Prevention of Future Deaths reports · 2015

Daniel Foss

Regulation 28 report to prevent future deaths, reference 2015-0062, written 8 Apr 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report8 Apr 2015
Reference2015-0062
DeceasedDaniel Foss
CoronerColin Phillips
Coroner areaSwansea Neath & Port Talbot
CategoryRoad (Highways Safety) related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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.

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (2)

NOTE: This form is to be used before an inquest.

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:

1. Chief Executive of the City & County of Swansea

2. Leader of the City & County of Swansea

3. Head of Legal Democratic Services & Procurement of the City & County of
Swansea

1 | CORONER

lam Colin Phillips, acting Senior Coroner, for the coroner area of Swansea Neath &
Port Talbot

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

On 2™ October 2013 the Senior Coroner commenced an investigation into the death of
Daniel Hannen Foss aged 37 years. The investigation has not yet concluded and the
inquest has not yet been heard.

4 | CIRCUMSTANCES OF THE DEATH

A collision occurred at a pedestrian crossing on the Kingsway Swansea at approximately
16.50 hrs on Tuesday 24 September 2013 when Mr Foss stepped from the central
reservation into the path of a Single Decker Coach without looking in the direction from
which the coach was coming.

5 | CORONER’S CONCERNS

During the course of the investigation my inquiries 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:-

Since 1° January 2008 there have been in excess of 100 reported road traffic collisions
and incidents on the Kingsway/Metro system which in a large number of cases included
incidents of injuries or near misses between pedestrians and coaches. There have been
2 fatalities including Mr Foss and most recently the death of Sgt Louise Lucas. There
would appear to be a serious design issue which must be addressed by the Local
Authority to make the road safer for the public.

6 | ACTION SHOULD BE TAKEN

In my opinion urgent 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 3 June 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.

COPIES and PUBLICATION

| have sent a copy of my report to the Chief Coroner.

lam 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.

co

08.04.2015 SIGNED BY ACTING SENIOR CORONER

Responses

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.

Response from Swansea City Council (PDF)
City Anb CouNTYy OF SWANSEA

DINnAS A Sirk ABERTAWE

Please ask for:

Gofynnweh am:

Colin Phillips Directs:
Acting Senior Coroner Lline!l Uniongyrch
Civic Centre E-Mail:
Oystermouth Road onme
Swansea Ein Cyt.
SA1 3SN Your Ref:

Fich Cyt:

: th
Deda a: 12" August 2015
Dear Coroner,

Re. Daniel Foss - Ingusst
| write further in response to your Regulation 28 Prevention of Future Deaths Report
issued on 7 April 2015.

First, | would like to express my sincere condolences to the family and friends of both
Daniel Foss and Louise Lucas. Any death on a City and County of Swansea road is
a concern and this Authority will do everything it can to reduce the risk to all users.

Your report raises essentially two matters of concer, namely the number of
incidents/collisions since 24 September 2013 and there appearing to be a serious
design issue on the Kingsway.

Since the issue of the report you have obtained a report from Mark Steventon dated
10 July 2015. That report is presently being considered and the observations and
further mitigating/alternative measures put forward will be considered in light of the
measures set out below.

In relation to your concern that the Kingsway must be made safer for the public |
respond as follows:

* An advisory 20 mph speed limit was introduced in November 2014.
Cont'd...

EXECUTIVE BOARD! BWRDD GWEITHREDOL

The Guildhall, Swansea, SA1 4PE
Neuadd y Ddinas, Abertawe, SA1 4PE
www.swansea.gov.uk
To receive this information in alternative format, please contact the above.
1 dderbyn yr wybodaeth hon mewn fformat arall, cysylitwch ’r person uchod.

“

Temporary pedestrian barriers were installed on 12 April 2015 to assist in
directing pedestrians to existing signal controlled pedestrian crossings. This is
however presently being monitored as to whether this contributes to any
reduction in accidents or poses any potential risk. | will keep you advised as to
whether the barriers will remain in situ following the monitoring period.

First Cymru has announced that the Metro bus is being decommissioned in
September 2015.

The Authority is revising the road layout and in particular removing the eastbound
bus movements along the Kingsway. This rerouting responds to the concerns
raised in your Regulation 28 Report and it also brings forward the infrastructure
changes required in the City Centre as part of the City Centre Regeneration
Framework. [| anticipate that once the formalities have been addressed this
revised layout will be in place during October 2015.

This Authority is committed to ensuring users of their highways are safe and takes
the concems raised in your report extremely seriously. The Authority will continue to
monitor the whole highway network and will continue to work closely with the Police
to respond to any safety concerms.

Yours faithfully,

(PME

Jack Straw
Chief Executive

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