PFD report

Pathushan Sutharsan · Prevention of Future Deaths report

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Issued 4 Jun 2021•West Sussex

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
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
8

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 raised3

  1. Lack of an alternative safe crossing at the junction
    Part of recurring concern: Inadequate control of pedestrian crossing risksPart of recurring concern: Inadequate safety controls at high-risk road junctions
  2. Lack of pavement alongside the A281 causing poor sight lines
  3. Failure to establish definitive plans to address junction safety issues
    Part of recurring concern: Failure to establish effective plans to address identified safety concernsPart of recurring concern: Failure to reliably develop and review risk-reduction plans
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.4

  1. Action

    Alter the height of speed terminal signs so they do not obstruct equestrians’ sightlines.

    Stated by West Sussex County CouncilStated completedThe respondent said that this action was complete when they made their response on 14 June 2021.
  2. Action

    Carry out additional hedge cutting to improve visibility for people crossing the road.

    Stated by West Sussex County CouncilStated plannedThe respondent said that this action was planned when they made their response on 14 June 2021.
  3. Action

    Undertake a feasibility study and options appraisal for improving the crossing point, including bridge and traffic-light-controlled crossing options.

    Stated by West Sussex County CouncilStated in progressThe respondent said that this action was in progress when they made their response on 14 June 2021.

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 an alternative safe crossing at the junction

Wider context from the report

“Whilst it was accepted that West Sussex County Council had, following Pathushan’s death, made significant improvements to the junction between the Downs link and the A281 evidence was heard from a number of different organisations (speaking on behalf of all the different users of the Downs link) that the junction in question still posed a substantial risk for cyclists, pedestrians and equestrians alike. This junction is the only part of the Downs link that crosses a major A-road where there is no alternative safe crossing, a Pegasus crossing or bridge. Evidence was heard that there is no pavement running alongside the A281 and therefore this causes poor sight lines for horse riders and, in some circumstances, cyclists who have to put their horse’s head or part of their bike out onto the road before they can see oncoming traffic. It is understood that WSCC has identified a need to address the issues at this junction and has undertaken (or is about to undertake a feasibility study) but it appears that at this stage there are no definitive plans in place to take this forward. Therefore the significant risk to the users of this junction remains. The Downs link is actively promoted as a recreational activity by West Sussex County Council. ”

Is this part of a recurring concern?

Yes — Inadequate control of pedestrian crossing risks; 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

Lack of pavement alongside the A281 causing poor sight lines

Wider context from the report

“Whilst it was accepted that West Sussex County Council had, following Pathushan’s death, made significant improvements to the junction between the Downs link and the A281 evidence was heard from a number of different organisations (speaking on behalf of all the different users of the Downs link) that the junction in question still posed a substantial risk for cyclists, pedestrians and equestrians alike. This junction is the only part of the Downs link that crosses a major A-road where there is no alternative safe crossing, a Pegasus crossing or bridge. Evidence was heard that there is no pavement running alongside the A281 and therefore this causes poor sight lines for horse riders and, in some circumstances, cyclists who have to put their horse’s head or part of their bike out onto the road before they can see oncoming traffic. It is understood that WSCC has identified a need to address the issues at this junction and has undertaken (or is about to undertake a feasibility study) but it appears that at this stage there are no definitive plans in place to take this forward. Therefore the significant risk to the users of this junction remains. The Downs link is actively promoted as a recreational activity by West Sussex County Council. ”

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

Failure to establish definitive plans to address junction safety issues

Wider context from the report

“Whilst it was accepted that West Sussex County Council had, following Pathushan’s death, made significant improvements to the junction between the Downs link and the A281 evidence was heard from a number of different organisations (speaking on behalf of all the different users of the Downs link) that the junction in question still posed a substantial risk for cyclists, pedestrians and equestrians alike. This junction is the only part of the Downs link that crosses a major A-road where there is no alternative safe crossing, a Pegasus crossing or bridge. Evidence was heard that there is no pavement running alongside the A281 and therefore this causes poor sight lines for horse riders and, in some circumstances, cyclists who have to put their horse’s head or part of their bike out onto the road before they can see oncoming traffic. It is understood that WSCC has identified a need to address the issues at this junction and has undertaken (or is about to undertake a feasibility study) but it appears that at this stage there are no definitive plans in place to take this forward. Therefore the significant risk to the users of this junction remains. The Downs link is actively promoted as a recreational activity by West Sussex County Council. ”

Is this part of a recurring concern?

Yes — Failure to establish effective plans to address identified safety concerns; Failure to reliably develop and review risk-reduction plans.

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

Alter the height of speed terminal signs so they do not obstruct equestrians’ sightlines.

Verbatim wording from the response

“Following consultation with the BHS, and in addition to those measures mentioned above, we have recently altered the height of the Speed terminal signs so that they do not block the site line for equestrians. Further planned improvements for this summer are enhanced red surfacing to further highlight the crossing to drivers and additional hedge cutting to further improve the visibility for people crossing the road.”

