Department for Transport
PFD Addressee
Reports: 133
Earliest: Oct 2013
Latest: 6 Apr 2026
77% 2-year response rate (below 83% average). 23% of classified responses show concrete action taken.
PFD Reports
133 resultsPeter Walker
Partially Responded
2023-0217
29 Jun 2023
Suffolk
Other related deaths
Concerns summary (AI summary)
The CAA's self-declaration system for older pilots lacks comprehensive medical guidance and a central licence revocation system, allowing revalidation without independent assessment of fitness to fly.
Action Planned
(AI summary)
The CAA has accepted the AAIB recommendations and is planning to update its Pilot Medical Declaration (PMD) system, including updating the PMD webpage and form, providing guidance to medical professionals, reviewing administrative approaches with the DVLA, and introducing PMD 'spot checks'. They will also review revalidation processes for certain pilots.
Karl Mitchell
Partially Responded
2023-0168
22 May 2023
Avon
Accident at Work and Health and Safety related deaths
Other related deaths
Concerns summary (AI summary)
Many older lorry-mounted cranes with dangerous stabiliser designs remain in use, posing a crush injury risk as safety modifications are not universally applied. There is an urgent need to disseminate safety learning and modification awareness throughout the industry.
Action Planned
(AI summary)
The Office of the Traffic Commissioner will assist in providing the HSE's safety notice relating to swing-up stabilisers to lorry operators, once it is published.
Rebecca Kirby
Partially Responded
2023-0110Deceased
29 Mar 2023
East Riding and Hull
Road (Highways Safety) related deaths
Concerns summary (AI summary)
The Lowgate area poses a severe pedestrian safety risk on busy nights due to inadequate crossing facilities, dangerous taxi operations, and insufficient traffic management for intoxicated crowds.
Action Planned
(AI summary)
The Hackney Carriage Association will put forward suggestions to the licensing authority and local authority, including reinstating railings next to the taxi rank and closing Lowgate to all vehicles except hackney carriages.
Kathleen Fancourt
Partially Responded
2023-0081Deceased
2 Mar 2023
West Sussex
Road (Highways Safety) related deaths
Concerns summary (AI summary)
The absence of mandatory medical checks for drivers over 70, relying instead on self-declaration, poses a serious risk to road users as enduring medical conditions may go undetected, contributing to fatal accidents.
Noted
(AI summary)
The Department for Transport acknowledges the coroner's concerns but states that current driver licensing arrangements are balanced and proportionate, requiring drivers to declare medical conditions and eyesight standards when renewing their license from age 70.
Natalie Young
All Responded
2023-0123
15 Feb 2023
Somerset
Other related deaths
Concerns summary (AI summary)
The absence of regulations for mobility scooter operators regarding vision, cognitive ability, and substance impairment, coupled with no registration requirements, poses significant safety risks, especially to vulnerable pedestrians.
Action Planned
(AI summary)
The Department for Transport reminded retailers to advise customers to show consideration for other pavement users and to undertake training in the use of mobility scooters and is supporting the roll-out of a nationwide certified powered wheelchair and mobility scooter assessment and training scheme through Driving Mobility.
Stephen Wood
All Responded
2023-0047Deceased
8 Feb 2023
Dorset
Road (Highways Safety) related deaths
Concerns summary (AI summary)
A significant road obstruction caused a fatal collision, highlighted by a lack of public awareness and legal obligation to report road hazards not directly caused.
Noted
(AI summary)
National Highways will conduct a study to identify options for improving road user notification of incidents, aiming to complete it by late Summer/Autumn 2023 and prepare an implementation plan. Dorset Road Safe partnership will add a clear link to their website indicating who to contact regarding road obstructions, highlight associated dangers, and launch a communications campaign across various media platforms to alert road users to obstructions on Dorset roads. Dorset Council, as part of Dorset Road Safe, will introduce a simple reporting process and contact information for obstructions/debris on the road to their website. A communications campaign will be constructed to alert all road users around obstructions/debris on Dorset’s roads using various media platforms. The Department for Transport outlines existing legislation and guidance regarding road obstructions, including the Highways Act 1980 and the Highway Code. They conclude that no further action is appropriate for the Department to take at this stage. BCP Council states that the response letter from the Dorset Police Chief Constable conveys the views of BCP Council, via the Dorset Road Safe Partnership.
