30 May 2022 Albert Thomas Stafford Manley · Prevention of Future Deaths report Wiltshire and Swindon
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Concerns raised 2 Failure to maintain chevron signage at the Tollard Green bend View source Failure to make the Tollard Green junction and bend sufficiently distinguishable to approaching motorists View source
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AI-generated summary
Albert Thomas Stafford Manley · 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
Albert Thomas Stafford Manley, known to his family as “Jim”, died at Southampton General Hospital on 31 May 2021 from multiple traumatic injuries sustained when his Ford Mondeo collided with an oncoming Land Rover Discovery on the B3081 near Tollard Royal. The report raises concern that the road layout, junction and bends could be misread by unfamiliar drivers, potentially contributing to collisions, and considers whether further warnings or other measures could reduce this risk.
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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 Wiltshire Council; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain chevron signage at the Tollard Green bend
Wider context from the report “Although I was unable to make a finding of fact in this case Jim more likely than not misunderstood the road lay out, I was satisfied that it was a possibility and I am concerned that a driver who is unfamiliar with that road section could read the road incorrectly taking into account what they physically see and having regard to the road signs approaching the junction, leading to such a misunderstanding. The national speed limit on this section of road is, of course, 60 mph and every driver have a duty to drive at a speed commensurate with road conditions and additionally owes a duty of care to other road users in terms of driving carefully and considerately. How is it possible to misread the road? In answering that question, see figure 1 below, is a photograph of the view using Google Earth cameras approaching the junction heading in the same south easterly direction that Jim would have been travelling.
Fig.1
At approximately 200 metres from the junction is a very clear sign (above) highlighting the junction with the main B3081 continuing left to Tollard Royal and the road leading off to Tollard Green. In the photograph in the road ahead depending on the type of vehicle being driven and its position you can see a left-hand bend ahead of you. The visible bend is in fact a left hand bend once you have left the B3081 and is part of the road heading towards Tollard Green. It is not the junction bend on careful analysis.
The next photograph at figure 2 shows a sign for tourist and information purposes which lies approximately 85 metres from the junction with Tollard Green. You can however see the bend ahead which again is the bend beyond the junction and is not the Tollard Green, Tollard Royal junction which is still hidden.
Fig2
In Fig3 below a chevron sign at the time of the collision was missing on the sign post to the right of the highway but this sign together with the road markings have now been replaced/refreshed. As a driver myself the chevron markings would be of more assistance to a driver at night time although, of course, they would be visible in the day time but due to size to a lesser degree. At night, the reflective paint differentiating between black and white in my personal view would make the sign more obvious especially when headlights would be unlikely to pick up he Tollard Green bend ahead.
Fig 3
In considering my duty to make a report to prevent future deaths I had a report prepared for ████████ from Wiltshire Police (copy attached) and in that report he documented a previous collision history in the last 5 years and in particular 2 incidents, 1 occurring in 2017 and the other in 2018, both of which involved vehicles turning right at the junction to Tollard Green. One incident involved a car and a motorcycle, the other involving a car and a van. I also heard evidence from ████████ who has lived in the area for a number of years that the route to via Tollard Green into Verwood and Bournemouth is used by many as a back road in respect of which he described it as “a rat run” and cars apparently do not necessarily slow to any great degree when exiting that junction from a south easterly direction. ████████ in his report makes 2 recommendations, one of which is to remove the hedgerow to the left to increase visibility around the bend. That recommendation, I have to say, is of some concern to me as I do not think that it would tempt drivers to slow down to any degree and they would be more likely in looking across to look for oncoming traffic and may not always pick up smaller vehicles such a cyclist and motorcycle users when looking to exit the junction heading towards Tollard Green. That recommendation is also of concern to me because Wiltshire at the end of the day is a rural county and its hedgerows and the wildlife contained within the hedgerows are an important feature of its character. I also heard evidence of one of our Coroners Officers, ████████, who commented that the hedgerows had an additional purpose in trying to prevent deer which are a feature in this particular area leaving the fields and crossing the roads. He acquired this information when he was a serving Police Officer and from speaking to one of the nearby landowners. Deer crossing road especially at night can pose a dangerous and unexpected hazard.
As regards the second recommendation from ████████, this maybe something that you might be willing to consider or whether there perhaps is a better way through the use of further signing to make it even clearer as regards the existence of the junction and the bend. In asking you to consider painting the word “SLOW” as you approach the bend in both directions as recommended by ████████, I am mindful of the fact that as the highway authority you are under no obligation to provide such warnings as was pointed out by the House of Lords in the 2003 Decision in “Gorringe”.
I am however concerned that there is a possibility that the road could be misread and that the bend having exited the junction heading towards Tollard Green could be mistaken by motorist unfamiliar with this section of the road, be confused with the bend and the junction on the B3081 heading towards Tollard Royal. The bend having exited the junction heading towards Tollard Green is very similar in shape to the bend heading towards Tollard Royal which is hidden until you get very close to it.
I can see the propensity for a mistake being made here even if it is a mistake that I myself, I hope, would not make and I would ask you to consider if there is anything further that could be done to warn of this junction and bend to further minimise the possibility of any misunderstanding being made by road users if you are minded not to adopt ████████ recommendation.
” 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 Wiltshire Council; that does not assign responsibility.
PFD Monitor interpretation Failure to make the Tollard Green junction and bend sufficiently distinguishable to approaching motorists
Wider context from the report “Although I was unable to make a finding of fact in this case Jim more likely than not misunderstood the road lay out, I was satisfied that it was a possibility and I am concerned that a driver who is unfamiliar with that road section could read the road incorrectly taking into account what they physically see and having regard to the road signs approaching the junction, leading to such a misunderstanding. The national speed limit on this section of road is, of course, 60 mph and every driver have a duty to drive at a speed commensurate with road conditions and additionally owes a duty of care to other road users in terms of driving carefully and considerately. How is it possible to misread the road? In answering that question, see figure 1 below, is a photograph of the view using Google Earth cameras approaching the junction heading in the same south easterly direction that Jim would have been travelling.
