PFD report

Sheila Slater · Prevention of Future Deaths report

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Issued 31 Mar 2016•South Lincolnshire

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
2

Of 1 recipient

Stated actions
6

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 raised1

  1. Unsafe staggered road-junction layouts
    Part of recurring concern: Inadequate safety controls at high-risk road junctionsPart of recurring concern: Unsafe road design and layout
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.1

  1. Action

    Undertake a scoping study to inform potential updates to design guidance for major and minor junctions and accesses, including staggered junctions.

    Stated by Department for TransportStated in progressThe respondent said that this action was in progress when they made their response on 31 March 2016.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Lincolnshire County Council is responsible for local road safety and deciding whether to install a roundabout on the local road.

    Stated by Department for TransportRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Unsafe staggered road-junction layouts

Wider context from the report

“1 The staggered junction of the A16 with the B1166 is part of the Crowland Bypass which was opened in 2010. As with all of the other staggered junctions in Lincolnshire it was built to DFT specifications. Since it was opened there have been 3 fatalities associated with this junction (2 at the junction and one on the approach to the south bound island) and 10 injury producing collisions. There have been fatalities at the other staggered junctions in Lincolnshire. DFT and Highways England have been made aware of the problems associated with these junctions both by S.28 reports and correspondence from officers of Lincolnshire County Council. At the inquest, into Mrs Slater's death evidence was given to the effect that this particular junction could be made safer if it were to be replaced by a roundabout but that local funding was not available for this purpose. Witnesses also were concerned about the safety record of other staggered junctions in Lincolnshire. ”

Is this part of a recurring concern?

Yes — Inadequate safety controls at high-risk road junctions; Unsafe road design and layout.

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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

Undertake a scoping study to inform potential updates to design guidance for major and minor junctions and accesses, including staggered junctions.

Verbatim wording from the response

“Highways England regional and area teams monitor local and specific safety issues and there does not appear to be a pattern of similar issues occurring at this type of junction. Highways England have been undertaking a scoping study with a view to updating the design guidance covering major and minor junctions and accesses, including this type of junction, subject to evidence and funding. The relevant team have been informed of these concerns.”

Source location

Response from Department for Transport
Page 1 · response
Published 31 March 2016

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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

Lincolnshire County Council is responsible for local road safety and deciding whether to install a roundabout on the local road.

Verbatim wording from the response

“The Design Manual for Roads and Bridges, a publication sponsored by my department sets out the national standards for such junctions, however local authorities are responsible for road safety on the local road network, in this case Lincolnshire County Council. Section 39 of The Road Traffic Act 1988 puts a 'statutory duty' on local authorities to deliver an appropriate road safety education service and for the provision of a safe local road network. This includes road construction, accident investigation and analysis, traffic calming, setting speed limits and facilities for pedestrians and cyclists. It is up to individual authorities to determine how they meet their ‘statutory duty’ and any decision about installing a roundabout on a local road is entirely a matter for Lincolnshire County Council.”

Source location

Response from Department for Transport
Page 1 · response
Published 31 March 2016

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

Highways England found no apparent pattern of similar safety issues at this type of junction.

Verbatim wording from the response

“Highways England regional and area teams monitor local and specific safety issues and there does not appear to be a pattern of similar issues occurring at this type of junction. Highways England have been undertaking a scoping study with a view to updating the design guidance covering major and minor junctions and accesses, including this type of junction, subject to evidence and funding. The relevant team have been informed of these concerns.”

Source location

Response from Department for Transport
Page 1 · response
Published 31 March 2016

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

    Generate automated electronic prescribing prompts directing prescribers to the opioid substitution therapy policy and community information-sharing arrangements.

    Stated by Great Western Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 31 March 2016.
  2. 2

    Share anonymised case learning across Trust governance and professional forums.

    Stated by Great Western Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 31 March 2016.
  3. 3

    Assess options for securely improving communication and confidential information sharing with community prescribing agencies.

    Stated by Great Western Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 31 March 2016.
  4. 4

    Implement an opioid substitution therapy guideline mandating referral and contact with relevant community providers and pharmacies for inpatients.

    Stated by Great Western Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 31 March 2016.
  5. 5

    Inform the relevant team about concerns regarding safety problems at staggered junctions.

    Stated by Department for TransportStated completedThe respondent said that this action was complete when they made their response on 31 March 2016.

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

Generate automated electronic prescribing prompts directing prescribers to the opioid substitution therapy policy and community information-sharing arrangements.

Verbatim wording from the response

“An automated pop-up message directing prescribers of OST/antidotes (e.g. naloxone, flumazenil) has been generated on EPMA (electronic prescribing platform). This will prompt the prescriber to be aware of the Opioid Substitution Therapy policy and allow referral/information sharing with community prescribers and community pharmacy.”

Source location

Response from The Great Western Hospital
Page 2 · response
Published 31 March 2016

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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

Share anonymised case learning across Trust governance and professional forums.

Verbatim wording from the response

“The learning has been shared anonymously across the Trust in governance and professional forums. The Trust is committed to ensuring that the lessons from this case contribute to meaningful and lasting improvements in our services.”

Source location

Response from The Great Western Hospital
Page 2 · response
Published 31 March 2016

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

Assess options for securely improving communication and confidential information sharing with community prescribing agencies.

Verbatim wording from the response

“An assessment of all options available to the Trust to improve communication with community prescribing agencies by the Deputy Chief Medical Officer. Considerations included sharing of confidential patient information in a secure manner.”

Source location

Response from The Great Western Hospital
Page 1 · response
Published 31 March 2016

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 an opioid substitution therapy guideline mandating referral and contact with relevant community providers and pharmacies for inpatients.

Verbatim wording from the response

“The Trust wide guideline on ‘Opioid Substitution Therapy’ was ratified on the 4th September 2025. This guidance governs practice around in-patients admitted on or commenced on Opioid Substitution Therapy. Key points are:”

Source location

Response from The Great Western Hospital
Page 1 · response
Published 31 March 2016

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

Inform the relevant team about concerns regarding safety problems at staggered junctions.

Verbatim wording from the response

“Highways England regional and area teams monitor local and specific safety issues and there does not appear to be a pattern of similar issues occurring at this type of junction. Highways England have been undertaking a scoping study with a view to updating the design guidance covering major and minor junctions and accesses, including this type of junction, subject to evidence and funding. The relevant team have been informed of these concerns.”

Source location

Response from Department for Transport
Page 1 · response
Published 31 March 2016

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