PACTS has published a new report which highlights significant gaps in how the UK handles learning from road traffic fatalities and calls for systemic changes to address these issues.
Unlike other transport sectors, road deaths in the UK lack a central investigation body dedicated to learning from each fatal incident, limiting the ability to prevent similar tragedies in future.
To bridge these gaps, PACTS has put forward a series of recommendations aimed at improving how fatalities are investigated, documented, and acted upon by relevant authorities.
Road fatalities occur daily in the UK, yet the approach to investigating and addressing them is inconsistent and fragmented. While air, rail, and maritime transport have dedicated investigation branches for serious incidents, the road sector has no such equivalent, resulting in missed learning opportunities that could inform preventative actions.
The report notes that police investigations into road collisions are often focused on apportioning blame. This can overlook broader, systemic factors that may contribute to fatalities, such as the design of the road environment or employer policies on work-related driving. Although local highway authorities are responsible for investigating collisions, they often lack the resources or mandate to conduct detailed analyses of individual incidents, leaving vital insights uncollected.
Findings: The Current System Falls Short
The report identifies several key shortcomings in the current system:
Underreporting and Limited Learning Opportunities: Only around 3% of road fatalities lead to a Prevention of Future Deaths (PFD) report from coroners. Although stakeholders are legally required to respond to PFD reports, there is little enforcement, allowing critical matters of concern to go unaddressed.
Lack of Systematic Record-Keeping and Trend Analysis: With no dedicated branch to analyse patterns across fatalities, it is difficult to identify emerging trends, such as high-risk demographic groups. By contrast, other transport sectors routinely compile and assess such data to inform preventative measures.
Absence of a Coordinated Mechanism: Currently, there is no unified approach for stakeholders to be notified of matters of concern and potential solutions arising from road incidents. This complicates stakeholders’ efforts to adopt proactive safety actions.
Recommendations for Change
The report makes five key recommendations to improve road safety by fully harnessing the lessons from fatal incidents:
Provide Safe System Training for Coroners: Coroners should receive training in the Safe System approach, which focuses on understanding how every road fatality might have been prevented through specific safety measures. This would allow coroners to make informed recommendations in PFD reports that reflect a comprehensive understanding of road safety principles.
Learn from Other Transport Sectors: The processes and practices used in the rail, air, and marine sectors could be adapted for road safety. Establishing a dedicated investigation branch for road transport—similar to the Air Accidents Investigation Branch (AAIB)—could prioritise serious incidents for investigation and share findings to enable all stakeholders to make life-saving changes.
Enhance Stakeholder Collaboration: Building stronger relationships among road safety stakeholders, such as local authorities, vehicle manufacturers, and navigation system providers, would allow for quicker action on PFD recommendations. This would enable stakeholders to address concerns promptly, helping to prevent future fatalities.
Ensure Consistency in PFD Reporting: Coroners should have clear, consistent guidelines for when and how to produce PFD reports. This consistency would bring closure for families affected by road deaths and create a public record to inform future preventative measures.
Strengthen the Follow-Up Process for PFD Reports: Legal obligations to respond to PFD reports should be enforced, ensuring that stakeholders take meaningful steps to address issues highlighted by coroners. Introducing sanctions for non-responses could improve accountability and lead to tangible safety improvements.
Moving Towards a Vision of Zero Road Deaths
The report supports a ‘Vision Zero’ approach—an ethically driven ambition to eliminate deaths and serious injuries on UK roads. Achieving zero deaths may seem challenging, especially given the unpredictable nature of road environments, yet every fatal incident provides an opportunity to learn and implement preventative measures. PACTS asserts that, by adopting these recommendations, the UK can make significant strides towards reducing road fatalities.
The report concludes with a powerful message: understanding the causes behind each road fatality is essential to preventing future deaths and saving lives. By following these recommendations, the UK could move closer to a transport system where no family has to endure the loss of a loved one in a preventable crash.
Jamie Hassall, PACTS Executive Director, said: “Failing to learn from tragedy such as a death due to a road collision creates an open wound for the families involved, knowing that others will suffer the same fate as them over and over again. The number of road deaths each year in the UK has stagnated over the past decade: failure to act to address known issues is not acceptable in other forms of transport so why is it tolerated on the roads? The road safety community believes that if a safe system approach is taken, road deaths could be reduced to zero. Every road death is preventable and deserves to have a PFD report published. Currently less than 3% of road deaths have a PFD report produced, and the reports that are published don’t currently follow a safe system approach meaning only limited action is taken.
“The UK has the evidence and expertise to draw on to enable PFD reports to be produced that really could prevent future deaths. I’m looking forward to more PFD reports being produced and being based on a safe system approach, so they start to live up to their name and begin preventing future deaths.”