Jordan Pry
All Responded
2023-0003Deceased
30 Dec 2022
Surrey
Road (Highways Safety) related deaths
Concerns summary (AI summary)
An ongoing risk of further aquaplaning deaths exists on the M25 due to a persistent road "flat spot" and surface water issues, despite a history of incidents and previous PFD reports, as a comprehensive risk management plan remains unfulfilled.
Noted
(AI summary)
Connect Plus outlines enhanced measures being implemented, including drainage system cleaning, gully cleaning frequency increases, and safety barrier upgrades. They will also deliver a comprehensive plan for risk management including a cost benefit analysis, a review of carriageway resurfacing, investigation of illuminated warning signs, and a verge review. The Department for Transport acknowledges the concerns and notes that National Highways is responsible for the safe management of the Strategic Road Network and is taking actions to reduce risks of future collisions. DfT officials will continue to work with National Highways on the points raised. National Highways has installed a vehicle restraint system at the location of the fatal collision. They have also commissioned an independent review of the drainage system and are considering the viability of reprofiling the carriageway.
Donald Hooker
All Responded
2022-0409
21 Dec 2022
East Riding and Hull
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Motorcyclist helmets are detaching in collisions, but there's a lack of research into why, no checks for correct helmet sizing, and inadequate rider education on proper fit, increasing fatality risks.
Noted
(AI summary)
TRL describes its role in supporting the SHARP helmet rating scheme and summarises existing research on helmet loss, concluding that more work should be done in light of changing motorcycle user demographics. They raise questions about the specific helmet and circumstances of the incident. The Department provides advice and guidance to motorcyclists through its Safety Helmet Assessment and Rating Programme (SHARP), including guidance on helmet selection and fitting on the SHARP website. DVSA's CBT syllabus includes helmet fitting and fastening, and examiners check helmet fastening. The Department will continue to review technical standards for helmets and promote helmet fitting and usage. The Forensic Collision Investigator provides information on the helmet involved in the incident and refers some queries to other agencies, stating the helmet met basic UK standards. They are unable to comment on how tightly the helmet was fastened when worn.
Jennifer Wong
All Responded
2023-0010Deceased
2 Sep 2022
Oxfordshire
Road (Highways Safety) related deaths
Concerns summary (AI summary)
A poorly designed nearside cycle lane creates confusion and places cyclists in conflict with right-turning vehicles, exacerbated by the lane being narrower than recommended standards.
Action Planned
(AI summary)
Oxfordshire County Council has already undertaken a detailed review of the Plain Roundabout and The Parkway junction with amendments planned to be implemented in November 2022, and has reviewed key junctions deemed a potential risk to vulnerable road users with input from cycle safety groups. The Department for Transport will write to the Construction Plant-hire Association (CPA) to raise the issue of compliance with regulations and encourage its members to consider additional devices or technology to help improve mobile crane driver vision.
Jennifer Davies
All Responded
2023-0098Deceased
30 Aug 2022
West Sussex
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Delivery van drivers, exempt from Working Time Regulations, can work excessively long hours without mandatory breaks, posing a significant risk to public safety, particularly pedestrians in populated areas.
Action Planned
(AI summary)
The Department for Transport will coordinate with the DVSA and ask them to investigate the case if provided with details of the driver's employer, to assess whether the delivery company adhered to working time and health and safety legislation regarding adequate rest.
Stanley Hardy
All Responded
2022-0237
2 Aug 2022
Newcastle and North Tyneside
Road (Highways Safety) related deaths
Concerns summary (AI summary)
A coach driver avoided emergency braking, despite seeing a pedestrian, due to training prioritising passenger welfare. Emergency braking procedures are not a required part of bus and coach driver training.
