PFD report

Heike MOJAY-SINCLARE · Prevention of Future Deaths report

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Issued 17 Sep 2021•Derby and Derbyshire

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
0

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 to include river fords and depth gauges in mandatory highways inspection requirements
    Part of recurring concern: Unreliable highway inspection and asset-recording processes
  2. Lack of mandatory requirements for water depth gauges at river ford crossings
  3. Lack of a prescribed design and standard for water depth gauges
Responses linked to these concerns

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

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

    The Government has no power to override local highway maintenance decisions or intervene in local inspection arrangements.

    Stated by Department for TransportOutside remitThe respondent said that this matter was outside its role or authority.

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 include river fords and depth gauges in mandatory highways inspection requirements

Wider context from the report

“2. The inquest heard that river fords and depth gauges do not currently lie within mandatory highways inspection requirements and therefore there is no guarantee of their maintenance and review, and therefore no guarantee that they continue to provide on-going usability and safety. ”

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

Lack of mandatory requirements for water depth gauges at river ford crossings

Wider context from the report

“1. The inquest heard that with regard to water depth gauges, specifically for river fords, the Traffic Signs and General Directions 2016 removed prescription of the type of signs to be used and the requirement for their use at river ford crossings. Those requirements were in the previous 2002 Directions. There s relevant guidance (Ch.4 Traffic Signs Manual) but this is not mandatory and leaves enactment to the discretion of the relevant local authority. As water depth gauges are outside of the regulatory regime there may be fords without gauges, or where they are installed they may be sub-optimal and deficient. There is also lack of clarity for local authorities and the lack of a prescribed design and standard means that manufacturers do not have an approved design to work to and provide to local authorities. ”

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

Lack of a prescribed design and standard for water depth gauges

Wider context from the report

“1. The inquest heard that with regard to water depth gauges, specifically for river fords, the Traffic Signs and General Directions 2016 removed prescription of the type of signs to be used and the requirement for their use at river ford crossings. Those requirements were in the previous 2002 Directions. There s relevant guidance (Ch.4 Traffic Signs Manual) but this is not mandatory and leaves enactment to the discretion of the relevant local authority. As water depth gauges are outside of the regulatory regime there may be fords without gauges, or where they are installed they may be sub-optimal and deficient. There is also lack of clarity for local authorities and the lack of a prescribed design and standard means that manufacturers do not have an approved design to work to and provide to local authorities. ”

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 notify relevant local authorities of serious river ford incidents

Wider context from the report

“3. The inquest heard that there were a number of previous serious incidents which it appears were not notified to the relevant local authority, and that if they had been there would likely have been a review of measures relating to the river ford. A mandatory requirement for inter-agency information sharing in these circumstances is indicated. ”

Is this part of a recurring concern?

Yes — Failure to reliably share road-safety incident information with highway authorities.

Open source report

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 Government has no power to override local highway maintenance decisions or intervene in local inspection arrangements.

Verbatim wording from the response

“3. With regards to highways inspection requirements, local highway authorities have a duty, under section 41 of the Highways Act 1980, to maintain the highway network in their area. The Act does not set out specific standards of maintenance, as it is for each individual local highway authority to assess which parts of its network are in need of repair and what standards should be applied, based upon their local knowledge and circumstances. The Government has no powers to override local decisions in these matters or intervene in these kinds of local issues.”

Source location

Response from Department for Transport
Page 2 · response
Published 23 September 2021

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

Local authorities decide whether to install water-depth gauges; their use is not mandated by the Department.

Verbatim wording from the response

“2. The water depth gauge was prescribed in the Traffic Signs Regulations and General Directions 2002, but the decision to place them at any site would have still been at the discretion of the local authority. Their use was not mandated by this Department.”

Source location

Response from Department for Transport
Page 1 · response
Published 23 September 2021

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

Local agencies are responsible for sharing information about incidents; no requirement requires police and local authorities to do so.

Verbatim wording from the response

“4. I appreciate that there were a number of previous incidents at this ford that the local highway authority was not made aware of, but I am afraid I cannot comment on the why this might have happened. While service agreements are often in place between forces and local authorities there are no existing requirements for this to take place. The sharing of information locally is a matter for local agencies. You may wish to consider bringing this matter to the attention of your Local Resilience Forum.”

Source location

Response from Department for Transport
Page 2 · response
Published 23 September 2021

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

No Departmental action is considered necessary because the relevant decisions rest with local authorities and tools are already available.

Verbatim wording from the response

“I hope this response has explained my thinking on why I do not believe there are any actions necessary from the Department. I am afraid the concerns that you have raised are issues where the decision to act rests with the local authority, and there are tools available to them already to enable them to do so.”

Source location

Response from Department for Transport
Page 2 · response
Published 23 September 2021

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

  1. 1

    Local authorities are responsible for identifying hazards on their networks and providing appropriate warning signs.

    Stated by Department for TransportRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Local authorities are responsible for identifying hazards on their networks and providing appropriate warning signs.

Verbatim wording from the response

“1. With regard to signing, I should first clarify that it is the responsibility of local authorities to ensure hazards on their network are identified and appropriately signed to warn drivers.”

Source location

Response from Department for Transport
Page 1 · response
Published 23 September 2021

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