PFD report

Jordan Kevin Pry · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 30 Dec 2022•Surrey

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
3

Named on the report

Responses found
3

Of 3 recipients

Stated actions
24

Described in 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. Failure to implement an informed and comprehensive plan for risk management at the location
  2. Persistent road-surface flat spot and associated aquaplaning hazard
    Part of recurring concern: Inadequate controls for icy and slippery surfacesPart of recurring concern: Inadequate road drainage allowing hazardous surface water to remain on carriagewaysPart 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.18

  1. Action

    Commission an independent review of the drainage system to identify improvements likely to reduce carriageway flooding.

    Stated by National HighwaysStated in progressThe respondent said that this action was in progress when they made their response on 9 January 2023.
  2. Action

    Install temporary surface-water warning signs at Marker Posts 36/7 and 36/4.

    Stated by National HighwaysStated completedThe respondent said that this action was complete when they made their response on 9 January 2023.
  3. Action

    Implement a wet-weather monitoring protocol and activate “Surface Water – Slow” variable-message signs when appropriate.

    Stated by National HighwaysStated completedThe respondent said that this action was complete when they made their response on 9 January 2023.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    National Highways is responsible for safely managing the Strategic Road Network, including the accident location.

    Stated by Department for TransportRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking 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

Failure to implement an informed and comprehensive plan for risk management at the location

Wider context from the report

“As stated in my Conclusion (above), Jordan Pry died on the M25 motorway at marker post B4348, when he drove his vehicle through an area of surface water and the car began to aquaplane and rotate, causing it to leave the carriageway and collide with a tree. There is a long and significant history of aquaplaning incidents at the location, including a previous similar fatality following which, in 2010, a Prevention of Future Deaths Report was issued by the then Senior Coroner for Surrey. That report drew attention to the presence of surface water from rain and the effects of a blocked drain, and the presence of a flat spot on the road. Subsequently, changes were made to the drainage system at the location, first in 2011 by means of a small scale improvement scheme and secondly, as part of works completed in 2015, by means of the introduction of a slot drain. However, the flat spot still remains and aquaplaning incidents have continued. I was told in evidence that there are ongoing investigations concerning the risk arising at the location, that a decision as to whether or not the flat spot should be addressed is still to be taken, and that a comprehensive plan for the management of the risk at the location cannot be made until that decision is taken. The concern arising, therefore, is that there is an ongoing risk of further death at this location pending the implementation of an informed and comprehensive plan for risk management. ”

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

Persistent road-surface flat spot and associated aquaplaning hazard

Wider context from the report

“As stated in my Conclusion (above), Jordan Pry died on the M25 motorway at marker post B4348, when he drove his vehicle through an area of surface water and the car began to aquaplane and rotate, causing it to leave the carriageway and collide with a tree. There is a long and significant history of aquaplaning incidents at the location, including a previous similar fatality following which, in 2010, a Prevention of Future Deaths Report was issued by the then Senior Coroner for Surrey. That report drew attention to the presence of surface water from rain and the effects of a blocked drain, and the presence of a flat spot on the road. Subsequently, changes were made to the drainage system at the location, first in 2011 by means of a small scale improvement scheme and secondly, as part of works completed in 2015, by means of the introduction of a slot drain. However, the flat spot still remains and aquaplaning incidents have continued. I was told in evidence that there are ongoing investigations concerning the risk arising at the location, that a decision as to whether or not the flat spot should be addressed is still to be taken, and that a comprehensive plan for the management of the risk at the location cannot be made until that decision is taken. The concern arising, therefore, is that there is an ongoing risk of further death at this location pending the implementation of an informed and comprehensive plan for risk management. ”

Is this part of a recurring concern?

Yes — Inadequate controls for icy and slippery surfaces; Inadequate road drainage allowing hazardous surface water to remain on carriageways; 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

Commission an independent review of the drainage system to identify improvements likely to reduce carriageway flooding.

Verbatim wording from the response

“Improvement to the Drainage System”

Source location

Response from National Highways
Page 3 · response
Published 9 January 2023

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 temporary surface-water warning signs at Marker Posts 36/7 and 36/4.

Verbatim wording from the response

“With CP, NH have commissioned CPS to review the effectiveness of the existing fixed warning sign to identify whether any measures are possible, within the legislative provisions that govern signage, to enhance the visibility of the sign.”

Source location

Response from National Highways
Page 2 · response
Published 9 January 2023

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

Implement a wet-weather monitoring protocol and activate “Surface Water – Slow” variable-message signs when appropriate.

Verbatim wording from the response

“NH has implemented a specific protocol to monitor the Clacket Lane area in times of wet weather and set warning messages of the form “Surface Water – Slow” on the variable message signs in the location when appropriate.”

Source location

Response from National Highways
Page 2 · response
Published 9 January 2023

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

Commission an independent review of the existing fixed warning sign’s effectiveness and possible visibility improvements.

