Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0527, written 15 Dec 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Dec 2023 |
|---|---|
| Reference | 2023-0527 |
| Deceased | John Thomas |
| Coroner | John Gittins |
| Coroner area | North Wales (East and Central) |
| 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.
John Gittins
Senior Coroner for North Wales (East and Central)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Denbighshire County Council (“the Local Authority”)
CORONER
I am John Gittins, Senior Coroner for North Wales (East and Central)
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
1
2
3
On the 6th of December 2023 an investigation was commenced into the death of John
Michael Thomas (DOB 4/5/94) who died on the 2nd of December 2023 following a road
traffic collision on the A539 outside Llangollen. An inquest has been opened in relation
to Mr Thomas’ death and has been adjourned to allow a Roads Policing Investigation to
provide evidence concerning this death.
4
CIRCUMSTANCES OF THE DEATH
The death occurred when the deceased lost control of the motorcycle he was riding
and collided with an oncoming vehicle, sustaining fatal injuries as a result.
5
CORONER’S CONCERNS
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. –
Initial indications by way of witness evidence suggest that the loss of control occurred
as a result of Mr Thomas’ motorcycle “slipping on the road”.
My understanding is that this has occurred near to the Sun Trevor Public House, and I
have been made aware that some issues regarding flooding and the general condition
of this part of the highway had been made known to the Local Authority prior to the
accident.
Furthermore my understanding is that concerns have also been raised with the Local
Authority in relation to surface water/flooding on another part of the A539 near to
Llangollen, namely near to the Wenfrwdd Pocket Park entrance.
Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN
I am therefore concerned that if action is not taken to remedy these issues, there is a
risk that future deaths may occur.
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.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely 9th February 2024. I, John Gittins, 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 the Family of the Deceased and to the Chief Coroner.
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
Dated 15th December 2023
Signature
Senior Coroner for North Wales (East and Central)
Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN
|
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.
Response of Denbighshire County Council to Regula�on 28 Report of His Majesty’s Coroner, Mr John Gi�ns 1. Background 1.1 1.2 1.3 1.4 On 15 December 2023, His Majesty’s Coroner sent a Regula�on 28 Report (“the Report) to Denbighshire County Council (“the Council”). The Report confirmed that a fatal road traffic accident occurred on 2nd December 2023 when John Michael Thomas lost control of his motorcycle on the A539 outside Llangollen, near to the Sun Inn Public House. An inquest has been opened and adjourned. The Council takes this opportunity to express its sympathy to Mr Thomas’ family for their loss. 2. The Report 2.1 In the Report dated 15 December 2023, HM Coroner sets out the following issues and concerns: • HM Coroner understands that “issues regarding flooding and the general condition of the highway” at the accident loca�on (near to the Sun Inn ) “had been made known to the local authority prior to the accident” – The Sun Inn Loca�on. • HM Coroner understands that “concerns have also been raised with the local authority in relation to surface water/flooding on another part of the A539 near to Llangollen” near to the Wenffrwd Pocket Park Entrance – The Wenffrwd Loca�on. • HM Coroner confirms his concern that “if action is not taken to remedy these issues, there is a risk that future deaths may occur”. 2.2 The Report requires the Council to respond and confirm details of ac�on taken or proposed to be taken and the �metable for such ac�on. 3. The A539 at the Wenffrwd Loca�on, Llangollen 3.1 3.2 This is located approximately one kilometre from the loca�on of the accident. It is shown at Loca�on A on the plan at Appendix 1. On occasions of heavy rainfall or extended periods of wet weather, the land (field) adjacent to the highway becomes saturated and can cause excess water to run off the land and onto the highway. This is not uncommon, par�cularly in rural loca�ons and where there is natural landscape immediately adjacent to the highway. 