PFD report

Ernest Charles Harper · Prevention of Future Deaths report

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Issued 9 May 2014•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
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
12

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Fall hazard between the safety barrier and the back of the vehicle
    Part of recurring concern: Inadequate physical barriers preventing access to dangerous drops or areas
  2. Reliance on voluntarily supplied passenger health and mobility information instead of formal assessment
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 a client-specific risk assessment by the Social Care Transport Team for every non-ambulant client.

    Stated by Bedford Borough CouncilStated plannedThe respondent said that this action was planned when they made their response on 9 May 2014.
  2. Action

    Retrofit safety devices to the doors of all Ford Transit vehicles to block gaps between the vehicle rear and handrail.

    Stated by Bedford Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 9 May 2014.
  3. Action

    Implement the new transport risk-assessment controls by 14 July 2014.

    Stated by Bedford Borough CouncilStated plannedThe respondent said that this action was planned when they made their response on 9 May 2014.

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

Fall hazard between the safety barrier and the back of the vehicle

Wider context from the report

“(1) That it was possible to fall between the safety barrier and the back of the vehicle ”

Is this part of a recurring concern?

Yes — Inadequate physical barriers preventing access to dangerous drops or areas.

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

Reliance on voluntarily supplied passenger health and mobility information instead of formal assessment

Wider context from the report

“(2) That details of a passenger’s health and/or mobility (for the purpose of risk assessing the passenger’s safety when accessing and egressing the vehicle) is dependant upon information supplied voluntarily by the passenger and/or his family rather than by a formal assessment ”

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

Require a client-specific risk assessment by the Social Care Transport Team for every non-ambulant client.

Verbatim wording from the response

“A newly redesigned Client Transport Referral Form has also been devised by the Transport Operations Group, in conjunction with Adult Services. The form which has been re-designed through consultation with our Occupational Therapists will focus on the person’s functional ability and will be used for initial transport requests, as well as requests for reinstatement of the transport service when there has been a break in service due to medical reasons. This new form will capture information taken from the person/family member and will help to determine whether the reinstatement of the previous transport arrangements are appropriate. The new proposed process also includes a requirement for a client specific risk assessment to be conducted by the Social Care Transport Team for every client who is not ambulant. The redesigned referral form will be introduced by 14 July 2014.”

Source location

2014-0223-Response-by-Bedford-Borough-Council
Page 2 · response
Published 9 May 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

Retrofit safety devices to the doors of all Ford Transit vehicles to block gaps between the vehicle rear and handrail.

Verbatim wording from the response

“Devices have been retro-fitted to the doors on all Ford Transit vehicles, the type of vehicle the accident occurred on. This blocks the gaps between the back of the vehicle and the handrail.”

Source location

2014-0223-Response-by-Bedford-Borough-Council
Page 1 · response
Published 9 May 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

Implement the new transport risk-assessment controls by 14 July 2014.

Verbatim wording from the response

“A redesign of risk assessments is currently being carried out by the Transport Operations Group regarding getting on/off vehicles; these revised risk assessments will be cross referenced to safe systems of work. Generic risk assessments eg transport of elderly passengers, are being produced on the Council’s health and safety web based software system, AssessNET, with a plan in place to introduce client specific risk assessments. These new controls will be implemented by 14 July 2014. In the future as any new vehicles are introduced, risk assessments and safe systems of work will also be reviewed to take into account any differences in vehicle design and specification.”

Source location

2014-0223-Response-by-Bedford-Borough-Council
Page 2 · response
Published 9 May 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

Redesign transport risk assessments for boarding and exiting vehicles and cross-reference them to safe systems of work.

Verbatim wording from the response

“A redesign of risk assessments is currently being carried out by the Transport Operations Group regarding getting on/off vehicles; these revised risk assessments will be cross referenced to safe systems of work. Generic risk assessments eg transport of elderly passengers, are being produced on the Council’s health and safety web based software system, AssessNET, with a plan in place to introduce client specific risk assessments. These new controls will be implemented by 14 July 2014. In the future as any new vehicles are introduced, risk assessments and safe systems of work will also be reviewed to take into account any differences in vehicle design and specification.”

Source location

2014-0223-Response-by-Bedford-Borough-Council
Page 2 · response
Published 9 May 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

Introduce client-specific risk assessments for transport passengers.

Verbatim wording from the response

“A redesign of risk assessments is currently being carried out by the Transport Operations Group regarding getting on/off vehicles; these revised risk assessments will be cross referenced to safe systems of work. Generic risk assessments eg transport of elderly passengers, are being produced on the Council’s health and safety web based software system, AssessNET, with a plan in place to introduce client specific risk assessments. These new controls will be implemented by 14 July 2014. In the future as any new vehicles are introduced, risk assessments and safe systems of work will also be reviewed to take into account any differences in vehicle design and specification.”

Source location

2014-0223-Response-by-Bedford-Borough-Council
Page 2 · response
Published 9 May 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.7

  1. 1

    Produce generic transport risk assessments on the Council’s health and safety software system.

    Stated by Bedford Borough CouncilStated in progressThe respondent said that this action was in progress when they made their response on 9 May 2014.
  2. 2

    Review risk assessments and safe systems of work when new vehicles are introduced, accounting for differences in design and specification.

    Stated by Bedford Borough CouncilStated plannedThe respondent said that this action was planned when they made their response on 9 May 2014.
  3. 3

    Implement a written information system for transferring Day Centre client information to vehicle staff and relevant social-care teams.

