PFD report

Sonia Elvira Stante · Prevention of Future Deaths report

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Issued 28 Nov 2017•Inner North London

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
5

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
3

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 raised5

  1. Confusing pedestrian crossing arrangement caused by two separate junctions
    Part of recurring concern: Inadequate control of pedestrian crossing risks
  2. Foreign visitors’ possible lack of understanding of the junction
  3. Lack of road markings indicating the direction pedestrians should look when crossing
    Part of recurring concern: Inadequate control of pedestrian crossing risksPart of recurring concern: Inadequate road markings for road-user safety
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

    Inspect the crossings and review their layout to identify changes that could further assist pedestrians.

    Stated by Transport for LondonStated completedThe respondent said that this action was complete when they made their response on 27 February 2018.
  2. Action

    Fit additional louvres to two further pedestrian-signal aspects on the Pentonville Road crossing.

    Stated by Transport for LondonStated completedThe respondent said that this action was complete when they made their response on 27 February 2018.
  3. Action

    Install ‘Look left, Look right’ road markings at each pedestrian crossing at the junction.

    Stated by Transport for LondonStated completedThe respondent said that this action was complete when they made their response on 27 February 2018.

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

  1. Position

    The pedestrian signals were functioning normally at the time of the collision, including the existing louvres intended to prevent confusion between crossings.

    Stated by Transport for LondonDisputes 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

Confusing pedestrian crossing arrangement caused by two separate junctions

Wider context from the report

“Following the incident ████████ Traffic Management Officer undertook a review of the road traffic layout at the scene. He met with TfL on site on 16 August 2017 and a number of findings were made: (1) No road markings indicating the direction pedestrians should look when crossing (2) Two separate junctions at that location make that crossing confusing for pedestrians (3) The phasing of the green man operates for each carriageway independently so causing confusion for pedestrians who may look at the wrong phasing (4) Missing louvre on the green man on the north side of the crossing making the green man more visible to pedestrians crossing from the south (5) With the location being close to the Eurostar Terminal there are several hotels nearby and foreign visitors may not have a full understanding if the junction. ”

Is this part of a recurring concern?

Yes — Inadequate control of pedestrian crossing risks.

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

Foreign visitors’ possible lack of understanding of the junction

Wider context from the report

“Following the incident ████████ Traffic Management Officer undertook a review of the road traffic layout at the scene. He met with TfL on site on 16 August 2017 and a number of findings were made: (1) No road markings indicating the direction pedestrians should look when crossing (2) Two separate junctions at that location make that crossing confusing for pedestrians (3) The phasing of the green man operates for each carriageway independently so causing confusion for pedestrians who may look at the wrong phasing (4) Missing louvre on the green man on the north side of the crossing making the green man more visible to pedestrians crossing from the south (5) With the location being close to the Eurostar Terminal there are several hotels nearby and foreign visitors may not have a full understanding if the junction. ”

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 road markings indicating the direction pedestrians should look when crossing

Wider context from the report

“Following the incident ████████ Traffic Management Officer undertook a review of the road traffic layout at the scene. He met with TfL on site on 16 August 2017 and a number of findings were made: (1) No road markings indicating the direction pedestrians should look when crossing (2) Two separate junctions at that location make that crossing confusing for pedestrians (3) The phasing of the green man operates for each carriageway independently so causing confusion for pedestrians who may look at the wrong phasing (4) Missing louvre on the green man on the north side of the crossing making the green man more visible to pedestrians crossing from the south (5) With the location being close to the Eurostar Terminal there are several hotels nearby and foreign visitors may not have a full understanding if the junction. ”

Is this part of a recurring concern?

Yes — Inadequate control of pedestrian crossing risks; Inadequate road markings for road-user safety.

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

Green-man phasing failing to provide clear pedestrian crossing signals across each carriageway

Wider context from the report

“Following the incident ████████ Traffic Management Officer undertook a review of the road traffic layout at the scene. He met with TfL on site on 16 August 2017 and a number of findings were made: (1) No road markings indicating the direction pedestrians should look when crossing (2) Two separate junctions at that location make that crossing confusing for pedestrians (3) The phasing of the green man operates for each carriageway independently so causing confusion for pedestrians who may look at the wrong phasing (4) Missing louvre on the green man on the north side of the crossing making the green man more visible to pedestrians crossing from the south (5) With the location being close to the Eurostar Terminal there are several hotels nearby and foreign visitors may not have a full understanding if the junction. ”

Is this part of a recurring concern?

Yes — Inadequate control of pedestrian crossing risks.

