Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0335, written 24 Oct 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Oct 2022 |
|---|---|
| Reference | 2022-0335 |
| Deceased | Matthew Rouch |
| Coroner | Rachel Knight |
| 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:
Chief Executive, Vale of Glamorgan 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 Matthew James Rouch on 29th
September 2021. It concluded on 18th October 2022 following an inquest.
4
CIRCUMSTANCES OF THE DEATH
These were recorded as :-
Matthew Rouch was aged 41 when on 29th September 2021 he was fatally injured on
the A48 near Cowbridge. He was on a stretch of the road with a relatively new junction
and layout. It is more likely than not that Matthew approached the new roundabout too
quickly, and despite braking in reaction and trying to steer, he lost control of his
motorbike and collided with the roundabout. Despite the extensive efforts of various
medical professionals on scene within moments, Matthew did not survive the
catastrophic multiple injuries he had sustained.
Conclusion: road traffic collision
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 A48 ‘Forage roundabout junction’ seems to be dangerous.
(2) Unless changes are made to make all road users more aware of this junction
and to slow down drivers approaching it from every direction, more deaths may
occur.
1
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.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 20th December. 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 Rouch 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
24th October 2022 SIGNED:
Rachel Knight
HM Assistant Coroner
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.
Date/Dyddiad 12111 December 2022 Ask for/Gofynwch am Telephone/Rhif ffon Fax/Ffacs The Vale of Glamorgan Council The Alps, Wenvoe CF5 6AA Cyngor Bro Morgannwg Yr Alpau, Gwenfo CFS 6AA VALE or GLAMORGAN Via email and post Ms R. Knight Assistant Coroner The Coroner's Office The Old Courthouse Courthouse Street Pontypridd CF371JW Dear Ms Knight Regulation 28: Report to Prevent Future Deaths Inquest into the Death of Matthew James Rouch -24th October 2022 Thank you for your letter of 24"' October 2022 and the copy of the Regulation 28 report, which followed a Coroner's investigation into the death of Matthew James Rouch, which concluded on 18th October 2022. I would firstly advise that the Council's thoughts are very much with Mr Rouch's family as they continue to come to terms with this tragic accident. I note that within the Regulation 28 report it states that during the inquest, evidence revealed matters giving rise to concern in relation to the A48 'Forage roundabout junction' near Cowbridge. Although the Regulation 28 report indicates the Assistant Coroner's opinion that the 'Forage roundabout junction 'seems dangerous and unless changes are made to slow down drivers approaching it from every direction, more deaths may occur', however, there is no mention of the evidence considered during the inquest which supports this position. The Vale of Glamorgan Council has investigated the concerns raised in the Regulation 28 report relating to the safety of the 'Forage roundabout junction' and considered the opinion expressed by the Assistant Coroner and would offer the response below. The roundabout design conforms to the design guidance provided in the Design Manual for Roads and Bridges (DMRB) published by Highways England and endorsed by Welsh Government. The DMRB includes all current standards, advice notes and other documents relating to the design, assessment, and operation of trunk roads, including motorways and whilst not mandatory, is adopted as a best practice guide, as appropriate, for the design of main roads within the Vale of Glamorgan Council's local highway network. The advanced directional signage on approach to the roundabout in all directions fully complies with the Traffic Road Signs and General Directions (TRSGD) 2016 as well as the appropriate Chapter of the Traffic Signs Manual. This signage is considered to provide excellent advanced warning of the approaching roundabout in all directions. COll'espondence Is welcomed In Welsh or Engllsh/Croesawir Gohebiaelh yn y Gymraeg neu yn Saesneg Director of Environment and Housing Services/Cyla,wyddwr Gwasanaethau'r Amgylchedd a Thai - The scheme design and construction has been the subject of a full Road Safety Audit (RSA) process, carried out by an independent specialist consultant approved by the Council in accordance with DMRB document GG119 'Road safety audit' (formerly HD 19/15). This process includes RSA's at completion of detail design stage (RSA Stage 2); completion of construction (RSA Stage 3); and post opening monitoring (RSA Stage 4a) - copies attached for information. The Stage 3 and 4a RSA comprised both a daytime and night-time site survey which was conducted by the independent Audit team and attended by the South Wales Police Roads Safety team and a qualified and