Fig.1
At approximately 200 metres from the junction is a very clear sign (above) highlighting the junction with the main B3081 continuing left to Tollard Royal and the road leading off to Tollard Green. In the photograph in the road ahead depending on the type of vehicle being driven and its position you can see a left-hand bend ahead of you. The visible bend is in fact a left hand bend once you have left the B3081 and is part of the road heading towards Tollard Green. It is not the junction bend on careful analysis.
The next photograph at figure 2 shows a sign for tourist and information purposes which lies approximately 85 metres from the junction with Tollard Green. You can however see the bend ahead which again is the bend beyond the junction and is not the Tollard Green, Tollard Royal junction which is still hidden.
Fig2
In Fig3 below a chevron sign at the time of the collision was missing on the sign post to the right of the highway but this sign together with the road markings have now been replaced/refreshed. As a driver myself the chevron markings would be of more assistance to a driver at night time although, of course, they would be visible in the day time but due to size to a lesser degree. At night, the reflective paint differentiating between black and white in my personal view would make the sign more obvious especially when headlights would be unlikely to pick up he Tollard Green bend ahead.
Fig 3
In considering my duty to make a report to prevent future deaths I had a report prepared for ████████ from Wiltshire Police (copy attached) and in that report he documented a previous collision history in the last 5 years and in particular 2 incidents, 1 occurring in 2017 and the other in 2018, both of which involved vehicles turning right at the junction to Tollard Green. One incident involved a car and a motorcycle, the other involving a car and a van. I also heard evidence from ████████ who has lived in the area for a number of years that the route to via Tollard Green into Verwood and Bournemouth is used by many as a back road in respect of which he described it as “a rat run” and cars apparently do not necessarily slow to any great degree when exiting that junction from a south easterly direction. ████████ in his report makes 2 recommendations, one of which is to remove the hedgerow to the left to increase visibility around the bend. That recommendation, I have to say, is of some concern to me as I do not think that it would tempt drivers to slow down to any degree and they would be more likely in looking across to look for oncoming traffic and may not always pick up smaller vehicles such a cyclist and motorcycle users when looking to exit the junction heading towards Tollard Green. That recommendation is also of concern to me because Wiltshire at the end of the day is a rural county and its hedgerows and the wildlife contained within the hedgerows are an important feature of its character. I also heard evidence of one of our Coroners Officers, ████████, who commented that the hedgerows had an additional purpose in trying to prevent deer which are a feature in this particular area leaving the fields and crossing the roads. He acquired this information when he was a serving Police Officer and from speaking to one of the nearby landowners. Deer crossing road especially at night can pose a dangerous and unexpected hazard.
As regards the second recommendation from ████████, this maybe something that you might be willing to consider or whether there perhaps is a better way through the use of further signing to make it even clearer as regards the existence of the junction and the bend. In asking you to consider painting the word “SLOW” as you approach the bend in both directions as recommended by ████████, I am mindful of the fact that as the highway authority you are under no obligation to provide such warnings as was pointed out by the House of Lords in the 2003 Decision in “Gorringe”.
I am however concerned that there is a possibility that the road could be misread and that the bend having exited the junction heading towards Tollard Green could be mistaken by motorist unfamiliar with this section of the road , be confused with the bend and the junction on the B3081 heading towards Tollard Royal. The bend having exited the junction heading towards Tollard Green is very similar in shape to the bend heading towards Tollard Royal which is hidden until you get very close to it.
I can see the propensity for a mistake being made here even if it is a mistake that I myself, I hope, would not make and I would ask you to consider if there is anything further that could be done to warn of this junction and bend to further minimise the possibility of any misunderstanding being made by road users if you are minded not to adopt ████████ recommendation.
” 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 Continue monitoring the hedgerow situation alongside the highway and landowner responsibilities.
Verbatim wording from the response “I note the recommendations within the Police report regarding the removal of the hedgerow and your observations on the matter. The hedgerow is outside of the highway boundary and is the responsibility of the landowner, and at present it is not proposed to suggest the removal of the hedgerow for the reasons you mention, but we will continue to monitor the situation and enter discussion with the landowner if deemed necessary in the future.” Source location Response from Wilshire 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 Assess the site and review existing traffic-sign arrangements through experienced road-safety professionals.
Verbatim wording from the response “Following your suggestion that consideration be given to the introduction of further road markings and review of the current signing arrangements, I can advise the site has been visited by experienced road safety professionals with these comments in mind.” Source location Response from Wilshire 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 Add “SLOW” road markings to the Council’s road-marking programme for delivery in the coming months.
Verbatim wording from the response “With regards to your other observation that the existing signing could be supplemented using road markings depicting the characters ‘SLOW’, this is something that is considered to be appropriate and would be beneficial in assisting motorists to negotiate this section of road. I confirm that this work will be added to the Council’s road marking programme of works for the coming months.” Source location Response from Wilshire 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 Existing road signs accurately represent the layout and hazards, so no further amendments are proposed.
Verbatim wording from the response “Whilst the observations regarding the traffic signs are appreciated, the review has concluded that the existing sign arrangements are representative of the road layout and offer motorists the correct information of the hazards they should expect when negotiating this section of road. Therefore, no further amendments to the road signs are proposed.” Source location Response from Wilshire Council
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13 Aug 2018 Nana Kwabena Boansi BOATENG · Prevention of Future Deaths report Wiltshire and Swindon
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Concerns raised 2 Failure to maintain working cats eyes on the road View source Failure to maintain visible central road markings on the sharp left-hand bend 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
Nana Kwabena Boansi BOATENG · 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
Nana Kwabena Boansi BOATENG died at the scene on 24 December 2017 from chest trauma with haemorrhage after his car collided with a DAF light goods vehicle on the A429. The principal concern was that severely worn or absent central road markings and non-functioning cats’ eyes on the bend might have contributed to loss of positional awareness and created a road-safety risk.