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

Missing louvre on the north-side green-man signal

Wider context from the report

“Following the incident ████████ Traffic Management Officer undertook a review of the road traffic layout at the scene. He met with TfL on site on 16 August 2017 and a number of findings were made: (1) No road markings indicating the direction pedestrians should look when crossing (2) Two separate junctions at that location make that crossing confusing for pedestrians (3) The phasing of the green man operates for each carriageway independently so causing confusion for pedestrians who may look at the wrong phasing (4) Missing louvre on the green man on the north side of the crossing making the green man more visible to pedestrians crossing from the south (5) With the location being close to the Eurostar Terminal there are several hotels nearby and foreign visitors may not have a full understanding if the junction. ”

Is this part of a recurring concern?

Yes — Inadequate control of pedestrian crossing risks.

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

Inspect the crossings and review their layout to identify changes that could further assist pedestrians.

Verbatim wording from the response

“We inspected the crossings again on 11 September 2017 to review the layout and consider whether any changes could be made to assist pedestrians further. Subsequent to this visit, additional louvres were fitted on 13 October 2017 to two further green figure light aspects on the Pentonville Road crossing, including on the north side of the crossing (see Figure 2), to reduce the likelihood of pedestrians crossing when they were not invited to do so.”

Source location

2017-0428-Response-by-Transport-for-London
Page 2 · response
Published 27 February 2018

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

Fit additional louvres to two further pedestrian-signal aspects on the Pentonville Road crossing.

Verbatim wording from the response

“We inspected the crossings again on 11 September 2017 to review the layout and consider whether any changes could be made to assist pedestrians further. Subsequent to this visit, additional louvres were fitted on 13 October 2017 to two further green figure light aspects on the Pentonville Road crossing, including on the north side of the crossing (see Figure 2), to reduce the likelihood of pedestrians crossing when they were not invited to do so.”

Source location

2017-0428-Response-by-Transport-for-London
Page 2 · response
Published 27 February 2018

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

Install ‘Look left, Look right’ road markings at each pedestrian crossing at the junction.

Verbatim wording from the response

“Road markings (‘matters of concern’ point 1) The provision of ‘Look left, Look right’ markings is assessed by TfL on a site-by-site basis, in line with the national guidance. Following your report, these have been installed at each of the pedestrian crossings at this junction.”

Source location

2017-0428-Response-by-Transport-for-London
Page 2 · response
Published 27 February 2018

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

The pedestrian signals were functioning normally at the time of the collision, including the existing louvres intended to prevent confusion between crossings.

Verbatim wording from the response

“Green figure ‘louvres’ on pedestrian signals (‘matters of concern’ point 4) At the time of the collision, pedestrian signals at both crossings were functioning normally. This included louvres (a slatted cover designed to prevent confusion between the green figure light aspects of the separate crossings) on two of the green figure light aspects at the pedestrian crossings. These louvres were in place at the time of the site visit with the Metropolitan Police on 16 August 2017.”

Source location

2017-0428-Response-by-Transport-for-London
Page 2 · response
Published 27 February 2018

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

The staggered crossing arrangement is a common, efficient junction design that reduces pedestrian waiting and delays to other road users.

Verbatim wording from the response

“Junction design and layout (‘matters of concern’ points 2 and 3) The junction of Pentonville Road and King’s Cross Road operates as a single junction with two separately signalled pedestrian crossings. The crossing of King’s Cross Road is known as a ‘straight across’ crossing and the crossing on Pentonville Road as a ‘staggered’ crossing. This is a common arrangement and used throughout London. At a staggered crossing, a pedestrian must cross the road in two stages as each green figure light aspect will display independently of the other. Each green figure light aspect is sufficiently far apart to discourage pedestrians from looking at the other. This arrangement allows the junction to operate in the most efficient manner overall, reducing the time that pedestrians must wait before they are able to cross the road as well as delays to other road users.”

Source location

2017-0428-Response-by-Transport-for-London
Page 1 · response
Published 27 February 2018

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

Although tourists use the area, the signs and highway design are clear and understandable for users regardless of their origins or familiarity.

Verbatim wording from the response

“Understanding of the junction by foreign visitors (‘matters of concern’ point 5) We take the safety of our highway extremely seriously and adopt an approach of continual improvement to reducing road danger. The measures we have undertaken at this junction will further enhance pedestrian safety at this location. There are hotels and tourists in the area, including those from outside the UK. This type of location, however, is not atypical in London and signs are designed and operate the highway so that it is clear and understandable for all users, regardless of their origins and familiarity of the area.”

Source location

2017-0428-Response-by-Transport-for-London
Page 2 · response
Published 27 February 2018

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