Wilfred Fitchett, Jevon Hirst, Hugo Morris and Harvey Owen

Kate Robertson
Senior Coroner for North West Wales

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO:
Secretary of State for Transport,
The Department for Transport

1

CORONER

I am Kate Robertson, HM Senior Coroner for North West Wales

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 27 November 2023 I commenced an investigation into the deaths of Wilfred John
Fitchett, Jevon Alexander Hirst, Hugo Oliver Morris and Harvey Graham Owen. The
investigation concluded at the end of the inquest on 16 October 2024.  A Road Traffic
Collision conclusion was recorded with deaths for all four young men resulting from
drowning.

4

CIRCUMSTANCES OF THE DEATH

The circumstances of the death are as follows :-

Hugo Morris was aged 18 at the time of his death. On 19 November 2023 he was
driving a motor vehicle and carrying three passengers who were aged 17 (Wilfred), 16
(Jevon) and 17 (Harvey), along the A4085 Garreg, Llanfrothen having been on a
camping trip when the motor vehicle in ques(cid:415)on veered onto the nearside grass verge
and entered into a water-filled drainage ditch which led to the deaths of all four young
men, where the exis(cid:415)ng signage would not have given adequate warning of the 
upcoming bend. The motor vehicle with the four young men was not found un(cid:415)l 21 
November 2023.

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.

Coroner's Office, Shirehall Street, Caernarfon

 The MATTERS OF CONCERN are as follows  –

a. Hugo was aged 18 at the time of his death following the collision and had

passed his driving test on 23 May 2023. This was 6 months and 16 days prior to
the collision. At the time of the collision, he was legally carrying 3 other young
persons, his friends.

b. Currently, there are no legal restrictions upon the licences of young and/or
newly qualified drivers and the current vehicle licensing regime permits the
carrying of young persons as passengers in circumstances such as these.

c.

d.

It is noted that young drivers are exponen(cid:415)ally more likely to be involved in a 
collision with each similar aged passengers in the car.

I am concerned that deaths will continue to occur or will occur into the future
where younger persons are carried in motor vehicles being driven by newly
qualified and/or young drivers.

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 12 December 2024. I, Kate Robertson, 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 Families, Interested Persons, Driver Vehicle
Licencing Authority 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 17 October 2024

Coroner's Office, Shirehall Street, Caernarfon

 Signature
Kate Robertson
HM Senior Coroner for North West Wales

Coroner's Office, Shirehall Street, Caernarfon

Response to Regulation 28 Report to Prevent Future Deaths, on behalf of the Trustees of the
Ymddiriedolaeth Clough Williams-Ellis Foundation.

1.

Introduction

1.1 The following has been prepared in response to the Coroner’s Regulation 28 Report to Prevent
Future deaths issued to the Trustees of the Ymddiriedolaeth Clough Williams-Ellis Foundation
as Landowners of the Brondanw Estate.

1.2 It goes without saying that the death of the four young men on 19th November 2023 is deeply

upsetting and tragic.

1.3 The land upon which the vehicle ended up is owned by the Trustees, but let to the 

 under a contract of tenancy governed by the Agricultural Holdings

Act 1986.

2. The Coroner’s Report

2.1 The Coroner’s Report, in so far as the Landowner is concerned, states:

2.2 A stock fence had been erected (likely by the private Landowner) concerning the lane of the
road in question. It is understood that Cyngor Gwynedd had no responsibility for this given
that it was on private land. The stock fence had been damaged and had not been replaced
prior to the collision on 19th November 2023.

2.3 Whilst the evidence could not determine whether or not the fence, had it been repaired and
in situ at the time of the collision, would have altered the outcome the risk to road users
who leave the road accidentally is that they may land in the ditch below road level.

3. The Brondanw Estate’s Position

3.1 It is extremely unlikely that the roadside fence would have been erected by the Landowner.
Under the terms of the tenancy, fencing is the responsibility of the Tenant. The Tenant has
confirmed to us that in this case the fence was in fact erected by Cyngor Gwynedd a number
of years ago. The Tenant has further confirmed that there would be no reason to have erected
a fence in that location as the ditch and embankment act as the stock proofing for the adjacent
field.

3.2 In any case stock fencing is not meant to be a feature of highway safety and is not designed
to  withstand  the  force  of  a  car  hitting  it  at  speed,  and  if  that  was  its  intended  purpose
something more robust ought to have been considered.

3.3 Over the years there have been a number of accidents on the section of road in question.

3.4 Any  works  on  or  adjacent  to  a  public  highway  to  enhance  safety  for  road  users  are  the

responsibility of the relevant Authority and not the adjoining Landowner.

 3.5 The below photograph shows the section of stock fencing erected by Cyngor Gwynedd behind

bollards recently erected by Cyngor Gwynedd.

3.5 The  below  photograph  shows  the  point  where  the  car  entered  the  ditch,  where  no  stock

fencing exists or existed, but now has the bollards installed by Cyngor Gwynedd.

 3.6 The bollards, whilst delineating the edge of the carriageway, are of low quality and unlikely to
be sufficiently strong to prevent a vehicle crashing through them and potentially ending up in
the ditch below.

