Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0302, written 27 Sep 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 27 Sep 2022 |
|---|---|
| Reference | 2022-0302 |
| Deceased | Aaron Edwards |
| Coroner | Rachael Knight |
| Coroner area | South Wales Central |
| Category | Road (Highways Safety) related deaths · Wales prevention of future deaths reports (2019 onwards) |
| 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:
Chief Executive, Merthyr Tydfil County Borough Council
1
CORONER
I am Rachel Knight, 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
I commenced an investigation into the death of Aaron David Edwards on 10th October
2020. It concluded on 27th September 2022 following an inquest.
4
CIRCUMSTANCES OF THE DEATH
These were recorded as :-
Aaron David Edwards was aged 42 when he died on 30th August 2020 at the junction of
Goitre Lane and the Gurnos Ring Road in Merthyr Tydfil. Mr Edwards was riding his
Kawasaki motorcycle at over twice the speed limit when he collided with a car that was
emerging from a side road. Despite extensive efforts of civilians and professionals, he
had sustained catastrophic injuries and died at the scene.
5
CORONER’S CONCERNS
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) The junction of Goitre Lane and the Gurnos Ring Road appears to be
dangerous. Visibility is poor for the driver entering the Ring Road due to the
bend in the road to the right and the railings protecting a subway below.
(2) Traffic and parked cars around this area at the nearby school Pen-Y-Dre at pick-
up and drop off times add to this danger.
(3) Unless changes are made to slow down drivers on the Gurnos Ring Road more
deaths may occur.
6
ACTION SHOULD BE TAKEN
1
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 23rd November 2022. 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 family of Mr Edwards, and the other driver involved
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
27th September 2022 SIGNED: Rachel Knight
HM Assistant Coroner
(Electronic signature)
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.
Chief Executive Rachel Knight HM Assistant Coroner South Wales Central Coroners Office The Old Courthouse Courthouse Street Pontypridd CF371JW Canolfan Ddinesig, Stryd y Castell, MerthyrTudful, CF47 BAN Civic Centre, Castle Street, Merthyr Tydfil, CF47 SAN www.merthyr.gov Cyngo, Bwr~ Sltol MERTHYR TUDFUL MERTHYR TYDFIL Ccunty eon.qi Qud Dyddiad/Date: 2151 November 2022 Dear Rachel Re: Aaron David Edwards (Deceased) Thank you for your letter dated 28th September 2022 and the accompanying Regulation 28 report. We have considered all the concerns that were raised within the report in relation to the junction layout and would like to make the following observations. It has been determined that visibility at this junction is poor, however, we respectfully disagree as there is no immediate obstruction to the right while approaching the junction from Goitre Lane and the vision splay meets the requirements in accordance with Manual for Streets at 2.4m x 40m, therefore, visibility at this junction is acceptable. As noted a bridge/subway parapet does obstruct vision at circa 2.4m x 55m although the sightline extends behind the back of the parapet to 2.4m x 90m. It is also worth noting that the stopping sight distance for a 30mph road is 43m when accounting for a car bonnet length, therefore a vehicle travelling at 30mph would be able to stop safely if a car emerged from Goitre Lane. As highlighted within the report Mr Edwards was riding his Kawasaki motorcycle at over twice the speed limit when he collided with a car, which in our view negates the junction layout as a contributing factor in the collision. The time of the road traffic collision has not been made clear within the report but if it did occur during school start or end times then it is likely cars were parked on the Gurnos Ring Road which may have reduced visibility. However, if the incident did occur during these times where children were walking along Gurnos Ring Road then further responsibility should be attributed to Mr Edwards by traveling at over 60mph on a 30mph road with children in the area. Merthyr Tudful ... lie i fod yn falch ohono Merthyr Tydfil ... a place to be proud of Croesawn ohebu yn Gymraegafydd gohebu yn y Gymraeg ddlm yn arwaln at oedl. Rhowch wybod lnnl beth yw'ch dewls lalth e.e Cymraeg neu'n ddwylelthog. We welcome correspondence In Welsh and colll!spondlngwith us In Welsh will not lead to a delay. Let us know your language choice IfWelsh or bilingual. Cont/.... For information, the SCRIM (Sideway-Force Coefficient Routine Investigation Machine) which measures the skid resistance over a stretch of a road is undertaken every year on Merthyr's roads by an independent contractor WDM. The results from the SCRIM surveys at this location in 2019, 2020, 2021 and 2022 identify that no action is needed as the skid resistance of this road is good. Skid resistance is an important factor in highway safety particularly in damp or wet conditions. With reference to making changes on Gurnos Ring Road to slow vehicle speeds, it is proposed to alter the road layout at this location as part of Welsh Governments A465 dualling project which is currently under construction and will continue between now and May 2025. The road bridge will be removed including the parapet and an elevated roundabout will be located adjacent to Penydre School, this will prevent parents parking on Gurnos Ring Road or near the junction of Goitre Lane. In addition, due to Welsh Governments new legislation with regard to a default 20mph speed limit, the Gurnos Ring Road will become 20mph on the 17th of September 2023. I hope the above information is satisfactory and if you have any further queries, please do not hesitate to contact me. CHIEF EXECUTIVE Merthyr Tudful ... lie i fod yn falch ohono Merthyr Tydfil ... a place to be proud of Croesawn ohebu yn Gymraeg a fydd gohebu yn yGymraeg ddlm yn arwaln at oedl. Rhowch wybod lnnl beth yw'ch dewls lalth e.e Cymraegneu'n ddwyielthog. We welcome conespondence In Welsh and conespondlngwlth us In Welsh wl!I not lead to adelay. Let us know your language choice IfWelsh orblllngual.
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