PFD report

Mrs Tipper · Prevention of Future Deaths report

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Issued 3 Oct 2018•Black Country

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.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

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

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Report evidence summary

Concerns raised1

  1. Failure to maintain adequate visual awareness and eye contact with other drivers when emerging from junctions
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 refresher defensive-driving training and assess the driver against its principles.

    Stated by National Express West MidlandsStated plannedThe respondent said that this action was planned when they made their response on 26 February 2019.
  2. Action

    Discuss the driver’s Inquest comments, explain the associated dangers, and consider whether further training action is required.

    Stated by National Express West MidlandsStated plannedThe respondent said that this action was planned when they made their response on 26 February 2019.
  3. Action

    Assess the driver’s driving standards and provide feedback to support improvement.

    Stated by National Express West MidlandsStated plannedThe respondent said that this action was planned when they made their response on 26 February 2019.

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 maintain adequate visual awareness and eye contact with other drivers when emerging from junctions

Wider context from the report

“1. Evidence emerged during the inquest that the driver either through training or discussion with work colleagues had developed a practice of only focussing directly ahead with minimal eye contact with other drivers when emerging from junctions. It appears this was done so as not to give any other drivers an indication to pull out in front of his bus. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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 refresher defensive-driving training and assess the driver against its principles.

Verbatim wording from the response

“3. ████████ will undertake a refresher of our defensive driving training and will be assessed against the principles.”

Source location

2018-0327-Response-by-National-Express-West-Midlands
Page 3 · response
Published 26 February 2019

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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

Discuss the driver’s Inquest comments, explain the associated dangers, and consider whether further training action is required.

Verbatim wording from the response

“1. We will have a discussion with ████████ in relation to his comments at the Inquest and look to gain more insight in to why he has felt the need to carry out this practice. We will remind him of the dangers that this way of driving creates. We will consider whether his response requires any further action in relation to training delivery and will highlight this case to our driver trainers.”

Source location

2018-0327-Response-by-National-Express-West-Midlands
Page 3 · response
Published 26 February 2019

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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 the driver’s driving standards and provide feedback to support improvement.

Verbatim wording from the response

“2. ████████ will undergo an assessment of his driving standards and will be provided feedback to enable him to improve as necessary.”

Source location

2018-0327-Response-by-National-Express-West-Midlands
Page 3 · response
Published 26 February 2019

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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

Highlight the case to driver trainers.

Verbatim wording from the response

“1. We will have a discussion with ████████ in relation to his comments at the Inquest and look to gain more insight in to why he has felt the need to carry out this practice. We will remind him of the dangers that this way of driving creates. We will consider whether his response requires any further action in relation to training delivery and will highlight this case to our driver trainers.”

Source location

2018-0327-Response-by-National-Express-West-Midlands
Page 3 · response
Published 26 February 2019

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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
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Data last updated 7 September 2026