PFD report

Amal Mohamed AHMED · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 23 Aug 2024•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.

View original report
Concerns
5

Raised in this report

Recipients
6

Named on the report

Responses found
5

Of 6 recipients

Stated actions
13

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised5

  1. Inadequate positioning and visibility of No Entry signage for wrong-way slip-road entry
    Part of recurring concern: Inadequate controls preventing dangerous vehicle movements between slip roads and carriagewaysPart of recurring concern: Inadequate road warning signagePart of recurring concern: Inadequate safety controls at high-risk road junctions
  2. Frequent wrong-way driving down the slip road into oncoming traffic
    Part of recurring concern: Inadequate controls preventing dangerous vehicle movements between slip roads and carriagewaysPart of recurring concern: Inadequate safety controls at high-risk road junctions
  3. Slip-road geometry allowing wrong-way vehicles to enter and build up considerable speed
    Part of recurring concern: Inadequate control of recurring collision risks at hazardous road locationsPart of recurring concern: Inadequate controls preventing dangerous vehicle movements between slip roads and carriagewaysPart of recurring concern: Inadequate safety controls at high-risk road junctionsPart of recurring concern: Unsafe road design and layout
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.11

  1. Action

    Implement safeguards that time verbal navigation commands closer to the exit and after drivers pass the off-slip road.

    Stated by TomTom International B.V.Stated completedThe respondent said that this action was complete when they made their response on 29 December 2023.
  2. Action

    Review navigation instructions near the junction by simulating driver-speed scenarios and assessing instruction timing.

    Stated by TomTom International B.V.Stated completedThe respondent said that this action was complete when they made their response on 29 December 2023.
  3. Action

    Investigate and develop improvements to the timing of Google Maps audio guidance.

    Stated by Google UK LimitedStated in progressThe respondent said that this action was in progress when they made their response on 29 December 2023.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.5

  1. Position

    Maps had no data or routing error that contributed to the deaths.

    Stated by Apple (UK) LimitedDisputes 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

Inadequate positioning and visibility of No Entry signage for wrong-way slip-road entry

Wider context from the report

“The exit point of the A5 "off" slip road at the Little Brickhill junction is wide. The signage indicating No Entry appears to be inadequate as there are two No Entry signs which are widely spaced at the junction. One is positioned to appear to forbid entry to the road over the bridge leading over the A5 and does not obviously relate to the slip road. The second is positioned such that it obliquely faces the road over the bridge and would not be visible to a driver turning right onto the slip road until they had completed the manoeuvre placing them at risk. There is a No Right Turn sign as the junction is approached. There is also No Entry in large white letters at the mouth of the slip road junction, however, this may be (1) obscured by vehicles leaving the slip road and (2) the junction is unlit and was said by a witness as being "pitch black". After the collision attention police officers saw three further vehicles perform exactly the same manoeuvre as Ms Ahmed and attempt to travel down the slip road in the wrong direction. Local residents have contacted police and claimed that it is a very common occurrence for drivers to mistakenly travel down the slip road in the wrong direction. The slip road is long and allows for the build up of considerable speed in turn facilitating what the police describe as a high energy impact. Following the collision, large temporary No Entry signs were positioned at the slip road junction. They were quickly removed apparently because the original signs were deemed to comply with necessary regulations. That seems wholly irrelevant to me because drivers are clearly commonly not seeing the signs because of the large numbers who mistakenly drive the wrong way onto the slip road. In my opinion, consideration should be given to alternative arrangements to prevent vehicles entering and travelling along the slip road in the wrong direction. ”

Is this part of a recurring concern?

Yes — Inadequate controls preventing dangerous vehicle movements between slip roads and carriageways; Inadequate road warning signage; Inadequate safety controls at high-risk road junctions.

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

Frequent wrong-way driving down the slip road into oncoming traffic

Wider context from the report

“I have made observations regarding the slip road at this junction in my initial pre-Inquest Report To Prevent Future Deaths dated the 21st December 2023. National Highways undertook a number of immediate remedial measures to try to prevent drivers turning and travelling the wrong way down this slip road, including narrowing the "mouth" of the slip road to one lane, placement of very large temporary "No Entry" signs and placement of signs indicating "Do Not Use Satnav" at the site. CCTV monitoring of driver behaviour was commenced. Police activity and monitoring by National Highways showed that despite these measures, drivers were still turning early and attempting to drive the wrong way down the slip road. Further enquiries by the police and information volunteered by members of the public who made the same incorrect manoeuvre led to the finding that while the visual map display on commonly used satnav applications at this junction displayed the correct information, the verbal commands gave information likely to confuse and direct drivers down the wrong slip road into the path of oncoming traffic. This was observed to happen frequently. ”

Is this part of a recurring concern?

Yes — Inadequate controls preventing dangerous vehicle movements between slip roads and carriageways; Inadequate safety controls at high-risk road junctions.