Balfours LLP,
New Windsor House,
Oxon Business Park,
Shrewbury, SY3 5HJ

Agents to the Trustees of the Ymddiriedolaeth Clough Williams-Ellis Foundation

February 2024

Adran Amgylchedd 
Environment Department 

Pennaeth Cynorthwyol yr Adran/Assistant Head of Department  
Gwasanaethau Trafnidiaeth / Transport Services 

Ein Cyf / Our Ref:  
Eich Cyf / Your Ref: 

Kate Robertson 
Uwch Grwner EF ar gyfer Gogledd Orllewin Cymru  
HM Senior Coroner for North West Wales 
Swyddfa’r Crwner / Coroner’s Office 
Stryd y Jêl / Shirehall Street 
Caernarfon 
Gwynedd 
LL55 1SH 

Annwyl Grwner, 

11/12/2024 

Ymateb i’r Adroddiad Rheoliad 28 i Atal Marwolaethau yn y Dyfodol (PFD)  

Ymhellach i'r Adroddiad Rheoliad 28 a gyflwynwyd i Gyngor Gwynedd ar 24 Hydref 2024, ar ôl diwedd y 
Cwest  a  gynhaliwyd  ar  16  Hydref  2024  i  farwolaethau  trasig  Hugo  Morris,  Jevon  Hirst,  Harvey  Owen  a 
Wilfred Fitchett, gweler ynghlwm ymateb y Cyngor fel Atodiad 1. 

Dear Coroner, 

Response to Regulation 28 Report to Prevent Future Deaths (PFD) 

Further  to  the Regulation  28  Report  issued  to  Cyngor  Gwynedd  on  the 24  October  2024,  following  the 
conclusion of the Inquest held on the 16 October 2024 into the tragic deaths of Hugo Morris, Jevon Hirst, 
Harvey Owen and Wilfred Fitchett, please find attached as Appendix 1 the Council’s response. 

Yn gywir / Yours sincerely, 

Pennaeth Adran Cynorthwyol 
Assistant Head of Department 

Gwasanaethau’r Adran: Cynllunio; Polisi Cynllunio; Rheolaeth Adeiladu; Gwastraff ac 
Ailgylchu Gwarchod y Cyhoedd; Traffig a Pharcio; Cludiant Cyhoeddus; Cefn Gwlad a 
Bioamrywiaeth: Gwybodaeth am y gwasanaethau ar gael YMA 
Services  within  the  Department:  Planning;  Planning  Policy;  Building  Regulations;  Waste 
and Recycling; Public Protection; Traffic and Parking; Public Transport; Countryside and 
Biodiversity. Information relating to these services can be found HERE 

  Swyddfa’r Cyngor 
  Caernarfon 
  Gwynedd. LL55 1SH 
  01766 771000 

www.gwynedd.llyw.cymru  

 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Atodiad 1 

Ymateb i’r Adroddiad Rheoliad 28 i  
Atal Marwolaethau yn y Dyfodol (PFD) 
_______________________________________________________________________________ 

1. 

CYFLWYNIAD 

1.1  Mae'r  canlynol  wedi'i  baratoi  mewn  ymateb  i  adroddiad  Rheoliad  28  y  Crwner  i  Atal 
Marwolaethau yn y Dyfodol (PFD) a gyflwynwyd i Gyngor Gwynedd. Mae hyn ymhellach i Gwest 
y  Crwner  ar  16  Hydref  2024  a  fu'n  ymdrin  â  marwolaethau  pedwar  dyn  ifanc  a  fu  farw  mewn 
gwrthdrawiad traffig ffordd enbyd ar 19 Tachwedd 2023 ger Garreg Llanfrothen, Gwynedd. 

1.2 

Fe wneir cyfeiriad penodol at y pryder isod a gaiff ei godi yn yr Adroddiad: 

“nad oes rhwystr neu ffens neu unrhyw beth arall i atal cerbydau modur rhag gadael y ffordd” 

2. 

CEFNDIR 

2.1  Mae'r  A4085  yn  Briffordd  Dosbarth  1  sydd  wedi'i  dynodi'n  Brif  Ddosbarthwr  CH1  yn  Llawlyfr 
Cynnal Priffyrdd Cyngor Gwynedd. Mae'r rhain yn briffyrdd rhwng llwybrau strategol sy’n cysylltu 
canolfannau  trefol 
lle  digwyddodd  y 
i’r  rhwydwaith  strategol.  Mae'r  rhan  o'r  A4085 
i 
gwrthdrawiad  yn  darparu  cysylltiad  rhwng  Penrhyndeudraeth,  Beddgelert  ac  ymlaen 
Gaernarfon.  Caiff  ei  defnyddio  at  ddibenion  bob  dydd  gan  drigolion  lleol  ac  mae'n  boblogaidd 
gyda thwristiaid ac ymwelwyr eraill, yn cynnig mynediad i galon Parc Cenedlaethol Eryri.   