Action Planned
(AI summary)
While the Department for Transport believes there is already an adequate framework, the DVSA will review all learning materials where emergency braking skills are covered at the next opportunity and consider whether these sections could benefit from additional or stronger information.
Charles Wheatley
All Responded
2022-0304
29 Jul 2022
County Durham and Darlington
Road (Highways Safety) related deaths
Concerns summary (AI summary)
The current system illogically allows individuals to purchase and keep a car without possessing a driving license, raising concerns about road safety.
Noted
(AI summary)
The Department for Transport explains that there is no legal requirement to hold a driving licence to register a vehicle, or to become the keeper of an already registered vehicle, and outlines circumstances where this might occur.
Sangeerth Girirathan
All Responded
2022-0151
Milton Keynes
Hospital Death (Clinical Procedures and medical management) related deaths
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Alarms on ICU monitors were disengaged, preventing staff from being alerted to critical patient deterioration, which resulted in a cardiac arrest.
Noted
(AI summary)
The Department for Transport outlined existing GB domestic and working time regulations for drivers of light goods vehicles. They stated that if the driver fell asleep due to inadequate rest, existing regulations would apply, and offered to coordinate with DVSA for an investigation if employer details are provided. NHS Milton Keynes University Hospital NHS Foundation Trust has communicated to all Registered Nurses (RNs) and senior staff via matrons and safety huddles, reiterating the importance of active monitor alarms and staff visibility. Senior nursing teams have also provided initial training on transferring data from monitors to modules, which will be added to medical equipment training.
Emiliano Sala
All Responded
2022-0089
18 Mar 2022
Dorset
Other related deaths
Concerns summary (AI summary)
The market for illegal commercial flights, especially in sports, operates without required safety standards, risking future deaths. The Civil Aviation Authority has limited powers to investigate and prosecute these breaches.
Noted
(AI summary)
The RFU cascaded the findings in the Regulation 28 Report to all clubs involved in the Premiership. The RFU also raised this subject at the June meeting of the Professional Game Board. The ECB intends to circulate communications to appropriate representatives, including a list of steps from the CAA, within one month and emphasize the need to share the information directly with players. All corporate travel for ECB employees and representatives must be booked through the ECB's travel management company Ventur. The EFL reissued guidance to all Clubs, which was received in March 2021. The EFL will reissue a link to the guidance in advance of each transfer window. The British Horseracing Authority briefed its Board and prepared a draft guidance note to send to its member bodies and engaged with the Civil Aviation Authority (CAA). The Department for Transport and the CAA are reviewing the powers available to them in investigating breaches of aviation regulations and what powers they would find of assistance in their investigative and enforcement role. The FA states they were not aware of the coroner's report until it was provided by the English Football League. The FA relayed CAA guidance on illegal flights to clubs and Registered Intermediaries in March 2021. The Jockey Club requires aircraft operating at its racecourses to obtain prior permission, demonstrate pilot licensing, provide aircraft registration and insurance, and confirm whether flights are private or commercial. The Jockey Club and Helicopter & Aviation Services Ltd provide records of aircraft activities to authorities when requested. The organisation circulated a note to its members recommending that they do not pay for or use unlicensed commercial flights, sharing the concerns of the Dorset Coroner. The Professional Footballers Association has written to its current members and put information on its website to raise awareness on the issue of unlicensed aircraft, and attached the guidance issued by the CAA. UK Athletics has distributed information regarding private flights to World Class Programme athletes, coaches, support staff, and known agents, emphasizing the need to check the legality of flights. The Institute of Directors included a statement in its 'Influence' email to 20,000 members and posted a notice on its website warning of the dangers of unauthorised flights, following a request from the Civil Aviation Authority. The LTA sent a communication to relevant players on 9 August 2022 regarding commercial flights from unlicensed operators, including a link to CAA guidance. The Premier League will send correspondence to the Legal, Club Secretarial, and Football departments at each of the Clubs. The Premier League met with Clubs at the Annual General Meeting on 9 June 2022 and raised the issue to the Chairs/Chief Executives/Owners attending. The Confederation of British Industry plans to publish an article on employee wellbeing and safety linking to the Sala case, use social media to amplify the importance of employee well-being and safety, and flag the case to its account managers who manage the CBI's aerospace members. The