Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0066, written 21 Feb 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Feb 2023 |
|---|---|
| Reference | 2023-0066 |
| Deceased | Andrew Still |
| Coroner | Caroline Saunders |
| Coroner area | Gwent |
| Category | 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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Monmouthshire County Council – Chief Executive – Council Leader CORONER I am Caroline Saunders, Senior Coroner for the Area of Gwent 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 INVESTIGATION AND INQUEST On 14/6/2022 an investigation was opened into the death of Andrew Mark STILL The investigation concluded at the end of the inquest on: 15/02/2023 The conclusion of the inquest was recorded as: 1 2 3 Road Traffic Collision The medical cause of death was: 1a. Multiple injuries 1b. Blunt vehicular trauma 4 CIRCUMSTANCES OF THE DEATH On 03/06/2022 Andrew Mark Still was riding his motorcycle on the A466 towards Chepstow from Tintern. Approximately 1 mile from the village of Tintern, Andrew encountered a double bend. As he rode into the second bend, Andrew was on the wrong side of the road and collided with a VW campervan travelling in the opposite direction. Andrew suffered extensive injuries and died at the scene. 5 CORONER’S CONCERNS The MATTERS OF CONCERN are as follows: - There was a warning sign which alerted motorists to the forthcoming series of bends and the extended white road marking indicated a pending hazard. There was also a chevron marker closer to the bend. At the inquest I found that Andrew had overtaken vehicles prior to the bends and would have seen the warning sign and the road markings. However, I found that the chevron sign near to the bend was overgrown. Moreover there was evidence that there had previously been 3 markers but two had been removed and not replaced. I was informed that the relevant authority had been made aware of this problem by Gwent Police after Andrew’s death but there was no evidence at the inquest that any remedial action had been taken 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. I should be grateful if the following information be provided to me: Confirm that plans are in place for the chevron markers to be replaced and foliage removed from the remaining chevron marker to ensure it is visible to motorists. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely 18 April 2023. I, 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 I have sent a copy of my report to the Chief Coroner and the following Interested Person (s) • The family of Andrew Mark Still 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 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: 21 February 2023 Signed: 8 9 Caroline Saunders His Majesty’s Senior Coroner for the Area of Gwent.
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.
Monmouthshire County Council PO Box 106 Caldicot NP26 9AN Cyngor Sir Fynwy Blwch SP106 Cil-y-Coed NP26 9AN Tel/Ffôn: 01633 644604 E-mail/Ebost: Web/Gwefan: www.monmouthshire.gov.uk 9th May 2023 Caroline Saunders Senior Coroner Gwent Coroner Service Civic Centre Newport NP20 4UR Dear HM Coroner, Ref: Your letter Re: Mr Andrew Mark Still dated 21 February 2023 The above letter and enclosed regulation 28 report contained the following action for Monmouthshire County Council: “Confirm that plans are in place for the chevron markers to be replaced and foliage removed from the remaining chevron marker to ensure it is visible to motorists.” I can confirm that the chevron signs were erected on 22nd March 2023 and that the foliage has been cut. An email dated 19th April 2023 has been sent to the Gwent Coroner Service to show pictures of the relevant signs/foliage. Yours Faithfully [sent electronically] Chief Officer People and Governance Monitoring Officer Monmouthshire County Council
See every Prevention of Future Deaths report matching Road (Highways Safety) related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.