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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 Wiltshire Council; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain working cats eyes on the road
Wider context from the report “During the course of the inquest the evidence I had been provided with a copy of a collision investigation report prepared by ████████ of Wiltshire Constabulary. In the report I had regard to a number of photographs but in particular I noted a photograph that appeared on page 29 of 39 of his report which showed the approach to the left hand bend where the incident took place at night. As part of any road traffic Inquest I use Google Earth and in particular the “street view” function in order to get a feel for the location where the incident took place. I have included with this report three additional pictures of the location that have been lifted from Google Earth. The imagery was as at May 2017 according to the web browser which of course was some seven months prior to Nana’s death. The photographs show the northern approach to the left-hand bend which is exactly the same path that Nana would have been travelling on that Christmas Eve morning. Whilst the state of the road surface appears to be in good condition what is not in good condition are the road markings. It is clear from the first picture that this section of road being a sharp left-hand bend travelling south is subject to no overtaking restrictions in both directions. Looking at the photographs the white lines that should be present in the centre of the highway have been significantly worn away to the extent that immediately approaching the left-hand bend they are non-existent. I was informed and as can be seen from the photograph in the police collision report, the cats eyes are also not in working condition .
I appreciate that one should drive at a speed relative to the road conditions but in this instance, it is clear from the photographs that the road markings effectively suddenly disappear as a result of road wear. Whilst I was not able to make a finding on a balance of probabilities that the absence and the poor state of these central road markings more likely than not contributed to Nana losing positional awareness on the highway and crossing onto the opposite side of the highway where upon a collision then ensued as he attempted to return to his side of the highway, it does remain a possibility hence this report.
I am sure you will appreciate road markings provide not only guidance to road users so that they can position their vehicle accordingly on the public highway but also serve to provide information to road users, as in this case, that this section of highway was subject to no overtaking in both directions. I would ask in view of this report that you urgently review this section of highway as its current state in terms of road markings is of great concern to me.
” 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 Wiltshire Council; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain visible central road markings on the sharp left-hand bend
Wider context from the report “During the course of the inquest the evidence I had been provided with a copy of a collision investigation report prepared by ████████ of Wiltshire Constabulary. In the report I had regard to a number of photographs but in particular I noted a photograph that appeared on page 29 of 39 of his report which showed the approach to the left hand bend where the incident took place at night. As part of any road traffic Inquest I use Google Earth and in particular the “street view” function in order to get a feel for the location where the incident took place. I have included with this report three additional pictures of the location that have been lifted from Google Earth. The imagery was as at May 2017 according to the web browser which of course was some seven months prior to Nana’s death. The photographs show the northern approach to the left-hand bend which is exactly the same path that Nana would have been travelling on that Christmas Eve morning. Whilst the state of the road surface appears to be in good condition what is not in good condition are the road markings . It is clear from the first picture that this section of road being a sharp left-hand bend travelling south is subject to no overtaking restrictions in both directions. Looking at the photographs the white lines that should be present in the centre of the highway have been significantly worn away to the extent that immediately approaching the left-hand bend they are non-existent . I was informed and as can be seen from the photograph in the police collision report, the cats eyes are also not in working condition.
I appreciate that one should drive at a speed relative to the road conditions but in this instance, it is clear from the photographs that the road markings effectively suddenly disappear as a result of road wear . Whilst I was not able to make a finding on a balance of probabilities that the absence and the poor state of these central road markings more likely than not contributed to Nana losing positional awareness on the highway and crossing onto the opposite side of the highway where upon a collision then ensued as he attempted to return to his side of the highway, it does remain a possibility hence this report.
I am sure you will appreciate road markings provide not only guidance to road users so that they can position their vehicle accordingly on the public highway but also serve to provide information to road users, as in this case, that this section of highway was subject to no overtaking in both directions. I would ask in view of this report that you urgently review this section of highway as its current state in terms of road markings is of great concern to me.
” 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 Relay road markings on the bend by the end of October.
Verbatim wording from the response “However, it is recognised that road markings can play a significant role in the overall efficiency and safety of the highway network. Unfortunately, due to funding shortfalls in recent years there has been a deterioration of road marking condition on many roads nationally. This has been recognised in Wiltshire and funding has been allocated to address this in the current highways budgets.” Source location Response from Wiltshire 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 Highway authorities are not legally required to provide road markings; drivers must adapt their driving to encountered conditions.
Verbatim wording from the response “I would firstly advise that there is no obligation upon Highway Authority’s in the United Kingdom to provide any road markings, be this centre lines, edge lines or any other markings. It is for the driver to adjust their driving style to the conditions that are encountered and drive appropriately.” Source location Response from Wiltshire Council
Open published response
26 May 2017 Doreen Helen MILLER · Prevention of Future Deaths report Wiltshire and Swindon
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Concerns raised 9 Failure of the serious-incident review and learning system View source Failure to record the rationale for crucial decisions View source Failure to properly investigate safeguarding referrals before sign-off View source Failure to undertake a mental capacity assessment for a serious and complex decision View source Failure to transfer important cognitive assessment information at discharge View source Insufficient training for therapy-led teams handling complex cases View source Failure of the healthcare-record archiving system to retain and provide records View source Lack of knowledge of Mental Capacity Act safeguarding measure limitations in privately funded community care View source Lack of individual ownership and leadership for MDT decisions View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Doreen Helen MILLER · 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
Doreen Helen MILLER, a vulnerable and housebound adult, was discharged home after an intermediate-care placement despite concerns about unusual toileting behaviour, possible cognitive impairment, self-neglect and limited provisions. She was found severely hypothermic in her cold, dark flat the next morning and died at hospital on 13 January 2016. The principal concerns included safeguarding referrals not being properly investigated, important cognitive information not being communicated, poor record-keeping and decision-making, insufficient assessment of mental capacity, and inadequate systems for reviewing serious incidents and learning from them.
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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 Wiltshire Council; that does not assign responsibility.
PFD Monitor interpretation Failure of the serious-incident review and learning system
Wider context from the report “e) (Wiltshire Health & Care) Having commenced a Coronial Investigation I tasked Coroners Officers to make a number of enquiries on my behalf and that included securing statements. As part of documentation that was disclosed by Wiltshire Health and Care was an email from Intermediate Care Lead Carol Langley-Johnson, her email sent to Acting Coroner’s Officer ███████ on 4th July 2016 contained a final paragraph that said “I have no concern about the standards of care provided by my team, I have read their statements and feel that this is a fair representation of rehab she received”. As will have been abundantly clear from reading this report and my Narrative Conclusion I did not share the same view as Ms Langley-Johnson and I am concerned and surprised that prior to the Inquest Final Hearing that no attempt was undertaken to carry out any form of Serious Case Review by Wiltshire Health and Care, formerly Great Western Hospital. I am concerned as regards the system in place that will pick up serious incidents for review and the mechanism in place to undertake investigations with a view to learning points being highlighted, the consideration of procedural changes and the implementation of any changes including additional training needs where required . I am concerned that there may be other incidences where there are learning points where there has not been a review and whilst those incidents may not have resulted in the death of an individual that the learning points have not been recognised and therefore there is the potential out there for repetition and in extreme circumstances repetition of dangerous practice that may lead to death and the involvement of me and my office.
