PFD report

Tracy Michelle ROOKE · Prevention of Future Deaths report

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Issued 9 Oct 2014•Wiltshire and Swindon

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
4

Raised in this report

Recipients
1

Named on the report

Responses found
0

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

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Report evidence summary

Concerns raised4

  1. Deficiencies in road signage, including its location and condition
    Part of recurring concern: Inadequate road warning signage
  2. Delays in acting on road safety recommendations
    Part of recurring concern: Failure to implement identified safety actions
  3. Inadequate practices and procedures for dealing with mud on the highway
Responses linked to these concerns

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

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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

Deficiencies in road signage, including its location and condition

Wider context from the report

“During the course of the Inquest I heard evidence from ████████ whose role is the Force’s Traffic Management and Road Safety Assessment Officer. He is a former Collision Investigator. As part of his evidence he produced a copy of his report dated 26 June 2014 in respect of which I believe you received a copy back in June. In that report and specifically at pages 10 & 11 of the report, a copy of which I have attached to this Regulation 28 report, he sets out a number of recommendations. I share the concerns that are raised by ████████ in his report which focuses on identified issues concerning road signage, the location of road signage and the current state of road signage in this particular area. I am concerned that if these are not addressed that they potentially could contribute to future road traffic incidents that may result in injury or even death. I am additionally concerned having regard to the evidence that ████████ gave in respect of which he indicated that whilst you have been given a copy of his report including recommendations that no action would be taken until I make a report with a view to the prevention of future deaths. That concerns me as Highways Authority you believe there is merit in relation to the recommendations then it should not have to wait until a Coroner makes a report some months after the Traffic Management and Road Safety Assessment Report is submitted before action is taken. ”

Is this part of a recurring concern?

Yes — 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

Delays in acting on road safety recommendations

Wider context from the report

“During the course of the Inquest I heard evidence from ████████ whose role is the Force’s Traffic Management and Road Safety Assessment Officer. He is a former Collision Investigator. As part of his evidence he produced a copy of his report dated 26 June 2014 in respect of which I believe you received a copy back in June. In that report and specifically at pages 10 & 11 of the report, a copy of which I have attached to this Regulation 28 report, he sets out a number of recommendations. I share the concerns that are raised by ████████ in his report which focuses on identified issues concerning road signage, the location of road signage and the current state of road signage in this particular area. I am concerned that if these are not addressed that they potentially could contribute to future road traffic incidents that may result in injury or even death. I am additionally concerned having regard to the evidence that ████████ gave in respect of which he indicated that whilst you have been given a copy of his report including recommendations that no action would be taken until I make a report with a view to the prevention of future deaths. That concerns me as Highways Authority you believe there is merit in relation to the recommendations then it should not have to wait until a Coroner makes a report some months after the Traffic Management and Road Safety Assessment Report is submitted before action is taken. ”

Is this part of a recurring concern?

Yes — Failure to implement identified safety actions.

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

Inadequate practices and procedures for dealing with mud on the highway

Wider context from the report

“The above having been said if evidence is presented to a Coroner as part of an Inquest process irrespective of it being unconnected with the circumstances of that person’s death, a Coroner can make a Regulation 28 report if he or she has concerns with a view to prevention of future deaths. I am concerned in relation to the quantity of mud visible in the photographs and also as regards the quality of signage located in such close proximity to the start of the muddied section of highway. I have dealt with deaths on Wiltshire roads that have involved farm mud on the highway and I am aware of the hazard it creates. I fully accept farmers have a livelihood to make however I would ask that you review and inform me of your practice and procedures to deal with mud on the highway and as to whether or not in the light of the photographs your practices could be improved and if so how. You may also like to consider seeking advice from either the National Farmers Union or Wiltshire Council as Highways Authority. ”

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

Inadequate signage near the start of the muddied section of highway

Wider context from the report

“The above having been said if evidence is presented to a Coroner as part of an Inquest process irrespective of it being unconnected with the circumstances of that person’s death, a Coroner can make a Regulation 28 report if he or she has concerns with a view to prevention of future deaths. I am concerned in relation to the quantity of mud visible in the photographs and also as regards the quality of signage located in such close proximity to the start of the muddied section of highway. I have dealt with deaths on Wiltshire roads that have involved farm mud on the highway and I am aware of the hazard it creates. I fully accept farmers have a livelihood to make however I would ask that you review and inform me of your practice and procedures to deal with mud on the highway and as to whether or not in the light of the photographs your practices could be improved and if so how. You may also like to consider seeking advice from either the National Farmers Union or Wiltshire Council as Highways Authority. ”

Is this part of a recurring concern?

Yes — Inadequate road warning signage.

Open source report
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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

No official response is included in the current published snapshot.