Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0472, written 29 Oct 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 Oct 2014 |
|---|---|
| Reference | 2014-0472 |
| Deceased | Alan Evans |
| Coroner | Andrew Barkley |
| Coroner area | Powys, Bridgend & Glamorgan Valleys |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. 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. Powys Highways Department
2. Chief Coroner
3. Family –
1
CORONER
I am Andrew Barkley, Senior Coroner, for the coroner area of Powys, Bridgend and
Glamorgan Valleys
2
CORONER’S LEGAL POWERS
I 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 the 13th May 2014 I commenced an investigation into the death of Alan Derek Evans.
The investigation concluded at the end of the inquest on the 23rd October 2014. The
conclusion of the inquest was Accidental death.
4
CIRCUMSTANCES OF THE DEATH
On the 4th May 2014 the deceased was riding his Honda Fireblade motorcycle travelling
on the A489 between Newtown and Kerry heading towards Kerry when at approximately
11:50 he overtakes a vehicle prior to a left hand bend. On returning to his lane he loses
control of his vehicle and veers into the “wrong lane” and his hit by an oncoming vehicle
before being run over by one travelling immediately behind the first. He was declared
deceased at the scene.
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) The road at this particular location is governed by a single broken white line
indicating that overtaking is permitted. Given the layout of the road, the existence of a
side entrance to it, the impact of hedges obscuring the view of the road consideration, in
my opinion, ought to be given to putting double white line markings on this particular
stretch of road.
(2) The evidence suggested that one of the most likely causes of the deceased losing
control of his motorcycle was contact with a protruding cats eye. This was agreed by the
senior investigation officer and the collision investigation officer who both held the view
1
that this may have contributed to the accident. Consideration in my view ought to be
given to replacing the “old style cats eyes” with the newer “slim line” version to minimise
this risk in the future should it not be considered appropriate to make the area subject to
double white lines to prohibit overtaking.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you and your
organisation have the power to take such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 25th December 2014. I, 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.
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner, Powys Highways Department,
Collision Investigating Officer with Dyfed Powys Police and
Senior Investigating Officer with Dyfed Powys Police Collision Investigation Unit and
who may find it useful or of interest.
I 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.
9
29th October 2014 SIGNED:
Mr Andrew Barkley
HM Senior Coroner
2
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