PFD report

Matthew James WILMOT · Prevention of Future Deaths report

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Issued 17 Apr 2018•Bedfordshire and Luton

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
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
3

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. Insufficient consideration of unique-route risks in path risk assessments
    Part of recurring concern: Unreliable objective criteria for safety risk assessment
  2. Pedestrian use of uniquely routed closed paths
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.2

  1. Action

    Make the amended briefing mandatory in new-operative induction and refresh it for existing operatives every six months.

    Stated by M & S Water Services (Utilities) LimitedStated plannedThe respondent said that this action was planned when they made their response on 17 June 2018.
  2. Action

    Amend the operative briefing to require assessment of alternative pedestrian routes and supervisory escalation for unsuitable routes at unique locations.

    Stated by M & S Water Services (Utilities) LimitedStated completedThe respondent said that this action was complete when they made their response on 17 June 2018.

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

  1. Position

    The relevant risk assessment complied with the Red Book and industry standards, and the path was not located in an area of risk.

    Stated by B & D Civil Engineers LtdDisputes 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

Insufficient consideration of unique-route risks in path risk assessments

Wider context from the report

“The accident happened on a path which had been excavated to find a stop cock. The excavation had been abandoned as a Deep Excavation Team was required. The path was closed by placing a sign at each end of the path stating that the path was closed. The hole and spoil were fenced off by using a metal railed fence which was alongside the path and 4 plastic yellow barriers which were secured to the metal fence. A risk assessment had taken place. The evidence was that the risk assessment was in line with the Red Book and Industry Standards. The Red Book encourages a risk assessment based on the locality, footfall, etcetera. My concern is that not enough consideration was given to the nature of the path. To all intents and purposes there are two types of paths. The most common is the path that runs parallel to a highway. If that path is closed, the pedestrian can be guided around the excavation or told to cross the road. It is unlikely that the pedestrian would walk through a barriered area in such circumstances as that would be slower than walking around it. The second type of path is one that is unique in its journey from A to B, ie there is no road to the side. This particular path lead from the road to a row of houses, which were not accessible by road. The alternative route (which was not signposted) was 150 metres away, meaning a diversion of about 300 metres. The path was not located in an area of risk. However, my concern is that a route that is unique is always at risk as pedestrians will want to travel the shortest route. This is backed up by the evidence in the Inquest which recorded 9 pedestrians (including the deceased) travelling through the closed path in the 7 hours before the deceased was found. The excavators took photographs of the site just before they left it. Looking at those photographs, I would have risked walking down the closed path. My concern is that there is not enough emphasis within the risk assessment process that a route that is unique has different risks to a path that is parallel. ”

Is this part of a recurring concern?

Yes — Unreliable objective criteria for safety risk assessment.

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

Pedestrian use of uniquely routed closed paths

Wider context from the report

“The accident happened on a path which had been excavated to find a stop cock. The excavation had been abandoned as a Deep Excavation Team was required. The path was closed by placing a sign at each end of the path stating that the path was closed. The hole and spoil were fenced off by using a metal railed fence which was alongside the path and 4 plastic yellow barriers which were secured to the metal fence. A risk assessment had taken place. The evidence was that the risk assessment was in line with the Red Book and Industry Standards. The Red Book encourages a risk assessment based on the locality, footfall, etcetera. My concern is that not enough consideration was given to the nature of the path. To all intents and purposes there are two types of paths. The most common is the path that runs parallel to a highway. If that path is closed, the pedestrian can be guided around the excavation or told to cross the road. It is unlikely that the pedestrian would walk through a barriered area in such circumstances as that would be slower than walking around it. The second type of path is one that is unique in its journey from A to B, ie there is no road to the side. This particular path lead from the road to a row of houses, which were not accessible by road. The alternative route (which was not signposted) was 150 metres away, meaning a diversion of about 300 metres. The path was not located in an area of risk. However, my concern is that a route that is unique is always at risk as pedestrians will want to travel the shortest route. This is backed up by the evidence in the Inquest which recorded 9 pedestrians (including the deceased) travelling through the closed path in the 7 hours before the deceased was found. The excavators took photographs of the site just before they left it. Looking at those photographs, I would have risked walking down the closed path. My concern is that there is not enough emphasis within the risk assessment process that a route that is unique has different risks to a path that is parallel. ”

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

Make the amended briefing mandatory in new-operative induction and refresh it for existing operatives every six months.

Verbatim wording from the response

“The briefing will be a mandatory part of the induction process for any new operatives and will be refreshed for all existing operatives at six monthly intervals.”

Source location

2018-0107-Response-by-M-S-Water-Services
Page 2 · response
Published 17 June 2018

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

Amend the operative briefing to require assessment of alternative pedestrian routes and supervisory escalation for unsuitable routes at unique locations.

Verbatim wording from the response

“It is submitted that the additional guidance given to operatives within three days of the accident on 28 May 2017 should assuage the concern regarding unique sites and whether or not there is sufficient focus in the risk assessment process on the likelihood of the public using the alternative route. It will be appreciated that on the Devon Road site the M&S operatives were required to complete the Amey Utility Services Limited risk assessment template.”

Source location

2018-0107-Response-by-M-S-Water-Services
Page 2 · response
Published 17 June 2018

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 relevant risk assessment complied with the Red Book and industry standards, and the path was not located in an area of risk.

Verbatim wording from the response

“We note the concern is that there was not enough emphasis within the risk assessment process that a route that does not run parallel to a highway has different risks to a path that is parallel to a highway.”

Source location

2018-0107-Response-by-B-D-Civil-Engineering-Limited
Page 1 · response
Published 17 June 2018

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

Additional operative guidance is considered sufficient to address concerns about unique sites and public use of alternative routes.

Verbatim wording from the response

“It is submitted that the additional guidance given to operatives within three days of the accident on 28 May 2017 should assuage the concern regarding unique sites and whether or not there is sufficient focus in the risk assessment process on the likelihood of the public using the alternative route. It will be appreciated that on the Devon Road site the M&S operatives were required to complete the Amey Utility Services Limited risk assessment template.”

Source location

2018-0107-Response-by-M-S-Water-Services
Page 2 · response
Published 17 June 2018

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

Job planning and identifying unique locations are assigned to the Job Initiator and Job Planner, not M&S.

Verbatim wording from the response

“It is important to stress that M&S does not fulfil the role of the Job Initiator or Job Planner. The evidence of Amey (paragraph 4.5 of statement dated 14th December 2017) was that the Job Planner reviews the job for any special requirements based on the Job Initiator's comments. The process involves a visit to the site by the Customer Services Technician. To this extent there is also the opportunity within the planning / permitting process to identify any 'unique' locations.”

Source location

2018-0107-Response-by-M-S-Water-Services
Page 2 · response
Published 17 June 2018

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

    Make the revised briefing mandatory for new B&D operatives and brief and refresh existing operatives every six months.

    Stated by B & D Civil Engineers LtdStated plannedThe respondent said that this action was planned when they made their response on 17 June 2018.

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

Make the revised briefing mandatory for new B&D operatives and brief and refresh existing operatives every six months.

Verbatim wording from the response

“Our client is advised the revised Briefing will be a mandatory part of the induction process for any new operatives supplied by B & D and existing operatives will be briefed and refreshed at six-month intervals.”

Source location

2018-0107-Response-by-B-D-Civil-Engineering-Limited
Page 2 · response
Published 17 June 2018

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

Official responses located
2/2

Data last updated 7 September 2026