Rugby Football League wrote to all member clubs advising them of the situation regarding private flights and asking them to ensure they do not use such flights. The Department for Digital, Culture, Media and Sport shared CAA guidance with sports organisations, Live music Industry Venues & Entertainment (LIVE), the Music Venues Trust (MVT), and the Musicians' Union. Motorsport UK will publish advice to its license holders on its website and in its monthly ezine regarding air-worthiness of chartered aircraft and pilot qualifications. The RFU requested Premiership clubs review the PFD report on commercial flight chartering and ensure flights are legal and have required authorisations, certifications and permissions, and pass the information to relevant employees. The British Chambers of Commerce circulated briefing materials to its Chamber of Commerce members, raised the issue in a call with Chamber of Commerce CEOs, and highlighted the importance of taking action at the BCC Board. UK Sport asserts that the use of illegal private plane journeys is not permitted with their funding and that the risk of government funded sports using them is minimal. The EFL circulated a CAA notice to club secretaries raising awareness of the risks of illegal public transport using unlicensed aircraft. The Executive Association of Great Britain stated that the report and concerns are not applicable to their particular circumstances as they do not arrange travel for members, and members do not travel by air to attend meetings.
James McKeough
All Responded
2021-0414
9 Dec 2021
West Sussex
Other related deaths
Road (Highways Safety) related deaths
Concerns summary (AI summary)
The positioning, brightness, and color of rear flashing LED lights on trailers can mask or be misinterpreted as turn indicators, hindering other drivers' ability to discern turning intentions.
Action Planned
(AI summary)
The Department for Transport will write to the National Police Chiefs’ Council, Driver and Vehicle Standards Agency, Society of Motor Manufacturers and Traders, Agricultural Engineers Association, National Farmers’ Union of England and Wales, and the National Farmers Union of Scotland to provide guidance and raise awareness of requirements for amber warning beacons on agricultural vehicles.
Croydon Tram Incident
All Responded
2021-0337
South London
Other related deaths
Railway related deaths
Road (Highways Safety) related deaths
Concerns summary (AI summary)
The absence of a centrally funded national tram safety passenger group creates a significant systemic oversight for public safety.
Noted
(AI summary)
Transport for London has already procured, developed, and installed a bespoke Physical Prevention of Overspeed System (PPOS) on the London Tram network, reducing the risk of overturning by 76%. They are also investigating the feasibility of strengthening tram doors and will incorporate learnings into future fleet specifications. Bombardier Transportation (now Alstom) has completed a door vulnerability assessment, performed design reviews for current and future tram door systems, and engaged with suppliers regarding enhancements. They plan to finalize improvement actions and recommendations for door strengthening for both in-service and new tram fleets by March 2022, and engage with authorities to review UK regulation for light rail doors by April 2022. Tram Operations Ltd is already a member of CIRAS (Confidential Reporting for Safety) for anonymous staff reporting and publicises this to staff. Regarding passenger ejection through doors, they confirm they do not own the trams but welcome discussions with London Trams and would support implementation of strengthening if feasible. Transport Focus clarifies its limited remit and resources to initiate a centrally funded national tram passenger safety group. They state they will engage with operators on passenger safety issues brought to their notice and support any such group initiated by another body. The Department for Transport reports that the Light Rail Safety and Standards Board (LRSSB) has published guidance on driver inattention and speed management, and all tram networks in England now subscribe to the Confidential Incident Reporting & Analysis System (CIRAS). DfT is also consulting on establishing a national tram safety group and supports LRSSB's planned work on automatic braking systems, door strengthening standards, and promoting CIRAS. The LRSSB has published new Light Rail Guidance on Driver Inattention (LG3) and Light Rail Standards on Speed Management Systems (LS4), incorporating RAIB recommendations. They have also commissioned a trial of specific technology for driver inattention and speed management, with outcomes expected by January 2022. The Light Rail Safety and Standards Board confirms that all seven UK tramways already subscribe to the Confidential Incident Reporting & Analysis System (CIRAS). LRSSB further plans to produce a tramway-specific guidance note and communication campaign to promote the benefits of such schemes to front-line staff by March 2022. The Light Rail Safety and Standards Board is engaging with European Standards working groups to inform regulation on tram door security and crashworthiness, and plans to consult with TfL/London Trams to determine remedial actions. LRSSB will then publish a briefing or guidance note for the sector, with timelines to be confirmed.
