PFD report

Paul Stephen Collingridge · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 20 Feb 2025•Essex

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
4

Named on the report

Responses found
4

Of 4 recipients

Stated actions
13

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.

Concerns raised4

  1. Inadequate Code of Practice guidance for calculating street works distances where standard reference points or markings are unavailable or variable
    Part of recurring concern: Unsafe street works setup and control
  2. Difficulties in calculating distances for roadworks set up in darkness
    Part of recurring concern: Unsafe street works setup and control
  3. Failure to place road works warning signs without obscuring visibility of joining traffic
    Part of recurring concern: Inadequate road warning signagePart of recurring concern: Unreliable safety controls for temporary traffic management schemesPart of recurring concern: Unsafe street works setup and control
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.8

  1. Action

    Devise and roll out a toolbox talk addressing sight-line issues and the procedure changes across the business.

    Stated by Hatton Traffic Management LimitedStated completedThe respondent said that this action was complete when they made their response on 25 February 2025.
  2. Action

    Complete a full review of emergency works procedures.

    Stated by Hatton Traffic Management LimitedStated completedThe respondent said that this action was complete when they made their response on 25 February 2025.
  3. Action

    Roll out new detailed design layouts and sign-placement guidance for all traffic-light schemes and road speeds.

    Stated by Hatton Traffic Management LimitedStated completedThe respondent said that this action was complete when they made their response on 25 February 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.8

  1. Position

    Affinity disputes that fatal incidents must be notified on retrospective roadworks permit applications, stating that no such requirement exists.

    Stated by Affinity Water LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Inadequate Code of Practice guidance for calculating street works distances where standard reference points or markings are unavailable or variable

Wider context from the report

“(2) The Safety of Street Works Code of Practice sets out how to take measurements to set out street works that include utilising street furniture that are at set distances and standard road markings that have standard lengths on carriageways with specific road speeds. a. Some carriageways do not have street furniture b. Some of the road markings on the carriage where the fatal collision did not comply to standard lengths and therefore the markings can have variations. c. The Code of Practice does not set out how to calculate the distance where there is road curvature where the road markings have differing lengths on opposing sides where the markings are delineated on bends in a carriageway. ”

Is this part of a recurring concern?

Yes — Unsafe street works setup and control.

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

Difficulties in calculating distances for roadworks set up in darkness

Wider context from the report

“(1) Where Road Works Permits are required by utility companies these are often urgent to carry out vital repairs. This can mean that roadworks are set up in hours of darkness and may cause difficulties calculating distances as set out in the Safety at Street Works Code of Practice. ”

Is this part of a recurring concern?

Yes — Unsafe street works setup and control.

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 place road works warning signs without obscuring visibility of joining traffic

Wider context from the report

“(3) A road works warning sign was placed at the junction that joined the carriageway of a road that obscured visibility of traffic joining the main carriageway. Whilst this did not cause or contribute to this incident this was not in accordance with the Code of Practice. ”

Is this part of a recurring concern?

Yes — Inadequate road warning signage; Unreliable safety controls for temporary traffic management schemes; Unsafe street works setup and control.

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

Absence of a requirement to notify fatalities within roadworks on permit applications

Wider context from the report

“(4) The fatal incident that occurred on 6 December 2022 was not notified on the retrospective permit application for roadworks on the following day. There is no requirement for a fatality within roadworks be notified on application for an application for a permit . ”

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

Devise and roll out a toolbox talk addressing sight-line issues and the procedure changes across the business.

Verbatim wording from the response

“A specific toolbox talk addressing this issue and the above changes, was devised and rolled out across the business on 30th January 2025.”

Source location

Response from Hatton Traffic Management
Page 1 · response
Published 25 February 2025

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

Complete a full review of emergency works procedures.

Verbatim wording from the response

“Insofar as recommendation 5 (3) is concerned, HTML can confirm that it undertook a full review of emergency works procedures which resulted in new design layouts for all traffic light schemes on all road speeds. These provide additional more detailed guidance and direction on the placement of signs and were rolled out across the business on 23rd January 2025.”

Source location

Response from Hatton Traffic Management
Page 1 · response
Published 25 February 2025

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

Roll out new detailed design layouts and sign-placement guidance for all traffic-light schemes and road speeds.

Verbatim wording from the response

“Insofar as recommendation 5 (3) is concerned, HTML can confirm that it undertook a full review of emergency works procedures which resulted in new design layouts for all traffic light schemes on all road speeds. These provide additional more detailed guidance and direction on the placement of signs and were rolled out across the business on 23rd January 2025.”

