PFD report

MELVIN BANDTOCK · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 3 Apr 2014•County Durham and Darlington

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
2

Of 1 recipient

Stated actions
6

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.

Report evidence summary

Concerns raised2

  1. Lack of collective information sharing between police and the local authority
    Part of recurring concern: Failure of police operational communications to reliably share safety-critical informationPart of recurring concern: Failure to reliably share road-safety incident information with highway authoritiesPart of recurring concern: Unreliable winter road maintenance response
  2. Failure of County Council practices and procedures to ensure a timely and proportionate response to potentially dangerous road conditions
    Part of recurring concern: Unreliable winter road maintenance response
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.5

  1. Action

    Require meaningful communication with weather forecasters when conditions are marginal or change, so revised actions can be implemented.

    Stated by Durham County CouncilStated completedThe respondent said that this action was complete when they made their response on 3 April 2014.
  2. Action

    Deploy winter maintenance vehicles on standby at strategic depots during specified low-confidence amber warnings for immediate gritting response.

    Stated by Durham County CouncilStated plannedThe respondent said that this action was planned when they made their response on 3 April 2014.
  3. Action

    Deploy Duty Highway Inspectors on standby at strategic depots during specified low-confidence amber warnings to monitor forecasts and support decisions.

    Stated by Durham County CouncilStated plannedThe respondent said that this action was planned when they made their response on 3 April 2014.

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

  1. Position

    Snow and ice risks cannot be completely eliminated because forecasting and salting effectiveness depend on uncertain weather and traffic conditions.

    Stated by Durham 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

Lack of collective information sharing between police and the local authority

Wider context from the report

“Evidence was given that there is a Duty Manager on call to assess changing weather reports and the collation of information obtained from other sources, in particular the police, in order to decide whether salting/gritting machines should be deployed either on a local or County wide basis. On the day in question the Duty Manager believed that weather temperatures would increase in a relatively short period of time whereas in reality they did not do so. There were a high number of collision incidents reported to the police that morning some of which resulted in report being made to the County Council. Some gritting/salting vehicles were deployed. It will take about an hour for gritting/salting lorries to be able to commence their work and a route would take up to three hours to complete. The time that it therefore takes to complete a gritting/salting run is a factor which is considered by the Duty Manager on the question of whether to deploy or not in conjunction with the weather condition reports and as a result of information gleaned from road temperature monitoring. It was said that this procedure had been in place for many years and was tried and tested. A Regulation 28 report is being sent to Durham Constabulary and a copy provided to the local authority herewith and the evidence indicates that a better collective sharing of information between the two organisations may well be of benefit together with a review of the County Council's own practices and procedures to ensure that a timely and proportionate response to potentially dangerous road conditions can be delivered to promote the safety of all road users. The Highways Manager indicated that with the information that the Duty Manager had following receipt of the 6.00 a.m. weather report his decision not to deploy gritting/salting vehicles was a reasonable one but that with the benefit of hindsight knowing what happened with regard to ambient temperature conditions and incidents around the County on the road network this decision was regrettable. I confirmed that it was not my intention to blame or be seen to blame any individual for the death in this case but it was my statutory obligation to draw to the appropriate authorities attention relevant issues that might be appropriate to prevent future deaths. I also recognised that English weather can be unpredictable. ”

Is this part of a recurring concern?

Yes — Failure of police operational communications to reliably share safety-critical information; Failure to reliably share road-safety incident information with highway authorities; Unreliable winter road maintenance response.

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 County Council practices and procedures to ensure a timely and proportionate response to potentially dangerous road conditions

Wider context from the report

“Evidence was given that there is a Duty Manager on call to assess changing weather reports and the collation of information obtained from other sources, in particular the police, in order to decide whether salting/gritting machines should be deployed either on a local or County wide basis. On the day in question the Duty Manager believed that weather temperatures would increase in a relatively short period of time whereas in reality they did not do so. There were a high number of collision incidents reported to the police that morning some of which resulted in report being made to the County Council. Some gritting/salting vehicles were deployed. It will take about an hour for gritting/salting lorries to be able to commence their work and a route would take up to three hours to complete. The time that it therefore takes to complete a gritting/salting run is a factor which is considered by the Duty Manager on the question of whether to deploy or not in conjunction with the weather condition reports and as a result of information gleaned from road temperature monitoring. It was said that this procedure had been in place for many years and was tried and tested. A Regulation 28 report is being sent to Durham Constabulary and a copy provided to the local authority herewith and the evidence indicates that a better collective sharing of information between the two organisations may well be of benefit together with a review of the County Council's own practices and procedures to ensure that a timely and proportionate response to potentially dangerous road conditions can be delivered to promote the safety of all road users. The Highways Manager indicated that with the information that the Duty Manager had following receipt of the 6.00 a.m. weather report his decision not to deploy gritting/salting vehicles was a reasonable one but that with the benefit of hindsight knowing what happened with regard to ambient temperature conditions and incidents around the County on the road network this decision was regrettable. I confirmed that it was not my intention to blame or be seen to blame any individual for the death in this case but it was my statutory obligation to draw to the appropriate authorities attention relevant issues that might be appropriate to prevent future deaths. I also recognised that English weather can be unpredictable. ”

Is this part of a recurring concern?

Yes — Unreliable winter road maintenance response.

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

Require meaningful communication with weather forecasters when conditions are marginal or change, so revised actions can be implemented.