2.2  Mae'r A4085 yn lôn tua 21 milltir o hyd sy'n dolennu yma ac acw, wrth iddi ddringo'n raddol o 
fod bron yn lefel â'r môr ym Mhenrhyndeudraeth tuag at droed y mynyddoedd yn Eryri, ac yn ôl 
tua lefel y môr yng Nghaernarfon. Mae nodweddion y lôn wledig olygfaol hon yn debyg i lonydd 
eraill sy'n croesi'r un fath o amgylchedd a thopograffi. 

2.3 

Roedd  y  llifau  traffig  dyddiol  cyfartalog  am  y  cyfnod  30/10/2023-05/11/2023  yn  Tŷ-Maen, 
Llanfrothen, tua 1.1 milltir i'r de ar yr A4085 o safle'r gwrthdrawiad, yn 511. Nid yw'r rhan hon 
o'r rhwydwaith yn profi tagfeydd gan fod llif y traffig yn isel, ac mae cymeriad y ffordd yn wledig 
gyda choed o boptu iddi am rannau helaeth, creigiau'n ymestyn allan a rhannau cul, yn ogystal â 
nifer o bantiau a throeon. Mae’r rhain yn ffurfio cymeriad nifer o ffyrdd gwledig yng Ngwynedd. 

2.4  Mae'r Cyngor yn derbyn gwybodaeth gan y system adrodd STATS19 ar ddata gwrthdrawiadau a 
chan  wasanaeth  Heddlu  Gogledd  Cymru  drwy  Lywodraeth  Cymru.  O  ddadansoddi  data  a 
ddaliwyd rhwng 2019 tan fis Mawrth 2024, yr unig ddigwyddiad sydd wedi'i gofnodi yn lleoliad y 
gwrthdrawiad yw'r gwrthdrawiad angheuol ym mis Tachwedd 2023. 

2.5  Mae  cofnodion  mewnol  y  Cyngor  o  ymholiadau  a  chwynion  yn  cadarnhau  nad  oes  unrhyw 
gofnod o unrhyw gwynion neu ymholiadau wedi'u derbyn gan yr Uned Traffig mewn perthynas 
â'r rhan hon o'r ffordd. 

2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 3. 

SAFBWYNT CYNGOR GWYNEDD 

3.1 

3.2 

Ar  sail  y  ffactorau  dylanwadol  uchod,  gan  roi  ystyriaeth  i'r  arweiniad  yn  y  Llawlyfr  Arwyddion 
Traffig, mae Cyngor Gwynedd yn dal i fod o'r farn fod yr arwyddion traffig a marciau ffordd oedd 
mewn  lle  yng  nghyffiniau  safle'r  gwrthdrawiad  ar  adeg  y  gwrthdrawiad  yn  briodol  ac  yn 
rhesymol, yn rhoi rhybudd digonol o'r tro sydd o'ch blaen. Er bod hyn yn groes i farn y Crwner, 
caiff y farn hon ei chefnogi gan dystiolaeth a gyflwynwyd i'r Cwest gan Swyddog Gwrthdrawiadau 
Fforensig Heddlu Gogledd Cymru ynghyd ag Uwch Beiriannydd Traffig Cyngor Gwynedd. 

Fodd  bynnag,  ar  ôl  y  gwrthdrawiad,  gan  ddefnyddio  pwerau  sydd  wedi'u  breinio  i  Gyngor 
Gwynedd fel yr Awdurdod Priffyrdd yn Neddf Traffig Ffyrdd 1998 “er mwyn rheoli, gwarchod neu 
gynorthwyo symudiad traffig ar ffyrdd”, mae'r Cyngor wedi gweithredu'r gwelliannau a ganlyn ar 
sail dewisol ac anrhagfarnol. 

•  wedi gosod byrddau 'chevron' ar gornel y tro hir. 
•  wedi uwchraddio'r marciau “Araf/Slow” yn y ddau gyfeiriad ger lleoliad y gwrthdrawiad. 
•  wedi uwchraddio arwyddion yn rhybuddio am y tro llaw-dde. 
• 

⁠wedi gosod cyfres o farcwyr ymyl ffordd adlewyrchol ar ymyl y tro. 

4. 

ASESIAD RHWYSTR FFORDD AR GYFER SAFLE PENODOL 

4.1 

Oherwydd:  

1.  Natur drasig, proffil uchel a sensitif y sefyllfa. 
2.  Bod  cyfeiriad  penodol  yn  cael  ei  wneud  at  y  pryder  a  godwyd  yn  Adroddiad  Rheoliad  28  y 

Crwner: 

“nad oes rhwystr neu ffens neu unrhyw beth arall i atal cerbydau modur rhag gadael y ffordd” 

4.2 

4.3 

4.4 

Fe gynhaliwyd asesiad ar gyfer darparu System Rhwystr Ffordd (RRS – road restraint system) yn y 
safle. 

Roedd  yr  asesiad  yn  seiliedig  ar  yr  arweiniad  sydd  wedi'i  amlinellu  yng  Nghanllaw  Dylunio  a 
Chynnal  a  Chadw'r  Adran  Drafnidiaeth  ar  gyfer  Ffyrdd  Awdurdodau  Cyhoeddus,  Darparu 
Systemau Rhwystr Ffordd ar Ffyrdd Awdurdodau Cyhoeddus. 