Source location

Response from Hatton Traffic Management
Page 1 · response
Published 25 February 2025

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

Add a process-flow question requiring operatives to record whether signage sight lines have been checked and assessed as appropriate.

Verbatim wording from the response

“In addition, an additional question has been added to the installation process flow which requires the relevant operative to answer and record whether sight lines to signage have been checked and assessed as appropriate.”

Source location

Response from Hatton Traffic Management
Page 1 · response
Published 25 February 2025

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

Strengthen planning and execution of emergency roadworks and implement stricter contractor-oversight protocols, supported by regular audits and assessments.

Verbatim wording from the response

“Following Paul’s death, Affinity reviewed its traffic management practices including the strengthening of our planning and execution of emergency works and have already implemented stricter protocols with regard to oversight of our contractors. Regular audits and assessments are carried out to monitor adherence and identify areas for continuous improvement. This has resulted in a significant reduction in the number of street works requiring emergency permits.”

Source location

Response from Affinity Water
Page 2 · response
Published 25 February 2025

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 collaboratively with the Department for Transport and councils on proposed Code revisions or new rules for permit applications and safe roadworks.

Verbatim wording from the response

“Affinity will also work collaboratively with DfT and councils in relation to any proposed revisions to the Code and/or any new rules with regard to permit applications and the safe conduct of roadworks.”

Source location

Response from Affinity Water
Page 3 · response
Published 25 February 2025

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

Update the Safety Code through consultation, incorporating the report’s findings and publishing a revised version.

Verbatim wording from the response

“The Safety Code was last published in 2013 and is currently in the process of being updated, with a consultation due to take place in early summer. We are inviting comments on whether there are any parts of the Safety Code that can be improved to maximise safety, and we plan to publish an updated version by the end of 2025. I will ensure that we take into account your report when completing this work.”

Source location

Response from Department for Transport
Page 2 · response
Published 25 February 2025

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

Raise the absence of a Street Manager field for reporting serious incidents and unusual events with the Department for Transport.

Verbatim wording from the response

“3. When applying for retrospective permission for street works there is no requirement for a statutory undertaker to notify the authority of any serious incidents that have occurred during the emergency period. There is a national database run by the Department for Transport named Street Manager. This is the way that all local authorities communicate with all statutory undertakers. That database does not have a data field to allow permit applicants to report incidents or unusual events. We will raise this with the Department for Transport. However, the involvement of the police in any fatal road accident already provides a communications channel, meaning that in practice ECC is notified quickly of any fatalities and can quickly take any necessary action that it has the power to take.”

Source location

Response from Essex County Council
Page 2 · response
Published 25 February 2025

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

Affinity disputes that fatal incidents must be notified on retrospective roadworks permit applications, stating that no such requirement exists.

Verbatim wording from the response

“(3) Matter of concern: The fatal incident that occurred on 6 December 2022 was not notified on the retrospective permit application for roadworks on the following day. There is no requirement for a fatality within roadworks be notified on application for an application for a permit.”

Source location

Response from Affinity Water
Page 2 · response
Published 25 February 2025

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

Responding to the second concern falls outside Affinity’s remit because the Department for Transport publishes and controls the Safety at Street Works Code.

Verbatim wording from the response

“is proposed. We have not provided a response to the second matter of concern as the Safety at Street Works Code of Practice (the “Code”) is published and controlled by the Department of Transport (DfT) and therefore we do not believe that Affinity is required to respond to that point.”

Source location

Response from Affinity Water
Page 2 · response
Published 25 February 2025

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

There is no requirement to record a site fatality on an immediate-works permit application because the permit concerns timings and durations.

Verbatim wording from the response

“You raised a final concern that the fatality was not mentioned on the permit application for the works. For immediate works, permits can be submitted within two hours of arriving on site. If a fatality happens at the site, there is no requirement for it to be referred to on the permit application, as the permit is concerned with agreeing timings and durations of works. It is the Safety Code and the risk assessments that are carried out that take account of incidents to ensure sites are set up correctly.”

Source location

Response from Department for Transport
Page 2 · response
Published 25 February 2025

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

Those carrying out works are responsible for accurately measuring Safety Code distances, including during darkness.

