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
81 results
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) 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. 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. 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 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 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 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.
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. 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. 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 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.
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.
Gillian Davey
All Responded
2020-0121 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 MCA is increasing HM Coastguard vehicle patrols to known safety hotspots for surveillance and swift response. The RNLI is revising plans to increase lifeguard cover on beaches, working with landowners and councils to confirm beaches and timings, with public announcements to follow. The MCA states they have no statutory responsibilities for beach safety, but continue to work with partners on safety campaigns, including a joint campaign with the RNLI; they are ready to support the inquests.
Russell Curwen
All Responded
2023-0122 24 Apr 2020 Lancashire and Blackburn with Darwen
Other related deaths Road (Highways Safety) related deaths
Concerns summary (AI summary) The legal framework for "blood bike" volunteers' use of emergency vehicle exemptions (blue lights, speed limits) for routine courier services appears unclear, potentially leading to unsafe practices or misapplication of regulations.
Noted (AI summary) The Department for Transport expresses sympathy and acknowledges the coroner's report. The response states the department is opposed to extending exemptions to road traffic laws and describes that existing laws and procedures did not appear to be followed in the incident.
Ashley Holden
All Responded
2020-0096 17 Apr 2020 Lincolnshire
Accident at Work and Health and Safety related deaths Other related deaths
Concerns summary (AI summary) Inconsistent and absent definitive guidance for stacking, unstacking, loading, and securing bales in agriculture creates a risk of unsafe practices and fatalities from falling bales.
Noted (AI summary) HSE acknowledges the concerns and highlights existing guidance and enforcement approaches related to vehicle loading and workplace safety, particularly regarding bales. They will consider improvements to guidance INDG125 during its next periodic review. The DVSA will update the 'Load Securing - Vehicle Operators Guidance' in collaboration with HSE, focusing on generic safe loading principles rather than specific bale/trailer combinations. The DfT Code of Practice, 'Safety Loads on Vehicles' (2002) will be amended to cross-reference the updated guidance.
Suzanna Bull
All Responded
2019-0404 29 Nov 2019 Birmingham and Solihull
Road (Highways Safety) related deaths
Concerns summary (AI summary) A dashboard tray creates a dangerous blind spot in moving vehicles, yet there are no warnings on the product, nor general advisories to manufacturers or users, about this safety hazard.
Action Planned (AI summary) The DVSA will circulate information to haulage operators stating that aftermarket dashboard trays breach testing rules and should be removed when HGVs are driven and publish similar information on gov.uk. The Department for Transport will also make umbrella bodies aware of the concerns. DVSA published a Moving On blog on GOV.UK and sent a link to haulage operators reminding them to keep windscreens clear; they will highlight concerns at a Heavy Vehicle Industry Forum, and will update guidance to warn drivers against putting objects in their lorry which restrict their view.
London Bridge & Borough Market Terror Attack
All Responded
2019-0332 1 Nov 2019 London Inner (South)
Other related deaths
Concerns summary (AI summary) The coroner identified matters of concern which are being reported to the addressees, after taking into account submissions from the bereaved.
Noted (AI summary) The City of London Police (CoLP) are working with partner agencies to test interoperability of communications and enhance training scenarios, including a 7 day live trial in February 2020 to station staff in the MPS control room, with a review in Autumn 2020, and are engaging with the MPS in ICCS and CAD upgrade projects, planning an interim solution until upgrades are complete. The BVRLA has worked with the DfT and law enforcement to prevent the use of rental vehicles in terrorist attacks, providing training, guidance and engagement opportunities to members, and has included additional criteria within member audits from Jan 2020 to monitor awareness, training and compliance against the Rental Vehicle Security Scheme. The LAS is planning a live trial for seven days in February 2020, with LAS and LFB staff based in the MPS control room, and will analyze the outcome and consider a recommendation for approval by Autumn 2020; it is also working with its emergency service partners and increased visibility of the HART and TRU teams. The Home Office acknowledges the coroner's concerns and provides context, stating that the issues raised are technical and will be considered by the police in collaboration with the Emergency Services Network programme. It also mentions ongoing work led by the National Police Chiefs' Council. The MPS is trialing a "London Emergency Services Contact Centre" with representatives from the LFB and LAS deployed within the Specialist Operations Room, with a table top exercise followed by a real-life 7-day trial planned for early 2020.
