Prevention of Future Deaths reports · 2024

Kial Thurman

Regulation 28 report to prevent future deaths, reference 2024-0454, written 13 Aug 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report13 Aug 2024
Reference2024-0454
DeceasedKial Thurman
CoronerNicholas Walker
Coroner areaStaffordshire and Stoke on Trent
CategoryRoad (Highways Safety) related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

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.  Staffordshire County Council 

1 

CORONER 

I am Nicholas Walker, assistant coroner, for the coroner area of Staffordshire and Stoke-
on-Trent. 

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 18th December 2023 an investigation was commenced into the death of Kial Ryce 
Thurman. The investigation concluded at the end of the inquest on 2 nd August 2024. The 
conclusion of the inquest was that Kial Ryce Thurman died in a road traffic collision on 1 st 
December 2023. 

4 

CIRCUMSTANCES OF THE DEATH 

Kial was driving a transit van at speed along the A518 in the Lower Loxley area of 
Staffordshire heading in the direction of Uttoxeter when he lost control while navigating a 
right-hand bend immediately before a bridge that crossed the River Blythe.  Either because 
Kial over-corrected his steering, or because the van hit the nearside kerb and rebounded, 
the van entered the opposing carriageway and into the path of an HGV.  The impact 
caused the van to enter the river.  Kial suffered multiple injuries and died at the scene. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 5 

CORONER’S CONCERNS 

During the inquest the evidence revealed matters giving rise to concern. In my opinion 
there is a risk that future deaths could occur unless action is taken. In the circumstances it 
is my statutory duty to report to you. 

The MATTERS OF CONCERN are as follows.  –  

The rural, unlit road is governed by the national speed limit of 60 mph and narrows in both 
directions at the point of the bridge.  Driving towards Uttoxeter, drivers are faced with a 
right-hand bend that the inquest heard can catch drivers unawares and has been the 
location of other road traffic accidents. The inquest heard that the bridge has been 
repaired a number of times as a consequence of collisions.  Although the road has signs 
that warn drivers of the nature of the hazard ahead, a police collision expert considered 
that a reduction in the speed limit at this location would reduce the risk of collisions.   

I am concerned that the national speed limit on the A518 at the point of the Blythe Bridge 
at Lower Loxley is too high and carries the risk of future deaths.  

6 

ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe you [AND/OR 
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 8th October 2024 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 the Chief Coroner and to the following Interested 
Persons: 
The family of Mr Thurman 

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 

Signed by the Coroner 13th August 2024

Responses

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 from Staffordshire County Council (PDF)
Accident Investigation Unit       

Staffordshire County Council                                                                             

                                          Staffordshire Place 1 
                                                     Tipping Street 
Stafford 
                                                            ST16 2DH  

E-mail: 

07/10/2024 

Mr N Walker 
Assistant Coroner  
Staffordshire and Stoke-on-Trent 
Coroners Service 
Stoke Town Hall 
Stoke on Trent 
ST4 1HH 

Dear Mr Walker, 

Re: K Thurman (Deceased) 
A518 Lower Loxley 

I refer to your Regulation 28 report regarding the inquest into the death of Kial Ryce Thurman 
and your comments concerning the A518 Lower Loxley.  

This letter is in response to the matters of concern recorded in section 5 of your report, 
which states the following points. 

(1) Drivers  travelling  towards  Uttoxeter  are  faced  with  a  right-hand  bend  that  the 
inquest  heard  can  catch  drivers  unawares  and  has  been  the  location  of  other 
road traffic accidents  

(2) Although the road has signs that warn drivers of the nature of the hazard ahead, 
a  police  collision  expert  considered  that  a  reduction  in  the  speed  limit  at  this 
location would reduce the risk of collisions.  

To date, the following action has been taken in response to the concerns raised:  

•  A site visit with representatives from Staffordshire County Council Highways has taken 
place to review the layout of the road and consider the points raised through the PFD 
report submitted. 

•  Research and analysis of historical personal injury collisions has been undertaken at the 

point of the right-hand turn and bridge location of concern.  

•  Wider  highways  asset  management  colleagues  have  been  consulted  regarding  the 

history of the bridge and immediate area. 

•  An assessment of the general speed of traffic has taken place. 

 
 
 
 
                                                                                                       
     
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 Personal Injury Collision History 

During the last complete 5-year period (2018-2022) and including any reports we have received 
from Staffordshire Police since, there has been one other (slight injury) collision recorded in this 
area  of  concern,  and not associated  with  the  right-hand  turn heading  towards  Uttoxeter.  The 
causation  of  this other  collision  was  due  to a  vehicle  following  another too  close,  there is no 
indication of excessive or inappropriate speed. 

Staffordshire County council are aware of a number of minor non-injury collisions which are not 
reportable/recordable that may have occurred on the bridge over the last decade, but we do not 
have any the details of the mechanics of these collisions required to analyse vehicle movements 
or contributory factors to assess the common patterns.  

Site Layout 

In relation to point 1, upon approach to the right hand turn when travelling towards Uttoxeter 
drivers are pre-warned by the following highway features: 

•  Large yellow backed right hand bend & narrow carriageway signage. 
•  SLOW markings on the carriageway. 
•  Double while line system. 
• 

Illuminating  ‘Bend  Ahead’  electronic  vehicle  activated  signage  (inspected  and  in  good 
working order on 16/11/2023). 

•  Large  yellow  backed  chevron  signage  at  the  point  of  the  right-hand  bend  along  the 

highway curvature. 

•  Reflective marker posts on the bend and at the point of the bridge. 

It is assessed that the current safety features are sufficiently appropriate to warn drivers of the 
approaching bend. The same features exist when approaching from the opposite direction. 

Of  note,  a  future  long-term  proposal  to  replace  the  bridge  structure  is  currently  underway 
depending on funding.  

Speed Limit 

National  speed  limit  roads are  applied  throughout the  county  network in  accordance  with  the 
Department  for  Transport  “setting  of  local  speed  limit”  guidelines.  Speed  limits  should  be 
evidence-led and self-explaining and seek to reinforce people’s assessment of what is a safe 
speed to travel. They should encourage self-compliance. Speed limits should be seen by drivers 
as the maximum rather than a target speed. An assessment of the speeds at this location shows 
and all-day average traffic speed of 39.7mph, with 85% of the traffic travelling at 45.5mph or 
less. 

When setting a lower speed limit, robust consideration needs to be applied to assess if motorists 
will then interpret a lower limit as the recommended safe target speed rather than the maximum, 
thus causing more of a risk.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 As  part  of  our  statutory  functions  and  commitment  to  our  communities  and  road  safety, 
Staffordshire  County Council  routinely monitors personal injury collision  data  reported  on  the 
public  highway  to  identify  accident  clusters  and  trends.  Any  treatable  pattern  of  accidents 
identified  will  have  proportionate  remedial  measures  put  forward  for  funding  and  will  be 
prioritised  against  other  locations  around  Staffordshire.  Any  appropriate  mitigating  solutions 
identified  at  this  location  will  be  prioritised  alongside  our  annual  programme  of  road  safety 
schemes.   

I  hope  the  information  provided  within  this  letter  is useful.  Please  let  me  know  if  you  require 
anything further. 

Yours sincerely, 

Road Safety Manager 
Staffordshire County Council

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