experienced traffic engineer representing the Highways and Engineering team from the Vale of Glamorgan Council. The Stage 3 RSA's dated 10th January 2020 identified a number of minor issues in relation to surface water, carriageway surfacing, vehicle and pedestrian restraint barriers, drop kerb crossings and lack of signage associated with the shared cycleway / footway and drainage lagoon, which have subsequently been the subject of remedial works. The Stage 3 RSA also raised more specific concern in relation to the roundabout as identified below: • • • • The chevron warning signs being these have subsequently been replaced with enlarged signs incorporating a yeflow border to further enhance signage on the roundabout. too small (problem 2.3.4); The road signs (flag type directional signs on splitter-island) are un-lit (problem 2.3.5); the legislation (TSRGD) does not require these signs to be ifluminated. The lack of 50mph speed signs (problem 2.3.6); these signs were subsequently installed prior to removing temporary traffic management. The lack of advanced warning signs (problem 2.3.7); the presence of large Advanced Directional Signs (ADS) identifying the approaching roundabout and traffic routes is considered to provide sufficient and adequate advanced warning to approaching traffic. The Stage 4a RSA dated 31 st August 2021, which involved a desk top study and a further daytime and night-time site visit, identified only two safety issues as recorded below: • Existing warning sign obstructs the lower half of the eastbound ADS (problem 2.1.1 ); the offending sign was relocated to avoid the obstruction. • Lack of lane designation signs could lead to drivers undertaking sudden lane changing (problem 2.1.2); additional arrow markings added on westbound approach, however, to add additional markings eastbound. insufficient length of approach lanes The Council has also liaised with the South Wales Police (SWP) regarding the investigation into the collision and has been provided with a copy of the 'Feedback form to Police/ Welsh Government: Fatal traffic Collision' dated 30th September 2021, which it is presumed would have been fully considered as significant evidence during the inquest and Assistant Coroner's considerations. The Feedback form specifically did not identify any highways implications or contributing factors associated with the fatal collision which occurred on 29th September 2021. Based on the above information, the Vale Council considers that a robust and appropriate process has been followed regarding the design and construction of the new A48 'Forage roundabout junction,' in accordance with all appropriate guidelines and legislation, and that the junction is safe for its intended purpose. Any initial road safety issues have been appropriately identified and considered and, where necessary, resolved through the RSA process explained above. It is also considered that there is a series of suitable design highway signage to warn of the approaching roundabout junction and assist in necessary speed reduction. Therefore, given the evidence presented above, the Council would dispute that the 'Forage roundabout junction' is either dangerous or, unless changes are made to make users aware of the junction and to slow down drivers, more deaths may occur. Furthermore, the Council considers the advanced warning signage to be good and that the junction is safe for all traffic if drivers exercise responsible driving practices and take due care and attention of the provided signage and road markings, as well as comply with their legal obligations and follow the 'General rules, techniques and advice for all drivers and riders' (Rule 103 to 158) of the Highway Code. Notwithstanding the information above, the Council recognises the need to consider appropriate ways to enhance road safety on its existing local highway network and, where possible, measures should be implemented to best avoid any deaths or collisions involving serious personal injury. Therefore, subsequent to the fatality on the 291h September, the Council took steps to publish a Legal Order (TRO) with the intention of reducing the speed limit on the A48 Cowbridge bypass from National speed limit to 50mph, and the immediate approaches to the 'Forage roundabout junction' to 30mph. Whilst the Order has completed the appropriate legal process, the necessary new signage in accordance with TSRGD and Traffic Signs Manual is estimated to cost over £1 00k to implement the new speed restriction along the A48, and this work is therefore subject to identifying available budget. The proposed signage will also include lane designation signage on approach to the roundabout to compliment the reduction in speed limit. l hope the above adequately responds to and satisfies the requirements of the Regulation 28 report and clarifies the Council's position regarding the safety of the A48 'Forage roundabout junction'. Yours sincerely Chief Executive Enclosures
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