PFD report

Christopher Thomas INNES · Prevention of Future Deaths report

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Issued 10 Apr 2019•Central and South East Kent

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
4

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
9

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 raised4

  1. Vegetation restricting pedestrians’ safe standing area beside the bus stop
    Part of recurring concern: Unsafe bus stop siting and pedestrian access
  2. Lack of a safe pedestrian route and crossing facility near the bus stop
    Part of recurring concern: Failure to provide safe pedestrian routes alongside roadsPart of recurring concern: Inadequate control of pedestrian crossing risksPart of recurring concern: Unsafe bus stop siting and pedestrian access
  3. Lack of signage or warning identifying the designated bus stop to approaching vehicles
    Part of recurring concern: Inadequate road warning signagePart of recurring concern: Unsafe bus stop siting and pedestrian access
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

    Advise bus operators not to stop near Nickle Cottages as an interim safety measure.

    Stated by Kent County CouncilStated completedThe respondent said that this action was complete when they made their response on 14 June 2019.
  2. Action

    Work with the landowner to remove low-level vegetation along the southern verge and include the cleared section in cyclic maintenance.

    Stated by Kent County CouncilStated plannedThe respondent said that this action was planned when they made their response on 14 June 2019.
  3. Action

    Install pedestrian-crossing warning signs in both directions near Nickle Cottages and additional signs for the Mansfield Farm junction.

    Stated by Kent County CouncilStated plannedThe respondent said that this action was planned when they made their response on 14 June 2019.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.7

  1. Position

    A hard-standing pedestrian refuge cannot be provided because the available verge is too narrow for required accessible infrastructure.

    Stated by Kent County CouncilUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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

Vegetation restricting pedestrians’ safe standing area beside the bus stop

Wider context from the report

“(1) The presence and position of the unmarked bus stop on the carriageway, where Mr Innes alighted from the bus may be considered a hazard. The bus stop is known locally but is absent any signage or warning to approaching vehicles. The evidence revealed at the Inquest was that this may have led to him being in a position of vulnerability at the side of the carriageway, where there is no footway available for use but only a small grass verge. In order to reach a footway to progress in either direction of the A28 at this point, Mr Innes was required to cross the carriageway to which a 50mph speed limit applies and which has no pedestrian crossing facility in the vicinity. (2) Although it is lawful for buses to stop at this location and the stop is recognised as a “hail and ride stop”, there is not at present signage indicating that this is a designated bus stop, and this is of concern given that the carriageway has a 50mph speed limit. (3) The vegetation close to the area where buses stop includes substantial trees and hedgerows alongside the carriageway and the close proximity of this to the carriageway causes restriction for any pedestrian alighting from the bus to negotiate an appropriate place to stand on a busy rural road prior to attempting to cross a 50mph road. Although the Highways Department at Kent County Council have completed work in respect of cutting back vegetation as part of a site review on the 31st October 2018, there is no clear responsibility for the management of the cutting away of the vegetation and no clear indication of ownership of the land close to the bus stop as the Highway Authority did not concede any responsibility for the land adjoining the hard carriageway. ”

Is this part of a recurring concern?

Yes — Unsafe bus stop siting and pedestrian access.

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 a safe pedestrian route and crossing facility near the bus stop

Wider context from the report

“(1) The presence and position of the unmarked bus stop on the carriageway, where Mr Innes alighted from the bus may be considered a hazard. The bus stop is known locally but is absent any signage or warning to approaching vehicles. The evidence revealed at the Inquest was that this may have led to him being in a position of vulnerability at the side of the carriageway, where there is no footway available for use but only a small grass verge. In order to reach a footway to progress in either direction of the A28 at this point, Mr Innes was required to cross the carriageway to which a 50mph speed limit applies and which has no pedestrian crossing facility in the vicinity. (2) Although it is lawful for buses to stop at this location and the stop is recognised as a “hail and ride stop”, there is not at present signage indicating that this is a designated bus stop, and this is of concern given that the carriageway has a 50mph speed limit. (3) The vegetation close to the area where buses stop includes substantial trees and hedgerows alongside the carriageway and the close proximity of this to the carriageway causes restriction for any pedestrian alighting from the bus to negotiate an appropriate place to stand on a busy rural road prior to attempting to cross a 50mph road. Although the Highways Department at Kent County Council have completed work in respect of cutting back vegetation as part of a site review on the 31st October 2018, there is no clear responsibility for the management of the cutting away of the vegetation and no clear indication of ownership of the land close to the bus stop as the Highway Authority did not concede any responsibility for the land adjoining the hard carriageway. ”

Is this part of a recurring concern?

