Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0541, written 18 Dec 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 18 Dec 2014 |
|---|---|
| Reference | 2014-0541 |
| Deceased | Brendan Ryan |
| Coroner | Andrew Barkley |
| Coroner area | Powys, Bridgend & Glamorgan Valleys |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
ANNEXA 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. Chief Coroner 2. 3. CORONER -Powys County Council 1 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 th August 2013 I commenced and investigation into the death of Brendan Owain On the 6 Ryan, aged 21. The investigation concluded at the end of an inquest on the 11th December 2014. The conclusion of the inquest was of "Road Traffic Collision" and the medical case of death was: 1a. Neck Injuries 1b. Road Traffic Incident 4 CIRCUMSTANCES OF THE DEATH Brendan Owain Ryan was the front seat passenger in a Peugeot 205 vehicle driven by his best friend, Powys when on the 31 st July 2013 the vehicle left the road colliding with a stock fence and entering a field. Mr Ryan was declared deceased at the scene. along the A488 between Pen-Y-Bont and Knighton in 5 CORONE~SCONCERNS 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. - 1. There is evidence of an unusually high number of incidents taking place at this particular location. Powys County Council are aware of three injury collisions and there is evidence, from the residents of Brook House, that there have been many accidents at or near this location which the evidence indicated are most likely to have been caused by excess speed. Furthermore it is believed there were three collisions at or near this collision site within a six day period surrounding this incident. 2. Evidence from the Collision Investigator in this case showed that the maximum speed at which the bends in this road at this location could be travelled at were 50 and 53 mph depending on the direction of approach. Whilst it is acknowledged that the County Council have installed new signing and double white lines in the area in light of the unusually high number of incidents in which vehicles appear to have left the road, most likely as a direct result of excessive speed, it is felt that consideration ought to be given to a restricted speed area at this location. 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 12'h February 2015. 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 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 18m December 2014 2
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.
Powys Priffyrdd, Trafnidiaeth & Ailgyichu Pennaeth Priffyrdd, Trafnidiaeth & Ailgyichu Highways, Transport & Recycling Head of Highways, Transport & Recycling Cyngor Sir Powys County Council Neuadd y Sir/County Hall Llandrindod Wells, Powys, LD1 5LG HMC Andrew Barkley Os yn galw gofynnwch am /If calling please ask for: Her Majesty’s Coroner Enw /Name: a Rock Grounds Ffén/Tel: Ps First Floor Ffacs /Fax : 01597 826651 Aberdare Ebost / Email : traffic@powys.gov.uk CF44 7AE Eich cyf/ Your Ref : Ein cyf/ Our Ref : po Dyddiad / Date: 12 February 2015 Dear Mr Barkley Brendan Owain Ryan (deceased) | refer to your letter dated 19'" December 2014 enclosing the regulation 28 form for which | wish to make the following response. | apologise for the delay in providing this response. Highway Authorities should pay regard to guidance from the Welsh Government on the setting of local speed limits [WG Circular No 24/2009]. This is to ensure speed limits are imposed in a consistent manner across wales. The guidance makes it clear that speed limits should not be used to attempt to solve the problem of isolated hazards. Following the fatal collision on the 6" August 2013 a number of measures were taken at this site. This initially consisted of temporary traffic management measures until detailed surveys could be undertaken to establish the road conditions. The surface grip test indicated that the surface was fine but a topographical survey noted a small area of concern to the northwest of the bridge. As a result of the survey, a reprofiling scheme was identified and works were completed during summer of 2014 following a successful bid to the Welsh Government for grant funding. An accident analysis of the recorded personal injury collisions was undertaken and did not highlight any patterns which would have identified this site as being of concern. However due to the anecdotal evidence of the number of damage only collisions it was considered prudent to implement additional engineering solutions to provide further warnings to motorists. Surveys into the signing and lining resulted in sections of double solid white centre line being introduced though the bends and additional series of bends warning signs being erected on both approaches. The solid centre lines were considered appropriate not just because of the reduced forward visibility but also from concerns raised by the Community Council of poor overtaking manoeuvres. Verge marker posts have also been added adjacent to the bridge parapet to highlight its presence and assist in denoting the road alignment. a4 9¥ Cymunedau eryf yng, nghalon werdd Cymru oye. ge 8 . Strong communities in the green heart of Wales - nyaoes www. powys.gov.uk (ya These engineering measures are considered appropriate measures to meet the duty of this Authority under Section 122 of the Road Traffic Regulation Act 1984 as amended. Given this and the Welsh Government guidance not recommending speed limits for individual hazards it is not considered appropriate to impose a lower speed limit at this location. Yours sincerely Road Safety and Traffic Systems Manager
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