PFD report

Tracey Julie HAYBITTLE · Prevention of Future Deaths report

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Issued 22 Aug 2024•Milton Keynes

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
2

Raised in this report

Recipients
5

Named on the report

Responses found
4

Of 5 recipients

Stated actions
16

Described in responses

Recipients and published responses

Source document

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 raised2

  1. Failure of commonly used satnav applications to provide safe verbal directions at the junction
    Part of recurring concern: Inadequate control of recurring collision risks at hazardous road locationsPart of recurring concern: Inadequate safety controls at high-risk road junctions
  2. Frequent wrong-way driving on the slip road
    Part of recurring concern: Inadequate controls preventing dangerous vehicle movements between slip roads and carriageways
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.15

  1. Action

    Implement safeguards that time verbal commands closer to the exit and after the off-slip road.

    Stated by TomTom International B.V.Stated completedThe respondent said that this action was complete when they made their response on 30 August 2024.
  2. Action

    Review navigation instructions and simulate speed scenarios near the junction.

    Stated by TomTom International B.V.Stated completedThe respondent said that this action was complete when they made their response on 30 August 2024.
  3. Action

    Deploy temporary ‘Do not follow Sat Nav’ and customer-information signs at the junction.

    Stated by National HighwaysStated completedThe respondent said that this action was complete when they made their response on 30 August 2024.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    It is not clear whether Google Maps was involved in the incidents described in the reports.

    Stated by Google UK LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 commonly used satnav applications to provide safe verbal directions at the junction

Wider context from the report

“I have made observations regarding the slip road at this junction in my initial pre-Inquest Report To Prevent Future Deaths dated the 21st December 2023 in respect of the linked case of Amal Mohamed Ahmood. National Highways undertook a number of immediate remedial measures to try to prevent drivers turning and travelling the wrong way down this slip road, including narrowing the "mouth" of the slip road to one lane, placement of very large temporary "No Entry" signs and placement of signs indicating "Do Not Use Satnav" at the site. CCTV monitoring of driver behaviour was commenced. Police activity and monitoring by National Highways showed that despite these measures, drivers were still turning early and attempting to drive the wrong way down the slip road. Further enquiries by the police and information volunteered by members of the public who made the same incorrect manoeuvre led to the finding that while the visual map display on commonly used satnav applications at this junction displayed the correct information, the verbal commands gave information likely to confuse and direct drivers down the wrong slip road into the path of oncoming traffic. This was observed to happen frequently. ”

Is this part of a recurring concern?

Yes — Inadequate control of recurring collision risks at hazardous road locations; Inadequate safety controls at high-risk road junctions.

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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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Frequent wrong-way driving on the slip road

Wider context from the report

“I have made observations regarding the slip road at this junction in my initial pre-Inquest Report To Prevent Future Deaths dated the 21st December 2023 in respect of the linked case of Amal Mohamed Ahmood. National Highways undertook a number of immediate remedial measures to try to prevent drivers turning and travelling the wrong way down this slip road, including narrowing the "mouth" of the slip road to one lane, placement of very large temporary "No Entry" signs and placement of signs indicating "Do Not Use Satnav" at the site. CCTV monitoring of driver behaviour was commenced. Police activity and monitoring by National Highways showed that despite these measures, drivers were still turning early and attempting to drive the wrong way down the slip road. Further enquiries by the police and information volunteered by members of the public who made the same incorrect manoeuvre led to the finding that while the visual map display on commonly used satnav applications at this junction displayed the correct information, the verbal commands gave information likely to confuse and direct drivers down the wrong slip road into the path of oncoming traffic. This was observed to happen frequently. ”

Is this part of a recurring concern?

Yes — Inadequate controls preventing dangerous vehicle movements between slip roads and carriageways.

Open source report

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Implement safeguards that time verbal commands closer to the exit and after the off-slip road.

Verbatim wording from the response

“As part of our ongoing efforts to enhance road safety, we recently implemented additional safeguards, to limit drivers’ confusion where possible, regardless of their speed behavior on the road, by timing the verbal commands closer to the actual exit, and in any event after passing the off-slip road. However, please note that in order for these changes to be effective and visible by end users, they need to use the latest map and therefore in certain circumstances need to update their systems/devices.”