Yes — Failure to provide safe pedestrian routes alongside roads; Inadequate control of pedestrian crossing risks; Unsafe bus stop siting and pedestrian access.

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 signage or warning identifying the designated bus stop to approaching vehicles

Wider context from the report

“(1) The presence and position of the unmarked bus stop on the carriageway, where Mr Innes alighted from the bus may be considered a hazard. The bus stop is known locally but is absent any signage or warning to approaching vehicles. The evidence revealed at the Inquest was that this may have led to him being in a position of vulnerability at the side of the carriageway, where there is no footway available for use but only a small grass verge. In order to reach a footway to progress in either direction of the A28 at this point, Mr Innes was required to cross the carriageway to which a 50mph speed limit applies and which has no pedestrian crossing facility in the vicinity. (2) Although it is lawful for buses to stop at this location and the stop is recognised as a “hail and ride stop”, there is not at present signage indicating that this is a designated bus stop, and this is of concern given that the carriageway has a 50mph speed limit. (3) The vegetation close to the area where buses stop includes substantial trees and hedgerows alongside the carriageway and the close proximity of this to the carriageway causes restriction for any pedestrian alighting from the bus to negotiate an appropriate place to stand on a busy rural road prior to attempting to cross a 50mph road. Although the Highways Department at Kent County Council have completed work in respect of cutting back vegetation as part of a site review on the 31st October 2018, there is no clear responsibility for the management of the cutting away of the vegetation and no clear indication of ownership of the land close to the bus stop as the Highway Authority did not concede any responsibility for the land adjoining the hard carriageway. ”

Is this part of a recurring concern?

Yes — Inadequate road warning signage; Unsafe bus stop siting and pedestrian access.

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

Unclear responsibility for vegetation management and adjoining land ownership at the bus stop

Wider context from the report

“(1) The presence and position of the unmarked bus stop on the carriageway, where Mr Innes alighted from the bus may be considered a hazard. The bus stop is known locally but is absent any signage or warning to approaching vehicles. The evidence revealed at the Inquest was that this may have led to him being in a position of vulnerability at the side of the carriageway, where there is no footway available for use but only a small grass verge. In order to reach a footway to progress in either direction of the A28 at this point, Mr Innes was required to cross the carriageway to which a 50mph speed limit applies and which has no pedestrian crossing facility in the vicinity. (2) Although it is lawful for buses to stop at this location and the stop is recognised as a “hail and ride stop”, there is not at present signage indicating that this is a designated bus stop, and this is of concern given that the carriageway has a 50mph speed limit. (3) The vegetation close to the area where buses stop includes substantial trees and hedgerows alongside the carriageway and the close proximity of this to the carriageway causes restriction for any pedestrian alighting from the bus to negotiate an appropriate place to stand on a busy rural road prior to attempting to cross a 50mph road. Although the Highways Department at Kent County Council have completed work in respect of cutting back vegetation as part of a site review on the 31st October 2018, there is no clear responsibility for the management of the cutting away of the vegetation and no clear indication of ownership of the land close to the bus stop as the Highway Authority did not concede any responsibility for the land adjoining the hard carriageway. ”

Is this part of a recurring concern?

Yes — Unreliable land-ownership determination for safety responsibilities.

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

Advise bus operators not to stop near Nickle Cottages as an interim safety measure.

Verbatim wording from the response

“7. KCC provided advice to bus operators using the A28 that they should consider not stopping in the vicinity of Nickle Cottages. KCC do not have to power to forbid commercial operators from stopping at that location, but are able to make such requests. That advice was accepted and at the present time no buses stop at that location as an interim measure.”

Source location

2019-0124-Response-by-Kent-County-Council
Page 2 · response
Published 14 June 2019

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 the landowner to remove low-level vegetation along the southern verge and include the cleared section in cyclic maintenance.

Verbatim wording from the response

“27. Whilst the verge is not in the ownership of KCC, further investigation has indicated that a 1m may be subject to public maintenance. KCC conclude that working with the landowner that low level vegetation can be removed within the southern verge for a section from the bend west of Nickle Cottages through to a point just east of Chartham Corn Mill.”

Source location

2019-0124-Response-by-Kent-County-Council
Page 5 · response
Published 14 June 2019

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 pedestrian-crossing warning signs in both directions near Nickle Cottages and additional signs for the Mansfield Farm junction.

Verbatim wording from the response

“19. In order to increase the conspicuousness of pedestrians crossing the road after alighting a bus in this area on the A28, and in the absence of a formal stop or crossing point, it is proposed that a diagram 544.1 is installed in advance of the Nickel Cottage area in both directions. There are no appropriate supplementary plates which can be installed with this sign.”