Verbatim wording from the response

“We have reviewed our procedures and made a number of changes to improve the margin of safety against inaccurate weather forecasts and changing conditions:”

Source location

2014-0147-Response-by-Durham-County-Council
Page 2 · response
Published 3 April 2014

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

Deploy winter maintenance vehicles on standby at strategic depots during specified low-confidence amber warnings for immediate gritting response.

Verbatim wording from the response

“In circumstances where weather forecasts indicate an amber warning less than or equal to 1°C, with low confidence, winter maintenance vehicles will be deployed on standby at all strategic depots in readiness for gritting activity, therefore should weather conditions deteriorate from that forecast, an immediate gritting response can be implemented.”

Source location

2014-0147-Response-by-Durham-County-Council
Page 3 · response
Published 3 April 2014

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

Deploy Duty Highway Inspectors on standby at strategic depots during specified low-confidence amber warnings to monitor forecasts and support decisions.

Verbatim wording from the response

“Amber Warning In circumstances where weather forecasts indicate an amber warning less than or equal to 1°C, with low confidence, Duty Highway Inspectors will be deployed on standby at the key strategic depots for the purpose of monitoring forecast information and where appropriate undertaking a route inspection to assist the Duty Manager in the decision making process.”

Source location

2014-0147-Response-by-Durham-County-Council
Page 2 · response
Published 3 April 2014

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 information-sharing protocols with Durham Constabulary to identify improvements.

Verbatim wording from the response

“Sharing of Information Following receipt of your letter we met with Durham Constabulary on 29th April 2014 to review existing information sharing protocols and to identify how these could be improved.”

Source location

2014-0147-Response-by-Durham-County-Council
Page 2 · response
Published 3 April 2014

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

Remind Duty Managers to prioritise highway-network safety and maintain appropriate resources for rapidly changing conditions.

Verbatim wording from the response

“We have reviewed our procedures and made a number of changes to improve the margin of safety against inaccurate weather forecasts and changing conditions:”

Source location

2014-0147-Response-by-Durham-County-Council
Page 2 · response
Published 3 April 2014

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

Snow and ice risks cannot be completely eliminated because forecasting and salting effectiveness depend on uncertain weather and traffic conditions.

Verbatim wording from the response

“However, winter maintenance is not an exact science and the decision to deploy gritters for precautionary salting relies upon weather forecasts and professional judgement. Whilst weather forecasting has greatly improved in recent years it is not 100% accurate and the actual weather conditions on 28 December 2013 were worse than forecast which was a significant factor in this accident.”

Source location

2014-0147-Response-by-Durham-County-Council
Page 1 · response
Published 3 April 2014

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 communication mechanisms and information-sharing protocols are considered effective for managing highways through partnership working.

Verbatim wording from the response

“Sharing of Information Following receipt of your letter we met with Durham Constabulary on 29th April 2014 to review existing information sharing protocols and to identify how these could be improved.”

Source location

2014-0147-Response-by-Durham-County-Council
Page 2 · response
Published 3 April 2014

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 existing Winter Service Plan is considered effective and sufficient to meet the Council’s reasonably practicable highway safety duty.

Verbatim wording from the response

“Statutory Duty Section 41(1)(a) of the Highways Act 1980 (c. 66) (duty of Highway Authority to maintain highway) states:”

Source location

2014-0147-Response-by-Durham-County-Council
Page 1 · response
Published 3 April 2014

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

Established procedures, supervision and communication arrangements with the Council are considered robust and fit for purpose.

Verbatim wording from the response

“The dispatchers for that area would then deploy officers to the incident and contact Durham County Council as appropriate. There is also a dispatch pod (call sign LA) which deals with all highways issues for the County. Any incident which was affecting the road network would have a ‘highways’ tag placed on it and would be managed in conjunction with the area response. The LA dispatcher, having overall view of the County’s road network, would normally be the dispatcher who would contact the Council, should issues become apparent. This would be recorded on the incident log so the area dispatcher would know what had been done and what actions were being taken. The dispatch room is overseen by 2 supervisors and an inspector is on duty at all times to manage critical incidents and firearms deployments.”

Source location

2014-0147-Response-by-Durham-Constabulary
Page 2 · response
Published 3 April 2014

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 Constabulary disputes that road incident reporting was ad hoc or lacked supervisory oversight.

Verbatim wording from the response

“The matter of concern by the Coroner for the Constabulary was that the process for contacting Durham County Council was done by an individual call handler on an ad hoc basis with no monitoring or supervision. There was also a concern that there was no oversight that might lead a supervisory officer to conclude a potentially serious situation was developing on the County’s roads. This is not the case for both issues.”

Source location

2014-0147-Response-by-Durham-Constabulary
Page 1 · response
Published 3 April 2014

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

    Meet weather forecasters before the next winter season to determine whether weather-change notifications can be improved.

    Stated by Durham County CouncilStated plannedThe respondent said that this action was planned when they made their response on 3 April 2014.

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

Meet weather forecasters before the next winter season to determine whether weather-change notifications can be improved.

Verbatim wording from the response

“Communication When weather conditions are marginal, improved communication with the weather forecaster is essential, particularly when conditions deteriorate or change from that forecast. The Duty Manager will ensure that communication with the forecaster is meaningful in order that the extent and duration of the changes are fully understood and appropriate revised actions are implemented. The Council intends to meet with the forecasters prior to the next winter season to determine whether notifications relating to changes in weather can be improved.”

Source location

2014-0147-Response-by-Durham-County-Council
Page 2 · response
Published 3 April 2014

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

Official responses located
2/1

Data last updated 7 September 2026