Preventing Future Death reports analysis shows more needs to be done to prevent road death

Beccy Taylor

RoadPeace members Nicole and Chris Taylor have recently produced a detailed analysis of the Preventing Future Death reports (PFDs) issued by coroners after an Inquest. Their daughter Beccy (pictured here) was killed in a road crash in 2008.

They wanted to understand the impact of environmental factors on road deaths. There is no equivalent of a CQC or Ofsted for highway authorities and Nicole and Chris believe road maintenance is often not investigated sufficiently. For many road victim fatalities, the Inquest is the only opportunity to investigate their death and identify how to prevent future deaths.

Vulnerable road victims accounted for 58% of PFDs with a category of Road (Highways Safety), with pedestrians accounting for 32%, motorcyclists 14% and cyclists 9%. 83% of PFDs had environmental contributory factors with design or maintenance being a factor in all but 2 of them. The number of PFDs that involved flooding and potholes increased from 2 in 2013-16 to 10 in 2017-20. This data seems to indicate the risk-based Code of Practice for Well Maintained Highways (introduced in October 2016) has not had the intended impact.

Nicole and Chris were surprised by the wide variation of PFDs issued by coroner area:

  • Whilst the Isle of Wight reported 4 PFDs for 25 road deaths, Cambridgeshire and Peterborough reported 0 PFDs for 253 road deaths
  • Over 50% of coroners had raised less than 3 PFDs related to highways safety over a 7-year period.
  • For every forty road deaths only one is reported by a coroner as being preventable.
  • 30% of coroner areas issue over 50% of the PFDS.
  • For example, Manchester South reported 1 in 11 deaths and Inner North London reported 1 in 14 deaths as being preventable.

Nicole and Chris say:

‘PFDs for highways safety appear low compared to railways, 2.6% compared to 19.6%. Our research supports the argument that the highways should be subject to the same governance framework as railways, including the Office of Road and Rail being responsible for Health and Safety on our roads. With a Road Collision Investigation Branch and greater focus on health and safety on our roads, including through the coroner system, it would be harder for the government to ignore initiatives like a Graduated Driving Licence and reduced speed limits on rural roads.’

For more information about this research and a copy of this report please contact