PACTS report calls for urgent overhaul of road accident investigations

A new report that highlights significant gaps in how the UK handles learning from road traffic fatalities and calls for systemic changes to address these issues is now out from the Parliamentary Advisory Council for Transport Safety (PACTS).

The Learning from Tragedy report finds 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, leaving critical safety concerns unresolved.

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

This includes a dedicated Road Accident Investigation Branch, modelled after the Air Accidents Investigation Branch, and enabling deeper investigations and fostering shared learning among stakeholders.

Unlike air, rail, and maritime transport, road deaths lack a dedicated investigative body, which limits the nation’s ability to prevent future tragedies.

The previous government announced two years ago that it was launching a Road Safety Investigation Branch to make independent safety recommendations and shape future road safety policy, and Labour recently announced plans for a new Road Safety Strategy, expected under the guidance of Future of Roads Minister, Lilian Greenwood.

The PACTS report also highlights the underutilisation of PFD reports, which coroners can issue to flag systemic safety issues. Despite their potential, these reports are often ignored, leaving safety risks unaddressed. The report calls for ‘safe system’ training for coroners to help them produce more actionable and safety-focused PFD reports.

Other recommendations include standardised PFD reporting through the introduction of clear guidelines for coroners and strengthened accountability by enforcing legal obligations on authorities and organisations to respond to PFD reports and introducing sanctions for non-compliance.”

The report endorses the Vision Zero approach, which seeks to eliminate road deaths and serious injuries entirely – and says by systematically learning from each fatality and implementing preventative measures, the UK can make significant strides towards this ambitious goal.

Jamie Hassall, executive director, PACTS, said: “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.”

Ross Morlock, chief executive officer at road safety charity Brake, said: “The fact that so few PFD reports are produced following road deaths is deeply concerning, and this must improve. Without stronger follow-up, enforcement and accountability, we risk missing critical lessons from the needless loss of life on our roads every day. To prevent further tragedies, this process must be strengthened to drive decisive action that saves lives and reduces suffering for families and communities.”

D.tec International has also urged policymakers to adopt the report’s recommendations and create a safer future for all road users.

Ean Lewin, MD of the drug and alcohol screening solutions firm, said there were missed opportunities to learn from tragedy and implement life-saving measures.

“Between 2013 and 2023, nearly 17,000 people lost their lives on UK roads. Thousands of these road deaths are likely due to impaired driving – whether from alcohol, prescription medications, or illegal drugs – yet we are left relying on estimates because coroners are not legally required to perform toxicology tests on every road traffic fatality,” said Lewin.

“We need a system that doesn’t just respond to road fatalities but learns from every loss to prevent the next,” he added. “This means mandating thorough investigations, including toxicology testing, for all road deaths. Without this data, we cannot fully understand the scale of the problem or take the decisive action needed to save lives.”

Lewin added: “As a company working at the forefront of tackling impaired driving, D.tec International fully supports the call for reform. We need leadership at the national level to prioritise this issue – ensuring no life is lost in vain.”

The PACTS Learning from Tragedy report is online here.