Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0203, written 17 Sep 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Sep 2013 |
|---|---|
| Reference | 2013-0203 |
| Deceased | Luke Lyons |
| Coroner | Dr Elizabeth Earland |
| Coroner area | Exeter & Greater Devon |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
eae HM Senior Coroner for the County of Devon Exeter and Greater Devon District Dr Elizabeth A Earland MB.Ch.B.,D.A.,Dip.Law,L.P.C,Hon.LLD. Date: 17" September 2013 Sustainable and Safe Travel Team Manager Devon County Council Our ref: © EAE/NLP ABG Lucombe House File No: 247/2013 County Hall Topsham Road Your ref: Exeter EX2 4QD Re Luke James LYONS Deceased — DOD 25.01.2013 Inquest — 13.09.2013 at Devon County Hall, Topsham Road Report pursuant to Regulation 28 Coroner’s and Justice Act 2009 I write following the Inquest into the death of Luke James Lyons who died on 25" J anuary 2013 at the scene of the accident just past Cove on the A396 when his vehicle hit a patch of black ice which had formed overnight. Tenclose a copy of the record of findings of Inquest, a recording and copies of the map of the location and scale plan of the incident for information; along with the data contained in CS, C6 and C7 regarding the gritting of the area. I received evidence that the area in question was subject to water egress from the land at the side of the road which flowed from the higher ground across the road, thereby washing away any salt gritting put down by the Highway Department in anticipation of bad weather. It was clear that procedures were followed, gritting undertaken which it was anticipated would have satisfied the need for gritting the area in question in the absence of the localised water problem. I received evidence that a number of vehicles going through this area also lost control despite the gritting but had managed to counteract the loss of control. I understand that the Highways Department have since placed a drain at the location in order to combat the problem but it appears that it is inadequate (from information received from nn of Devon and Cornwall Constabulary). Clearly a repetition of Luke’s death in the forthcoming winter would be a disaster if it could be avoided by further action. Exeter and Greater Devon Coroner's Office, Room 226, Devon County Hall, Topsham Road, Exeter, EX2 4QD Telephone: 01392 383636 Fax: 01392 383635 Email: coroner@exgd-coroner.co.uk I therefore feel it necessary to bring this matter to your attention pursuant to Regulation 28 Coroner’s and Justice Act 2009 and look forward to your substantive response within the statuary 56 days. I am copying this letter to the Chief Coroner and all Properly Interested Persons. I await hearing from you. Yours sincerely AGA Dr Elizabeth A Earland MB.Ch.B.,D.A.,Dip.Law,L.P.C,Hon.LLD HM Senior Coroner
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
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