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 resultsGillian 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 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 is increasing HM Coastguard vehicle patrols to known safety hotspots for surveillance and swift response. 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.
James Anthony Lewis and Lorraine Molyneaux
Partially Responded
2020-0033
17 Feb 2020
Dorset
Alcohol, drug and medication related deaths
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Repeated pedestrian fatalities at an uncontrolled crossing point, driven by bus stop proximity and inadequate lighting, highlight an urgent need for a new controlled crossing and neglected funding applications.
Action Planned
(AI summary)
BCP Council will carry out a site assessment to confirm lighting levels and inform a new lighting design linked to the planned road layout adjustments and a new crossing. They will prioritize the additional survey and design work, although definitive timescales cannot be provided yet.
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 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. 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 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.
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.
Herbert Francis
Partially Responded
2018-0242
26 Jul 2018
Carmarthenshire and Pembrokeshire
Road (Highways Safety) related deaths
Concerns summary (AI summary)
The junction lacks adequate road markings, early warning signs, and properly positioned speed limit signs. Filter lanes are too short, and there's no westbound filter, increasing road safety risks.
Action Planned
(AI summary)
The Welsh Government will consider the concerns raised in the report as a priority as part of the ongoing three-year speed limit review looking at road safety issues. Preliminary investigations have begun to develop further overtaking opportunities & safety improvements along the length of the A40 including improvements at Redstone Cross.
Tyrone Evans
Partially Responded
2018-0227
16 Jul 2018
Coventry
Road (Highways Safety) related deaths
Concerns summary (AI summary)
There is no legal requirement for quad bike riders to wear crash helmets, even on road-adapted vehicles, despite evidence suggesting a helmet could prevent fatal head injuries.
Noted
(AI summary)
The Department for Transport acknowledges the coroner's concerns regarding quad bike safety and helmet use but states there are no immediate plans to make helmet use compulsory, though the position is under review. They note changes to casualty statistics are made as part of quinquennial reviews.
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.
Bryan Allsop
Historic (No Identified Response)
2018-0185
18 Jun 2018
Derby and Derbyshire
Other related deaths
Concerns summary (AI summary)
Pilot licensing does not mandate instruction and testing in partial engine power loss scenarios for light aircraft, despite this being a common and challenging factor in crashes.
Geoffrey Taylor
Partially Responded
2017-0226
11 Sep 2017
Cornwall and the Isles of Scilly
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Limited DVLA mechanisms exist for medically reviewing elderly drivers with deteriorating health, and GPs face conflicts of interest in reporting, potentially leading to patients withholding crucial medical information to retain licenses.
Action Taken
(AI summary)
The Department for Transport highlights existing processes for medical assessments of drivers, including the legal requirement for drivers to report medical conditions, investigations by the DVLA, and guidance for medical professionals. They also point to an older driver website developed with Department funding.
Henry Prow
Partially Responded
2017-0227
11 Sep 2017
Cornwall and the Isles of Scilly
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Limited DVLA mechanisms exist for medically reviewing drivers with deteriorating health, and GPs face conflicts of interest in reporting, potentially leading to drivers withholding information. Vehicle modification relevance also goes unchecked.
Action Planned
(AI summary)
The Department for Transport notes the DVLA is reviewing how restrictions imposed on driving licences are communicated to drivers. They also highlight existing processes for medical assessments of drivers, including the legal requirement for drivers to report medical conditions and revised GMC guidance to doctors on reporting concerns.
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 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. 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. 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.
Sousse (Tunisia)
Historic (No Identified Response)
2017-0206
7 Jul 2017
London (West)
Other related deaths
Concerns summary (AI summary)
Travel companies lacked board-level security advisors and failed to prominently display government travel advice, leaving customers potentially uninformed about terrorism risks in destination countries.
Lucy Goldstone
Historic (No Identified Response)
2017-0168
26 May 2017
Manchester (City)
Other related deaths
Railway related deaths
Concerns summary (AI summary)
There are no Automated Electronic Defibrillators (AEDs) available on trams or at tram stops across the Metrolink network.
Raymond Berry
Historic (No Identified Response)
2017-0108
7 Apr 2017
Surrey
Road (Highways Safety) related deaths
Concerns summary (AI summary)
The parameters for Supplementary Restraint System (airbag) deployment may be inadequate, failing to activate airbags in collisions where impact is absorbed by the crumple zone away from sensors, resulting in severe injury or death.