PFD report

Matthew SCOTT · Prevention of Future Deaths report

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Issued 7 May 2024•Derby and Derbyshire

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
2

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 raised2

  1. Failure to survey and act on reported road defects
    Part of recurring concern: Failure of the highway hazard reporting and response processPart of recurring concern: Unreliable highway safety risk assessment and remedial-work prioritisation
  2. Defective and subsided road surface capable of accumulating ice
    Part of recurring concern: Failure to maintain roads, pavements and verges in a safe state of repairPart of recurring concern: Unreliable road-surface grip for vehicles
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.2

  1. Action

    Undertake full-width resurfacing from Melbourne View Hotel approximately 200 metres eastward to level road-surface deviations.

    Stated by Derbyshire County CouncilStated plannedThe respondent said that this action was planned when they made their response on 4 July 2024.
  2. Action

    Conducted a laser survey of Station Road to assess whether an actionable safety defect existed.

    Stated by Derbyshire County CouncilStated completedThe respondent said that this action was complete when they made their response on 4 July 2024.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Quarterly inspections by competent inspectors were sufficient to identify and repair significant road defects.

    Stated by Derbyshire County CouncilExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 survey and act on reported road defects

Wider context from the report

“At 6 weeks post Mr Scott's death - on the 28th of April 2023 - a discussion took place between collision investigator officers, a traffic management officer (all of Derbyshire police) with the Project Engineer of the Highways Authority of Derbyshire County Council. The officers raised their concerns that at the place where Mr Scott lost control of his vehicle (Station Road, Melbourne Derbyshire) there was a lengthy, defective and subsided stretch of road. Further that at the time of Mr Scott's death the subsided section of road was some 4 metres in width, 37 metres in length and 5 cms in depth. Further, that it was deep enough to have had standing water in it which at the time of Mr Scott's death had turned to ice. Ice in the said defect would likely cause a vehicle to lose grip on the road surface. At that section of road, the road starts to bend to the right such that losing control on the ice could cause a vehicle to veer to the offside of the road, either into the path of an oncoming vehicle, into the opposite field or as in Mr Scott’s case, a tree. The Project Engineer of the Highways Authority discussed his concerns and the concerns that had been raised by the police, with the highway maintenance department in early May 2023. As at the date of the inquest into Mr Scott' death (22 April 2024) this stretch of road had not been surveyed, no consideration had been given to the concerns of the police and no decisions taken to repair the defect so as to prevent any further accidents. ”

Is this part of a recurring concern?

Yes — Failure of the highway hazard reporting and response process; Unreliable highway safety risk assessment and remedial-work prioritisation.

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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

Defective and subsided road surface capable of accumulating ice

Wider context from the report

“At 6 weeks post Mr Scott's death - on the 28th of April 2023 - a discussion took place between collision investigator officers, a traffic management officer (all of Derbyshire police) with the Project Engineer of the Highways Authority of Derbyshire County Council. The officers raised their concerns that at the place where Mr Scott lost control of his vehicle (Station Road, Melbourne Derbyshire) there was a lengthy, defective and subsided stretch of road. Further that at the time of Mr Scott's death the subsided section of road was some 4 metres in width, 37 metres in length and 5 cms in depth. Further, that it was deep enough to have had standing water in it which at the time of Mr Scott's death had turned to ice. Ice in the said defect would likely cause a vehicle to lose grip on the road surface. At that section of road, the road starts to bend to the right such that losing control on the ice could cause a vehicle to veer to the offside of the road, either into the path of an oncoming vehicle, into the opposite field or as in Mr Scott’s case, a tree. The Project Engineer of the Highways Authority discussed his concerns and the concerns that had been raised by the police, with the highway maintenance department in early May 2023. As at the date of the inquest into Mr Scott' death (22 April 2024) this stretch of road had not been surveyed, no consideration had been given to the concerns of the police and no decisions taken to repair the defect so as to prevent any further accidents. ”

Is this part of a recurring concern?

Yes — Failure to maintain roads, pavements and verges in a safe state of repair; Unreliable road-surface grip for vehicles.

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

Undertake full-width resurfacing from Melbourne View Hotel approximately 200 metres eastward to level road-surface deviations.

Verbatim wording from the response

“Nonetheless Derbyshire County Council take road safety very seriously and the area from Melbourne View Hotel to a point approximately 200 metres in an easterly direction has been put in for full width road surfacing work to be undertaken. This will be completed by 31 October 2024 and will level some of the deviations in the road surface caused by various pot hole repairs.”

Source location

Response from Derbyshire County Council
Page 2 · response
Published 4 July 2024

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

Conducted a laser survey of Station Road to assess whether an actionable safety defect existed.

Verbatim wording from the response

“Due to the inconsistency between the site report carried out by ████████ and the concerns raised by the Coroner Derbyshire County Council have undertaken a laser survey dated 26/04/2024. The results of the survey also clearly shows there was not an actionable safety defect that measured 4m wide by 37 meters in length, as that was the ice formation.”

Source location

Response from Derbyshire County Council
Page 1 · response
Published 4 July 2024

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

Quarterly inspections by competent inspectors were sufficient to identify and repair significant road defects.

Verbatim wording from the response

“As referenced above the road in question, Station Road, Melbourne is subject to quarterly inspections. We have noted the following from records; 13 January 2023 – 2 customer reports of pot hole received on the same day – area put in for ad hoc inspection 17 January 2023 - ad hoc inspection – a number of separate pot holes put in for repair ref. 50186345 works completed 1 March 2023 17 February 2023 routine inspection – defect noted – 28 day repair requested ref. 50189695 - completed 20 February 2023 9 May 2023 – routine inspection – jobs raised outside Melbourne view repair requested ref 50197481– completed 30 May 2023 17 August 2023 – routine inspection – potholes repairs requested ref. 50204692 and 50204693 completed 04 September 2023. 22 November 2023 – routine inspection – potholes repairs requested ref. 50210507 completed on 21 December 2023.”

Source location

Response from Derbyshire County Council
Page 2 · response
Published 4 July 2024

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 reported 37-metre-wide road defect was ice formation, not an actionable safety defect; pooled water was limited and typical.

Verbatim wording from the response

“The site report states as follows “Large patch of ice on the road surface measuring 4 metres in diameter and 37 meters in length. Commencing in the centre of the carriageway, 4 meters prior to the entrance of the Melbourne Hotel, and terminating in the south-east bound lane. The area predominantly covered the south-east bound lane. It must be noted that this had reduced in size during my attendance due to weather conditions”. This does not say that there was a defect in the road but ice formation. There were some minor differences in level within the carriageway which allowed water to stand, such minor differences in level would be typical of an evolved road network in similar settings such as this and other areas of road across the county.”

Source location

Response from Derbyshire County Council
Page 1 · response
Published 4 July 2024

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.1

  1. 1

    Photographed the referenced road area on two dates after rainfall to assess pooled water.

    Stated by Derbyshire County CouncilStated completedThe respondent said that this action was complete when they made their response on 4 July 2024.

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

Photographed the referenced road area on two dates after rainfall to assess pooled water.

Verbatim wording from the response

“Further in order to consider the issue of pooled water we have had photographs taken over the area referenced by the coroner on two separate dates following periods of rain fall – these were dated 29th May 2024 and 4th June 2024. Although there is some pooling which is normal it is not evident that there are any large areas of concern. It should be noted that these investigations post date the issue of the Regulation 28 Report and some pothole areas have already been repaired.”

Source location

Response from Derbyshire County Council
Page 1 · response
Published 4 July 2024

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