Dewiswyd y Canllaw hwn oherwydd y lefel isel o draffig sy'n defnyddio'r A4085. Mae’r Canllaw 
yn  rhoi  fframwaith,  ond  nid  yw'n  gyfarwyddol.  Cydnabyddir  y  bydd  nifer  o  ffactorau  yn 
dylanwadu ar briodoldeb a chyfiawnhad system RRS ac mae'r rheiny'n cynnwys natur a defnydd 
y  ffordd,  data  gwrthdrawiadau,  perchnogaeth  tir,  ystyriaethau  peirianyddol,  amgylcheddol  ac 
esthetig yn ogystal â chost (costau cyfalaf ar gyfer gosod y system, a chostau refeniw parhaus ar 
gyfer ei harchwilio a'i chynnal a chadw wedi hynny). 

4.5  Mae'r Canllaw yn cynnwys diffiniadau ac eglurhad mwy manwl ynghylch yr hyn y cyfeirir atynt fel 

Dull A (Asesu Damweiniau) a Dull C (Sgorio Risg). Mae’r isod yn rhoi crynodeb: 

•  Mae Dull A yn ystyried data ar wrthdrawiadau i asesu'r tebygolrwydd o ddamwain ddifrifol yn 

digwydd. 

•  Mae Dull C yn ystyried natur y ffordd a'r peryglon sy'n bresennol yn fwy na'r tebygolrwydd. 

3 

 
 
 
  
 
 
 
 
 
 
 
 
 
 
 4.6 

Fel sydd wedi'i nodi yn y Canllaw, nid asesiad Dull C fyddai'r prif ddull o asesu risg os oes data 
gwrthdrawiadau  ar  gael  ac  felly  mae  modd  defnyddio  dull  A.  Fodd  bynnag,  at  ddibenion  yr 
asesiad hwn fe ddefnyddiwyd Dull A a Dull C. 

4.7  Mae Casgliad yr asesiad a wnaed i'w weld isod. 

Casgliad 
Wrth  ddefnyddio'r  asesiadau  a  amlinellir  yng  Nghanllaw  Dylunio  a  Chynnal  a  Chadw'r  Adran 
Drafnidiaeth  a'r  UK  Roads  Liaison  Group  ar  gyfer  Ffyrdd  Awdurdodau  Cyhoeddus,  Darparu 
Systemau Rhwystr Ffordd ar Ffyrdd Awdurdodau Cyhoeddus:  

•  Daw Dull A i'r casgliad fod y safle yn safle blaenoriaeth isel yn seiliedig ar amlder damweiniau 

hanesyddol. 

•  Daw  Dull  C  i'r  casgliad  fod  y  safle  yn  safle  blaenoriaeth  ganolig  uchaf  yn  seiliedig  ar 

nodweddion y ffordd. 

Mae'r  canllaw  ar  gyfer  safleoedd  blaenoriaeth  ganolig  yn  datgan  efallai  fod  cyfiawnhad  am 
system rhwystr ffordd, fodd bynnag mae'n bosib y byddai dull nad yw'n defnyddio RRS i leihau'r 
risg yn ddigonol i negyddu’r angen am RRS. 

Oherwydd diffyg ymyl ffordd gwastad, nid oes modd gosod system rhwystr ffordd yn hawdd heb 
waith sylweddol i greu ymyl ffordd, a fyddai'n golygu costau helaeth. 

Byddai tynnu'r peryglon presennol hefyd yn gofyn am waith sylweddol a byddai yna ganlyniadau 
amgylcheddol yn ei sgil. 

Mae'r lefelau traffig ar yr A4085 yn isel iawn i ffordd A ac mae'r cyflymderau a fesurwyd hefyd yn 
llawer is na'r 60mya a ganiateir oherwydd aliniad y ffordd. 

Mae'r  arwyddion  ar  y  tro  eisoes  wedi  cael  eu  gwella  yn  dilyn  y  ddamwain  angheuol,  ac  wedi 
cynyddu'r  rhybudd  i  fodurwyr  am  y  tro  sydd  o'u  blaen,  a  bydd  hyn  yn  lleihau'r  tebygolrwydd 
ymhellach  o  gerbyd  yn  gadael  y  ffordd  ar  y  tro.  Mae'n  bosib  iawn  y  bydd  hyn  yn  ddigonol  i 
negyddu'r angen am system RRS. 

4.8 

Fe  nodir  yn  y  Canllaw,  mewn  sawl  achos  y  gellir  ystyried  RRS  fel  y  'dewis  olaf',  gyda  mesurau 
lliniaru eraill yn cael eu hystyried i fod yn ddigon priodol. Mae'r rhain yn cynnwys y canlynol sydd 
eisoes wedi cael eu gweithredu yn safle'r gwrthdrawiad: 

•  Gosod  byrddau  chevron  ac  arwyddion  rhybuddio,  yn  cynnwys  arwyddion  sy’n  cael  eu  rhoi 

ymlaen gan gerbydau. 