Source location

Response from TomTom
Page 1 · response
Published 30 August 2024

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Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Review navigation instructions and simulate speed scenarios near the junction.

Verbatim wording from the response

“Following the report, we reviewed our navigation systems’ verbal instructions provided near the junction at hand. We have simulated different scenarios, including speed variations of 60mph and 30mph, to better understand how our navigation systems presented instructions based on driver speed. The scenarios assumed that the driver would either (i) maintain maximum speed until the junction; or (ii) slow down when approaching it. The outcome of the review revealed that instructions were given either (i) right when passing by the off-slip road; or (ii) after passing by the off-slip road, when on the overpass towards the exit.”

Source location

Response from TomTom
Page 1 · response
Published 30 August 2024

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

Deploy temporary ‘Do not follow Sat Nav’ and customer-information signs at the junction.

Verbatim wording from the response

“Again, on the 29 April 2024, the location was visited by National Highways and Thames Valley Police (Traffic Management Officer). During the site visit, a vehicle was observed to attempt to turn right into the slip road against the No-Entry signing. The driver was flagged down and aborted the turn. On speaking to the driver, they said that the Sat Nav app said to turn right. This raised concerns that Sat Nav instructions may have been leading to driver confusion.”

Source location

Response from National Highways
Page 5 · response
Published 30 August 2024

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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

Restore and maintain the temporary and fixed No-Entry signing, including correcting sign orientation, removing graffiti and repairing sign-related defects.

Verbatim wording from the response

“Following a site inspection on 24 April 2024, it was observed that the offside fixed (permanent) No-Entry sign had been rotated to face westwards (facing the Little Brickhill approach). This alteration had not been instructed or carried out by National Highways.”

Source location

Response from National Highways
Page 1 · response
Published 30 August 2024

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Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Install additional temporary No-Entry signs at the A5 off-slip exit to mitigate wrong-way driving.

Verbatim wording from the response

“Additional temporary signing has been put in place at the exit point of the A5 off slip at the Little Brickhill junction in the form of two large 1200mm ‘No Entry’ signs on A-frames on each side of the carriageway (Traffic Signs Regulations and General Directions (TSRGD), Diagram 616 No entry for vehicular traffic). These signs are intended to provide mitigation against further wrong way driving incidents while a full safety review of the junction has been undertaken.”

Source location

Response from National Highways
Page 1 · response
Published 30 August 2024

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Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Carry out detailed design and programme implementation of permanent junction works for the 2025/26 financial year.

Verbatim wording from the response

“Following completion of above actions, detailed design will be carried out and implementation programmed for the 2025/26 financial year.”

Source location

Response from National Highways
Page 7 · response
Published 30 August 2024

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Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Investigate Sat Nav routing and liaise with Google Maps, Apple Maps and WAZE regarding potentially confusing audible instructions.

Verbatim wording from the response

“Investigations have been undertaken to understand the potential influence Sat Nav instructions are having on driver behaviour. Route drives were undertaken using various Sat Nav apps (Google Maps, Apple Maps and WAZE) to review route guidance given to drivers.”

Source location

Response from National Highways
Page 6 · response
Published 30 August 2024

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Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Commission and complete consultant feasibility assessments of permanent junction options, including safety risk, effectiveness, cost, engineering difficulty and lighting appraisal.

Verbatim wording from the response

“Following receipt of the Regulation 28 Report to Prevent future Deaths, we commissioned our external design consultant (WSP) to carry out feasibility work to determine and recommend appropriate permanent changes at the junction, including the following key activities:”

Source location

Response from National Highways
Page 7 · response
Published 30 August 2024

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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 seven-day, 24-hour CCTV monitoring to measure the effectiveness of the temporary layout.

Verbatim wording from the response

“As part of continued monitoring of the junction, we are planning to undertake CCTV monitoring, initially for 24hours a day for a period of 7 days, to measure the effectiveness of the temporary layout.”