Priscilla Tropp
All Responded
2019-0213 24 Jun 2019 London (North)
Other related deaths
Concerns summary (AI summary) The station lacked a clear flow chart or plan to guide staff on appropriate steps to take when a person falls ill, risking further injury.
Noted (AI summary) The Office of Rail and Road believes the report would be better served to the station operator and infrastructure manager, as ORR does not have the power to take the action proposed by the Coroner. Govia Thameslink Railway has produced a new staff aide-memoire and is briefing staff on it, is updating Local Incident Response Plans, and has ordered new privacy screens for key locations. The Department for Transport is satisfied that measures undertaken by Govia Thameslink Railway should resolve the Coroner's concerns and will continue to manage all of its franchises through normal commercial management procedures.
Clive Jones
All Responded
2019-0217 30 Apr 2019 Plymouth, Torbay and South Devon
Other related deaths
Concerns summary (AI summary) An independent review of UK Search and Rescue operational capability and HM Coastguard is needed, alongside a thorough review of their information technology systems for reliability.
Action Taken (AI summary) An independent review of the UK search and rescue (SAR) operational capability and functionality will be completed by Jersey Coastguard and Guernsey Coastguard between 24 and 26 June. A review of SAR information technology systems has been completed, and the MCA confirmed this in a letter sent to the MAIB on 31 May.
Julia Peto
All Responded
2019-0119 4 Apr 2019 London Inner (South)
Road (Highways Safety) related deaths
Concerns summary (AI summary) Many two-stage pedestrian crossings nationally may lack louvres to prevent 'see-through' confusion from green signals and proper road markings to warn pedestrians of traffic direction.
Noted (AI summary) The Department for Transport states it is updating the Traffic Signs Regulations and General Directions (TSRGD), including Chapter 5 on pedestrian crossings, with updated advice on the design of pedestrian facilities, therefore no further action is considered necessary.
Matthew Bilby
All Responded
2019-0112 7 Mar 2019 Lincolnshire
Road (Highways Safety) related deaths
Concerns summary (AI summary) A dangerous and confusing staggered junction, identified as an accident blackspot with multiple fatalities, poses an ongoing risk to road users due to its layout and lack of traffic calming measures.
Noted (AI summary) The Department for Transport states that responsibility for traffic management on local roads rests with the local highway authority, and their role is to provide overarching strategy, policy, and guidance. They provide links to relevant guidance documents. The council states that there is currently no funding available for a roundabout project. Average speed cameras have reduced speeding offences, and the junction has been re-assessed with a lower priority ranking.
Kurt Cochran; Leslie Rhodes; Aysha Frade; Andreea Cristea; PC Keith Palmer.
All Responded
2018-0304 19 Dec 2018 London Inner (West)
Other related deaths
Concerns summary (AI summary) A Prevention of Future Deaths report was issued to multiple authorities following the Westminster terror attack to address systemic issues related to such events.
