Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0051, written 22 Feb 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Feb 2017 |
|---|---|
| Reference | 2017-0051 |
| Deceased | Ashley Talbot |
| Coroner | Andrew Barkley |
| Coroner area | South Wales Central |
| Category | Child Death (from 2015) · Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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. Chairman of the Board of Governors at the Maesteg Comprehensive
School
2. Head teacher
3. Chief Executive of the Bridgend County Borough Council
(1 CORONER |
| am Andrew Barkley, Senior Coroner, for the coroner area of South Wales Central
| CORONER'S LEGAL POWERS
On the 18” December 2014 | commenced an investigation into the death of Ashley
Daniel Talbot aged 15. The investigation concluded al the end of an inquest held at the
Aberdare Coroners Court between Monday 13" February 2017 through to Thursday 16"
February 2017 The conclusion of the inquest was “Accidental Death’.
2 |
| {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
4 | CIRCUMSTANCES OF THE DEATH
The deceased was a pupil at the Maesteg Comprehensive school and shortly after 3pm
on the 10"" December 2014 was running with a fellow pupil to catch his bus home when
he was struck by a school minibus being driven in the school grounds as he entered the
carriageway from between 2 parked buses. He suffered extensive injuries to his head
and chest and was confirmed deceased at the scene
'5 | CORONER'S CONCERNS
During the course of the inquest, and the investigation leading up to tt, the evidence
| revealed matters giving rise to concern. In my opinion there is a risk that future deaths
could occur unless action ts 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 evidence revealed clear deficiencies in relation to the design of the “service
road" leading up to the school. This included the construction of a "bus bay’
which was inadequate for the number of vehicles required to transport children |
from the school at the end of the school day. As a direct result of this buses
were parked outside the designated bus bay on the other side of the road |
necessitating children to cross the road which was. at the time of the accident,
being used by other vehicles such as staff vehicles. visitors vehicles and school
vehicles. This created a highly dangerous situation which resulted in the loss of
life. The evidence also revealed that there had been several “near misses’
which appeared to have gone unreported
8
At the time of the accident there was insufficient staff supervision of children
boarding buses at the end of the school day. Given the issues with the site,
which the evidence indicated had been raised when the schoo! was still under
construction and before it opened in 2008, the number and position of staff was
inadequate to ensure children boarded their buses safely
(3
The wider investigation revealed that there was a clear lack of accountability
between the various stakeholders in the design and construction of the school
premises {o ensure that a safe facility was constructed. Appropriate Safety
Advice at an early stage, the evidence showed, would have reduced the
likelihood of injury or death
6 | 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
“7 | YOUR RESPONSE
| You are under a duty to respond to this report within 56 days of the date of this report
| namely by 19" April 2017. |, 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
| have sent a copy of my report to the Chief Coroner, the Welsh Assembly Government
and the family who may find it useful or of interest
| am aiso 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 | 22" February 2017 SIGNE
Add
HM Senior Coroner
2 responses 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.
Andrew Barkley HM senior coroner South Wales central area Your ref RE Ashley Talbot deceased. Dear sir, | reply regarding the regulation 28 notice and the concerns raised by the coroner. (1) The bus bay being inadequate for the no. of vehicles. The bus bay has now been extended and now provides adequate parking for all buses, there is now no parking of buses outside of the designated bay. There is a lockdown of the school premises prior to and during pupils exiting the school and loading onto the buses, there is no vehicle movement during this period. (2) Staff supervision has been increased and there are now adequate nos. in place when children are boarding the buses at the end of the day. (3) While | agree with the lack of accountability regarding the construction of a safe facility school governors would have had no input regarding the design or construction. (4) Additional measures now in place include a Smph speed limit within the school grounds. Staff managed pedestrian crossing points where pupils access the school via our safe routes to school pathways. (5) A vehicle drop off point approximately 200 metres from the main gates which allows children to access the school via steps leading to the back of the school lessening the vehicle nos. which caused congestion outside the main gates. The governing body has worked closely with HSE representatives since the time of this tragic accident and all their recommendations have been carried out . Yours — Chair of governors Maesteg school RECEIVE... La APR zu
Cyngor Bwrdeistref Sirol Pen-y-bont ar Ogwr Bridgend County Borough Council Swyddfeydd Dinesig, Stryd yr Angel, Pen-y-bont, CF31 4WB / Civic Offices, Angel Street, Bridgend, CF31 4WB Prif Weithredwr / Chief Executive Mr Andrew Barkley Deialu uniongyrchol / Direct line: (01656) 642616 HM Senior Coroner Gofynnwch am / Ask for: South Wales Central Area Rock Grounds Ein cyf / Our ref: First Floor Eich cyf / Your ref: Aberdare CF44 7AE Dyddiad / Date: 19 April 2017 Dear Mr Barkley Thank you for your letter and Regulation 28 report dated 22 February 2017 following the inquest into the death of Ashley Talbot. This was a tragic accident and the Council would like to express its sincere condolences to Ashley's family. In accordance with Regulation 28, we have considered the concerns you have raised and will respond as follows: 1. Road layout Following this incident, the traffic management arrangements at all schools in the Borough were observed by Health and Safety Officers and Road Safety Officers. Both internal and external arrangements at the school were observed and documented. Advice was provided to all headteachers at their forum meetings and a checklist was developed to assist them in monitoring their current arrangements. A programme of works was identified for the physical environment which is currently being implemented. Examples of work undertaken at these locations included extra crossings, the installation of additional barriers and bollards. Works were also carried out at Maesteg Comprehensive School. The bus bay has been extended and can now accommodate seven buses. If there are changes to the number of buses required, this will be reviewed to ensure the space remains sufficient. The schoo! site is now also subject to a lockdown, with no vehicles being allowed to enter or move around the site until the children have alighted/boarded the buses. Buses are only permitted to arrive/leave under controlled operation. A new drop-off area has been created on the access road (Ffordd Dysgu). The Corporate Health and Safety Team has promoted near-miss reporting within the current accident procedure across the Council. This was promoted with all headteachers at their forum meetings. 2. Staff supervision The supervision of the children falls under the responsibility of the school. The Council has monitored all schools’ supervision arrangements during their observations by health and safety eat csiFax: 01656 66817 nas Ebe alktous@bridgend.gov.uk Negeseuon SMS/ SMS Messaging: r (i Twitter@bridgendCBC ¢ Gwefan/Website: www.bridgend.gov.uk Cyfnewid testun: Rhowc © flaen unrhyw un/o'n rhifau ffon ar gyfer y gwasanaeth trosglwyddo testun ut 18004 before any of our phone numbers for the text relay service and road safety officers. The traffic management checklist provided to all schools includes a question on staff supervision during the start and end of the school day. 3. Design and construction The design project board for any new school build is now a multi-discipline team including designers, clients, highways road safety staff and health and safety officers. The project is now planned more strategically and with a holistic view. Early consideration is given to traffic management arrangements both internal and external for any new schools. Advice is sought at an options appraisal stage to ensure any potential highway issues are identified prior to a site being chosen. Infrastructure costs, including works to highways and on-site parking/drop- off arrangements, are now included in the overall costs of the budget. Once a site is identified and design is underway, the project board maintains a link with the on-site management of the build. | hope the above reassures you that Bridgend County Borough Council has taken appropriate steps to respond to the events at Maesteg Comprehensive School, and has also considered the actions that are needed throughout the Borough. The Council is committed to improving health and safety within the schools and will continue to work with the governing bodies and headteachers to ensure the situation at all schools is monitored and actions taken as necessary. lf you have any further queries, please do not hesitate to contact us. Yours sincerely Darren Mepham Chief Executive
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