Investigations into UK road deaths need urgent reform

The Parliamentary Advisory Council for Transport Safety (PACTS) is calling for an urgent overhaul of the investigation of road traffic fatalities in the UK. 

In a new report, published on 4 December, it points out that:  

• Every day, road traffic fatalities claim lives across the UK, yet the systems meant to investigate these incidents often fall short.
• Just 3% of road deaths result in prevention of future deaths (PFD) reports from coroners.
• There is no formal follow-up to reports: local authorities face no sanctions for failing to act on recommendations.
• Unlike other transport sectors, road fatalities lack a central body for analysing trends and identifying at-risk groups.
• Poor collaboration among stakeholders delays safety improvements across organisations.
• Failing to learn from and act on any such tragedy creates an open wound for the families involved and puts others at risk of the same fate.

PACTS – along with all road safety campaigners – believes all road fatalities are preventable. The report makes five key recommendations aimed at transforming how road deaths are investigated, documented, and acted upon.

• Provide ‘safe system’ training for coroners to help them produce more actionable and safety-focused PFD reports.
• Adapt lessons from other transport sectors: Establishing a dedicated Road Accident Investigation Branch, modelled after the Air Accidents Investigation Branch, would facilitate deeper investigations and foster shared learning among stakeholders.
• Enhance collaboration through stronger partnerships between local authorities, manufacturers, and safety organisations to help with faster, coordinated responses to road safety concerns.
• Standardise PFD reporting by introducing clear guidelines for coroners – this will ensure more consistent reporting and create a robust public record to inform future prevention strategies.
• Strengthen accountability by enforcing legal obligations on authorities and organisations to respond to PFD reports and introducing sanctions for non-compliance.

Currently, PFD reports, mandated by the Coroners and Justice Act 2009, are issued when an inquest identifies concerns that, in the opinion of the coroner, could prevent future deaths if they were adequately addressed. 

These reports, sent to relevant authorities or organisations, must receive a response within 56 days detailing actions either taken or planned to address the concerns (or an explanation as to why no action has, or will be, carried out). 

However, there is no requirement for coroners to follow up on these responses and no sanctions for those who fail to respond or act upon receipt of a PFD report.

Unlike air, rail, and maritime transport, road deaths lack a dedicated investigative body, a gap that limits the nation’s ability to prevent future tragedies. A consortium of more than 100 road safety campaigners, health, police and local authorities have called on the government to establish this for road.

 Jamie Hassall, executive director of PACTS, 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.”

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