Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0080, written 14 Mar 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Mar 2022 |
|---|---|
| Reference | 2022-0080 |
| Deceased | Margaret Lewis |
| Coroner | Dr Sarah-Jane Richards |
| Coroner area | South Wales Central |
| Category | Wales prevention of future deaths reports (2019 onwards) · 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.
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. Highways Department, Powys County Council;
2.
, Legal Director of the Canal and River Trust;
1
1. CORONER
I am Dr. Sarah-Jane Richards, HM Assistant Coroner, for the Coroner area of South Wales
Central.
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 11 November 2020, I commenced an investigation into the death of Mrs. Margaret May
Lewis. The investigation concluded at Inquest on 11 March 2022.
The medical cause of death provided by histopathologist, Dr.
and Telford Hospital was:
, Shrewsbury
1(a) Traumatic Injuries
The Coroner’s short-form conclusion was that of “Road Traffic Collision”.
4 CIRCUMSTANCES OF THE DEATH
These were recorded as:-
On the 6 November 2020 the deceased was walking on the tow path alongside the
Montgomeryshire Canal. She passed through a ‘kissing gate’ onto the B4398 with the intention
of re-joining the towpath through a similar gate diagonally opposite on the other side of the
road.
Mrs. Lewis was crossing the road, when a car driven at between 16.5 – 22 mph came round a
bend and into the glare of low autumnal sun which dazzled the driver. Because of this, he did
not see Mrs. Lewis crossing the road and the car struck her causing fatal injuries. Witnesses
state that the car had a quiet engine which could not be heard at the time of the accident. Low
sun with commensurate glare was confirmed by witnesses and within the Police Investigation
Report.
5 The Montgomeryshire canal and its adjacent towpath is a popular venue for adults with children
1
and dogs; and joggers many of whom will wear earphones. They, like Mrs. Lewis who was
thought to be wearing earphones at the time, will need to cross the B4398 (which has a 60 mph
speed limit) to continue their exercise.
With the increasing popularity of noiseless electric cars, the frequency of wearing of earphones
whilst taking exercise and the B4398 having a 60mph speed limit, I consider there is a risk of
reoccurrence of such an accident.
Within the Highway Code for pedestrians it states “Keep looking and listening for traffic while
you cross, in case there is any traffic you did not see, or in case other traffic appears suddenly.
Do not walk diagonally across the road.”
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.
• Provide warning signage on the tow path at the ‘kissing’ gates either side of the B4398
noting the Highway Code for pedestrians with the added warning of wearing earphones
when crossing a road with a 60mph speed limit.
• Provide warning signage on B4398 of pedestrians crossing the road with dogs and
children possibly wearing earphones.
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 May 2022, allowing for statutory holidays. I may extend this period upon request.
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, His Honour Judge Thomas Teague QC;
(husband of the deceased); and the Canal River Trust legal representatives,
, Health and Safety lawyer
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. 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 Dated – 14 March 2022
SIGNED:
Dr. Sarah - Jane Richards, HM Assistant Coroner for South Wales Central
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.
rr Canal &
= River Trust
Dr. Sarah-Jane Richards,
HM Assistant Coroner, for the Coroner area of South Wales Central,
The Coroner's Office,
The Old Courthouse,
Courthouse Street
Pontypridd
CF37 1dW
10 May 2022
Dear Madam,
RE: Mrs Margaret May Lewis - Deceased
Regulation 28: Report to Prevent Future Deaths
| am the Director for the West Midlands Region, for Canal and River Trust (the “Trust”) and | am responding on
behalf of the Trust in relation to the Regulation 28: Report to Prevent Further Deaths notice dated 14"" March
2022 (the “PFD Notice’), following the conclusion of the Inquest into the death of Mrs Margaret May Lewis who
sadly died on 6" November 2020.
Our thoughts are very much with the family and friends of Mrs Lewis. On behalf of the Trust, we were greatly
saddened by Mrs Lewis's tragic death and offer our sincere condolences to her family.
