John Paul Clarke · Prevention of Future Deaths report

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Issued 6 Jul 2015•Inner West London

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

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Concerns
5

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
12

Described in responses

Recipients and published responses

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised5

  1. Failure of highway inspections to identify missing road signs
    Part of recurring concern: Unreliable highway inspection and asset-recording processes
  2. Failure of highway inspections to identify defective sign lighting
    Part of recurring concern: Unreliable highway inspection and asset-recording processes
  3. Insufficiently comprehensive highway asset database
    Part of recurring concern: Unreliable highway inspection and asset-recording processes

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.12

  1. Westminster City Council

    Train inspectors on updated missing-asset works-order and inventory-reporting protocols.

  2. Westminster City Council

    Agree the scope and method for updating legacy scheme areas, including whether to resurvey them and use Confirm Connect.

  3. Westminster City Council

    Monitor uncommitted works orders daily using a newly introduced Confirm report.

  4. Westminster City Council

    Introduce fortnightly monitoring of temporary traffic-cone locations and follow-up visits where permanent repairs remain outstanding.

  5. Westminster City Council

    Provide additional regulatory-signage and TSRGD training to inspectors in January 2016.

  6. Westminster City Council

    Complete physical inventory updates for outstanding legacy scheme areas by 31 March 2016.

  7. Westminster City Council

    Replace illuminated-sign attributes with a handheld Sign Number and Description attribute, with rollout to non-illuminated signs if successful.

  8. Westminster City Council

    Fund inspector training in industry standards, safe working, traffic management, disability awareness and other work-related qualifications.

  9. Westminster City Council

    Require inspectors to hold current City and Guilds Streetworks Supervisor accreditation.

  10. Westminster City Council

    Develop protocols enabling lighting crews to correct base inventory data during routine maintenance inspections.

  11. Westminster City Council

    Implement Confirm Connect for lighting maintenance to provide real-time inventory updates.

  12. Westminster City Council

    Complete illuminated-asset inventory updates over two full maintenance inspection cycles by 31 March 2018.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Westminster City Council

    Existing inspection, contingency and inventory systems ensure missing or incorrectly recorded assets generate remedial work and prompt database updates.

    Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure of highway inspections to identify missing road signs

Wider context from the report

“1. Westminster City Council in its capacity as the highways authority carried out monthly walked inspections of Northumberland Avenue (along with other inspections). These inspections did not register that a “Keep Left” sign located at the easterly end of the traffic island involved in the incident was missing and had been missing for at least three years. ”

Is this part of a recurring concern?

Yes — Unreliable highway inspection and asset-recording processes.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure of highway inspections to identify defective sign lighting

Wider context from the report

“2. The various inspections carried out by Westminster City Council failed to register that the external lighting arrangement for the “Keep Left” sign that was located on the traffic island was defective and had probably not been working for three years. ”

Is this part of a recurring concern?

Yes — Unreliable highway inspection and asset-recording processes.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Insufficiently comprehensive highway asset database

Wider context from the report

“5. The database of street signs and other highway assets used by Westminster City Council as a basis for its periodic inspections was not sufficiently comprehensive. ”

Is this part of a recurring concern?

Yes — Unreliable highway inspection and asset-recording processes.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure of the inspection system to facilitate remedial works for road-sign and lighting defects

Wider context from the report

“4. The inspection system in force in the period 2011-2014 was not sufficiently effective to identify missing road signs and/or lighting defects which good practice required to be in place and to facilitate remedial works to rectify the situation. ”

Is this part of a recurring concern?

Yes — Unreliable highway inspection and asset-recording processes.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to record highway signs in the inspection asset database

Wider context from the report

“3. The missing “Keep Left” sign and the Keep Left sign which was in place at the western end of the traffic island, were not recorded on the database of assets used by Westminster City Council in the course of their inspections. This omission made it less likely that the defects referred to would be noticed and hindered any attempts to initiate remedial works. ”

Is this part of a recurring concern?

Yes — Unreliable highway inspection and asset-recording processes.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Train inspectors on updated missing-asset works-order and inventory-reporting protocols.

Verbatim wording from the response

“6.1 The user guide produced for the inspectors on the use of Confirm Connect is attached as Appendix 1. This is used as part of the inspector training, including induction for new staff, and has been updated to include the protocol for raising works orders when the asset is missing (page 32 for highways assets, page 56 for lighting assets and page 61 for gully assets).”

Source location

Response
Page 14 · response
Published 6 July 2015

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Agree the scope and method for updating legacy scheme areas, including whether to resurvey them and use Confirm Connect.

Verbatim wording from the response

“4.5 There remain some schemes from our previous contract that have not been updated in the inventory. A scope of works and method are actively in discussion, including the need to resurvey these areas and whether the Confirm Connect could be used. The timeline to complete the physical inventory updates is by the end of the current financial year (31 March 2016).”

Source location

Response
Page 12 · response
Published 6 July 2015

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Monitor uncommitted works orders daily using a newly introduced Confirm report.

Verbatim wording from the response

“2.9 Outstanding committed works orders issued to the service provider are monitored every day through a report generated from Confirm and at regular monitoring meetings. In certain circumstances works orders can become stuck and stay ‘uncommitted’ in the system. When this happens, the works order does not go through to the service provider. However, a new report has been introduced to allow staff and the provider to monitor these on a daily basis as well.”

Source location

Response
Page 7 · response
Published 6 July 2015

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Introduce fortnightly monitoring of temporary traffic-cone locations and follow-up visits where permanent repairs remain outstanding.