•  Gosod nodweddion ymyl-ffordd goddefol fel awgrym gweledol o berygl e.e. pyst adlewyrchol 

hyblyg (deformable reflective posts). 

4.9  Mae'r Canllaw hefyd yn nodi: 

Mae'r penderfyniad i ddarparu system RRS mewn sefyllfa llif isel neu gyflymder isel yn un anodd 
oherwydd  y  costau  uchel  a'r  risg  isel  posib  o  ddamweiniau  mewn  lleoliad  penodol.  Gall  un 
ddamwain  sy'n  cynnwys  cerbyd  yn  gadael  y  gerbyd-lon  fod  yn  ganlyniad  i  nifer  o  ffactorau 
priffordd, ond gall arwain at gryn bwysau gan y cyhoedd i ddarparu system RRS. 

4 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Ni ddylai'r sawl sy'n gwneud y penderfyniad fod ofn gwneud dim byd, os mai gwneud dim yw'r 
casgliad priodol a ddaw o'r broses asesu sydd wedi'i hamlinellu yn y Canllaw. 

4.10  Ar sail yr uchod, gan ystyried y gwelliannau sydd eisoes wedi cael eu gweithredu, mae opsiynau 
yn y tymor byr i osod RRS yn gyfyngedig o ran y sgôp a'r cyfiawnhad. Fodd bynnag, fe gaiff hyn ei 
adolygu  gan  fod  yna  ffactorau  eraill  a  allai  ddylanwadu  ar  hyn.  Gallai'r  rhain  gynnwys  gwaith 
cynnal  a  chadw  yn  y  dyfodol  a/neu  welliannau  ehangach  a  mwy  sylweddol  i'r  briffordd  a  allai 
effeithio ar yr ystyriaethau sy'n pennu a ddylid gosod RRS ai peidio.  

4.11  O safbwynt sawl peth, gan gynnwys y gost, y safbwynt amgylcheddol a pherchnogaeth tir, efallai 
y byddai darpariaeth RRS fel rhan o gynllun ehangach yn fwy hyfyw a chyfiawnadwy na chynllun 
unigol i osod RRS oherwydd yr ystyriaethau a chyfyngiadau sy'n benodol i'r safle dan sylw. 

4.12  Bydd  Cyngor  Gwynedd  hefyd  yn  ystyried  pa  ymyraethau  pellach,  ac  os  oes  yna  unrhyw 
ymyraethau pellach ar wahân i RRS, fydd efallai'n cael eu gweithredu i liniaru ymhellach y risgiau 
sy'n gysylltiedig â'r gwrthdrawiad hwn ac amgylchiadau'r marwolaethau trasig. 

5. 

CASGLIAD 

5.1 

5.2 

5.3 

Fe all fod yna gyfleoedd i wneud newidiadau i'r briffordd mewn ymdrech i gael dylanwad positif 
ar ymddygiad gyrwyr, lleihau pa mor ddifrifol yw gwrthdrawiadau posib, neu wneud newidiadau 
dyluniad i'r ffordd er mwyn lleihau'r risg o wrthdrawiadau.  

Fodd bynnag, mae yna gyfyngiadau cyllidol, adnoddau, ffisegol, peirianyddol, cyfreithiol ac eraill 
sy'n  golygu  bod  yna  gyfyngiadau  ar  yr  hyn  y gall,  ac  y gellir  disgwyl  i,  Awdurdodau  Priffyrdd  ei 
wneud i wella diogelwch y rhwydwaith priffyrdd ymhellach. 

Nid gwneud newidiadau i'r rhwydwaith priffyrdd yw'r unig fodd o leihau nifer y damweiniau ar y 
rhwydwaith.  Mae  swyddogion  Cyngor  Gwynedd  yn  gweithio'n  barhaus  mewn  partneriaeth  â 
Heddlu  Gogledd  Cymru  ac  mae'r  ymdrechion  cydweithio  yma  wedi  bod  hanfodol  wrth  gael 
dylanwad positif ar nifer y gwrthdrawiadau ar ein rhwydwaith. 

5.4  Mae'r penderfyniad a'r cyfiawnhad i ddarparu system RRS mewn sefyllfa llif isel a/neu gyflymder 
isel  yn  un  anodd  ar  rwydwaith  priffyrdd  gwledig  enfawr.  Mae  hyn  yn  rhoi  ystyriaeth  i  ac  yn 
adlewyrchu  cymesuroldeb  a  phriodoldeb  ymyraethau  o'r  fath  o  safbwynt  risg  (tebygolrwydd  a 
difrifoldeb), cyfyngiadau peirianyddol, ystyriaethau amgylcheddol ac esthetig, cost a chysondeb. 
O ran costau mae hyn yn cynnwys y costau gosod cyfalaf sylweddol ynghyd â'r costau cynnal a 
chadw parhaus wedi hynny. 