THE CANAL AND RIVER TRUST - AN OVERVIEW
The Canal & River Trust came into being as a Charity on 2nd July 2012 — the biggest ever single transfer of
state infrastructure into a charitable body ~ and included 2,000 miles of historic canals, rivers, reservoirs and
docks across England and Wales.
The network flows from London to Lancaster and Wales to the Wash, connecting most of the country’s major
towns and cities. There were around 750 million visits to the waterways in 2020/21, around 34,000 licensed
boats on the network (more than during the Industrial Revolution). The Trust is also the largest owner of fishing
rights in the UK and has 100,000 angling customers.
The Canal & River Trust spent an estimated £183m on our charitable activities in 2020/21. The Trust is the third
largest owner of Listed structures/buildings in the UK, has over 1,000 wildlife conservation sites, 63 Sites of
Special Scientific Interest (SSSIs) and 46 Scheduled Monuments.
THE PFD NOTICE
The PFD Notice states that the Montgomeryshire canal and its adjacent towpath is a popular venue for adults
with children and dogs; and joggers many of whom will wear earphones. They, like Mrs. Lewis who was thought
to be wearing earphones at the time, will need to cross the B4398 (which has a 60 mph speed limit) to continue
their exercise. With the increasing popularity of noiseless electric cars, the frequency of wearing of earphones
whilst taking exercise and the B4398 having a 6O0mph speed limit, HM Coroner considers that there is a risk of
reoccurrence of such an accident.
In the opinion of HM Coroner, action should be taken to prevent future deaths and she believes that the Trust
and Powys County Council have the power to take such action, namely,
e Provide warning signage on the tow path at the ‘kissing’ gates either side of the B4398 noting the
Highway Code for pedestrians with the added warning of wearing earphones when crossing a road with
a 60mph speed limit.
¢ Provide warning signage on B4398 of pedestrians crossing the road with dogs and children possibly
wearing earphones.
THE MONTGOMERY CANAL
The Montgomery Canal is one of the most important canals in the country for nature, much of it is a Site of
Special Scientific Interest and the Welsh section is of international importance, designated a Special Area of
Conservation for its aquatic plants.
The Montgomery Canal towpath is moderately used by local people and sees pedestrians and some cyclists.
The towpath does have many sections where the towpath stops at a road and then restarts on the other side of
the road. In order to ensure that any user of the canal prepares for the crossing there is a barrier in the form of
a kissing gate as per photograph below.
Wee af
These gates allow the towpath user to slow and prepare for the crossing and provide an adequate measure as.
a physical barrier to hi-light to the towpath user to stop.
Currently, there is no highways signage on the ‘Kissing Gates’ as we are not responsible for risk control
measures for the Highway itself and the barrier that the gate provides, slows and stops the user at the end of
our towpath. However, at your request, we have designed warning signage to be placed on front and rear of
the ‘kissing’ gates either side of the B4398 which will read as follows:
r ) Gtendwr Cymr PAV bie085 Gymce
\ T ae ee
=
Mecae Urata
Caewch y
giat
Please shut
the gate
We have sent our design out for quotation (which is currently awaited) and we are in a position to place our
order immediately. We will be reliant on the delivery of the signs (which can often take a couple of weeks) but
we will erect these as soon as possible thereafter.
For your information, we have identified a further 30 similar gates on the Welsh section of the canal where we
will place these signs and 10 gates on the English section (as the Montgomery canal crosses the
Welsh/English border) we will be ordering a number of Bi-lingual Welsh/English and for the Welsh side of the
border (and then just English for the English side).
If | can be of further assistance to HM Coroner or if you would like to discuss my response, please do get in
touch.
Yours faithfully,
Regional Director
West Midlands
Canal and River Trust
Approval
{ endorse this report and the details within it
Name: Julie Sharman Date: 10/05/2022
Title: Chief Operating Officer, Canal and River Trust
Signed:
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