Source location

2021-0193-Response-from-West-Sussex-County-Council_Published
Page 1 · response
Published 14 June 2021

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

Carry out additional hedge cutting to improve visibility for people crossing the road.

Verbatim wording from the response

“Following consultation with the BHS, and in addition to those measures mentioned above, we have recently altered the height of the Speed terminal signs so that they do not block the site line for equestrians. Further planned improvements for this summer are enhanced red surfacing to further highlight the crossing to drivers and additional hedge cutting to further improve the visibility for people crossing the road.”

Source location

2021-0193-Response-from-West-Sussex-County-Council_Published
Page 1 · response
Published 14 June 2021

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 a feasibility study and options appraisal for improving the crossing point, including bridge and traffic-light-controlled crossing options.

Verbatim wording from the response

“A feasibility study looking into ways to improve the crossing point is currently being undertaken by the authority’s term consultant, WSP. An options appraisal report will be completed by October 2021. The study is primarily focused on, but not limited to, the options for a bridge or traffic light controlled road crossing. If the report determines that there are appropriate, technically feasible solutions, the preferred option will be progressed through the WSC’s capital governance procedures, either as a project to be taken forward in the Local Transport Investment Programme or as a major scheme. In either case a full business case will be developed and the scheme assessed against the County Council’s objectives and priorities for potential inclusion in a future capital programme.”

Source location

2021-0193-Response-from-West-Sussex-County-Council_Published
Page 1 · response
Published 14 June 2021

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

Clear vegetation to improve visibility at the crossing point.

Verbatim wording from the response

“Following the police notification of the fatal collision involving Mr Sutharsan the authority began its own now well-established investigation procedure. Based on the information available at the time a number of remedial measures were implemented to mitigate the occurrence of a similar incident involving cyclists travelling on the Downs Link. The measures were detailed in our report to the coroner dated the 7th December 2020. In summary these works consist of:”

Source location

2021-0193-Response-from-West-Sussex-County-Council_Published
Page 1 · response
Published 14 June 2021

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.4

  1. 1

    Standardise A281 traffic signs in both directions to warn motorists about equestrians, cyclists and the pedestrian crossing.

    Stated by West Sussex County CouncilStated completedThe respondent said that this action was complete when they made their response on 14 June 2021.
  2. 2

    Form a chicane at the downhill approach to the A281 to compel users to slow down before the junction.

    Stated by West Sussex County CouncilStated completedThe respondent said that this action was complete when they made their response on 14 June 2021.
  3. 3

    Install enhanced red surfacing to highlight the crossing to drivers.

    Stated by West Sussex County CouncilStated plannedThe respondent said that this action was planned when they made their response on 14 June 2021.
  4. 4

    Install permanent warning signs down the slope and on the chicane to alert users to the main road ahead.

    Stated by West Sussex County CouncilStated completedThe respondent said that this action was complete when they made their response on 14 June 2021.

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

Standardise A281 traffic signs in both directions to warn motorists about equestrians, cyclists and the pedestrian crossing.

Verbatim wording from the response

“Following the police notification of the fatal collision involving Mr Sutharsan the authority began its own now well-established investigation procedure. Based on the information available at the time a number of remedial measures were implemented to mitigate the occurrence of a similar incident involving cyclists travelling on the Downs Link. The measures were detailed in our report to the coroner dated the 7th December 2020. In summary these works consist of:”

Source location

2021-0193-Response-from-West-Sussex-County-Council_Published
Page 1 · response
Published 14 June 2021

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

Form a chicane at the downhill approach to the A281 to compel users to slow down before the junction.

Verbatim wording from the response

“Following the police notification of the fatal collision involving Mr Sutharsan the authority began its own now well-established investigation procedure. Based on the information available at the time a number of remedial measures were implemented to mitigate the occurrence of a similar incident involving cyclists travelling on the Downs Link. The measures were detailed in our report to the coroner dated the 7th December 2020. In summary these works consist of:”

Source location

2021-0193-Response-from-West-Sussex-County-Council_Published
Page 1 · response
Published 14 June 2021

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 enhanced red surfacing to highlight the crossing to drivers.

Verbatim wording from the response

“Following consultation with the BHS, and in addition to those measures mentioned above, we have recently altered the height of the Speed terminal signs so that they do not block the site line for equestrians. Further planned improvements for this summer are enhanced red surfacing to further highlight the crossing to drivers and additional hedge cutting to further improve the visibility for people crossing the road.”

Source location

2021-0193-Response-from-West-Sussex-County-Council_Published
Page 1 · response
Published 14 June 2021

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 permanent warning signs down the slope and on the chicane to alert users to the main road ahead.

Verbatim wording from the response

“Following the police notification of the fatal collision involving Mr Sutharsan the authority began its own now well-established investigation procedure. Based on the information available at the time a number of remedial measures were implemented to mitigate the occurrence of a similar incident involving cyclists travelling on the Downs Link. The measures were detailed in our report to the coroner dated the 7th December 2020. In summary these works consist of:”

Source location

2021-0193-Response-from-West-Sussex-County-Council_Published
Page 1 · response
Published 14 June 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