⁠5.5 

5.6 

Yn  ei  hanfod,  pwrpas  RRS  yw  cadw  cerbydau  oddi  fewn  i  derfynau'r  briffordd  lle  mae  ongl  yr 
ardrawiad  yn  berthnasol.  Fe  allai  system  RRS  mewn  lleoliad  fel  safle'r  gwrthdrawiad  fod  yn 
wrthrych disymud sydd wedyn yn creu perygl ynddo'i hun petai, er enghraifft, cerbyd yn ei daro 
i  droi  drosodd  ac/neu  arwain  at 
wrth  deithio'n  gyflym  a  allai  beri'r  cerbyd 
ardrawiadau/gwrthdrawiadau gyda cherbydau eraill. 

Nid yw cyflwyno system RRS yn gwneud sefyllfa yn gwbl ddiogel bob tro, a byddai gosod system 
sy'n cydymffurfio â'r canllaw yn y lleoliad hwn yn golygu costau sylweddol. Bob blwyddyn, mae 
yna anafiadau sy'n cael eu hachosi pan fydd cerbydau yn taro systemau RRS ac mae'r Canllaw yn 
cydnabod bod elfen o risg ymhlyg mewn unrhyw system RRS. Mae'n rhaid cydbwyso’r risg hwn 
yn erbyn y budd o liniaru difrifoldeb unrhyw ddamwain am gost fforddiadwy. 

5 

 
 
 
 
 
 
 
 
 
 
 
 5.7  Mae Rheolau’r Ffordd Fawr (The Highway Code) yn pwysleisio'r pwysigrwydd bod modurwyr yn 
parhau i ganolbwyntio ar y ffordd sydd o'u blaen, a bod ganddynt rôl a chyfrifoldeb sylweddol yn 
niogelwch y ffordd. 

6 

 
 
 
 
 Appendix 1 

Response to Regulation 28 Report 
to Prevent Future Deaths (PFD) 
_______________________________________________________________________________ 

1. 

INTRODUCTION 

1.1 

The following has been prepared in response to the Coroners’ Regulation 28 Report to Prevent 
Future  Deaths  (PFD)  issued  to  Cyngor  Gwynedd.  This  is  further  to  the  Coronial  Inquest  of  16 
October 2024 touching the deaths of four young men who died in a tragic road traffic collision on 
the 19 November 2023 near Garreg Llanfrothen, Gwynedd.   

1.2 

Specific reference being made to the concern raised in the Report that: 

“there is no barrier or fence or otherwise to prevent motor vehicles leaving the road” 

2. 

BACKGROUND 

2.1 

2.2 

2.3 

2.4 

The  A4085  is  a  Class  1  Highway  designated  a  CH1  Main  distributor  in  the  Cyngor  Gwynedd 
Highways Maintenance Manual. These are highways between strategic routes and linking urban 
centres to the strategic network. The section of the A4085 where the collision occurred provides 
a  link  between  Penrhyndeudraeth,  Beddgelert  and  onwards  to  Caernarfon.  It  is  used  for 
everyday  purposes  by  local  residents  and  is  popular  with  tourists  and  other  visitors  affording 
access to the heart of the Eryri National Park.   

The  A4085  is  an  approximate  21-mile  route that  is  meandering  in  nature  as  it  climbs  gradually 
from  near  sea  level  at  Penrhyndeudraeth  towards  the  foothills  of  the  mountains  in  Eryri  and 
back  towards  sea  level  at  Caernarfon.  Features  of  this  scenic  route  are  similar  to  others 
traversing the same kind of environment and topography. 

Daily  average  traffic  flows  for  the  period  30/10/2023-05/11/2023  at  Tŷ-Maen,  Llanfrothen, 
approximately 1.1 mile south on the A4085 from the site of the collision, was 511.  This part of 
the  network  is  not  subject  to  congestion  as  the  traffic  flows  are  low,  and  the  character  of  the 
road  is  rural  with  extensive  tree  coverage,  rocky  outcrops  and  narrow  sections  as  well  as 
numerous dips and bends.  These form the character of many rural roads in Gwynedd. 

The Council receive information from the STATS19 reporting system on collision data and from 
the  North  Wales  Police  Service  via  the  Welsh  Government.    From  analysing  data  captured 
between 2019 and March 2024, the only incident that has been recorded at the collision location 
is the tragic fatal collision in November 2023.   

2.5 

The  Council’s  internal  enquiries  and  complaints  records  confirm  that  there  is  no  record  of  any 
complaints or enquiries received by the Traffic Unit relating to this section of road.  

7 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 3.  

CYNGOR GWYNEDD’S POSITION 

3.1 

On  the  basis  of  the  above  influencing  factors,  giving  consideration  to  the  guidance  within  the 
Traffic  Signs  Manual,  Cyngor  Gwynedd  maintains  the  position  that  the  traffic  signs  and  road 
markings in situ in the vicinity of the collision site at the time of the collision  were appropriate 
and  reasonable  giving  adequate  warning  of  the  upcoming  bend.  While  this  is  contrary  to  the 
opinion of the Coroner this position is supported by evidence presented to the Inquest by both 
the  North  Wales  Police  Forensic  Collision  Officer  as  well  as  Cyngor  Gwynedd’s  Senior  Traffic 
Engineer.  