3.3 Prior to the Report from HM Coroner, the Council was aware of the aforemen�oned issue at this loca�on. It was not (and is not) considered to present a specific safety concern or an issue that requires remedial ac�on. As above, such issues are common across the highway network, par�cularly in rural loca�ons and it is not caused by an issue related to the highway infrastructure. The issue only presents at �mes of heavy or extensive rainfall. It does not result in an amount of water that makes the highway in any way unpassable for traffic and the loca�on is the subject of winter maintenance and gri�ng in accordance with the Council’s winter maintenance policy. 3.4 As a mater of completeness, the Council will contact the owner of the field adjacent to the highway to see if any altera�ons could be made to this private land that may assist in retaining the water on the land on the occasions when it becomes saturated. 4. The A539 at the Sun Inn Loca�on, Llangollen 4.1 4.2 4.3 4.4 4.5 5.0 5.1 5.2 The area of the A539 at the Sun Inn is approximately 200 metres west of the accident loca�on. It is shown as Loca�on B on the plan at Appendix 2. At this loca�on a drainage system from an adjacent road flows into a manhole which is par�ally blocked. As a result, there is an overflow which runs on the highway to flow into a gully approximately 70 metres away, before draining under the road and into the canal. At �mes of heavy or extended rainfall, water runs off the inclined bank and onto the highway and the drainage mechanism described above takes �me to carry away the water. The reason for this is mul�-faceted and includes: • The satura�on of land adjacent to the highway at �mes of heavy or extended rainfall. • The incline of the land adjacent to the highway, such that water falls towards the highway. • The gully being located 70 metres away from this loca�on. • The capacity of gully. The Council is con�nuing to inves�gate this use. It seems likely that a new ou�all system may need to be installed, poten�ally to include new drainage infrastructure in the car park of the Sun Inn. If this work is required, then it will be completed by September 2024 at the latest to ensure it is completed before the requirement for general winter maintenance and gri�ng begins. Drainage feature east of the accident loca�on On the north side of the road there is a stone feature which collects run – off from the land behind it and feeds it into a culvert which again runs under the carriageway to ou�all into the canal. This is shown as Loca�on C on the plan at Appendix 2. The stone feature referred to is historical. It was iden�fied that ongoing use of the private land behind the feature by livestock had altered the layout/surface of the land. This in turn impacted on the flow of water off the land into the feature so that it was not collec�ng all the flow of water from the land. This has been rec�fied. Debris had also collected in the stone feature, and this has been cleared. Whilst it is impossible to eliminate the risk of water run-off onto the highway, these remedial measures have been effec�ve in improving drainage at the loca�on and they are measures that will be retained and con�nued by the Council. 5.3 The council has a list of cri�cal culverts which are known to require higher maintenance standards and this feature will now be added to it a monitored more closely. 6. Other maters 6.1 We have addressed above the specific concerns highlighted in the Report of HM Coroner. More generally, and in an effort to assist HM Coroner, the Council is able to provide further informa�on in rela�on to the A539 in this sec�on of its response. 6.2 6.3 6.4 6.5 The A539 is subject to a regular system of rou�ne inspec�ons in accordance with the Council’s policy for highway maintenance. Rou�ne inspec�ons are carried out every three months. The A539 forms part of the highway gri�ng network in accordance with the Council’s Winter Maintenance Policy. Following the extensive rainfall and disrup�on caused by Storm Babet on 20th October 2023, the Council implemented a specific response ac�on of addressing the impact of the storm on drainage gullies and channels on the A539. This work has been completed with all gullies and channels being cleared. As an addi�onal safety measure, the Council has also erected warning signs on the A539 at both the Wenffrwd Junc�on loca�on and the Sun Inn loca�on. These warning signs alert motorists to the possibility of the presence of water or ice. 7. Conclusion 7.1 7.2 Across any highway network, there will always be loca�ons where issues of water drainage arise, par�cularly during �mes of heavy or extended rainfall. There are mul�ple poten�al reasons for this, to include the topography of the area. The safety of the highway network for the public is of paramount important to the Council. I am sa�sfied that the specific concerns iden�fied by HM Coroner have been carefully considered and reasonable and appropriate measures are in place to address them. 7.3 The Council is of course willing to assist HM Coroner with his inquiry in any way that it can. Head of Highways and Environmental Services 08.03.24
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