Source location

2019-0124-Response-by-Kent-County-Council
Page 4 · response
Published 14 June 2019

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

A hard-standing pedestrian refuge cannot be provided because the available verge is too narrow for required accessible infrastructure.

Verbatim wording from the response

“25. KCC has concluded that providing a hard-standing pedestrian refuge area would involve design considerations which could not be provided at this location or within a reasonable proximity to Nickle Cottages. The main limitation to this is that permanent infrastructure must be designed for people with mobility impairments and should be to the highest standard. This can include people with physical, sensory or mental impairment but also includes people using the facility with small children, carrying heavy shopping and older people. This would place requirements to accommodate facility widths and access arrangements which cannot be constructed within the available space of the verge.”

Source location

2019-0124-Response-by-Kent-County-Council
Page 5 · response
Published 14 June 2019

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

A bus-stop road marking would not address the concern because it marks only a fixed stop and does not provide advance warning.

Verbatim wording from the response

“21. Bus stops can be marked using the diagram 1025.1 TSRGD 2016. This marking is used on fixed bus stops in urban areas predominantly to prevent parking within the bus stop location. This marking is not used in rural areas and would not be considered to provide an advance warning of the presence of a bus stop as it is marked at the exact location of the stop. For that reason KCC does not consider that such a marking would address the concerns outlined in the PFD report.”

Source location

2019-0124-Response-by-Kent-County-Council
Page 5 · response
Published 14 June 2019

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

KCC does not accept that absent signage contributed to the death; pedestrian warning signs may nevertheless provide some betterment.

Verbatim wording from the response

“20. KCC does not concede that the absence of signage was in any way a contributing factor in the death of Mr Innes, however it does consider that the installation of warning signs to warn of pedestrians in road ahead may provide some betterment for users of the bus service at this location.”

Source location

2019-0124-Response-by-Kent-County-Council
Page 5 · response
Published 14 June 2019

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

KCC does not accept that vegetation or verge condition contributed to the death, although vegetation clearance may improve visibility and access.

Verbatim wording from the response

“28. KCC have also decided that this can be included in future cyclic maintenance in order to keep sections of low level vegetation between the established trees. KCC does not concede that the vegetation and the condition of the verge was in any way contributory to the death of Mr Innes, but does consider that this action will provide a betterment to the service in terms of increasing the opportunities to access the bus service and also increase the visibility of any pedestrians standing on the verge to approaching drivers.”

Source location

2019-0124-Response-by-Kent-County-Council
Page 6 · response
Published 14 June 2019

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

No specific traffic sign is available under the regulations to warn drivers specifically about a bus stop ahead.

Verbatim wording from the response

“16. The Traffic Signs Regulations and General Directions 2016 (TSRGD 2016) does not prescribe any highway sign which warns of the presence of a bus stop. The only signs which can warn of other hazards is diagram 562 below. There are 15 supplementary plates which can accompany this sign to advise drivers of the specific hazard. None of these supplementary plates relate to the presence of a bus stop. Without the provision of a supplementary plate, drivers will not be able to understand what they need to prepare for ahead and this warning will be less effective.”

Source location

2019-0124-Response-by-Kent-County-Council
Page 4 · response
Published 14 June 2019

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

A controlled pedestrian crossing is not considered appropriate because pedestrian crossing numbers and general footway use are minimal.

Verbatim wording from the response

“33. Controlled pedestrians’ crossings in the form of a zebra, pelican or puffin crossing are only considered where there are high numbers of pedestrians crossing within a small area and where the volume of traffic provides very little opportunity for pedestrians to cross a road. In this instance the level of pedestrians crossing the road is very minimal and level of pedestrian traffic generally on the provided footways is very low. A controlled crossing at this location is therefore not considered appropriate.”

Source location

2019-0124-Response-by-Kent-County-Council
Page 6 · response
Published 14 June 2019

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

An uncontrolled crossing cannot be provided because there is no southern footway and insufficient verge width for an accessible facility.

Verbatim wording from the response

“34. An uncontrolled crossing in the form of dropped kerbs on either side of the road, can only be provided where there is a continuous route of footways. In this instance there is no southern footway and the available verge width is insufficient to provide a facility suitable for all users.”

Source location

2019-0124-Response-by-Kent-County-Council
Page 6 · response
Published 14 June 2019

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.6

  1. 1

    Review the existing warning signs.

    Stated by Kent County CouncilStated completedThe respondent said that this action was complete when they made their response on 14 June 2019.
  2. 2

    Re-mark the centre line at the Mansfield Farm junction.

    Stated by Kent County CouncilStated completedThe respondent said that this action was complete when they made their response on 14 June 2019.
  3. 3

    Cleanse the road gully at the Mansfield Farm junction.