Heike Mojay-Sinclare
All Responded
2021-0313
17 Sep 2021
Derby and Derbyshire
Other related deaths
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Lack of mandatory standards and inspection for river ford depth gauges, combined with poor inter-agency information sharing on previous incidents, creates significant safety risks, especially with increasing severe rainfall.
Noted
(AI summary)
The Department for Transport clarified that local authorities are responsible for hazard signage and highway maintenance, and that existing guidance is available but not mandatory.
Billy Warwick-Jones
Partially Responded
2021-0305
10 Sep 2021
West London
Community health care and emergency services related deaths
Other related deaths
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Inadequate advice to an older driver and their family about driving risks associated with acute illness-induced confusion, combined with insufficient testing and guidance for older drivers, highlights a systemic road safety failure.
Noted
(AI summary)
The Department for Transport explains current driver licensing arrangements and guidance for medical professionals, noting age is not an automatic barrier to driving, but they encourage drivers to discuss concerns with medical professionals, and points to an older driver website. The GMC has contacted the Royal College of General Practitioners (RCGP) to raise awareness of the risks of confusion related to UTIs and driving among their members.
Sarah Lewis
All Responded
2021-0251
20 Jul 2021
County of Dorset
Other related deaths
Road (Highways Safety) related deaths
Concerns summary (AI summary)
The absence of mandatory rear cameras on Large Goods Vehicles creates critical blind spots, contributing to collisions with pedestrians during reversing manoeuvres.
Action Planned
(AI summary)
The DfT is developing a new approval system for vehicles after leaving the EU and plans a call for evidence later this year to gather views on technologies like reversing detection systems, which will inform future legislation on mandatory fitting of these technologies.
Ella Kissi-Debrah
All Responded
2021-0113
20 Apr 2021
Inner South London
Child Death
Community health care and emergency services related deaths
Other related deaths
Concerns summary (AI summary)
National air pollution limits exceed WHO guidelines, and there is low public awareness of pollution levels. Medical professionals also fail to adequately communicate the adverse health effects of air pollution.
Action Planned
(AI summary)
DEFRA, DFT, and DHSC will continue to work to improve public awareness of air pollution, including a pilot project with GPs providing air quality advice and information to a range of vulnerable groups. They will also make expertise available to relevant professional organisations. The Mayor of London has implemented measures such as the Ultra Low Emission Zone (ULEZ) and is expanding the monitoring network. They are also supporting health and care system support for vital structural changes. NICE amended its asthma guideline (NG80) in March 2021 to clarify the link between air pollution and asthma and added links to NICE guidelines on air pollution: outdoor air quality and health and indoor air quality at home. The RCGP is in the process of producing a planetary health element of the curriculum that all new GPs will be assessed against and are also planning a high-profile webinar incorporating elements regarding pollution. The RCP will work with specialist societies to raise the profile of air pollution's impacts, review the internal medicine curriculum, increase knowledge among physicians, produce resources for professionals to discuss air pollution with patients, improve incentives for conversations, and urge government to tighten regulations. The NMC will consider the concerns in their evaluation of pre-registration standards, focusing on communication with families, and identify further activity to ensure professionals understand their obligations to communicate clearly with patients about evidence related to managing and preventing ill-health. The BTS intends to build upon work undertaken to date by raising awareness of the effects of poor air quality, producing an updated Position Statement on air quality and lung health, and adding the health care profession voice to the debate on climate change and air pollution through membership of the UK Health Alliance on Climate Change and involvement in the Taskforce for Lung Health. HEE will write to the relevant medical Royal Colleges, GMC and NMC to highlight that improving awareness of the impact of air pollution on health should be considered when developing curricula. The RCPCH curriculum includes a domain on health promotion, and they are working with NHS England/Improvement and Health Education England to develop asthma competencies for child health professionals and carers. They also declared a climate emergency and published a report on tackling climate change. The GMC will review standards for medical education to consider how environmental issues are covered, encourage medical schools to address air pollution in curricula, and promote inclusion of environmental impacts in postgraduate training curricula. HEE will add the theme of environmental impacts to the list of potentially important areas to consider as they progress the credentialing agenda. UKHACC delivered a pilot project with Global Action Plan, funded by Defra and the Clean Air Fund, to educate paediatricians and respiratory health professionals on air pollution advice for patients. The London Borough of Lewisham has expanded monitoring capacity, taken part in the Breathe London project, and refreshed the Joint Strategic Needs Assessment for Air Quality. They also promote air quality monitoring tools via social media and local advertising, and ensure information is positioned on relevant websites and newsletters.