Noted (AI summary) The Parliamentary Authorities confirm that they already plan to consider the automation of Carriage Gates and their general ease of use as part of the ongoing renewal project; and external reviewers have already been extensively involved in the New Palace Yard project, and will continue to be involved. The MPS will revise Post Instructions to relevant groups by direct emails, in hard copy and/or via electronic devices; MPS is working with MO19 and the National Police Chief’s Council to provide additional training on de-escalation techniques; and the MPS will ensure that there is appropriate input from tactical advisers at challenge panels, and the newly appointed PaDP OFC Sergeant will ensure that AFOs fully understand not only relevant changes to post instructions but also the rationale behind the changes. The BVRLA has increased counter terrorism training and guidance made available to vehicle rental and leasing firms, and routinely shares data and intelligence with police and counter terrorist authorities. The Department for Transport launched its Rental Vehicle Security Scheme in December 2018. The MCA states sufficient guidance already exists in the public domain for operating commercial vessels and leisure boats on navigable rivers and canals, referring to existing codes and training courses. The Home Office states the government accepts the Chief Coroner's recommendations and has taken action. The Department for Transport (DfT) launched the Rental Vehicle Security Scheme (RVSS) on 6th December 2018, and an industry led Advisory Panel was launched in January to oversee the development of the scheme. TfL implemented internal changes in October 2017 to improve communication of security advice. TfL is currently reviewing the height of all its bridge parapets to identify those that are below 1m high, with high priority bridges expected to be completed by April 2019. The London Ambulance Service states that the Chief Coroner found no matters of concern regarding their actions, so they will not be taking any further action.
Caitlin Huddleston and Skye Mitchell
All Responded
2025-0056 25 Sep 2018 Cumbria
Road (Highways Safety) related deaths
Concerns summary (AI summary) Inexperienced young drivers carrying multiple passengers face increased distraction and risk, highlighting the need for a Graduated Driving Licence Scheme with passenger restrictions and other safety measures.
Noted (AI summary) The Department for Transport acknowledges the concerns regarding Graduated Driver Licensing (GDL) but states it has no current plans to enforce further restrictions due to the ongoing COVID-19 pandemic and potential detrimental effects on young people. They will continue to monitor the pilot scheme in Northern Ireland. The Department for Transport is using the introduction of GDL in Northern Ireland as a pilot to gather evidence on the potential for GDL in Great Britain. They have also allowed learner drivers on motorways when accompanied by an Approved Driving Instructor in a dual control car and increased the penalty for using a handheld mobile phone while driving.
Jacob Brown
All Responded
2018-0187 19 Jun 2018 Staffordshire (South)
Road (Highways Safety) related deaths
Concerns summary (AI summary) There is a concern that not mandating 'black boxes' in young drivers' vehicles, which monitor driving actions, misses a significant opportunity to save lives.
Action Planned (AI summary) The Department for Transport is investigating the use of telematics as part of their £2 million research programme called ‘Driver 2020’. They also reference recent changes to legislation and campaigns targeting young drivers.
Roger Hamer
All Responded
2017-0259 21 Aug 2017 Manchester (North)
Road (Highways Safety) related deaths
Concerns summary (AI summary) Inadequate highway inspection practices failed to document carriageway deterioration, and a proposed new management procedure risks increasing deaths, particularly for cyclists, by raising the threshold for defect investigation and repair.
Noted (AI summary) Bury Council, as Highway Authority, states that all Highway Inspectors are scheduled to undergo specific training and competency checks to ensure they understand how to undertake their role under the new Code of Practice. There will be regular evidence based reviews of the new Code of Practice and monitoring. The Department for Transport acknowledges the concerns but notes that local highway authorities have a duty to maintain the highways network in their area and that Central Government has no powers to override local decisions in these matters. They endorse a code of practice, issued by the UK Roads Liaison Group, providing guidance to highway authorities on how to maintain and manage their highways.
Philip Clayton
All Responded
2017-0323 31 Jul 2017 Manchester (South)
Road (Highways Safety) related deaths
Concerns summary (AI summary) High-powered kit cars are sold without requiring specific driving courses, and their post-initial testing lacks rigor. Inexperienced drivers can operate these vehicles with a standard license, unlike the graduated system for motorcycles.
Noted (AI summary) The Department for Transport expresses condolences but states there are no current plans to limit engine capacity for young drivers. They highlight existing road safety initiatives and commissioned research on measures to improve young driver safety.
