PFD report

Susan Barbara HENDERSON and Margaret Louise SHAW · Prevention of Future Deaths report

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Issued 30 May 2019•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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

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 raised1

  1. Failure of road inspections to identify drain problems
    Part of recurring concern: Unreliable highway inspection and asset-recording processes
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.3

  1. Action

    Complete a review of inspection requirements and processes across the Strategic Road Network, including the speed of driven inspections.

    Stated by National HighwaysStated completedThe respondent said that this action was complete when they made their response on 14 August 2019.
  2. Action

    Issue a memorandum to all Areas highlighting recessed-gully locations, defect-recording methods, possible renewal of non-standard gullies, and communication of defects to Local Authorities.

    Stated by National HighwaysStated plannedThe respondent said that this action was planned when they made their response on 14 August 2019.
  3. Action

    Move Area 8 from Asset Support Contract arrangements to the Asset Delivery approach, with inspections undertaken in-house by Highways England staff.

    Stated by National HighwaysStated plannedThe respondent said that this action was planned when they made their response on 14 August 2019.

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

  1. Position

    Existing risk-based inspection requirements and processes are considered consistent and sufficient, so no changes are proposed beyond the Asset Delivery transition.

    Stated by National HighwaysExisting 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 road inspections to identify drain problems

Wider context from the report

“During the course of the evidence I heard how the roads are examined and monitored on a regular basis but that such inspections are conducted at speed and that the process failed to identify the problem with this particular drain on the A5. I believe that the process for inspection should be reviewed. ”

Is this part of a recurring concern?

Yes — Unreliable highway inspection and asset-recording processes.

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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

Complete a review of inspection requirements and processes across the Strategic Road Network, including the speed of driven inspections.

Verbatim wording from the response

““During the course of the evidence I heard how the roads are examined and monitored on a regular basis but that such inspections are conducted at speed and that the process failed to identify the problem with this particular drain on the A5. I believe that the process for inspection should be reviewed.””

Source location

Response from Highways England
Page 2 · response
Published 14 August 2019

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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

Issue a memorandum to all Areas highlighting recessed-gully locations, defect-recording methods, possible renewal of non-standard gullies, and communication of defects to Local Authorities.

Verbatim wording from the response

“Following the review of inspection requirements and processes Highways England has decided to issue a memorandum to all our Areas to highlight the importance of:”

Source location

Response from Highways England
Page 3 · response
Published 14 August 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

Move Area 8 from Asset Support Contract arrangements to the Asset Delivery approach, with inspections undertaken in-house by Highways England staff.

Verbatim wording from the response

“From the 1st October 2019 Area 8 will be moving from the current Asset Support Contract arrangements to the new Asset Delivery approach. Asset Delivery inspections will be undertaken in-house by Highways England staff.”

Source location

Response from Highways England
Page 3 · response
Published 14 August 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 risk-based inspection requirements and processes are considered consistent and sufficient, so no changes are proposed beyond the Asset Delivery transition.

Verbatim wording from the response

“Highways England’s review of the inspection requirements and processes used by Highways England’s Areas and Regions, and our supply chain, concluded they had a common risk based approach, and were understood by inspectors and applied consistently. Therefore, there are no proposals to change the requirements and processes.”

Source location

Response from Highways England
Page 4 · response
Published 14 August 2019

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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

    Move all Asset Support Contract areas to the Asset Delivery approach.

    Stated by National HighwaysStated plannedThe respondent said that this action was planned when they made their response on 14 August 2019.

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 sweeping and cleaning all-purpose trunk roads, while Highways England communicates relevant defects to them.

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

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

Move all Asset Support Contract areas to the Asset Delivery approach.

Verbatim wording from the response

“From July 2022 all Asset Support Contract areas will have moved over to Asset Delivery.”

Source location

Response from Highways England
Page 3 · response
Published 14 August 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

Local authorities are responsible for sweeping and cleaning all-purpose trunk roads, while Highways England communicates relevant defects to them.

Verbatim wording from the response

“• Communicating defects to Local Authorities as the body responsible for the sweeping and cleaning of All Purpose Trunk Roads.”

Source location

Response from Highways England
Page 4 · response
Published 14 August 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

Data last updated 7 September 2026