Caitlin Ann SWAN · Prevention of Future Deaths report

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Issued 27 Apr 2021•Cornwall and Isles of Scilly

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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
1

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 raised1

  1. Lack of warning signs for the junction with Trebost Lane on Tubbоn Hill
    Part of recurring concern: Inadequate road warning signage

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. Corserv Solutions Limited

    Erect additional warning signs at the Trebost junction on Tubbion Hill.

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

  1. Corserv Solutions Limited

    Junction warning signs are not routinely required; their absence at this junction was not unusual given site conditions and collision history.

    Disputes 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

Lack of warning signs for the junction with Trebost Lane on Tubbоn Hill

Wider context from the report

“There are no signs on Tubbоn Hill to warn road users of the junction with Trebost Lane, notwithstanding that the junction is only visible between 75 and 50 metres away for a road user descending the hill and that any vehicles negotiating the acute left turn into Trebost Lane are likely to be almost stationary in the road at some point. ”

Is this part of a recurring concern?

Yes — Inadequate road warning signage.

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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

Erect additional warning signs at the Trebost junction on Tubbion Hill.

Verbatim wording from the response

“Although I was unable to attend the inquest on the day, I subsequently viewed the recording and have also visited the site of the collision. I have discussed the findings of the inquest and your recommendations with senior officers of Cornwall Council, and am pleased to confirm that they have approved the provision of additional warning signing.”

Source location

2021-0121-Response-from-CORMAC-Redacted
Page 1 · response
Published 29 April 2021

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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

Junction warning signs are not routinely required; their absence at this junction was not unusual given site conditions and collision history.

Verbatim wording from the response

“Notwithstanding this, I would like to correct a perhaps misleading impression that may have been given at the inquest about such signs. I note that at one point it was suggested that the provision of junction warning signs would be “normal”; this could imply the absence of such a sign is some form of specific omission, of course. I can assure you this is not the case, and the formal guidance on their provision is:”

Source location

2021-0121-Response-from-CORMAC-Redacted
Page 1 · response
Published 29 April 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

Data last updated 7 September 2026