PFD report

Lee David Marsden · Prevention of Future Deaths report

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Issued 26 Mar 2021•Manchester North

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
3

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
6

Described in 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.

Report evidence summary

Concerns raised3

  1. Lack of internal review of fatal accident circumstances
    Part of recurring concern: Inadequate safety incident investigations
  2. Delays in activating warning signals for motorway traffic speed reduction
  3. Failure of communication processes to ensure appreciation of the significance of prefix numbers
    Part of recurring concern: Unreliable multi-agency communication procedures
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

    Brief regional operations staff and North West police operators on free-text incident-log entries and disseminate the briefing nationally as best practice.

    Stated by National HighwaysStated plannedThe respondent said that this action was planned when they made their response on 30 March 2021.
  2. Action

    Implement clearer free-text source details in electronic incident-log transfers between Highways England and police organisations.

    Stated by National HighwaysStated plannedThe respondent said that this action was planned when they made their response on 30 March 2021.
  3. Action

    Complete an internal review of Regional Operations Centre handling of the December 2019 incident and identify learning from it.

    Stated by National HighwaysStated completedThe respondent said that this action was complete when they made their response on 30 March 2021.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Existing national policy and work instructions for activating motorway warning signs and signals are considered robust and appropriate, so no further action is proposed.

    Stated by National HighwaysExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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

Lack of internal review of fatal accident circumstances

Wider context from the report

“3. No internal review of the circumstances of this fatal accident has been undertaken by Highways England with the consequent loss of an opportunity for learning ”

Is this part of a recurring concern?

Yes — Inadequate safety incident investigations.

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

Delays in activating warning signals for motorway traffic speed reduction

Wider context from the report

“1. There was a delay in activating the warning signals to reduce the speed of traffic travelling along the M66 motorway between junctions 2 and 3 to 30mph. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 of communication processes to ensure appreciation of the significance of prefix numbers

Wider context from the report

“2. The efficacy of communication between Highways England and North West Motorway Police Group in that there was a failure to appreciate the significance of the prefix numbers 06/8126 ”

Is this part of a recurring concern?

Yes — Unreliable multi-agency communication procedures.

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

Brief regional operations staff and North West police operators on free-text incident-log entries and disseminate the briefing nationally as best practice.

Verbatim wording from the response

“Highways England will brief the circumstances of this incident together with the outcome of our review to the North West Regional Operations Centre staff. The Police Operators within the NWMPG (Cheshire, Merseyside, Greater Manchester), as well as Lancashire Constabulary and Cumbria Constabulary will similarly be briefed. This joint approach will cover all the police forces operating within the North West geographic area of the Strategic Road Network.”

Source location

2021-0084-Response-from-Highways-England-Redacted
Page 2 · response
Published 30 March 2021

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 clearer free-text source details in electronic incident-log transfers between Highways England and police organisations.

Verbatim wording from the response

“Highways England and the NWMPG have agreed that going forward details relating to the source of information should be clearer and relayed between”

Source location

2021-0084-Response-from-Highways-England-Redacted
Page 1 · response
Published 30 March 2021

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 an internal review of Regional Operations Centre handling of the December 2019 incident and identify learning from it.

Verbatim wording from the response

“An internal review has been carried out into the Regional Operations Centre handling of the incident in December 2019, as requested by the Coroner. Our review concluded that on the information available to the Operations staff at the time, our staff complied with the company policy and work instructions in place, and the incident was managed appropriately. Highways England Regional Operations Centre staff were not aware that one of the entries on the log originated from a call from an off-duty police officer, or the significance and meaning of prefix numbers electronically transferred to the Highways England incident log from the NWMPG. The Coroner’s Officer brought this point to our attention shortly before the inquest. With that information, we have taken action as explained at paragraph b. above.”

Source location

2021-0084-Response-from-Highways-England-Redacted
Page 2 · response
Published 30 March 2021

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 the procedure for activating motorway variable signs and signals following reports of unconfirmed and confirmed pedestrians.

Verbatim wording from the response

“Highways England has a national policy and a work instruction in relation to the activation of motorway variable signs and signals. The notification of ‘unconfirmed pedestrian’ on the carriageway initially results in the setting of signs and signals to indicate an advisory 60mph speed limit supported by ‘unconfirmed’ signing, where available. Once the presence of a pedestrian has been confirmed by an approved, trusted source such as a Highways England Traffic Officer or Highways Inspector, or the police, the advisory speed limit is lowered further and supported by ‘confirmed’ signing, where available. We have reviewed our procedure and consider it to be robust and appropriate so no action is proposed.”

Source location

2021-0084-Response-from-Highways-England-Redacted
Page 2 · response
Published 30 March 2021

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

Existing national policy and work instructions for activating motorway warning signs and signals are considered robust and appropriate, so no further action is proposed.

Verbatim wording from the response

“a. Activating warning signals”

Source location

2021-0084-Response-from-Highways-England-Redacted
Page 2 · response
Published 30 March 2021

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.2

  1. 1

    Circulate a briefing note to NWMPG staff on using plain language to identify police and emergency-services employees in incident logs.

    Stated by Cheshire ConstabularyStated completedThe respondent said that this action was complete when they made their response on 30 March 2021.
  2. 2

    Add clear plain-language source descriptions to incident logs transferred between the police and Highways England.

    Stated by Cheshire ConstabularyStated plannedThe respondent said that this action was planned when they made their response on 30 March 2021.

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

Circulate a briefing note to NWMPG staff on using plain language to identify police and emergency-services employees in incident logs.

Verbatim wording from the response

“Police operators and supervisors within NWMPG will be briefed to add this plain language to logs.”

Source location

2021-0084-Response-from-North-West-Motorway-Police-Group-Redacted
Page 1 · response
Published 30 March 2021

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 clear plain-language source descriptions to incident logs transferred between the police and Highways England.

Verbatim wording from the response

“Highways England and the NWMPG have agreed that going forward details relating to the source of information will be clearer and a free text description will be added to the log to identify the source of information in clear language.”

Source location

2021-0084-Response-from-North-West-Motorway-Police-Group-Redacted
Page 1 · response
Published 30 March 2021

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