PFD report

Saeid Hedayat · Prevention of Future Deaths report

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Issued 2 Oct 2019•West Sussex

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.

View original report
Concerns
4

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
5

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.

Report evidence summary

Concerns raised4

  1. Failure of drain-clearance risk assessments to account for zone 1 blockages
  2. Failure to provide warning signs for recurring zone 1 road-flooding risk
    Part of recurring concern: Failure to reliably manage flooding and standing-water risks on roadsPart of recurring concern: Inadequate road warning signage
  3. Recurring zone 1 drain blockages from debris and silt
    Part of recurring concern: Inadequate drainage control of hazardous surface water on public routes
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.4

  1. Action

    Record Zone 1 blockages as obstructions before cleansing and include them in cleansing-data and defect reporting.

    Stated by West Sussex County CouncilStated completedThe respondent said that this action was complete when they made their response on 8 November 2019.
  2. Action

    Review the cleansing programme and reconsider risk levels for the new term maintenance contract.

    Stated by West Sussex County CouncilStated plannedThe respondent said that this action was planned when they made their response on 8 November 2019.
  3. Action

    Operate and periodically optimise a countywide, risk-based gully-cleansing programme using silt, flooding and cleansing data.

    Stated by West Sussex County CouncilStated completedThe respondent said that this action was complete when they made their response on 8 November 2019.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    Officer assessment of flooding reports, ad hoc cleansing, and use of recorded data are considered sufficient to address drainage risks and inform future optimisation.

    Stated by West Sussex County CouncilExisting 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 drain-clearance risk assessments to account for zone 1 blockages

Wider context from the report

“(1) West Sussex County Council’s risk assessment which was carried out to determine drain clearance frequency did not take any account of zone 1 blockages and I heard evidence that there is no time period set for reviewing the risk assessments. I heard evidence that the risk levels have not been reviewed since 2011 despite more recent data being available. (2) I also heard evidence that neither anomalous silt level reports nor reports from members of the public of road flooding would trigger a review of the risk assessments. (3) The highways authority representative at the inquest was not able to inform me of what plans West Sussex County Council has to reassess the drain risk levels in light of the increased severity of winter storms. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 provide warning signs for recurring zone 1 road-flooding risk

Wider context from the report

“(4) I found that drain numbered B9913 was blocked on a regular basis due to debris and silt collecting in zone 1. There are no warning signs (temporary or permanent) drawing drivers’ attention to the flood risk despite this. I heard evidence that signs would not normally be installed unless the highways authority were not able to immediately resolve the flooding if they attended. This approach does not appear to adequately deal with the risks posed where road flooding occurs regularly due to a zone 1 blockage. ”

Is this part of a recurring concern?

Yes — Failure to reliably manage flooding and standing-water risks on roads; Inadequate road warning signage.

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

Recurring zone 1 drain blockages from debris and silt

Wider context from the report

“(4) I found that drain numbered B9913 was blocked on a regular basis due to debris and silt collecting in zone 1. There are no warning signs (temporary or permanent) drawing drivers’ attention to the flood risk despite this. I heard evidence that signs would not normally be installed unless the highways authority were not able to immediately resolve the flooding if they attended. This approach does not appear to adequately deal with the risks posed where road flooding occurs regularly due to a zone 1 blockage. ”

Is this part of a recurring concern?

Yes — Inadequate drainage control of hazardous surface water on public routes.

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 review drain risk assessments at defined intervals and in response to relevant new information

Wider context from the report

“(1) West Sussex County Council’s risk assessment which was carried out to determine drain clearance frequency did not take any account of zone 1 blockages and I heard evidence that there is no time period set for reviewing the risk assessments. I heard evidence that the risk levels have not been reviewed since 2011 despite more recent data being available. (2) I also heard evidence that neither anomalous silt level reports nor reports from members of the public of road flooding would trigger a review of the risk assessments. (3) The highways authority representative at the inquest was not able to inform me of what plans West Sussex County Council has to reassess the drain risk levels in light of the increased severity of winter storms. ”

Is this part of a recurring concern?

Yes — Failure to update risk assessments after material changes or safety events.

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

Record Zone 1 blockages as obstructions before cleansing and include them in cleansing-data and defect reporting.

Verbatim wording from the response

“Moving forward, WSCC has now adopted the approach of recording Zone 1 blockages where the contractor is undertaking the cleansing programme. It will be logged as the asset being “obstructed prior to cleanse” and will be reported back with all other cleansing data and defects. This data, in addition to any recorded customer enquiries, will give enhanced data which will help identify areas where we might have ongoing zone 1 blockages and thus help address the Coroner’s concern.”

Source location

2019-0327-Response-by-West-Sussex-County-Council
Page 2 · response
Published 8 November 2019

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

Review the cleansing programme and reconsider risk levels for the new term maintenance contract.