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

Slip-road geometry allowing wrong-way vehicles to enter and build up considerable speed

Wider context from the report

“The exit point of the A5 "off" slip road at the Little Brickhill junction is wide. The signage indicating No Entry appears to be inadequate as there are two No Entry signs which are widely spaced at the junction. One is positioned to appear to forbid entry to the road over the bridge leading over the A5 and does not obviously relate to the slip road. The second is positioned such that it obliquely faces the road over the bridge and would not be visible to a driver turning right onto the slip road until they had completed the manoeuvre placing them at risk. There is a No Right Turn sign as the junction is approached. There is also No Entry in large white letters at the mouth of the slip road junction, however, this may be (1) obscured by vehicles leaving the slip road and (2) the junction is unlit and was said by a witness as being "pitch black". After the collision attention police officers saw three further vehicles perform exactly the same manoeuvre as Ms Ahmed and attempt to travel down the slip road in the wrong direction. Local residents have contacted police and claimed that it is a very common occurrence for drivers to mistakenly travel down the slip road in the wrong direction. The slip road is long and allows for the build up of considerable speed in turn facilitating what the police describe as a high energy impact. Following the collision, large temporary No Entry signs were positioned at the slip road junction. They were quickly removed apparently because the original signs were deemed to comply with necessary regulations. That seems wholly irrelevant to me because drivers are clearly commonly not seeing the signs because of the large numbers who mistakenly drive the wrong way onto the slip road. In my opinion, consideration should be given to alternative arrangements to prevent vehicles entering and travelling along the slip road in the wrong direction. ”

Is this part of a recurring concern?

Yes — Inadequate control of recurring collision risks at hazardous road locations; Inadequate controls preventing dangerous vehicle movements between slip roads and carriageways; Inadequate safety controls at high-risk road junctions; Unsafe road design and layout.

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 maintain adequate visibility of road-surface No Entry markings at the slip-road junction

Wider context from the report

“The exit point of the A5 "off" slip road at the Little Brickhill junction is wide. The signage indicating No Entry appears to be inadequate as there are two No Entry signs which are widely spaced at the junction. One is positioned to appear to forbid entry to the road over the bridge leading over the A5 and does not obviously relate to the slip road. The second is positioned such that it obliquely faces the road over the bridge and would not be visible to a driver turning right onto the slip road until they had completed the manoeuvre placing them at risk. There is a No Right Turn sign as the junction is approached. There is also No Entry in large white letters at the mouth of the slip road junction, however, this may be (1) obscured by vehicles leaving the slip road and (2) the junction is unlit and was said by a witness as being "pitch black". After the collision attention police officers saw three further vehicles perform exactly the same manoeuvre as Ms Ahmed and attempt to travel down the slip road in the wrong direction. Local residents have contacted police and claimed that it is a very common occurrence for drivers to mistakenly travel down the slip road in the wrong direction. The slip road is long and allows for the build up of considerable speed in turn facilitating what the police describe as a high energy impact. Following the collision, large temporary No Entry signs were positioned at the slip road junction. They were quickly removed apparently because the original signs were deemed to comply with necessary regulations. That seems wholly irrelevant to me because drivers are clearly commonly not seeing the signs because of the large numbers who mistakenly drive the wrong way onto the slip road. In my opinion, consideration should be given to alternative arrangements to prevent vehicles entering and travelling along the slip road in the wrong direction. ”

Is this part of a recurring concern?

Yes — Inadequate controls preventing dangerous vehicle movements between slip roads and carriageways; Inadequate road markings for road-user safety; Inadequate safety controls at high-risk road junctions.

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 of commonly used satnav applications to provide unambiguous verbal directions at the junction

Wider context from the report

“I have made observations regarding the slip road at this junction in my initial pre-Inquest Report To Prevent Future Deaths dated the 21st December 2023. National Highways undertook a number of immediate remedial measures to try to prevent drivers turning and travelling the wrong way down this slip road, including narrowing the "mouth" of the slip road to one lane, placement of very large temporary "No Entry" signs and placement of signs indicating "Do Not Use Satnav" at the site. CCTV monitoring of driver behaviour was commenced. Police activity and monitoring by National Highways showed that despite these measures, drivers were still turning early and attempting to drive the wrong way down the slip road. Further enquiries by the police and information volunteered by members of the public who made the same incorrect manoeuvre led to the finding that while the visual map display on commonly used satnav applications at this junction displayed the correct information, the verbal commands gave information likely to confuse and direct drivers down the wrong slip road into the path of oncoming traffic. This was observed to happen frequently. ”

Is this part of a recurring concern?

Yes — Inadequate controls preventing dangerous vehicle movements between slip roads and carriageways.

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

Implement safeguards that time verbal navigation commands closer to the exit and after drivers pass the off-slip road.