” 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 Wiltshire Council; that does not assign responsibility.
PFD Monitor interpretation Failure to record the rationale for crucial decisions
Wider context from the report “c) (Wiltshire Council, Wiltshire Health & Care and Great Western Hospital) As a general comment, my view in relation to the quality and substance of case notes was that they were poor in quality. My investigation was hampered due to the fact that the Archiving System at Great Western Hospital for Doreen’s therapy led healthcare notes failed in that the notes or at least the scanned images were lost and were not available. Given that some notes were recorded on the Wiltshire Council Care First System and the evidence was that the Healthcare records would not have been significantly different my concerns remain. Crucial and important decisions did not contain any rationale as to why and the basis upon which that decision was being made . As indicated when I summed up the evidence my view is that recording a rationale can act as a check in relation to the decision making process itself as it forces the author to consider the process and information that has led to that decision being made.
I also have concerns in relation to the way MDT’s work and reach decisions. The decisions very much appear in relation to the case decision amongst relevant members of the team as opposed to an individual making the decision based on information provided by relevant team members. There was no leadership. My concern as regards this consensual approach is that no-one actually takes ownership and responsibility for the decision itself and a consensual approach as evidenced in Doreen’s case can in my view lead to a situation whereby there is a false sense of reassurance in believing that nothing more could be done for Doreen that in this case led to wrong decisions being taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wiltshire Council; that does not assign responsibility.
PFD Monitor interpretation Failure to properly investigate safeguarding referrals before sign-off
Wider context from the report “a) (Wiltshire Council) When Doreen was admitted to hospital on 20th December 2015 the paramedics made a safeguarding referral to Wiltshire Council. Due to the fact that the admission took place on a Sunday the referral fax was sent to the Emergency Out of Hours Team. I was satisfied having heard a copy of the recording that South Western Ambulance Service also followed up that fax with a telephone call to the Emergency Services Team who confirmed that the fax had been received. It appears that in triaging the referral that it was signed off on the basis that Doreen had been admitted to The Great Western Hospital. I heard evidence from a Senior Adult Safeguarding Manager at Wiltshire Council ███████ who confirmed my suspicion that in relation to the self-neglect issues that they would ordinarily have been left for the team at Athelston House to address as that from a common sense point of view would be the most appropriate way forward. There however remained the issue as regards the possible financial abuse by a Carer of Doreen. I am concerned here as regards the procedures in place to ensure that safeguarding referrals are properly investigated and whilst I was satisfied that what happened here did not contribute to Doreen’s death I am concerned that a safeguarding issue was not followed up and in fact was signed off in circumstances when clearly it should not have been . I would like you to look into this matter with a view to reviewing what went wrong and providing assurances as regards what measures may be introduced to minimise the risk of this happening again in the future or if no action is proposed to be taken, why no action is to be taken;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wiltshire Council; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake a mental capacity assessment for a serious and complex decision
Wider context from the report “d) (Wiltshire Health & Care) As part of the evidence I heard that Doreen in the opinion of an Expert Geriatric Psychiatrist, not only had a mental impairment (cognitive impairment more likely with underlying dementia) but also more importantly that in relation to a serious and complex decision to return home she was of the view, in respect of which I accepted, that more likely than not Doreen could not understand her needs and was unable to recognise the risk of refusing the safeguarding recommendations and that in relation to her decision to return home and those associated decisions that she did not have mental capacity. I indicated in my summing up that this was a difficult case but I feel that the training given especially to the Therapy led members of the team did not sufficiently prepare them to deal with very complicated cases such as Doreen’s although that having been said if the advice that had been given had been followed the outcome possibly would have been different. I was however satisfied that had the advice been followed and a capacity test undertaken that Doreen would not have returned home when she did and therefore would not have died when she did. It was also readily apparent to me that members of the Therapy led Team and particularly ███████ was unaware that the safeguarding measures, part of the Mental Capacity Act and in particular the ability to secure either and urgent or standard authorisation for the deprivation of somebody’s liberty was not available where the individual concerned lives in the community and where their care is paid for privately. One witness said those cases can be extremely challenging and essentially those trying to do their best for the individual essentially have to wait for the next crisis to occur before they may be given an opportunity to introduce safeguarding measures. Had the mental impairment been recognised and the mental capacity assessment been carried out revealing that she did not have mental capacity in relation to the serious and complex decision to return home and associated decisions concerning additional safeguarding measures and if Doreen still wished to return home then it may have been in her best interests to have considered Deprivation of Liberty Safeguarding Order. I would hope that this particular case in particular could be used as a specific training case by all organisations involved but I have concerns that there were material gaps in individuals’ knowledge bases.
” 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 Wiltshire Council; that does not assign responsibility.
