Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0222, written 19 May 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 May 2014 |
|---|---|
| Reference | 2014-0222 |
| Deceased | Stephen Owens |
| Coroner | Graeme Hughes |
| Coroner area | Powys, Bridgend & Glamorgan Valleys |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1 . Head of Highways at RCTCBC 2. Chief Coroner 1 | CORONER | am Graeme Hughes, Assistant Coroner, for the coroner area of Powys, Bridgend and Glamorgan Valleys 2 | CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 | INVESTIGATION and INQUEST On 6" September 2013 | commenced an investigation into the death of Stephen John Owens age 42. The investigation concluded at the end of the inquest on 14” May 2014. The conclusion of the inquest was a road traffic collision and the medical cause of death was 1a.Massive Haemorrhage, 1b. Complicated Open Fracture of Right Tibia and Fibula, Rib Fractures and Left Lower Lobe Lung Contusion. 4 | CIRCUMSTANCES OF THE DEATH Mr Owens was fatally injured in a running down accident which occurred in the south bound carriageway of the Ely Valley Road, Coed Ely at approximately 21:35 hrs on the 29" August 2013. 5 | CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. — [BRIEF SUMMARY OF MATTERS OF CONCERN] (1) Street lamp number 19 situated on the pavement to the north bound carriageway of the Ely Valley Road was unilluminated at the time of the collision. (2) Street lamp number 18 again on the pavement adjacent to the north bound carriageway of the Ely Valley Road was obscured by overhanging foliage. (3) Consequent upon (1) and (2) the level of illumination in the proximity of the collision was likely to have had an effect upon the ability of the driver to see the deceased ahead of him on the south bound carriageway. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and your organisation have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 14™ July 2014. |, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner who may find it useful or of interest. | am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 19” May 2014 SIGNED:
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