PFD report

William David McCourt · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 14 Jan 2014•North Yorkshire (West)

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
9

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

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 raised9

  1. Failure to record the basis for land-ownership conclusions
    Part of recurring concern: Unreliable land-ownership determination for safety responsibilities
  2. Failure to make written time-bound ownership enquiries
  3. Failure to prevent prolonged drift of an unresolved flooding issue
    Part of recurring concern: Failure to reliably manage flooding and standing-water risks on roads
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.4

  1. Action

    Provide staff training to minimise human errors in logging and recording enquiries.

    Stated by North Yorkshire CouncilStated completedThe respondent said that this action was complete when they made their response on 12 December 2013.
  2. Action

    Give staff clearer direction to ensure more detailed records are created in future.

    Stated by North Yorkshire CouncilStated in progressThe respondent said that this action was in progress when they made their response on 12 December 2013.
  3. Action

    Circulate advice to relevant highway officers requiring actionable defects and warning signs to remain recorded until resolved.

    Stated by North Yorkshire CouncilStated completedThe respondent said that this action was complete when they made their response on 12 December 2013.

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 record the basis for land-ownership conclusions

Wider context from the report

“2) The maintenance manager who visited the site in June, 2012, formed the opinion that the land in question was owned by the Ministry of Defence. There is no note of the conversation which led to this conclusion, neither did the maintenance manager visit the occupier of the land from which the water was flowing. ”

Is this part of a recurring concern?

Yes — Unreliable land-ownership determination for safety responsibilities.

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 to make written time-bound ownership enquiries

Wider context from the report

“4) Nothing was ever put in writing to the Ministry of Defence requiring them to notify the Highways Authority within a reasonable time scale as to whether they owned the land and if so what action would be taken and by when. ”

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

Failure to prevent prolonged drift of an unresolved flooding issue

Wider context from the report

“5) This situation was allowed to ‘drift’ over at least a 3 month period prior to the accident. ”

Is this part of a recurring concern?

Yes — Failure to reliably manage flooding and standing-water risks on roads.

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 by inspectors to report potential hazards

Wider context from the report

“6) Inspectors should have reported all potential hazards and actions taken to address them. ”

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

Failure by inspectors to report actions taken to address hazards

Wider context from the report

“6) Inspectors should have reported all potential hazards and actions taken to address them. ”

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

Failure to record reports of flooding

Wider context from the report

“1) No record was found of the reports made by local residents prior to June, 2012, of flooding at this location either via the Highways website or by telephone on two occasions and, therefore, no action taken. ”

Is this part of a recurring concern?

Yes — Failure of the highway hazard reporting and response process.

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 to act on reported flooding

Wider context from the report

“1) No record was found of the reports made by local residents prior to June, 2012, of flooding at this location either via the Highways website or by telephone on two occasions and, therefore, no action taken. ”

Is this part of a recurring concern?

Yes — Failure of the highway hazard reporting and response process; Failure to reliably manage flooding and standing-water risks on roads.

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 to establish the relevant land occupier

Wider context from the report

“2) The maintenance manager who visited the site in June, 2012, formed the opinion that the land in question was owned by the Ministry of Defence. There is no note of the conversation which led to this conclusion, neither did the maintenance manager visit the occupier of the land from which the water was flowing. ”

Is this part of a recurring concern?

Yes — Unreliable land-ownership determination for safety responsibilities.

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 to progress resolution of the flooding issue

Wider context from the report

“3) Over a three month period nothing was done to address the issue other than to telephone the Ministry of Defence. The Ministry of Defence did not provide an answer to the question of ownership of the land until after this accident when they confirmed that they were not responsible for the land in question. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Provide staff training to minimise human errors in logging and recording enquiries.

Verbatim wording from the response

“(1) It is acknowledged by North Yorkshire County Council that no records of the alleged customer contacts could be found. During the inquest, it was identified that the customers were unable to provide evidence of these contacts so any further investigation, by the County Council is not possible. North Yorkshire County Council systems have been reviewed in the past and found to be robust. In addition, training has been provided to minimise the potential for human error to occur, resulting in an enquiry not being logged and recorded correctly.”

Source location

2013-0383-Response-by-North-Yorkshire-County-Council
Page 1 · response
Published 12 December 2013

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

Give staff clearer direction to ensure more detailed records are created in future.

Verbatim wording from the response

“(2) It was acknowledged at the inquest that on this occasion more detailed notes should have been taken and clearer direction is now being given to staff to ensure better records exist in the future. The Maintenance Manager, in this instance, was given every indication by the representative of the Ministry of Defence that they were responsible for the land in question and hence no further enquiries were made. It appeared that the farm buildings were unoccupied at the time the flooding event occurred.”

Source location

2013-0383-Response-by-North-Yorkshire-County-Council
Page 1 · response
Published 12 December 2013

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

Circulate advice to relevant highway officers requiring actionable defects and warning signs to remain recorded until resolved.

Verbatim wording from the response

“(6) North Yorkshire County Council’s highway officers record actionable defects (i.e those defects where work is intended) when carrying out inspections of the highway network. If temporary warning signs are in place to alleviate a hazard, the defect/warning signs should still be recorded until it has been resolved. Further advice has now been circulated to relevant highways officers through their managers to assert that this process is followed in future.”

Source location

2013-0383-Response-by-North-Yorkshire-County-Council
Page 2 · response
Published 12 December 2013

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 customer-contact recording systems to support robust logging and recording.

Verbatim wording from the response

“(1) It is acknowledged by North Yorkshire County Council that no records of the alleged customer contacts could be found. During the inquest, it was identified that the customers were unable to provide evidence of these contacts so any further investigation, by the County Council is not possible. North Yorkshire County Council systems have been reviewed in the past and found to be robust. In addition, training has been provided to minimise the potential for human error to occur, resulting in an enquiry not being logged and recorded correctly.”

Source location

2013-0383-Response-by-North-Yorkshire-County-Council
Page 1 · response
Published 12 December 2013

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
1/1

Data last updated 7 September 2026