PFD Monitor interpretation Failure to transfer important cognitive assessment information at discharge
Wider context from the report “b) (Great Western Hospital) In considering the evidence when Doreen was discharged from The Great Western Hospital initially on the 21st December 2015, she was sent with a discharge letter and a 4 page Medivo Summary summarising the paramedics’ attendance on the 20th December 2015. Of note that summary did not contain any information that the paramedic had undertaken a 6CIT Cognitive evaluation of Doreen and that she had failed that assessment . One can never guarantee that another document will reflect the information contained in the initial report and therefore a possible way forward could be to ensure in cases where the turnaround through hospital is short that as part of the Discharge Package that it includes a copy of the Paramedic handwritten report that would have been provide to Great Western Hospital when she was admitted. It is however for you to consider how to resolve the concern here that an important bit of information was not provided to the team at Athelston House ;
” 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 Wiltshire Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient training for therapy-led teams handling complex cases
Wider context from the report “d) (Wiltshire Health & Care) As part of the evidence I heard that Doreen in the opinion of an Expert Geriatric Psychiatrist, not only had a mental impairment (cognitive impairment more likely with underlying dementia) but also more importantly that in relation to a serious and complex decision to return home she was of the view, in respect of which I accepted, that more likely than not Doreen could not understand her needs and was unable to recognise the risk of refusing the safeguarding recommendations and that in relation to her decision to return home and those associated decisions that she did not have mental capacity. I indicated in my summing up that this was a difficult case but I feel that the training given especially to the Therapy led members of the team did not sufficiently prepare them to deal with very complicated cases such as Doreen’s although that having been said if the advice that had been given had been followed the outcome possibly would have been different. I was however satisfied that had the advice been followed and a capacity test undertaken that Doreen would not have returned home when she did and therefore would not have died when she did. It was also readily apparent to me that members of the Therapy led Team and particularly ███████ was unaware that the safeguarding measures, part of the Mental Capacity Act and in particular the ability to secure either and urgent or standard authorisation for the deprivation of somebody’s liberty was not available where the individual concerned lives in the community and where their care is paid for privately. One witness said those cases can be extremely challenging and essentially those trying to do their best for the individual essentially have to wait for the next crisis to occur before they may be given an opportunity to introduce safeguarding measures. Had the mental impairment been recognised and the mental capacity assessment been carried out revealing that she did not have mental capacity in relation to the serious and complex decision to return home and associated decisions concerning additional safeguarding measures and if Doreen still wished to return home then it may have been in her best interests to have considered Deprivation of Liberty Safeguarding Order. I would hope that this particular case in particular could be used as a specific training case by all organisations involved but I have concerns that there were material gaps in individuals’ knowledge bases .
” 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 Wiltshire Council; that does not assign responsibility.
PFD Monitor interpretation Failure of the healthcare-record archiving system to retain and provide records
Wider context from the report “c) (Wiltshire Council, Wiltshire Health & Care and Great Western Hospital) As a general comment, my view in relation to the quality and substance of case notes was that they were poor in quality. My investigation was hampered due to the fact that the Archiving System at Great Western Hospital for Doreen’s therapy led healthcare notes failed in that the notes or at least the scanned images were lost and were not available . Given that some notes were recorded on the Wiltshire Council Care First System and the evidence was that the Healthcare records would not have been significantly different my concerns remain. Crucial and important decisions did not contain any rationale as to why and the basis upon which that decision was being made. As indicated when I summed up the evidence my view is that recording a rationale can act as a check in relation to the decision making process itself as it forces the author to consider the process and information that has led to that decision being made.
I also have concerns in relation to the way MDT’s work and reach decisions. The decisions very much appear in relation to the case decision amongst relevant members of the team as opposed to an individual making the decision based on information provided by relevant team members. There was no leadership. My concern as regards this consensual approach is that no-one actually takes ownership and responsibility for the decision itself and a consensual approach as evidenced in Doreen’s case can in my view lead to a situation whereby there is a false sense of reassurance in believing that nothing more could be done for Doreen that in this case led to wrong decisions being taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wiltshire Council; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge of Mental Capacity Act safeguarding measure limitations in privately funded community care
Wider context from the report “d) (Wiltshire Health & Care) As part of the evidence I heard that Doreen in the opinion of an Expert Geriatric Psychiatrist, not only had a mental impairment (cognitive impairment more likely with underlying dementia) but also more importantly that in relation to a serious and complex decision to return home she was of the view, in respect of which I accepted, that more likely than not Doreen could not understand her needs and was unable to recognise the risk of refusing the safeguarding recommendations and that in relation to her decision to return home and those associated decisions that she did not have mental capacity. I indicated in my summing up that this was a difficult case but I feel that the training given especially to the Therapy led members of the team did not sufficiently prepare them to deal with very complicated cases such as Doreen’s although that having been said if the advice that had been given had been followed the outcome possibly would have been different. I was however satisfied that had the advice been followed and a capacity test undertaken that Doreen would not have returned home when she did and therefore would not have died when she did. It was also readily apparent to me that members of the Therapy led Team and particularly ███████ was unaware that the safeguarding measures, part of the Mental Capacity Act and in particular the ability to secure either and urgent or standard authorisation for the deprivation of somebody’s liberty was not available where the individual concerned lives in the community and where their care is paid for privately . One witness said those cases can be extremely challenging and essentially those trying to do their best for the individual essentially have to wait for the next crisis to occur before they may be given an opportunity to introduce safeguarding measures. Had the mental impairment been recognised and the mental capacity assessment been carried out revealing that she did not have mental capacity in relation to the serious and complex decision to return home and associated decisions concerning additional safeguarding measures and if Doreen still wished to return home then it may have been in her best interests to have considered Deprivation of Liberty Safeguarding Order. I would hope that this particular case in particular could be used as a specific training case by all organisations involved but I have concerns that there were material gaps in individuals’ knowledge bases.
” 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 Wiltshire Council; that does not assign responsibility.
PFD Monitor interpretation Lack of individual ownership and leadership for MDT decisions
Wider context from the report “c) (Wiltshire Council, Wiltshire Health & Care and Great Western Hospital) As a general comment, my view in relation to the quality and substance of case notes was that they were poor in quality. My investigation was hampered due to the fact that the Archiving System at Great Western Hospital for Doreen’s therapy led healthcare notes failed in that the notes or at least the scanned images were lost and were not available. Given that some notes were recorded on the Wiltshire Council Care First System and the evidence was that the Healthcare records would not have been significantly different my concerns remain. Crucial and important decisions did not contain any rationale as to why and the basis upon which that decision was being made. As indicated when I summed up the evidence my view is that recording a rationale can act as a check in relation to the decision making process itself as it forces the author to consider the process and information that has led to that decision being made.
I also have concerns in relation to the way MDT’s work and reach decisions. The decisions very much appear in relation to the case decision amongst relevant members of the team as opposed to an individual making the decision based on information provided by relevant team members. There was no leadership . My concern as regards this consensual approach is that no-one actually takes ownership and responsibility for the decision itself and a consensual approach as evidenced in Doreen’s case can in my view lead to a situation whereby there is a false sense of reassurance in believing that nothing more could be done for Doreen that in this case led to wrong decisions being taken.