Source location

Response from National Highways
Page 7 · response
Published 30 August 2024

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Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Review feasibility outcomes with consultants and develop the preferred permanent option through a workshop, outline design, cost estimate and Stage 1 road-safety-audit documents.

Verbatim wording from the response

“Details of the external design consultants’ initial assessment and options were submitted to National Highways on 14 June 2024, and we are currently reviewing the outcomes and planning the next steps, which include:”

Source location

Response from National Highways
Page 7 · response
Published 30 August 2024

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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

Operate daily inspections of the temporary signing and cones to monitor their condition and alignment.

Verbatim wording from the response

“These works were undertaken on the night of the 24 April 2024. A daily inspection regime was put in place to monitor the signs and cones, and this is ongoing.”

Source location

Response from National Highways
Page 5 · response
Published 30 August 2024

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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

Close the offside slip-road lane and reposition the temporary No-Entry signs closer together to reduce apparent two-way-road movements.

Verbatim wording from the response

“These further changes involved closing the offside lane of the slip road to remove the potential ‘appearance’ of a two-way road. This also enabled the two large diameter No-Entry signs to be positioned closer together, see images below:”

Source location

Response from National Highways
Page 4 · response
Published 30 August 2024

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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

Liaised with National Highways and reviewed dashcam footage of the junction to inform investigation of Google Maps audio guidance.

Verbatim wording from the response

“• We have liaised with National Highways and reviewed their helpful dashcam footage of the relevant junction. This has assisted our product and engineering teams in carefully investigating the audio guidance provided by Google Maps. Our teams are working on improvements to the timing of the audio guidance.”

Source location

Response from Google
Page 2 · response
Published 30 August 2024

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

Investigate and develop improvements to the timing of Google Maps audio guidance.

Verbatim wording from the response

“• We have liaised with National Highways and reviewed their helpful dashcam footage of the relevant junction. This has assisted our product and engineering teams in carefully investigating the audio guidance provided by Google Maps. Our teams are working on improvements to the timing of the audio guidance.”

Source location

Response from Google
Page 2 · response
Published 30 August 2024

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

Add special voice guidance instructing drivers to continue straight at the overpass and turn right onto the A5 toward Milton Keynes, Bletchley.

Verbatim wording from the response

“However, to ensure we were following the very best approach we are taking an additional measure to add the following special voice guidance for drivers heading past the A5 offramp toward the A5 onramp, which we intend will be live by the start of next week. - Drivers heading past the A5 offramp toward the A5 onramp would be instructed to “Continue straight at the overpass” (that will happen as they are travelling west toward the offramp). - While on the overpass, drivers would be instructed to “Turn right onto A5 toward Milton Keynes, Bletchley.””

Source location

Response from Apple
Page 1 · response
Published 30 August 2024

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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

It is not clear whether Google Maps was involved in the incidents described in the reports.

Verbatim wording from the response

“We recognise that the cases identified in the reports are tragic. While it is not clear whether Google Maps was involved, we have carefully considered whether there are improvements we can make to Google Maps to help ensure that similar incidents do not occur in future. We have therefore taken the following measures:”

Source location

Response from Google
Page 2 · response
Published 30 August 2024

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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

Maps had no data or routing error that contributed to the deaths.

Verbatim wording from the response

“We immediately investigated the concerns raised and found no data or routing error on Maps which would have contributed to these tragic events.”

Source location

Response from Apple
Page 1 · response
Published 30 August 2024

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Monitor abnormal-load applications so temporary works can be altered and reinstated as required.

    Stated by National HighwaysStated in progressThe respondent said that this action was in progress when they made their response on 30 August 2024.

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 abnormal-load applications so temporary works can be altered and reinstated as required.

Verbatim wording from the response

“The existing slip road includes a nearside overrun area. This is to cater for routing of Abnormal Loads. Whilst these temporary measures are in place, Network Occupancy teams are monitoring applications for abnormal loads to ensure changes can be made to the temporary works and replaced as required.”

Source location

Response from National Highways
Page 5 · response
Published 30 August 2024

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