Verbatim wording from the response

“Warning Messages for Drivers”

Source location

Response from National Highways
Page 2 · response
Published 9 January 2023

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

Commission investigations into carriageway reprofiling options, including outline designs and construction feasibility and cost.

Verbatim wording from the response

“Profile of the Carriageway”

Source location

Response from National Highways
Page 3 · response
Published 9 January 2023

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

Trial catchpit sensors to monitor water levels and flow and inform intervention frequency.

Verbatim wording from the response

“d) CPS are carrying out a trial of catchpit sensors to monitor the level of water and flow at the Location. The data gathered will be used to monitor asset performance and inform any changes to intervention frequency. CPS have installed these sensors at two catchpits in February 2023.”

Source location

Response from Connect Plus
Page 3 · response
Published 9 January 2023

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 drainage maintenance and inspection requirements, assess best practice and determine whether enhanced requirements are justified.

Verbatim wording from the response

“a) Recommendation 1 – Review of, and if appropriate improvements to, the drainage maintenance and inspection regime”

Source location

Response from Connect Plus
Page 4 · response
Published 9 January 2023

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

Assess carriageway profile and develop sufficiently detailed remediation proposals for cost-benefit analysis where issues are identified.

Verbatim wording from the response

“d) Recommendation 4 – Cost benefit analysis of carriage reprofiling”

Source location

Response from Connect Plus
Page 5 · response
Published 9 January 2023

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

Investigate flooding-hotspot anomalies and identify justified potential improvements to the drainage system.

Verbatim wording from the response

“c) Recommendation 3 – Improvement to drainage system”

Source location

Response from Connect Plus
Page 5 · response
Published 9 January 2023

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 vegetation cutting and remove excess vegetation from the adjacent landscape plot to reduce leaf burden.

Verbatim wording from the response

“c) Vegetation management”

Source location

Response from Connect Plus
Page 4 · response
Published 9 January 2023

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 scheduled drainage inspections, cleansing of blocked or silted assets, and sweeping of the hardstrip and central reserve.

Verbatim wording from the response

“b) Drainage system inspection and cleanse”

Source location

Response from Connect Plus
Page 3 · response
Published 9 January 2023

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

Maintain the newly installed temporary flooding warning signs and inspect them weekly for presence and function.

Verbatim wording from the response

“ii) Temporary ‘Road Liable to Flooding’ signs were installed in advance of the Location at MP436/7 & MP436/4 on the anti-clockwise B carriageway, and these are subject to a weekly driven visual inspection at prevailing traffic speeds to ensure presence and function.”

Source location

Response from Connect Plus
Page 3 · response
Published 9 January 2023

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 standards-based review of signage requirements, including whether the fixed warning sign should be illuminated.

Verbatim wording from the response

“2) Investigate whether the existing fixed warning sign could be illuminated: National Highways, Connect Plus and CPS have decided to undertake a thorough review of the signage required at the Location against NH standards. CPS will discuss the findings of the CPS design team's review with Connect Plus and National Highways by 28 April 2023.”

Source location

Response from Connect Plus
Page 5 · response
Published 9 January 2023

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

Develop and operate a severe-weather surface-water response procedure covering patrol deployment, incident logging, secondary response and CCTV monitoring.

Verbatim wording from the response

“b) CPS and National Highways are discussing the implementation of the following procedure:”

Source location

Response from Connect Plus
Page 2 · response
Published 9 January 2023

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 weekly visual inspections of slot drains and catchpit surfaces to identify debris accumulation.

Verbatim wording from the response

“1.1 Enhanced inspections”

Source location

Response from Connect Plus
Page 2 · response
Published 9 January 2023

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 whether alternative carriageway surfacing could provide beneficial risk mitigation.

Verbatim wording from the response

“2.2 Complementary measures”

Source location

Response from Connect Plus
Page 5 · response
Published 9 January 2023

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 and develop contingency plans for proactive management of heavy rain, surface water and associated warnings or restrictions.

Verbatim wording from the response

“b) Recommendation 2 – Development of surface water contingency plans”

Source location

Response from Connect Plus
Page 4 · response
Published 9 January 2023

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

Develop and issue an inspection guide defining acceptable debris levels for hardstrips, central reserves and slot drains.

Verbatim wording from the response

“c) CPS are developing an inspection guide/checklist to enable CPS ISU crews to have a clear understanding of the acceptable levels of surface debris on the hardstrip, central reserve and slot drains. This will be issued in March 2023 as an addendum to the ISU inspection check sheet.”

Source location

Response from Connect Plus
Page 3 · response
Published 9 January 2023

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

National Highways is responsible for safely managing the Strategic Road Network, including the accident location.

Verbatim wording from the response

“Responsibility for the safe management of the Strategic Road Network, which includes the location of this accident, falls to National Highways and I am aware that work has already been undertaken at this site since the accident, including the installation of a vehicle restraint system.”

Source location

Response from Department for Transport
Page 1 · response
Published 9 January 2023

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

CPS is responsible for implementing the enhanced measures and GG104 Programme, while Connect Plus monitors delivery.