” Open source report
1 Jul 2016 George Hedley Punton · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 1 Absence of pedestrian footways on the village route to the children’s playground 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
George Hedley Punton · 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
George Hedley Punton was a pedestrian walking his dog in Lockeridge, Wiltshire, when he was struck by a car on 21 November 2015. He sustained a serious head injury and died in hospital on 3 December 2015. The report raised concern about the absence of pedestrian pavements and the safety of access to a nearby children’s playground, noting a risk of future deaths unless action is taken.
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 Wiltshire Council; that does not assign responsibility.
PFD Monitor interpretation Absence of pedestrian footways on the village route to the children’s playground
Wider context from the report “During the course of hearing evidence I heard from ████████ who whilst not making any recommendations directly relating to the exact circumstances of George’s death did indirectly highlight a concern relative to a nearby children’s playground, the access to which from the village, which included the route George was on at the time highlighted the fact not unsurprisingly given the location that there were no pedestrian pavements . I think the simplest thing is for me to enclose with this report a copy of ████████ report which highlights the location of the playground in question which lies to the north of the collision point involving George which took place at OS grid reference 148677. The similarity with the circumstances of George’s death relate to the fact that George at the time was struck by the Zafira whilst walking on the highway due to the absence of any pavements .
My initial reaction when reading ████████ was that there could be many scenarios whereby villages due to their history in relation to highways may not be wide enough to accommodate pedestrian pavements but the location here of the playground and also regards its safe access by villagers including children does cause me concern . Whilst it is fair to say there have been no incidents in the previous four years I am sufficiently concerned so as to support ████████ recommendation that motorists and other highway users ought to be alerted to the fact that there are no footways and that pedestrians are likely to be walking at the side of the road and as such I am satisfied that there is a risk that future deaths will occur unless action is taken .
” 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 Undertake an assessment for a 20mph speed limit at Lockeridge.
Verbatim wording from the response “An assessment for a 20mph speed limit at Lockeridge has recently been undertaken, this assessment has recommended the implementation of a 20mph limit, the extents of which will include the roads around the playground / recreation ground area discussed in the Police Report. The implementation of the 20mph limit is due to be completed by the end of 2016 and will include the provision of the suggested warning signs that are considered appropriate for the location.” Source location 2016-0250-Response-by-Wiltshire-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 Implement a 20mph speed limit around Lockeridge’s playground and recreation ground, with appropriate warning signs, by the end of 2016.
Verbatim wording from the response “An assessment for a 20mph speed limit at Lockeridge has recently been undertaken, this assessment has recommended the implementation of a 20mph limit, the extents of which will include the roads around the playground / recreation ground area discussed in the Police Report. The implementation of the 20mph limit is due to be completed by the end of 2016 and will include the provision of the suggested warning signs that are considered appropriate for the location.” Source location 2016-0250-Response-by-Wiltshire-Council
Open published response
19 Jun 2015 Elizabeth Godwin · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 5 Failure to gather information from family and others involved in mental health assessments View source Failure to communicate and acknowledge transfers of patient care between agencies View source Failure to share mental health assessment information with other agencies involved in patient care View source Failure to assess, record and monitor the urgency of mental health assessments View source Failure to assign responsibility for patient care, mental health assessment and resulting treatment View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Elizabeth Godwin · 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
Elizabeth Godwin died by suicide on 28 January 2013 after attaching a dog-lead ligature to a shower cubicle and hanging herself at home. The report raised concerns about how mental-health information was gathered, urgency assessed and monitored, information shared, responsibility allocated, and transfers of care communicated between agencies.
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 Wiltshire Council; that does not assign responsibility.
PFD Monitor interpretation Failure to gather information from family and others involved in mental health assessments
Wider context from the report “I AM CONCERNED IN PARTICULAR AS TO THE FOLLOWING MATTERS:
a) As to the way in which information is gathered from the family and others involved where there is a need for an individual to have a mental health assessment .
b) As to how the urgency of carrying out that assessment, is assessed, recorded and monitored.
c) As to how that information is shared with other agencies involved in the care of that patient.
d) As to who has responsibility for the care of that patient including the carrying out of the mental health assessment and any treatment arising from it.
e) As to how a transfer of that care between the agencies is communicated and acknowledged so that there is a clear audit trail.
I would ask you to review the policy and procedures that you have in place to deal with the referral to another agency of a patient who appears to be suffering from mental health issues having regard to the above concerns.
” 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 Wiltshire Council; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate and acknowledge transfers of patient care between agencies
Wider context from the report “I AM CONCERNED IN PARTICULAR AS TO THE FOLLOWING MATTERS:
a) As to the way in which information is gathered from the family and others involved where there is a need for an individual to have a mental health assessment.
b) As to how the urgency of carrying out that assessment, is assessed, recorded and monitored.
c) As to how that information is shared with other agencies involved in the care of that patient.
d) As to who has responsibility for the care of that patient including the carrying out of the mental health assessment and any treatment arising from it.
e) As to how a transfer of that care between the agencies is communicated and acknowledged so that there is a clear audit trail .
I would ask you to review the policy and procedures that you have in place to deal with the referral to another agency of a patient who appears to be suffering from mental health issues having regard to the above concerns.
” 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 Wiltshire Council; that does not assign responsibility.
PFD Monitor interpretation Failure to share mental health assessment information with other agencies involved in patient care
Wider context from the report “I AM CONCERNED IN PARTICULAR AS TO THE FOLLOWING MATTERS:
a) As to the way in which information is gathered from the family and others involved where there is a need for an individual to have a mental health assessment.
b) As to how the urgency of carrying out that assessment, is assessed, recorded and monitored.
c) As to how that information is shared with other agencies involved in the care of that patient .
d) As to who has responsibility for the care of that patient including the carrying out of the mental health assessment and any treatment arising from it.
e) As to how a transfer of that care between the agencies is communicated and acknowledged so that there is a clear audit trail.
I would ask you to review the policy and procedures that you have in place to deal with the referral to another agency of a patient who appears to be suffering from mental health issues having regard to the above concerns.
” 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 Wiltshire Council; that does not assign responsibility.