    Stated by Kent County CouncilStated completedThe respondent said that this action was complete when they made their response on 14 June 2019.
  4. 4

    Conduct a speed survey near Nickle Cottages.

    Stated by Kent County CouncilStated completedThe respondent said that this action was complete when they made their response on 14 June 2019.
  5. 5

    Pursue extension of the 40mph speed limit to west of Chartham Corn Mill, including a gateway feature, coloured surfacing and carriageway markings.

    Stated by Kent County CouncilStated plannedThe respondent said that this action was planned when they made their response on 14 June 2019.
  6. 6

    Clear vegetation obstructing visibility around bends, warning signs and the carriageway near Nickle Cottages.

    Stated by Kent County CouncilStated completedThe respondent said that this action was complete when they made their response on 14 June 2019.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    KCC does not accept that the 50mph speed limit contributed to the death, but proposes extending the existing 40mph limit.

    Stated by Kent County CouncilDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
  2. 2

    KCC cannot prohibit commercial operators from stopping there; decisions about resuming hail-and-ride services rest with bus operators.

    Stated by Kent County CouncilRedirects 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

Review the existing warning signs.

Verbatim wording from the response

“f. A total review of the existing warning signs has been carried out - Completed November 2018”

Source location

2019-0124-Response-by-Kent-County-Council
Page 7 · response
Published 14 June 2019

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

Re-mark the centre line at the Mansfield Farm junction.

Verbatim wording from the response

“a. Re-marking of 12m of centre line marking at the junction with Mansfield Farm - Completed November 2018”

Source location

2019-0124-Response-by-Kent-County-Council
Page 7 · response
Published 14 June 2019

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

Cleanse the road gully at the Mansfield Farm junction.

Verbatim wording from the response

“b. Road gully on the corner of junction with Mansfield Farm has been cleansed - Completed November 2018”

Source location

2019-0124-Response-by-Kent-County-Council
Page 7 · response
Published 14 June 2019

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

Conduct a speed survey near Nickle Cottages.

Verbatim wording from the response

“29. The existing speed limit is 50mph and this is considered appropriate for the road geometry throughout this area. A speed limit review of this section has been undertaken and speed surveys have been carried out at 3 points in the vicinity of Nickle Cottages and these surveys have revealed that a majority of drivers are travelling within the speed limit with mean speeds of around 43mph.”

Source location

2019-0124-Response-by-Kent-County-Council
Page 6 · response
Published 14 June 2019

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

Pursue extension of the 40mph speed limit to west of Chartham Corn Mill, including a gateway feature, coloured surfacing and carriageway markings.

Verbatim wording from the response

“30. KCC does not concede that the speed limit of the road was in way a contributory factor in the death of Mr Innes, but have carefully considered the current speed limit and the results of the survey and concluded that a reduction of the speed limit to 40mph for a section on the route, namely an extension to the existing 40mph speed limit which currently terminates east of Mansfield Farm junction could be provided up to a point just west of Chartham Corn Mill.”

Source location

2019-0124-Response-by-Kent-County-Council
Page 6 · response
Published 14 June 2019

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 obstructing visibility around bends, warning signs and the carriageway near Nickle Cottages.

Verbatim wording from the response

“the Highways Department at Kent County Council have completed work in respect of cutting back vegetation as part of a site review on the 31st October 2018, there is no clear responsibility for the management of the cutting of the vegetation and no clear indication of ownership of the land close to the bus stop as the Highway Authority did not concede any responsibility for the land adjoining the hard carriageway.”

Source location

2019-0124-Response-by-Kent-County-Council
Page 2 · response
Published 14 June 2019

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

KCC does not accept that the 50mph speed limit contributed to the death, but proposes extending the existing 40mph limit.

Verbatim wording from the response

“29. The existing speed limit is 50mph and this is considered appropriate for the road geometry throughout this area. A speed limit review of this section has been undertaken and speed surveys have been carried out at 3 points in the vicinity of Nickle Cottages and these surveys have revealed that a majority of drivers are travelling within the speed limit with mean speeds of around 43mph.”

Source location

2019-0124-Response-by-Kent-County-Council
Page 6 · response
Published 14 June 2019

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

KCC cannot prohibit commercial operators from stopping there; decisions about resuming hail-and-ride services rest with bus operators.

Verbatim wording from the response

“7. KCC provided advice to bus operators using the A28 that they should consider not stopping in the vicinity of Nickle Cottages. KCC do not have to power to forbid commercial operators from stopping at that location, but are able to make such requests. That advice was accepted and at the present time no buses stop at that location as an interim measure.”

Source location

2019-0124-Response-by-Kent-County-Council
Page 2 · response
Published 14 June 2019

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