Verbatim wording from the response

“As part of our ongoing efforts to enhance road safety, we recently implemented additional safeguards, to limit drivers’ confusion where possible, regardless of their speed behavior on the road, by timing the verbal commands closer to the actual exit, and in any event after passing the off-slip road. However, please note that in order for these changes to be effective and visible by end users, they need to use the latest map and therefore in certain circumstances need to update their systems/devices.”

Source location

Response from TomTom
Page 1 · response
Published 29 December 2023

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

Review navigation instructions near the junction by simulating driver-speed scenarios and assessing instruction timing.

Verbatim wording from the response

“Following the report, we reviewed our navigation systems’ verbal instructions provided near the junction at hand. We have simulated different scenarios, including speed variations of 60mph and 30mph, to better understand how our navigation systems presented instructions based on driver speed. The scenarios assumed that the driver would either (i) maintain maximum speed until the junction; or (ii) slow down when approaching it. The outcome of the review revealed that instructions were given either (i) right when passing by the off-slip road; or (ii) after passing by the off-slip road, when on the overpass towards the exit.”

Source location

Response from TomTom
Page 1 · response
Published 29 December 2023

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

Investigate and develop improvements to the timing of Google Maps audio guidance.

Verbatim wording from the response

“• We have liaised with National Highways and reviewed their helpful dashcam footage of the relevant junction. This has assisted our product and engineering teams in carefully investigating the audio guidance provided by Google Maps. Our teams are working on improvements to the timing of the audio guidance.”

Source location

Response from Google
Page 2 · response
Published 29 December 2023

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

Add special voice guidance directing westbound drivers to continue straight at the overpass and turn right onto the A5 toward Milton Keynes and Bletchley.

Verbatim wording from the response

“However, to ensure we were following the very best approach we are taking an additional measure to add the following special voice guidance for drivers heading past the A5 offramp toward the A5 onramp, which we intend will be live by the start of next week. - Drivers heading past the A5 offramp toward the A5 onramp would be instructed to “Continue straight at the overpass” (that will happen as they are traveling westward from the offramp). - While on the overpass, drivers would be instructed to “Turn right onto A5 toward Milton Keynes, Bletchley.””

Source location

Response from Apple
Page 1 · response
Published 29 December 2023

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

Undertake further work to assess junction capacity and whether the A5 off-slip bell-mouth width can be reduced with hatched markings.

Verbatim wording from the response

“○ Width of the junction bell mouth at the end of the A5 off slip – the A5 off slip and junction bell mouth is two lanes wide. The bell mouth is effectively widened by the concrete overrun area along the eastern edge of the bell mouth. Reducing the width of the junction with hatched road markings may increase the conspicuity of the ‘No Entry’ measures. Further work will be undertaken to understand the capacity of the junction and whether the junction width can be reduced.”

Source location

Response from Highways
Page 2 · response
Published 29 December 2023

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

Continue developing enhanced A5 off-slip mitigation options and establish which measures will be progressed, including improved signage and road markings.

Verbatim wording from the response

“• The site assessment has established that, when measured against the Wrong Way Driving Toolkit, the junction has all the required ‘standard’ mitigation measures in place. However, potential improvements to road markings and signage on both National Highways and Milton Keynes City Council’s network have been identified.”

Source location

Response from Highways
Page 2 · response
Published 29 December 2023

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

Complete a full safety review of the junction against the current Wrong Way Driving: Mitigation Toolkit.

Verbatim wording from the response

“The site visit has informed a full safety review of the junction, including an assessment of the junction against the latest version of National Highways’ Wrong Way Driving: Mitigation Toolkit (v1.2 January 2021). The junction had previously been assessed against the previous version of the toolkit (first issued in 2017).”

Source location

Response from Highways
Page 1 · response
Published 29 December 2023

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 temporary large No Entry signs on A-frames at both sides of the A5 off-slip exit.

Verbatim wording from the response

“Further temporary signing has been put in place at the exit point of the A5 off slip at the Little Brickhill junction in the form of two large 1200mm ‘No Entry’ signs on A-frames on each side of the carriageway (Traffic Signs Regulations and General Directions (TSRGD), Diagram 616 No entry for vehicular traffic). These signs are intended to provide mitigation against further wrong way driving incidents while a full safety review of the junction has been undertaken.”

Source location

Response from Highways
Page 1 · response
Published 29 December 2023

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

Inspect the junction and assess signage and road markings for safety defects.

Verbatim wording from the response

“We received a ‘Report-It’ made on 28 May 2023. The records show that in this case a highways inspector visited the location on 2 June 2023 and made the following note ‘Inspection on 02/06/23 enough signage and road marking on road saying no entry. No safety defects found all below investigatory levels’. This reflects his remit to consider the condition of those assets in respect of safety. A standardised response was sent to the customer.”