    Stated by Bedford Borough CouncilStated plannedThe respondent said that this action was planned when they made their response on 9 May 2014.
  4. 4

    Engage vehicle manufacturers and the Driver and Vehicle Standards Agency about additional measures to improve safety.

    Stated by Bedford Borough CouncilStated in progressThe respondent said that this action was in progress when they made their response on 9 May 2014.
  5. 5

    Share the Council’s vehicle-safety experience with other local authorities through the Association of Transport Co-ordinating Officers.

    Stated by Bedford Borough CouncilStated in progressThe respondent said that this action was in progress when they made their response on 9 May 2014.
  6. 6

    Introduce the redesigned Client Transport Referral Form, capturing functional ability and supporting transport reinstatement decisions.

    Stated by Bedford Borough CouncilStated plannedThe respondent said that this action was planned when they made their response on 9 May 2014.
  7. 7

    Delete historical passenger information from Routewise forms so vehicle staff receive current information.

    Stated by Bedford Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 9 May 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

Produce generic transport risk assessments on the Council’s health and safety software system.

Verbatim wording from the response

“A redesign of risk assessments is currently being carried out by the Transport Operations Group regarding getting on/off vehicles; these revised risk assessments will be cross referenced to safe systems of work. Generic risk assessments eg transport of elderly passengers, are being produced on the Council’s health and safety web based software system, AssessNET, with a plan in place to introduce client specific risk assessments. These new controls will be implemented by 14 July 2014. In the future as any new vehicles are introduced, risk assessments and safe systems of work will also be reviewed to take into account any differences in vehicle design and specification.”

Source location

2014-0223-Response-by-Bedford-Borough-Council
Page 2 · response
Published 9 May 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 risk assessments and safe systems of work when new vehicles are introduced, accounting for differences in design and specification.

Verbatim wording from the response

“A redesign of risk assessments is currently being carried out by the Transport Operations Group regarding getting on/off vehicles; these revised risk assessments will be cross referenced to safe systems of work. Generic risk assessments eg transport of elderly passengers, are being produced on the Council’s health and safety web based software system, AssessNET, with a plan in place to introduce client specific risk assessments. These new controls will be implemented by 14 July 2014. In the future as any new vehicles are introduced, risk assessments and safe systems of work will also be reviewed to take into account any differences in vehicle design and specification.”

Source location

2014-0223-Response-by-Bedford-Borough-Council
Page 2 · response
Published 9 May 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

Implement a written information system for transferring Day Centre client information to vehicle staff and relevant social-care teams.

Verbatim wording from the response

“A system has been produced and this will be implemented by 14 July 2014, to ensure that any information provided verbally by Day Centre staff to vehicle staff on arrival regarding the client is also provided in a written format. The written form includes guidance notes for staff with regard to what type of information must be relayed. If any concerns are noted during the day at a Day Centre, the day centre staff will verbally relay this information to the transport staff on arrival, backed up with the written form; copies of which will also be provided to the Social Workers and Social Care Transport Team.”

Source location

2014-0223-Response-by-Bedford-Borough-Council
Page 2 · response
Published 9 May 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

Engage vehicle manufacturers and the Driver and Vehicle Standards Agency about additional measures to improve safety.

Verbatim wording from the response

“We are now talking to manufacturers and the Driver and Vehicle Standard Agency to see if there are any additional measures that can be introduced to further improve safety. In addition to this, through the Association of Transport Co-ordinating Officers, we are making other Local Authorities aware of our experiences.”

Source location

2014-0223-Response-by-Bedford-Borough-Council
Page 2 · response
Published 9 May 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

Share the Council’s vehicle-safety experience with other local authorities through the Association of Transport Co-ordinating Officers.

Verbatim wording from the response

“We are now talking to manufacturers and the Driver and Vehicle Standard Agency to see if there are any additional measures that can be introduced to further improve safety. In addition to this, through the Association of Transport Co-ordinating Officers, we are making other Local Authorities aware of our experiences.”

Source location

2014-0223-Response-by-Bedford-Borough-Council
Page 2 · response
Published 9 May 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

Introduce the redesigned Client Transport Referral Form, capturing functional ability and supporting transport reinstatement decisions.

Verbatim wording from the response

“A newly redesigned Client Transport Referral Form has also been devised by the Transport Operations Group, in conjunction with Adult Services. The form which has been re-designed through consultation with our Occupational Therapists will focus on the person’s functional ability and will be used for initial transport requests, as well as requests for reinstatement of the transport service when there has been a break in service due to medical reasons. This new form will capture information taken from the person/family member and will help to determine whether the reinstatement of the previous transport arrangements are appropriate. The new proposed process also includes a requirement for a client specific risk assessment to be conducted by the Social Care Transport Team for every client who is not ambulant. The redesigned referral form will be introduced by 14 July 2014.”

Source location

2014-0223-Response-by-Bedford-Borough-Council
Page 2 · response
Published 9 May 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

Delete historical passenger information from Routewise forms so vehicle staff receive current information.

Verbatim wording from the response

“Bedford Borough Council has deleted historical information from its Routewise forms provided to staff working on the vehicle to make current information regarding passengers clearer to staff. This ensures that the driver and passenger assistant have the most current information on passengers.”

Source location

2014-0223-Response-by-Bedford-Borough-Council
Page 2 · response
Published 9 May 2014

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

Data last updated 7 September 2026