PFD report

Ryan Gareth TAYLOR · Prevention of Future Deaths report

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Issued 25 May 2021•Cornwall and Isles of Scilly

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

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.

Report evidence summary

Concerns raised2

  1. Converging surface water on the A390 during heavy rainfall
    Part of recurring concern: Inadequate controls for icy and slippery surfacesPart of recurring concern: Inadequate drainage control of hazardous surface water on public routesPart of recurring concern: Unreliable road-surface grip for vehicles
  2. Failure to implement feasible road drainage improvements
    Part of recurring concern: Inadequate drainage control of hazardous surface water on public routesPart of recurring concern: Inadequate road drainage allowing hazardous surface water to remain on carriageways
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

    Erect warning signs on both approaches alerting drivers to possible surface water on the road ahead.

    Stated by Cornwall CouncilStated plannedThe respondent said that this action was planned when they made their response on 27 May 2021.
  2. Action

    Replace existing Coliza Hill slip-road gully grids with larger-capacity gratings.

    Stated by Cornwall CouncilStated plannedThe respondent said that this action was planned when they made their response on 27 May 2021.
  3. Action

    Undertake detailed drainage and topographical surveys of the main road alignment.

    Stated by Cornwall CouncilStated plannedThe respondent said that this action was planned when they made their response on 27 May 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

Converging surface water on the A390 during heavy rainfall

Wider context from the report

“(1) During periods of heavy rainfall surface water from the adjoining road known as Coliza Hill is likely to converge with surface water on the A390 in the vicinity of where Ryan initially lost control of his car. (2) A rear wheel drive car had been involved in an aquaplaning incident at the same location in similar conditions, four years before this collision. (3) Improvements to road drainage are feasible in this particular location but have not yet been implemented. These improvements may diminish the risks of vehicles aquaplaning due to converging surface water. ”

Is this part of a recurring concern?

Yes — Inadequate controls for icy and slippery surfaces; Inadequate drainage control of hazardous surface water on public routes; Unreliable road-surface grip for vehicles.

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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

Failure to implement feasible road drainage improvements

Wider context from the report

“(1) During periods of heavy rainfall surface water from the adjoining road known as Coliza Hill is likely to converge with surface water on the A390 in the vicinity of where Ryan initially lost control of his car. (2) A rear wheel drive car had been involved in an aquaplaning incident at the same location in similar conditions, four years before this collision. (3) Improvements to road drainage are feasible in this particular location but have not yet been implemented. These improvements may diminish the risks of vehicles aquaplaning due to converging surface water. ”

Is this part of a recurring concern?

Yes — Inadequate drainage control of hazardous surface water on public routes; Inadequate road drainage allowing hazardous surface water to remain on 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

Erect warning signs on both approaches alerting drivers to possible surface water on the road ahead.

Verbatim wording from the response

“• Signs will shortly be erected on both approaches warning of the possibility of surface water on the road ahead. This is an interim measure pending more substantial improvement.”

Source location

2021-0176-Response-from-CORMAC_Published
Page 1 · response
Published 27 May 2021

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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

Replace existing Coliza Hill slip-road gully grids with larger-capacity gratings.

Verbatim wording from the response

“• The existing gully grids on the Coliza Hill slip road will be replaced with larger capacity gratings. This is scheduled to take place in October, in combination with maintenance work programmed after the summer road works embargo period.”

Source location

2021-0176-Response-from-CORMAC_Published
Page 1 · response
Published 27 May 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 detailed drainage and topographical surveys of the main road alignment.

Verbatim wording from the response

“• Detailed drainage and topographical surveys will be undertaken on the main road alignment, again in combination with the scheduled maintenance work in October.”

Source location

2021-0176-Response-from-CORMAC_Published
Page 1 · response
Published 27 May 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.1

  1. 1

    Confirm the survey results and any resulting proposals to the coroner when they are known.

    Stated by Cornwall CouncilStated plannedThe respondent said that this action was planned when they made their response on 27 May 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

Confirm the survey results and any resulting proposals to the coroner when they are known.

Verbatim wording from the response

“Once the detailed survey information has been obtained it will be possible to identify if and how the main road drainage system can be upgraded, and a scheme potentially designed and implemented accordingly. You will appreciate that it is not possible to give a precise idea of what this further work will entail and how long it will take at the present time. You may be assured though that the highway authority is viewing this as a priority site. I will confirm to you the results of this investigatory work and any proposals arising from it when they are known.”

Source location

2021-0176-Response-from-CORMAC_Published
Page 1 · response
Published 27 May 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

Official responses located
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Data last updated 7 September 2026