colleague PC ████████ prior to the site visit, that there were records of non-injury related accidents along this stretch of road involving deer. PC ████████ had recorded 5 previous incidents since 2010. This information was new to the County Council, and informed officers of the tendency for deer to be present in the road at this location.” Source location 2014-0054-Response-by-Warwickshire-County-Council
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Install two diagram 551 wild-animal warning signs on the A3400 section near the identified deer crossing location.
Verbatim wording from the response “Warwickshire County Council has reviewed the evidence supporting the Coroner’s view that action should be taken to prevent future similar deaths by introducing signs to warn motorists that deer use this area as a ‘game track’ and the decision has been taken to introduce signs on this section of the A3400. An instruction has been passed to the Council’s contractors to install two signs. These signs are in accordance with the Traffic Signs, Regulations and General Directions 2002, signs to diagram 551 “Wild animals likely to be in the road”.” Source location 2014-0054-Response-by-Warwickshire-County-Council
Open published response
4 Dec 2013 Archibald WELLBELOVE · Prevention of Future Deaths report Warwickshire
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Concerns raised 1 Failure to review night-lighting policy with regard to pedestrian use and footpath visibility during unlit hours View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Archibald WELLBELOVE · 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
Archibald Wellbelove died in the early hours of 7 December 2012 after being struck by a taxi on the Kenilworth-bound carriageway of the A452, which was unlit at the time following a change in the County Council’s night-lighting policy. The principal concern was that the Council had not reviewed its night-lighting policy in light of pedestrian use of the road and possible lack of awareness of a footpath.
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 Warwickshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to review night-lighting policy with regard to pedestrian use and footpath visibility during unlit hours
Wider context from the report “(1) failure of the Council to review its night-lighting policy with specific regard to the circumstances of Mr Wellbelove’s death ; to include consideration of:
• evidence that pedestrians regularly use the road during the unlit hours ; and
• evidence that pedestrians, during the unlit hours, may not be aware of the presence of a footpath on the Leamington-bound side of the road, at the point of discontinuation of the footpath on the Kenilworth-bound side of the road .
” 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 Keep the street light nearest the crossing point illuminated throughout the night.
Verbatim wording from the response “The Council had scheduled a review of the policy for the early Summer but has brought forward this particular element in light of the Regulation 28 Report. Attached to this letter is a note of the investigations carried out by our highway engineers and their conclusions. From this it will be seen that it has been decided to make a number of changes at the point where the Kenilworth-bound footway terminates in order to reduce the risk of any future deaths. These changes are as follows:” Source location 2013-0324-Response-by-Warwickshire-County-Council
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the night-lighting policy against pedestrian use and awareness of the footpath termination.
Verbatim wording from the response “Failure of the Council to review its night-lighting policy with specific regard to the circumstances of Mr Wellbelove's death; to include consideration of:” Source location 2013-0324-Response-by-Warwickshire-County-Council
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations