Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0463, written 12 Nov 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Nov 2019 |
|---|---|
| Reference | 2019-0463 |
| Deceased | Jamie Staley |
| Coroner | Caroline Saunders |
| Coroner area | Gwent |
| Category | 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.
Regulations 28 and 29 of the coroners (investigations) Regulations 2013 REGULATION 28: REPORT TO PREVENT FUTURE DEATHS r REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | THIS REPORT IS BEING SENT To: 1. Monmouth County Council CORONER 'am Caroline Saunders, Senior Coroner for the Area of Gwent 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 i INVESTIGATION AND INQUEST On 25 September 2018 | commenced an investigation into the death of Jamie Staley DOB: 24 June 1998. The investigation concluded at the end of the inquest on 8 October 2019. The conclusion of the inquest was recorded as “Accident”. | The medical cause of death was “Multiple injuries” t CIRCUMSTANCES OF THE DEATH | On 22°4 September 2018, Jamie Staley died when he accidentally wandered onto the A40 near Monmouth after a night out drinking with friends. He was struck by a van and died immediately of his injuries. i i CORONER’S CONCERNS During the course of the inquest, 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: - The inquest determined that Jamie died after he accessed the A40 from Monmouth | Town, near the Gibraltar tunnels. In considering Jamie’s movements on the night he | died, the inquest determined that Jamie’s mistake had been caused by a combination of not knowing the area and being under the influence of alcohol, however access | Benerally to the A40 in the area of was considered. Police Constable 217 os gave evidence to the inquest and presented the findings of the Collision nvestigation Report. He indicated that there is relatively easy access onto the A40 in | i | | ~~ T this area and was surprised that there were no signs which could alert pedestrians to the Add, or to prevent them from entering onto the slip road. Although lack of signage did not contribute to Jamie’s death | consider that this is a matter for consideration in preventing pedestrians from straying inadvertently onto this busy road in future. The junction in question is the exit from the A40 travelling northbound immediately having travelled through the Gibraltar tunnels onto the B4233. The co-ordinates are 51.805620, -2.716463. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action. If, however you consider this to be the responsibility of | another agency, please let me know as soon as possible. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report. !, the Coroner, may extend this 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 necessary COPIES AND PUBLICATION | have sent a copy of my report to the Chief Coroner and the following Interested Person (s) e The family of Jamie Staley iam 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 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. DATE: 12/11/19 Signed Caroline Saunders, Senior Coroner for the Area of Gwent Le en
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.
a From: Fe Sent: 10 January 2020 21:22 To: NCC - Gwent Coroner Ce: Subject: Regulation 28 Report to Prevent Future Deaths Attachments: coroner - staley.pdf Dear Caroline Saunders - Senior Coroner for Gwent, Re: Jamie Staley, Regulation 28 Report to Prevent Future Deaths, My apologies for the delayed response regarding the Regulation 28 Report and the matters of concern raised within. Monmouthshire County Council pass on their sincerest condolences to the family and are grateful for the opportunity to respond to this report and the evidence of The A40 is the responsibility of Welsh Government and South Wales Trunk Road Agency (SWTRA). | have copied SWTRA colleagues into this response should they wish to add any further comments. At present, the left hand side of the B4233 has a dedicated footpath running alongside the River Monnow from the Town Centre leading to a subway under the A40 to Beach Road. (Beach Rd can also by footpath over the Gibraltar Tunnels alongside the B4293). The footpath continues and runs alongside the A40 slip road allowing pedestrians to cross the River Monnow heading northbound and gain access to Chippenham Fields. This kerbed footpath is well sign posted and physical barriers separate the slip road from the main A4Q. The right hand side of the B4233 leading to the slip road coming off the A40 where the accident occurred is unpaved with no pedestrian access. There is a narrow grass verge backed with hedging along the slip road which provides a sight line for motorists as they egress the A40. There is a petrol station OneWay access just past the slip road and there is a NO EXIT sign to the road and verge. The verge leading from the petrol station to the slip road is also obstructed with a Welcome to Monmouthshire sign facing the oncoming traffic, the sign runs the width of the verge biocking pedestrian access. There are two illuminated NO ENTRY signs on either side the slip road leading from the Gibraltar Tunnels and oncoming traffic. Physical barriers and further signage along the B4233 and non- pedestrianised verge could obstruct sight line vision and potentially lead to more accidents. Whilst the report identifies that signage did not contribute to the accident we will continue to work with SWTRA to identify any additional measures that may improve safety on this junction. Regard Head of Neighbourhood Services | County Council
Traf nidiaeth . Yr ;s-adran Rheoli' r Rhwydwaith Transport . Network Management Division Ein cyf / Our ref: oc.00054-20 CarGline A Saunders Senior Coroner for Gwent gwent. coroner@newport.gov. uk Dear Ms Saunders Re: DOB: Address: Jamie Staley 24.06.1998 Llywodraeth Cymru Welsh Government 10 March 2020 Skellow, Doncaster, South Yorkshire Further to our letter of 10 February, I can confirm that our South Wales Trunk Road Agent (SWTRA) has now completed the installation of Pedestrian Prohibition signs on the existing signing infrastructure. Yours sincerely Rheolwr Cyflenwi Rhaglen I Programme Delivery Manager Yr ls-adran RheoWr Rhwydwaith / Network Management Division Rydym yn croesawu derbyn goheblaeth yn Gymraeg. Byddwn yn ateb goheblaeth a dderbynnir yn Gymraeg yn Gymraeg ac nt fydd gohebu yn Gymraeg yn arwatn at oedt. We welcome receiving correspondence In Welsh. Any correspondence received In Welsh will be answered in Welsh and corresponding in Welsh will not lead to a delay in responding. Pare Cathays • Cathays Park Caerdydd • Cardiff CF10 3NQ Canolfan Cyswllt Cyntaf / First Point of Contact Centre: 0300 0604400 EST·NMDMailbox@llyw.cymru EST-NMDMallbox@gov. wales
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