3.2 

However, post collision, applying powers vested to Cyngor Gwynedd as the Highway Authority in 
Section 39 of the Road Traffic Act 1988 “for controlling, protecting or assisting the movement of 
traffic  on  roads”,  the  Council have  implemented  the following  enhancements  on  a  discretional 
and non-prejudicial basis: 

installed chevron boards on the corner of the sweeping bend. 

• 
•  upgraded the road “Araf/Slow” markings in both directions near to the collision location.  
•  upgraded warning signage of the right-hand bend.  
• 

installed a series of reflective verge markers on the edge of the bend. 

4. 

SITE SPECIFIC ROAD RESTRAINT ASSESSMENT 

4.1 

Due to:  

1.  The tragic, high profile and sensitive nature of the situation.  
2.  Specific  reference being  made  to the  concern  raised  in the  Coroners’  Regulation  28  Report 

that: 

“there is no barrier or fence or otherwise to prevent motor vehicles leaving the road” 

4.2 

4.3 

4.4 

an  assessment  for  the  provision  of  a  Road  Restraint  System  (RRS)  at  the  site  has  been 
undertaken.  

The assessment was based on the guidance outlined in the Department of Transport, Design and 
Maintenance Guidance for Local Authority Roads, Provision of Road Restraint Systems on Local 
Authority Roads.  

This  Guidance  was  selected  due  to  the  low  volume  of  traffic  using  the  A4085.  The  Guidance 
provides  a  framework  but  is  not  prescriptive.  It  is  acknowledged  that  a  number  of  factors  will 
influence the appropriateness and justification for RRS which includes the nature and usage of 
the  road,  collision  data, 
land  ownership,  engineering,  environmental  and  aesthetic 
considerations  as  well  as  cost  (capital  costs  for  installation  and  ongoing  revenue  costs  for 
inspection and maintenance thereafter). 

4.5 

The  Guidance  includes  more  detailed  definitions  and  explanations  with  regards  what  are 
referred  to  as  Method  A  (Accident  Assessment)  and  Method  C  (Risk  Scoring).  The  following 
provides a summary: 

•  Method A considers collision data to assess the probability of a serious accident occurring.  

8 

 
 
 
  
 
 
 
 
 
 
 
 
 
 
 •  Method C considers the nature of the road and hazards present more than the probability. 

4.6 

As  set  out  in  the  Guidance,  a  Method  C  assessment  would  not  be  the  primary  method  of 
assessing risk where collision data is available and Method A can therefore be applied. However, 
for the purposes of this assessment both Method A and Method C were applied. 

4.7 

The Conclusion of the assessment undertaken is provided below. 

Conclusion  
When using the assessments outlined in UK Roads Liaison Group and Department of Transport, 
Design and Maintenance Guidance for Local Authority Roads Provision of Road Restraint Systems 
on Local Authority Roads document:  

•  Method  A  concludes  that  the  site  is  of  low  priority  site  based  on  historic  accident 
frequencies.  
• Method C concludes that the site is of top medium priority based on the road features.  

The  guidance  for  medium  priority  sites  state  that  a  road  restraint  system  may  be  justified 
however a non- RRS approach to reducing the risk may prove sufficient to negate the need for a 
RRS.  

Due to lack of level verge a new restrain system cannot be easily installed without major works to 
create a verge which would have significant costs.  

Removing  the  existing  hazards  would  also  require  significant  works  and  have  environmental 
consequences.  

The traffic volumes on the A4085 are very low for a A road and the measured speeds are also far 
lower than the permitted 60mph due to the alignment of the road.  

The  signage  on  the  bend  has  already  been  improved  following  the  fatal  accident  and  has 
enhanced  the  warning  to  motorists  of  the  bend  which  will  further  reduce  the  probability  of  a 
vehicle running off the bend. This may well prove sufficient to negate the need for a RRS. 

4.8 

It is noted in the Guidance that in many cases RRS can be considered as a ‘last resort’ with other 
mitigating measures considered sufficiently appropriate. These include the following which have 
already been implemented at the collision site: 

• 
• 

Installation of chevron and warning signs, including vehicle activated signs. 
Installation of passive roadside features as a visual cue to a hazard e.g. deformable reflective 
posts. 

4.9 

The Guidance also notes: 

The decision to provide a RRS in a low flow or low speed scenario is a difficult one due to the high 
costs  and  the  potentially  low  risk  of  accidents  at  a  particular  location.  The  occurrence  of  one 
accident  involving  a  vehicle  leaving  the  carriageway  may  be  a  result  of  numerous  highway 
factors but can result in considerable public pressure to provide an RRS. 

9 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The decision taker must not be afraid of doing nothing, if to do nothing is the proper conclusion 
of the assessment process outlined in the Guidance. 

4.10  On the basis of the above, taking into account the enhancements already implemented, options 
in the short term to install a RRS are limited in respect of both scope and justification. However, 
this  will  be  subject  to  review  as  there  are  other  factors  which  may  influence  this.  These  could 
include  future  maintenance  and/or  wider  and  more  significant  improvements  to  the  highway 
which may affect the determining considerations in relation to installing a RRS.  

4.11 

From a number of perspectives, including cost, environmental and land ownership, RRS provision 
as  part  of  a  wider  scheme  may  be  more  viable  and  justifiable  than  a  stand-alone  scheme  to 
install RRS due to the site-specific considerations and constraints. 