Alexandru Murgeanu and Jason Mercer
Partially Responded
2021-0013
19 Jan 2021
South Yorkshire West
Other related deaths
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Smart motorways present foreseeable risks due to the absence of a hard shoulder and the inability to quickly identify stationary vehicles, necessitating better driver awareness and a wider public inquiry beyond inquest limitations.
Action Taken
(AI summary)
National Highways details numerous actions taken following a stocktake, including installing stopped vehicle detection systems, increasing traffic officers, changing the law to enable automatic detection of Red X violations, and converting dynamic hard shoulder motorways to all lane running. They have launched a road safety campaign and are updating the Highway Code. The Department for Transport commissioned a review of Smart Motorways, is abolishing dynamic hard shoulder motorways, and has launched a £5m campaign to remind road users to ‘Go Left’ in breakdowns. They are upgrading cameras to detect Red X violations and updating the Highway Code with improved safety information.
William Turner
Partially Responded
2020-0209
15 Oct 2020
County Durham and Darlington
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Current DVLA regulations for driving licences following epileptic seizures may need review, as a driver potentially experiencing a seizure lawfully held a licence, leading to a fatal incident.
Action Planned
(AI summary)
The DVLA will ask the Secretary of State for Transport’s Honorary Medical Advisory Panel on Disorders of the Nervous System to review the period of time required off driving before someone who has suffered a seizure can regain their driving licence.
Mollie Gifford
Partially Responded
2020-0211
30 Sep 2020
Birmingham and Solihull
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Standard lorry mirrors provide distorted, inadequate vision and are prone to dirt, creating an avoidable blind spot risk for drivers and posing a danger to other road users.
Action Planned
(AI summary)
The Department for Transport notes that camera-monitor systems are permitted as an alternative to mirrors. It is working internationally to develop requirements to improve vision for drivers around large goods vehicles, including improved direct vision and warning systems for vulnerable road users, with agreement anticipated later in the year.
Joan Williams
Historic (No Identified Response)
2020-0128
16 Jun 2020
Bedfordshire and Luton Coroner
Road (Highways Safety) related deaths
Concerns summary (AI summary)
The deceased, with dementia, continued driving despite medical advice, highlighting a systemic risk where current legislation places primary responsibility on the driver to inform the DVLA rather than mandating direct clinical referral.
Michael Pender
All Responded
2020-0122
28 May 2020
Cornwall and the Isles of Scilly
Other related deaths
Concerns summary (AI summary)
The complete absence of professional lifeguard cover on Cornish beaches poses a significant risk of further loss of life. A lack of transparent planning for resuming this essential service leaves the public vulnerable.
Noted
(AI summary)
The RNLI is revising plans to provide lifeguard cover on additional beaches, working with landowners and councils to confirm beaches and timings for public announcement. The MCA is increasing HM Coastguard vehicle patrols to known safety hotspots for surveillance and swift response. The MCA reiterates its role in coordinating search and rescue, clarifies that it has no statutory responsibility for beach safety, and states that it will continue to work with partners on safety campaigns.