Verbatim wording from the response

“As stated above, under our current Term Maintenance contract, we undertook a full review of the programme at the start of this year and a new optimised programme commenced on 1 April 2019. We are currently undertaking a procurement exercise for a new contract starting April 1st 2020 and there will be a review of the programme again and we will consider risk levels again. Award of the contract is likely to be made in December 2019 after which the specifications for drainage cleansing frequency within the new contract can be disclosed.”

Source location

2019-0327-Response-by-West-Sussex-County-Council
Page 2 · response
Published 8 November 2019

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

Operate and periodically optimise a countywide, risk-based gully-cleansing programme using silt, flooding and cleansing data.

Verbatim wording from the response

“At the start of our current Term Maintenance Contract (which commenced 1st July 2011) we worked with our contractor to develop an annual, county wide gully cleansing programme. To do this historical WSCC information regarding gully cleansing, silt levels and treatment intervals were assessed and an optimised cleansing programme developed. This approach involved looking at where flood events have occurred and, where silt levels in gullies have historically been high, arranging for these gullies to be cleaned more regularly than those in areas not prone to flooding and with historically low levels of silt.”

Source location

2019-0327-Response-by-West-Sussex-County-Council
Page 1 · response
Published 8 November 2019

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

Consider climate-change impacts and future-proof the highway network, including adapting drain risk levels to more severe winter storms.

Verbatim wording from the response

“As Highway Authority we will be considering the climate change impacts and how to future proof our network. This will include understanding and reacting to drain risk levels in light of any increased severity of winter storms.”

Source location

2019-0327-Response-by-West-Sussex-County-Council
Page 3 · response
Published 8 November 2019

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

Officer assessment of flooding reports, ad hoc cleansing, and use of recorded data are considered sufficient to address drainage risks and inform future optimisation.

Verbatim wording from the response

“Flooding incidents are not necessarily caused by blocked gullies. When we receive a report of a flooding incident where water is slow to drain, then an officer will attend site and assess the likely cause. There may not be any evidence of an issue and in this case the contractor may not be asked to attend. For example, where there has been an exceptional severe weather event and the gully and drainage system did not have the capacity to cope with the deluge. If an officer visits the site and the gully is silted they will arrange for our contractor to attend site and undertake an ad hoc cleanse. Whenever our contractor attends site for cleansing or jetting outside of the cleansing programme (i.e. when data is recorded as ‘Ad-Hoc’) if the level of silt recorded is above 50% then this would factor into the optimisation of the frequency of cleansing going forward.”

Source location

2019-0327-Response-by-West-Sussex-County-Council
Page 3 · response
Published 8 November 2019

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 flood-signing practice was considered sufficient because the authority was unaware of an ongoing zone 1 blockage at the location.

Verbatim wording from the response

“If we attend site and are unable to resolve a flooding issue immediately and this is impacting safe passage of the highway, our normal practice is to place temporary Flood Signs to warn motorists until we can resolve the issue.”

Source location

2019-0327-Response-by-West-Sussex-County-Council
Page 4 · response
Published 8 November 2019

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

Regular cleansing-cycle reviews and annual programme optimisation are considered sufficient to reassess drain risk and adjust cleansing frequencies.

Verbatim wording from the response

“The treatment intervals for each gully were reviewed on a regular basis to ensure that the most appropriate level of service is delivered. At the end of a two-year cleansing cycle, an optimised cleansing regime was agreed and this took into account any changes in silt levels and priority based on levels of risk determined by the assessment of need.”

Source location

2019-0327-Response-by-West-Sussex-County-Council
Page 2 · response
Published 8 November 2019

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

    Prepare guidance on climate-change risk assessment and adapting local-authority plans, policies, performance and infrastructure.

    Stated by West Sussex County CouncilStated completedThe respondent said that this action was complete when they made their response on 8 November 2019.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    A policy of signing occasional standing water caused by infrequent storm-related zone 1 restrictions would set an unnecessarily difficult precedent.

    Stated by West Sussex County CouncilDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Prepare guidance on climate-change risk assessment and adapting local-authority plans, policies, performance and infrastructure.

Verbatim wording from the response

“WSCC was part of the team who prepared the Guidance for Climate Change document (see attached). This document outlines the key areas that a local authority needs to consider in relation to climate change risk assessment and the adaptation of corporate plans, policies and performance and infrastructure. The document also considers our approach to land use, planning and the built environment which includes developments and drainage requirements and specifications for surface water drainage plans.”

Source location

2019-0327-Response-by-West-Sussex-County-Council
Page 3 · response
Published 8 November 2019

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

A policy of signing occasional standing water caused by infrequent storm-related zone 1 restrictions would set an unnecessarily difficult precedent.

Verbatim wording from the response

“It would set a very difficult precedent for the highway authority if we adopted a policy of signing occasional laying water as a result of Zone 1 restrictions which only occurred as a result of infrequent events (storms). In inclement weather rain intensity may cause any catchment area to become temporarily blocked by detritus.”

Source location

2019-0327-Response-by-West-Sussex-County-Council
Page 4 · response
Published 8 November 2019

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

Official responses located
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Data last updated 7 September 2026