PFD Monitor interpretation Failure to assess, record and monitor the urgency of mental health assessments
Wider context from the report “I AM CONCERNED IN PARTICULAR AS TO THE FOLLOWING MATTERS:
a) As to the way in which information is gathered from the family and others involved where there is a need for an individual to have a mental health assessment.
b) As to how the urgency of carrying out that assessment, is assessed, recorded and monitored .
c) As to how that information is shared with other agencies involved in the care of that patient.
d) As to who has responsibility for the care of that patient including the carrying out of the mental health assessment and any treatment arising from it.
e) As to how a transfer of that care between the agencies is communicated and acknowledged so that there is a clear audit trail.
I would ask you to review the policy and procedures that you have in place to deal with the referral to another agency of a patient who appears to be suffering from mental health issues having regard to the above concerns.
” 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 Wiltshire Council; that does not assign responsibility.
PFD Monitor interpretation Failure to assign responsibility for patient care, mental health assessment and resulting treatment
Wider context from the report “I AM CONCERNED IN PARTICULAR AS TO THE FOLLOWING MATTERS:
a) As to the way in which information is gathered from the family and others involved where there is a need for an individual to have a mental health assessment.
b) As to how the urgency of carrying out that assessment, is assessed, recorded and monitored.
c) As to how that information is shared with other agencies involved in the care of that patient.
d) As to who has responsibility for the care of that patient including the carrying out of the mental health assessment and any treatment arising from it .
e) As to how a transfer of that care between the agencies is communicated and acknowledged so that there is a clear audit trail.
I would ask you to review the policy and procedures that you have in place to deal with the referral to another agency of a patient who appears to be suffering from mental health issues having regard to the above concerns.
” Open source report
17 Apr 2015 Patrick Derek Sturivant · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 2 Foreseeable displacement of the Byway 11 safety hazard to the Byway 12 connection with the A303 View source Public use of the northernmost Byway 11 area as a car park or stopping point View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Patrick Derek Sturivant · 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
Patrick Derek Sturivant was struck by a Mercedes while crossing the A303 near Byway 11 at Stonehenge on 29 August 2014 and died in hospital the following day from an unsurvivable brain injury. The concerns were that public use of the area near Byway 11 for parking and viewing Stonehenge created a risk of similar deaths, and that closing or modifying Byway 11 could shift the risk to Byway 12.
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 Wiltshire Council; that does not assign responsibility.
PFD Monitor interpretation Foreseeable displacement of the Byway 11 safety hazard to the Byway 12 connection with the A303
Wider context from the report “(2) Even if the above proposal is adopted in co-operation with the National Trust and Wiltshire Council I have however a further concern that in my view it is reasonably foreseeable that the problem currently associated with the area adjacent to the point at which Byway 11 joins the A303 will move approximately 390 metres west to the point at which Byway 12 connects to the A303 . I know the area well and I can just see the problem shifting to this particular location and that concerns me from the point of view of the prevention of future deaths as if not addressed at this point could again lead to another fatality occurring in similar circumstances following the closure of Byway 11.
I heard evidence from ████████ that Byway 12 is actively used as a green lane and I am fully aware that any modification to Byway 12 due to its use as a connecting green lane between the A303 and the A360 is likely to be highly controversial and political but that does not remove the concern that I have that there in my view is a reasonably foreseeable risk in the future if the terminal end of Byway 11 is closed. It is within in mind and having considered the matter further after the inquest that I have included in the list of recipients of this Regulation 28 Report, The Department of Transport and English Heritage. The reason for this is of course last year the issue of the A303 generally in this area, having regard to the A344, has prompted a review of the highway infrastructure in this area from the point of view of diverting the A303 or indeed as regards the funding of a tunnel through which the A303 would pass underground in the vicinity of the Stonehenge Monument and I would therefore like my concerns relative to the issues raised in this report relative Byway 11 and Byway 12 south of the A303 to be taken into consideration.
” 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 Wiltshire Council; that does not assign responsibility.
PFD Monitor interpretation Public use of the northernmost Byway 11 area as a car park or stopping point
Wider context from the report “(1) At the end of the Inquest I heard live evidence from ████████ who had prepared a helpful Traffic Management and Road Safety Assessment. I have enclosed a copy of that report with this letter as it includes helpful diagrams and maps to help explain the issue.
He gave evidence having visited the scene that indications of activity on Byway 11 would appear to be limited to the area in the immediate vicinity of the A303 itself being used by the public as a car park or a stopping point so as to enable the occupants of vehicles, as indeed was the case with Pat and his passenger, to get a better view of the Stonehenge Monument lying to the north of the A303. Clearly the public are using this area in this manner and I am therefore concerned that there is a risk of future deaths occurring in similar circumstances if action is not taken.
It was not ████████ opinion that the rest of Byway 11 was being actively and frequently used as a green lane. Byway 11’s current designation is as a BOAT (Byway Open to All Traffic). In Highway Law the right of the public to use such a right of way is to pass and repass along it. The right does not extend in the absence of an emergency to parking.
████████ explained that discussions have taken place with the owner of the land, The National Trust and also with Wiltshire Council Rights of Way Department and their legal team with a view to possible closing of the terminal 600 metre section of Byway 11 laying immediately south of the A303 and the Stonehenge Monument, downgrading Byway 11 down to a Bridleway and then diverting the bridleway along a current permissive path on National Trust Property so that the diverted Right of Way will then join Byway 12 approximately 400 metres south of the A303. The explanation and a plan are found on the final page of ████████ Report.
I can entirely see the logic of this proposal and fully support the proposal as a means of addressing my concern relative to the area at the northernmost point of Byway 11. Such a modification would stop this area being used as a car park so as to facilitate free viewing access to the Stonehenge Monument.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Police enforcement of stopping restrictions and the no-right-turn order is the Police’s responsibility, rather than the Council’s.
Verbatim wording from the response “However as was recognised by you in your report, any potential solutions will require a multi-agency approach. Highways England own, maintain and control the surface (and verges) of the A303, and are also considering potential long term solutions in order to mitigate the continuing traffic difficulties along this section of the A303. Historic England owns the land on which Stonehenge is situated and has care and control of the stones as ancient monuments. The National Trust is a significant landowner in this area and own the land on which byway 11 is located. The Council are the local highway authority who own (on surface), control and maintain the rights of way in the area including byway 11. The Police are responsible for enforcement of the A303 clearway order and the no right turn out of byway 12.” Source location Wiltshire-Council-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 A long-term solution requires multiple agencies because responsibility for the road, land, rights of way and enforcement is distributed among them.