4.12  Cyngor Gwynedd will also consider what, and if, there are any further interventions, other that 
RRS, which may be implemented to further mitigate risks associated with this collision and the 
circumstances of the tragic deaths. 

5. 

CONCLUSION 

5.1 

5.2 

There can be opportunities to make changes to the highway as an effort to positively influence 
driver  behaviour,  reduce  the  severity  of  a  potential  collisions,  or  make  design  changes  to  the 
road layout to reduce the risk of collisions.  

However,  there  are  funding,  resource,  physical,  engineering,  legal  and  other  constraints  which 
mean  there  are  limitations  to  what  Highway  Authorities  can,  and  can  be  expected  to  do,  to 
further improve the safety of the highway network.  

5.3  Making changes to the highway network is not the only way to reduce the number of accidents 
on the network. Cyngor Gwynedd Officers work on an ongoing basis in partnership with North 
Wales  Police  and  these  collaborative  efforts  have  been  instrumental  in  having  a  positive 
influence on the number of collisions on our network. 

5.4 

5.5 

5.6 

The  decision  and  justification  to  provide  a  RRS  in  a  low-flow  and  /  or  low-speed  scenario  is 
difficult on what is an extensive rural highway network. This takes into account and reflects the 
proportionality  and  appropriateness  of  such  interventions  from  the  perspective  of  risk 
(likelihood  and  severity),  engineering  constraints,  environmental  and  aesthetic  considerations, 
cost and consistency. In terms of costs this includes the considerable capital installation costs as 
well as the subsequent ongoing maintenance costs.  

The purpose of a RRS is, essentially, to keep vehicles within the confines of the highway where 
the  angle  of  impact  is  relevant.  A  RRS  at  a  location  such  as  the  collision  site  could  be  an 
immovable  object  creating  a  hazard  in  its  own  right  which  if,  for  example,  it  was  hit  at  speed 
could cause a vehicle to flip and / or could result in impacts/collisions with other vehicles.  

The introduction of a RRS does not always make a situation totally safe and the installation of a 
compliant  system,  in  this  location,  would  come  at  significant  expense.  Every  year,  there  are 
injuries caused when vehicles hit RRSs and the Guidance recognises that any RRS has an inherent 
element  of  risk.  This  risk    must  be  balanced  by  the  benefit  of  mitigating  the  severity  of  any 
accident at an affordable cost. 

10 

 
 
 
 
 
 
 
 
 
 
 
 
 5.7 

The Highway Code emphasises the importance of motorists staying focused on the road ahead 
and that they have a significant role and responsibility to play in road safety. 

11

Kate Robertson 
Senior Coroner for North West Wales 
Coroner’s Office 
Shirehall Street 
Caernarfon 
Gwynedd 
LL55 1SH 

From the Parliamentary  
Under Secretary of State 

Great Minster House 
33 Horseferry Road 
London 
SW1P 4DR 

Web site: www.gov.uk/dft 

Our Ref: 

      11 December 2024 

Dear Ms Robertson, 

RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE 
DEATHS  

Thank you for your report of 17 October 2024 made under the Coroners and 
Justice Act 2009 and the Coroners (Investigations) Regulations 2013, 
following the inquest you conducted into the deaths of Hugo Oliver Morris, 
Jevon Alexander Hirst, Harvey Graham Owen and Wilfred John Fitchett. I am 
responding as the Minister for the Future of Roads. 

I am deeply saddened by the circumstances of Hugo Morris, Jevon Hirst, 
Harvey Owen, and Wilfred Fitchett’s deaths, and I would like to extend my 
condolences to their families. 

I am determined that we learn from tragedies like this and that we take action 
to reduce those killed and injured on our roads. 

I want to assure you that the Government treats road safety with the utmost 
seriousness. Whilst UK roads are among the safest in the world, there is no 
room for complacency and I have carefully considered your report and its 
recommendations relating to young and newly qualified drivers and young 
drivers carrying passengers of a similar age. 

The latest statistics do show that the number of fatalities for car drivers aged 
17-24 years-old on Britain’s roads is falling. However, there is still work to be 
done, particularly because, in terms of population and the number of miles 
driven, 17–24-year-olds, particularly young men, remain one of the highest 
fatality risk groups both as car drivers and passengers. 

 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
 In partnership with the Transport Research Laboratory, the Department 
commissioned the largest young driver research piece, the ‘Driver 2020’ 
project. The research included a telematics trial, and it provides an evaluation 
of non-legislative interventions, such as technical and educational measures, 
to improve the safety of young novice drivers.  

This Government takes road safety seriously, and we are committed to 
reducing the numbers of those killed and injured on our roads. My 
Department is developing our road safety strategy and will set out more 
details in due course. 

We absolutely recognise that young people are disproportionately victims of 
tragic incidents on our roads. As work progresses on the new Road Safety 
Strategy, findings from the Driver 2020 project will feed into considerations on 
further measures the Department can take to improve road safety for young 
drivers. 

Best wishes, 

MINISTER FOR THE FUTURE OF ROADS