Gustavo Da Cruz, Mohit Dupar, Inthushan Sriskantharasa, Gurushanth Srithavarajah, Kenugen Saththiyanathan, Kobikanthan Saththiyanathan and Nitharsan Ravi
All Responded
2023-0105Deceased 24 Jul 2017 East Sussex
Other related deaths
Concerns summary (AI summary) There is a lack of formal governance and risk management for beach safety. A national review of safety regimes and potential government powers to restrict beach access is needed.
Noted (AI summary) The RNLI recommends that landowners are responsible of implementing a range of appropriate control measures at beaches, and states that it can only establish new lifeguard units with the express permission of the relevant local authority, landowner, beach owner or operator. The Forum intends to update and expand the use of the WAID database and is seeking to identify suitable sources of funding for this development work. The council acknowledges the concerns and refers to previous reports and statements regarding beach management at Camber Sands, and states that restricting public use of beaches would be disproportionate. RoSPA states that it seeks to influence, inform, coordinate activity and advise within the existing structures for water safety, and states that significant landowners successfully manage sites with significant hazards to the public without noticeable impacts or blanket restrictions. The MCA has recently started working closely with the RNLI on coastal risk management, including a programme of visits to landowners to discuss and advise on local risks and the potential for raising public awareness through targeted safety interventions, and will conduct an independent review of its accident prevention activity.
Nina Maggs
All Responded
2017-0216 20 Jul 2017 Wiltshire and Swindon
Road (Highways Safety) related deaths
Concerns summary (AI summary) The pedestrian crossing at the junction is unsafe due to a lack of signals, audible/vibrating assistance, and an insufficient all-red light phase, posing significant risk.
Action Planned (AI summary) The council will commence stakeholder consultation on 18th September 2017 regarding proposals to improve pedestrian safety at the junction. Provisional arrangements have been made to assign resources to progress with the design and potential delivery of a scheme. The Department for Transport, while noting a lack of evidence, will consider with trade associations how to encourage signage on left-hand drive vehicles to alert pedestrians to the risks.
Colin Wellings
All Responded
2016-0348 5 Oct 2016 South Wales Central
Road (Highways Safety) related deaths
Concerns summary (AI summary) Current legislation exempts older, powerful vehicles from essential safety requirements like helmets or seatbelts, posing significant risks to riders and other road users.
Noted (AI summary) The Department for Transport acknowledges the concerns, explains current regulations regarding tricycle helmets and licensing, and notes that changes to collision reporting codes and helmet regulations are not planned but will be kept under review.
Christopher Sears
All Responded
2016-0212 25 May 2016 Surrey
Child Death
Concerns summary (AI summary) Bus drivers transporting students are not required to have Basic Life Support training or emergency protocols, and BLS is not routinely taught in secondary education.
Action Planned (AI summary) The DfE intends to consult on a revised version of guidance on school transport in the autumn and will consider whether they should further clarify the description of the training that drivers and escorts should receive. The DfT will reinforce the importance of basic life support training for drivers through targeted communications and social media, and raise the profile of the issue with bus industry and local authority stakeholders.
Tony Jopson and Michael Jopson
All Responded
2016-0172 4 May 2016 Cumbria
Child Death Road (Highways Safety) related deaths
Concerns summary (AI summary) The A66's varied road standard, including single carriageway sections, is inadequate for high traffic volumes, particularly HGVs, leading to head-on collisions; it should be dual carriageway throughout.
Action Planned (AI summary) The Department of Transport commissioned the Northern Trans Pennine study, covering the A66 and A69 and the Chancellor announced in the 2016 Budget his commitment to upgrade the A66 and A69. Safety improvements at specific locations on the A66 are to be delivered this financial year.
Michael Jopson
All Responded
2016-wp25249 4 May 2016 Cumbria
Road (Highways Safety) related deaths
Concerns summary (AI summary) The A66 is a mix of dual carriageway and winding country road, and the coroner suggests that from a road safety perspective the road should be dual carriageway throughout to avoid avoidable deaths.
1 response from Department of Transport