Source location

Response from Milton Keynes City Council
Page 2 · response
Published 29 December 2023

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

Reinspect the site after the incident and investigate whether an immediate safety hazard exists.

Verbatim wording from the response

“City highways officials visited the site on 20 November after the fatal incident with Thames Valley Police (TVP). TVP then conveyed a video call with MKCC and National Highways on 21 November and National Highways took subsequent actions on their junction. We would”

Source location

Response from Milton Keynes City Council
Page 1 · response
Published 29 December 2023

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

Review the junction situation later as part of the planned work programme.

Verbatim wording from the response

“We have another ‘Report-It’ made on 21 November 2023 which was made following the incident. The same inspector visited the site again and again found no immediate safety hazard based on condition (of the asset) and highlighted to the resident on 13 January 2024 that we have investigated and intend to review the situation at a later date as part of our planned work programme. A standardised response was sent to the customer.”

Source location

Response from Milton Keynes City Council
Page 2 · response
Published 29 December 2023

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

Maps had no data or routing error that contributed to the deaths.

Verbatim wording from the response

“We immediately investigated the concerns raised and found no data or routing error on Maps which would have contributed to these tragic events.”

Source location

Response from Apple
Page 1 · response
Published 29 December 2023

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 junction already has all standard wrong-way-driving mitigation measures required by the current toolkit.

Verbatim wording from the response

“• The site assessment has established that, when measured against the Wrong Way Driving Toolkit, the junction has all the required ‘standard’ mitigation measures in place. However, potential improvements to road markings and signage on both National Highways and Milton Keynes City Council’s network have been identified.”

Source location

Response from Highways
Page 2 · response
Published 29 December 2023

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 signage and road markings appeared adequate under applicable regulations, although illumination might improve the no-entry signage.

Verbatim wording from the response

“agree with National Highways that the signage appeared adequate to regulations, although we would suggest that the National Highways no-entry signage at the slip road junction may benefit from illumination (although the Traffic Signs Regulations and General Directions guidance does not require this).”

Source location

Response from Milton Keynes City Council
Page 2 · response
Published 29 December 2023

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

National Highways is responsible for the slip road junction, its signage and road markings, so it must undertake related improvements.

Verbatim wording from the response

“The slip road, its junction with the local road, and the signage and road markings at the end of the slip road are part of the National Highways asset and they are therefore the responsible highway authority.”

Source location

Response from Milton Keynes City Council
Page 1 · response
Published 29 December 2023

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 council has no powers to improve the junction mouth, signage or road markings because these are outside its highway authority functions.

Verbatim wording from the response

“The slip road, its junction with the local road, and the signage and road markings at the end of the slip road are part of the National Highways asset and they are therefore the responsible highway authority.”

Source location

Response from Milton Keynes City Council
Page 1 · response
Published 29 December 2023

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-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. 1

    Continue engaging with Milton Keynes City Council to progress improvements to the adjoining Woburn-Little Brickhill Road and coordinate delivery.

    Stated by National HighwaysStated in progressThe respondent said that this action was in progress when they made their response on 29 December 2023.
  2. 2

    Work with Thames Valley Police to optimise reporting of concerns relating to the strategic road network.

    Stated by National HighwaysStated in progressThe respondent said that this action was in progress when they made their response on 29 December 2023.

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

  1. 1

    Milton Keynes City Council is responsible for safety improvements on the adjoining Woburn-Little Brickhill Road.

    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

Continue engaging with Milton Keynes City Council to progress improvements to the adjoining Woburn-Little Brickhill Road and coordinate delivery.

Verbatim wording from the response

“• We continue to liaise with Milton Keynes City Council, who are responsible for the Woburn-Little Brickhill Road, with respect to the points raised above relating to their road and will continue to do so.”

Source location

Response from Highways
Page 2 · response
Published 29 December 2023

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

Work with Thames Valley Police to optimise reporting of concerns relating to the strategic road network.

Verbatim wording from the response

“We will continue to work closely with Thames Valley Police, with whom we have a close and collaborative relationship. We will work with them to optimise the process by which concerns relating to the strategic road network are reported.”

Source location

Response from Highways
Page 3 · response
Published 29 December 2023

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

Milton Keynes City Council is responsible for safety improvements on the adjoining Woburn-Little Brickhill Road.

Verbatim wording from the response

“A site visit has been undertaken during daylight and dark conditions on Monday 11th December 2023 between 15:30hrs and 18:30hrs. The site visit included a drive-through of the site extents within the A5 Trunk Road boundary (as the strategic road network (SRN) is inaccessible by foot at this location) and a drive-through and walk-through of the adjoining Woburn-Little Brickhill road that is the responsibility of the local authority (Milton Keynes City Council).”

Source location

Response from Highways
Page 1 · response
Published 29 December 2023

Open published response
Back to top

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