Verbatim wording from the response

“You made references to the use of street furniture and road markings to determine distances and measuring distances accurately in the hours of darkness. The Safety Code details the sequence for setting out a street work site with reference to a table of distances. These distances are determined with reference to the street work site and do not depend on the presence of street furniture or road markings. The Safety Code makes it clear that it is the responsibility of those carrying out the works to ensure that the distances are measured accurately. This also includes during the hours of darkness. Failure to comply with the distances set out in the Safety Code is evidence that an offence for failing to comply with the Safety Code has been committed.”

Source location

Response from Department for Transport
Page 2 · response
Published 25 February 2025

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 local highway authority that granted the permit is responsible for deciding enforcement action concerning incorrectly placed signs.

Verbatim wording from the response

“You raised a further concern regarding a sign that was placed incorrectly at a junction which obscured visibility but was not a contributing factor to Mr Collingridge’s death. It appears that the placement of the sign was not in accordance with the Safety Code. However, it is for the local highway authority that granted the permit to decide on any enforcement action. It would have been for them to do this at the time of the incident.”

Source location

Response from Department for Transport
Page 2 · response
Published 25 February 2025

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 Department for Transport is responsible for reviewing and improving the Code’s guidance on distance calculations for curved carriageways.

Verbatim wording from the response

“Regarding curved carriageways, the absence of specific guidance on distance calculation in the statutory Code of Practice is acknowledged. While this remains a broader area for review for the Department for Transport, Essex County Council is prepared to support any request from the Department of Transport to improve the Code to address such circumstances. There is an overarching duty for statutory undertakers to have a safe system of work and the training they have will cover this.”

Source location

Response from Essex County Council
Page 1 · response
Published 25 February 2025

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

Statutory undertakers and their contractors are responsible for safely setting up emergency works and ensuring Code compliance.

Verbatim wording from the response

“1. Road Works Permits and Setup in Hours of Darkness. All work is more difficult during the hours of darkness. Undertakers and those working on their behalf are responsible for ensuring emergency works are set up safely and are required to have a trained and qualified person on site to ensure compliance with the Code. ECC does not have the ability to inspect all emergency roadworks as that does not form part of the safety system.”

Source location

Response from Essex County Council
Page 1 · response
Published 25 February 2025

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

Police involvement in fatal road accidents provides a communications channel that promptly notifies the authority and enables action within its powers.

Verbatim wording from the response

“3. When applying for retrospective permission for street works there is no requirement for a statutory undertaker to notify the authority of any serious incidents that have occurred during the emergency period. There is a national database run by the Department for Transport named Street Manager. This is the way that all local authorities communicate with all statutory undertakers. That database does not have a data field to allow permit applicants to report incidents or unusual events. We will raise this with the Department for Transport. However, the involvement of the police in any fatal road accident already provides a communications channel, meaning that in practice ECC is notified quickly of any fatalities and can quickly take any necessary action that it has the power to take.”

Source location

Response from Essex County Council
Page 2 · response
Published 25 February 2025

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.5

  1. 1

    Improve training and operational protocols to reinforce compliance with permitting requirements, particularly for emergency and out-of-hours works.

    Stated by Affinity Water LimitedStated completedThe respondent said that this action was complete when they made their response on 25 February 2025.
  2. 2

    Add resources to ensure prompt permit applications, particularly for emergency and out-of-hours works.

    Stated by Affinity Water LimitedStated completedThe respondent said that this action was complete when they made their response on 25 February 2025.
  3. 3

    Improve communications with councils regarding roadworks permitting.

    Stated by Affinity Water LimitedStated completedThe respondent said that this action was complete when they made their response on 25 February 2025.
  4. 4

    Provide necessary departmental training to prevent future delays in responding to reports.

    Stated by Department for TransportStated plannedThe respondent said that this action was planned when they made their response on 25 February 2025.
  5. 5

    Operate a risk-based inspection system to identify and prioritise required road-marking and street-maintenance works.

    Stated by Essex County CouncilStated completedThe respondent said that this action was complete when they made their response on 25 February 2025.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.3

  1. 1

    Cannot respond or comment on recommendations 5(1), 5(2) and 5(4).

    Stated by Hatton Traffic Management LimitedUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
  2. 2

    Inspecting all emergency roadworks does not form part of the authority’s safety system.

    Stated by Essex County CouncilOutside remitThe respondent said that this matter was outside its role or authority.
  3. 3

    The authority cannot refuse compliant statutory undertaker works and is limited to regulating working hours and coordinating timings.