Verbatim wording from the response

“5.0 Temporary Signage Measures”

Source location

Response
Page 13 · response
Published 6 July 2015

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Provide additional regulatory-signage and TSRGD training to inspectors in January 2016.

Verbatim wording from the response

“6.4 While the inventory holds the sign diagram number already and will be updated to give both the TSRGD diagram number and the description so the inspectors see this, given the latter will take some time to complete, additional training on regulatory signage and TSRGD is being provided to the inspectors in January 2016.”

Source location

Response
Page 14 · response
Published 6 July 2015

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Complete physical inventory updates for outstanding legacy scheme areas by 31 March 2016.

Verbatim wording from the response

“4.5 There remain some schemes from our previous contract that have not been updated in the inventory. A scope of works and method are actively in discussion, including the need to resurvey these areas and whether the Confirm Connect could be used. The timeline to complete the physical inventory updates is by the end of the current financial year (31 March 2016).”

Source location

Response
Page 12 · response
Published 6 July 2015

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Replace illuminated-sign attributes with a handheld Sign Number and Description attribute, with rollout to non-illuminated signs if successful.

Verbatim wording from the response

“3.4 With the move to handheld technology, a new attribute of Sign Number and Description has been added to enable site staff, including highways inspectors, to easily select the sign type by description without having to know the TSRGD ref number (Figure 2). The drop down menu has the TSRGD number at the end of the description. This will replace the two existing Illuminated sign attributes listed in paragraph 3.3. This is a work in progress and if successful, it will be rolled out to Highways non-illuminated signs as well (Figure 1).”

Source location

Response
Page 10 · response
Published 6 July 2015

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Fund inspector training in industry standards, safe working, traffic management, disability awareness and other work-related qualifications.

Verbatim wording from the response

“6.5 While not a statutory requirement, the City Council requires that all of the Inspectors hold a current City and Guilds “Streetworks Supervisor” accreditation, which qualifies them to oversee and instruct roadworks contractors on the highway and to diagnose highway defects or errors in working practice. This qualification remains valid for 5 years and has to be renewed with a full week’s training course and examination at an accredited training centre. The Council has funded training for all Inspectors in various other industry standards; these include qualifications in setting out signage and managing traffic, safe working practices, and disability awareness. The Council also funds any specific training that an Inspector wishes to undertake which supports their skills in work.”

Source location

Response
Page 15 · response
Published 6 July 2015

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Require inspectors to hold current City and Guilds Streetworks Supervisor accreditation.

Verbatim wording from the response

“6.5 While not a statutory requirement, the City Council requires that all of the Inspectors hold a current City and Guilds “Streetworks Supervisor” accreditation, which qualifies them to oversee and instruct roadworks contractors on the highway and to diagnose highway defects or errors in working practice. This qualification remains valid for 5 years and has to be renewed with a full week’s training course and examination at an accredited training centre. The Council has funded training for all Inspectors in various other industry standards; these include qualifications in setting out signage and managing traffic, safe working practices, and disability awareness. The Council also funds any specific training that an Inspector wishes to undertake which supports their skills in work.”

Source location

Response
Page 15 · response
Published 6 July 2015

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop protocols enabling lighting crews to correct base inventory data during routine maintenance inspections.

Verbatim wording from the response

“4.4 As a result of the implementation of Confirm Connect in the lighting service, we are currently developing protocols that will enable the lighting crews to not only update the inventory with maintenance works carried out, but also to make corrections to the base inventory asset data during routine maintenance inspections. This means that over the course of the next two full year’s maintenance inspection cycles (by 31 March 2018) when every illuminated asset will have been inspected using the new hand held units, the inventory will be updated. Taken together with the other update protocols, this provides a complete cycle of keeping the inventory updated.”

Source location

Response
Page 12 · response
Published 6 July 2015

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implement Confirm Connect for lighting maintenance to provide real-time inventory updates.

Verbatim wording from the response

“4.2 There are two methods of updating the inventory. The first is using handheld units and this method updates the inventory for reactive and routine maintenance works carried out using the same Confirm Connect software as the inspectors. This is already used by our drainage provider and shortly will be used by our lighting service provider for both reactive and routine maintenance. This brings much greater opportunity to keep the inventory updated in real time.”

Source location

Response
Page 11 · response
Published 6 July 2015

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Complete illuminated-asset inventory updates over two full maintenance inspection cycles by 31 March 2018.

Verbatim wording from the response

“4.4 As a result of the implementation of Confirm Connect in the lighting service, we are currently developing protocols that will enable the lighting crews to not only update the inventory with maintenance works carried out, but also to make corrections to the base inventory asset data during routine maintenance inspections. This means that over the course of the next two full year’s maintenance inspection cycles (by 31 March 2018) when every illuminated asset will have been inspected using the new hand held units, the inventory will be updated. Taken together with the other update protocols, this provides a complete cycle of keeping the inventory updated.”

Source location

Response
Page 12 · response
Published 6 July 2015

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

Existing inspection, contingency and inventory systems ensure missing or incorrectly recorded assets generate remedial work and prompt database updates.

Verbatim wording from the response

“The aim of the measures that the City Council already has in place, and those to be implemented, is that the City Council maintains an accurate inventory. The systems in place ensure that where an asset is missing or the record of it is incorrect, that the inventory database, contingency protocols and inspector knowledge and awareness ensure that the required remedial work is always ordered for our service provider to action and that the required update to the inventory database occurs promptly.”

Source location

Response
Page 3 · response
Published 6 July 2015

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026