Verbatim wording from the response

“Set out below is an overview of enhanced measures at the Location which have been or are in the process of being implemented (Enhanced Measures), together with the programme of work to complete the comprehensive plan for risk management (GG 104 Programme). Connect Plus Services (CPS) has provided a written commitment to Connect Plus to implement both the Enhanced Measures and the GG104 Programme.”

Source location

Response from Connect Plus
Page 1 · response
Published 9 January 2023

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

National Highways retains control of safety-critical technology, including decisions on speed-limit signs and variable message warnings.

Verbatim wording from the response

“HM Senior Coroner will recall from evidence heard at the inquest that in May 2009 the Secretary of State for Transport signed a 30 year contract with Connect Plus (M25) Limited (Connect Plus) for the M25 Project Road Network. The Secretary of State's interest has since been transferred to National Highways Limited (National Highways). As is the case with privately financed projects, Connect Plus subcontracted a significant proportion of its core operations and maintenance obligations to CPS under a 30-year operations and maintenance agreement. National Highways retained control of most of the technology for the functioning of the M25 Project Road Network related to safety-critical assets, such as the setting of speed limit signs on overhead gantries.”

Source location

Response from Connect Plus
Page 1 · response
Published 9 January 2023

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

    Continue working with National Highways on the safety concerns raised.

    Stated by Department for TransportStated in progressThe respondent said that this action was in progress when they made their response on 9 January 2023.
  2. 2

    Install a vehicle restraint system in the verge at the location.

    Stated by National HighwaysStated completedThe respondent said that this action was complete when they made their response on 9 January 2023.
  3. 3

    Meet monthly with Connect Plus and Connect Plus Services to monitor progress and keep the safety actions on schedule.

    Stated by National HighwaysStated in progressThe respondent said that this action was in progress when they made their response on 9 January 2023.
  4. 4

    Review residual verge hazards and identify further changes to reduce vehicle risk.

    Stated by Connect Plus (M25) LimitedStated in progressThe respondent said that this action was in progress when they made their response on 9 January 2023.
  5. 5

    Investigate available technology for reliable passive surface-water monitoring at the Location.

    Stated by Connect Plus (M25) LimitedStated in progressThe respondent said that this action was in progress when they made their response on 9 January 2023.
  6. 6

    Review asset-maintenance best practice and consider relevant elements for inclusion in the 2023 Services Plan.

    Stated by Connect Plus (M25) LimitedStated in progressThe respondent said that this action was in progress when they made their response on 9 January 2023.

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

Continue working with National Highways on the safety concerns raised.

Verbatim wording from the response

“My DfT Officials will continue to work with National Highways on the points you have raised in your enquiry.”

Source location

Response from Department for Transport
Page 2 · response
Published 9 January 2023

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 a vehicle restraint system in the verge at the location.

Verbatim wording from the response

“In your report you raised concerns about the risk of further deaths at this location pending the implementation of an informed and comprehensive plan for managing the risk of surface water remaining on the carriageway in periods of heavy rain. In your finding you identified the blocked drain in the central reservation and the profile of the road surface as probable causes of Mr Pry’s death and absence of any warning sign and the absence of vehicle restraint system in the verge as possible contributory causes.”

Source location

Response from National Highways
Page 1 · response
Published 9 January 2023

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

Meet monthly with Connect Plus and Connect Plus Services to monitor progress and keep the safety actions on schedule.

Verbatim wording from the response

“Following conclusions of the various investigations set out above I will write to you again by 29 September 2023 setting out the further actions NH has taken and intends to take. If any recommendations are not to be pursued, I will set out the reasons for that decision.”

Source location

Response from National Highways
Page 3 · response
Published 9 January 2023

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 residual verge hazards and identify further changes to reduce vehicle risk.

Verbatim wording from the response

“3) Verge review: A review of any residual hazards in the verge at this Location is being undertaken by WSP as part of the Recommendation 2 workstream to determine if there are further changes that can be made to reduce the risk to vehicles. WSP's findings will be discussed with Connect Plus, CPS and National Highways by 16 June 2023.”

Source location

Response from Connect Plus
Page 5 · response
Published 9 January 2023

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

Investigate available technology for reliable passive surface-water monitoring at the Location.

Verbatim wording from the response

“e) CPS are investigating the developing technology market to establish whether there are reliable and suitable passive monitoring systems for detection of surface water at the Location.”

Source location

Response from Connect Plus
Page 3 · response
Published 9 January 2023

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 asset-maintenance best practice and consider relevant elements for inclusion in the 2023 Services Plan.

Verbatim wording from the response

“f) CPS are reviewing the best practice within ‘Asset delivery asset maintenance requirements’ standards and intend to incorporate any relevant elements in the Services Plan 2023.”

Source location

Response from Connect Plus
Page 3 · response
Published 9 January 2023

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
3/3

Data last updated 7 September 2026