    Stated by Essex County CouncilOutside remitThe respondent said that this matter was outside its role or authority.

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

Improve training and operational protocols to reinforce compliance with permitting requirements, particularly for emergency and out-of-hours works.

Verbatim wording from the response

“Affinity carried out a review of its permit application processes following Paul’s death and again following the inquest, and we have made a number of changes to our processes, including additional resourcing to ensure prompt permit applications, better communications with councils regarding permitting and improving our training and operational protocols to reinforce compliance with all permitting requirements, particularly for emergency or out-of-hours works.”

Source location

Response from Affinity Water
Page 3 · response
Published 25 February 2025

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

Add resources to ensure prompt permit applications, particularly for emergency and out-of-hours works.

Verbatim wording from the response

“Affinity carried out a review of its permit application processes following Paul’s death and again following the inquest, and we have made a number of changes to our processes, including additional resourcing to ensure prompt permit applications, better communications with councils regarding permitting and improving our training and operational protocols to reinforce compliance with all permitting requirements, particularly for emergency or out-of-hours works.”

Source location

Response from Affinity Water
Page 3 · response
Published 25 February 2025

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

Improve communications with councils regarding roadworks permitting.

Verbatim wording from the response

“Affinity carried out a review of its permit application processes following Paul’s death and again following the inquest, and we have made a number of changes to our processes, including additional resourcing to ensure prompt permit applications, better communications with councils regarding permitting and improving our training and operational protocols to reinforce compliance with all permitting requirements, particularly for emergency or out-of-hours works.”

Source location

Response from Affinity Water
Page 3 · response
Published 25 February 2025

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

Provide necessary departmental training to prevent future delays in responding to reports.

Verbatim wording from the response

“I am sorry again for the lengthy delay in responding to your letter. This was due to handling errors within the Department. My officials will review this case and ensure necessary training is undertaken to avoid delays occurring in the future.”

Source location

Response from Department for Transport
Page 2 · response
Published 25 February 2025

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

Operate a risk-based inspection system to identify and prioritise required road-marking and street-maintenance works.

Verbatim wording from the response

“2. Variations in Street Furniture and Road Markings: In general, road markings are maintained to standard lengths but everyone working in the highway – including statutory undertakers - will appreciate that there will always be variations to take account of local features in the road such as junction locations and curvature in the road. Road markings will also fade over time as a result of weather conditions, high traffic volumes, and other factors. At Essex County Council, we employ a robust inspection system according to our Maintenance Strategy, adopting a risk-based approach to identify and prioritise any required works. We also note that the Safety at Street Works Code of Practice provides guidance as to how to proceed in setting up appropriate traffic management.”

Source location

Response from Essex County Council
Page 1 · response
Published 25 February 2025

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

Cannot respond or comment on recommendations 5(1), 5(2) and 5(4).

Verbatim wording from the response

“HTML is not in a position to respond or comment in relation to recommendations 5 (1), (2) and (4) of the Regulation 28 Report.”

Source location

Response from Hatton Traffic Management
Page 1 · response
Published 25 February 2025

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

Inspecting all emergency roadworks does not form part of the authority’s safety system.

Verbatim wording from the response

“1. Road Works Permits and Setup in Hours of Darkness. All work is more difficult during the hours of darkness. Undertakers and those working on their behalf are responsible for ensuring emergency works are set up safely and are required to have a trained and qualified person on site to ensure compliance with the Code. ECC does not have the ability to inspect all emergency roadworks as that does not form part of the safety system.”

Source location

Response from Essex County Council
Page 1 · response
Published 25 February 2025

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 authority cannot refuse compliant statutory undertaker works and is limited to regulating working hours and coordinating timings.

Verbatim wording from the response

“The role of Essex County Council in the regulation of street works is that it has to operate a statutory scheme made by the Department for Transport. Certain organisations called ‘statutory undertakers’ have the right to work in the highway; although they need a permit applied for in advance – other than in an emergency where they are required to apply for a retrospective permit if the works are urgent – we can only issue permits to regulate hours of work and to co-ordinate timings, we do not have any ability to refuse permissions for works done in accordance with the Safety at Street Works Code of Practice (the Code). We can encourage good practice in some ways, but as statutory undertakers work with many different local authorities, local authorities are required to operate standard systems.”

Source location

Response from Essex County Council
Page 1 · response
Published 25 February 2025

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

Data last updated 7 September 2026