Verbatim wording from the response “However as was recognised by you in your report, any potential solutions will require a multi-agency approach. Highways England own, maintain and control the surface (and verges) of the A303, and are also considering potential long term solutions in order to mitigate the continuing traffic difficulties along this section of the A303. Historic England owns the land on which Stonehenge is situated and has care and control of the stones as ancient monuments. The National Trust is a significant landowner in this area and own the land on which byway 11 is located. The Council are the local highway authority who own (on surface), control and maintain the rights of way in the area including byway 11. The Police are responsible for enforcement of the A303 clearway order and the no right turn out of byway 12.” Source location Wiltshire-Council-Response
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 Council cannot yet provide decision and implementation timescales because a multi-agency long-term solution is still being explored.
Verbatim wording from the response “However as was recognised by you in your report, any potential solutions will require a multi-agency approach. Highways England own, maintain and control the surface (and verges) of the A303, and are also considering potential long term solutions in order to mitigate the continuing traffic difficulties along this section of the A303. Historic England owns the land on which Stonehenge is situated and has care and control of the stones as ancient monuments. The National Trust is a significant landowner in this area and own the land on which byway 11 is located. The Council are the local highway authority who own (on surface), control and maintain the rights of way in the area including byway 11. The Police are responsible for enforcement of the A303 clearway order and the no right turn out of byway 12.” Source location Wiltshire-Council-Response
Open published response
9 Oct 2014 Tracy Michelle ROOKE · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 4 Deficiencies in road signage, including its location and condition View source Delays in acting on road safety recommendations View source Inadequate practices and procedures for dealing with mud on the highway View source Inadequate signage near the start of the muddied section of highway 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
Tracy Michelle ROOKE · 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
Tracy Michelle Rooke died after losing control of her vehicle on the A3102 at Mile Elm, crossing the centre of the road and colliding with an oncoming van. The report identified thick fog and her unfamiliarity with the road as factors that more likely than not contributed to the incident and her death. A concern was raised about mud on the highway and the quality of nearby signage as potential hazards, although the report states that the mud played no part in Ms Rooke’s death.
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 Wiltshire Council; that does not assign responsibility.
PFD Monitor interpretation Deficiencies in road signage, including its location and condition
Wider context from the report “During the course of the Inquest I heard evidence from ████████ whose role is the Force’s Traffic Management and Road Safety Assessment Officer. He is a former Collision Investigator. As part of his evidence he produced a copy of his report dated 26 June 2014 in respect of which I believe you received a copy back in June.
In that report and specifically at pages 10 & 11 of the report, a copy of which I have attached to this Regulation 28 report, he sets out a number of recommendations. I share the concerns that are raised by ████████ in his report which focuses on identified issues concerning road signage, the location of road signage and the current state of road signage in this particular area .
I am concerned that if these are not addressed that they potentially could contribute to future road traffic incidents that may result in injury or even death.
I am additionally concerned having regard to the evidence that ████████ gave in respect of which he indicated that whilst you have been given a copy of his report including recommendations that no action would be taken until I make a report with a view to the prevention of future deaths. That concerns me as Highways Authority you believe there is merit in relation to the recommendations then it should not have to wait until a Coroner makes a report some months after the Traffic Management and Road Safety Assessment Report is submitted before action is taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wiltshire Council; that does not assign responsibility.
PFD Monitor interpretation Delays in acting on road safety recommendations
Wider context from the report “During the course of the Inquest I heard evidence from ████████ whose role is the Force’s Traffic Management and Road Safety Assessment Officer. He is a former Collision Investigator. As part of his evidence he produced a copy of his report dated 26 June 2014 in respect of which I believe you received a copy back in June.
In that report and specifically at pages 10 & 11 of the report, a copy of which I have attached to this Regulation 28 report, he sets out a number of recommendations. I share the concerns that are raised by ████████ in his report which focuses on identified issues concerning road signage, the location of road signage and the current state of road signage in this particular area.
I am concerned that if these are not addressed that they potentially could contribute to future road traffic incidents that may result in injury or even death.
I am additionally concerned having regard to the evidence that ████████ gave in respect of which he indicated that whilst you have been given a copy of his report including recommendations that no action would be taken until I make a report with a view to the prevention of future deaths . That concerns me as Highways Authority you believe there is merit in relation to the recommendations then it should not have to wait until a Coroner makes a report some months after the Traffic Management and Road Safety Assessment Report is submitted before action is taken .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wiltshire Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate practices and procedures for dealing with mud on the highway
Wider context from the report “The above having been said if evidence is presented to a Coroner as part of an Inquest process irrespective of it being unconnected with the circumstances of that person’s death, a Coroner can make a Regulation 28 report if he or she has concerns with a view to prevention of future deaths. I am concerned in relation to the quantity of mud visible in the photographs and also as regards the quality of signage located in such close proximity to the start of the muddied section of highway. I have dealt with deaths on Wiltshire roads that have involved farm mud on the highway and I am aware of the hazard it creates . I fully accept farmers have a livelihood to make however I would ask that you review and inform me of your practice and procedures to deal with mud on the highway and as to whether or not in the light of the photographs your practices could be improved and if so how. You may also like to consider seeking advice from either the National Farmers Union or Wiltshire Council as Highways Authority.
” 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 Wiltshire Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate signage near the start of the muddied section of highway
Wider context from the report “The above having been said if evidence is presented to a Coroner as part of an Inquest process irrespective of it being unconnected with the circumstances of that person’s death, a Coroner can make a Regulation 28 report if he or she has concerns with a view to prevention of future deaths. I am concerned in relation to the quantity of mud visible in the photographs and also as regards the quality of signage located in such close proximity to the start of the muddied section of highway . I have dealt with deaths on Wiltshire roads that have involved farm mud on the highway and I am aware of the hazard it creates. I fully accept farmers have a livelihood to make however I would ask that you review and inform me of your practice and procedures to deal with mud on the highway and as to whether or not in the light of the photographs your practices could be improved and if so how. You may also like to consider seeking advice from either the National Farmers Union or Wiltshire Council as Highways Authority.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations