Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0042, written 17 Jan 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Jan 2025 |
|---|---|
| Reference | 2025-0042 |
| Deceased | Donald Mitchell |
| Coroner | Patricia Morgan |
| Coroner area | South Wales Central |
| Category | Road (Highways Safety) related deaths · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
GRAEME HUGHES
HIS MAJESTY’S
SENIOR CORONER
SOUTH WALES CENTRAL
CORONER AREA
CORONER’S OFFICE
THE OLD COURTHOUSE
COURTHOUSE STREET
PONTYPRIDD
CF37 1JW
Telephone:
Email:
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:
The Chief Executive, Bridgend County Borough Council
Welsh Government, Cathays Park, Cardiff
1
2
CORONER
I am Patricia Morgan Area Coroner, for the coroner area of South Wales 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
On 31 December 2020 I commenced an investigation into the death of Donald John
Drummond MITCHELL . The investigation concluded at the end of the inquest 17/01/2025 .
The conclusion of the inquest was Road Traffic Collision.
The medical Cause of Death was:-
3
1a Blunt Head Injury, including Transection of both Internal Carotid Arteries
1b
1c
II
Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW
Phone/Ffôn
Fax/Ffacs
CIRCUMSTANCES OF THE DEATH
These were recorded as :-
4
Donald John Drummond Mitchell was cycling from his place of work to his home on 17
December 2020. Whilst cycling along the A48 road in an eastbound direction, between the
Laleston roundabout and the junction of Well Street, Mr Mitchell was struck by a vehicle
travelling in the same direction. Mr Michell suffered catastrophic head injuries as a
consequence of the collision and was sadly pronounced deceased at the scene.
Conclusion: Road Traffic Collision
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) Between 2015 and 2024, along the A48 between Pyle and Ewenny which is a
5.75 mile stretch of road, there have been 4 fatal collisions and 8 serious collisions.
Of these collisions, 5 involved cyclists.
5
(2) On the basis of the evidence of the nature of the road between Ewenny
roundabout and Pyle roundabout (which varies between a single and dual
carriageway), the speed limit in place (which varies between 40mph and up to
national speed limit), the current absence of an active travel route or modifications
to the route to specifically cater for cyclist safety, along with the data available as to
the number of collisions along this route relating to cyclist, I remain concerned that
there is a risk of future deaths occurring along this route unless action is taken.
ACTION SHOULD BE TAKEN
6
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.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by . I, the Coroner, may extend the period.
7
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.
Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW
Phone/Ffôn
Fax/Ffacs
COPIES and PUBLICATION
I have sent a copy of my report to family who may find it useful or of interest.
I am also under a duty to send the Chief Coroner a copy of your response.
8
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.
17 January 2025
SIGNED:
9
Patricia Morgan Area Coroner for South Wales Central Coroner Area
Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW
Phone/Ffôn
Fax/Ffacs
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.
on F pa) Cyngor Bwrdeistref Sirol Pen-y-bont ar Ogwr % Bridgend County Borough Council BRIDGEND Patricia Morgan The Chief Executive Area Coroner CORONER’S OFFICE Bridgend County Council THE OLD COURTHOUSE Civic Offices, COURTHOUSE STREET Angell Street, PONTYPRIDD CF37 1JW CF314WB E-mail: 11/03/2025 Dear Ms Morgan, Re: Donald John Drummond MITCHELL A48 Laleston, Bridgend | refer to your Regulation 28 report to prevent future deaths, received on 24 January 25 following your investigation into the death of Donald John Drummond Mitchell and your comments concerning the A48 Laleston, Bridgend. This letter is in response to the matters of concern recorded in section 5 of your report, which states: e the number of recorded Personal Injury Collisions between 2015 and 2024 e current absence of an active travel route or modifications to the route to specifically cater for cyclist safety and your request to identify actions which should be taken to prevent future deaths. In providing this response, the Council would again like to convey sincere condolences to the family for the loss of Mr Mitchell in such tragic circumstances. Background The A48 is one of the main access roads into Bridgend from the West and East, and carries a high volume of traffic throughout the day, it is also the dedicated alternative route for the M4 traffic between Junctions 37 Pyle and Junction 35 Pencoed if the M4 is closed following an incident on the Motorway. The character of the road is rural/semi-rural, wide in nature with a mix of dual carriageway and single lane, with speed limits set between 40mph and National speed limit. The section of highway where the incident occurred has a unique street reference number of 47605367 and is recorded as A48 Bypass Road Broadlands Roundabout to Laleston Roundabout. The 7-day average traffic flows for the period 16/1/2025-22/1/2025 on the A48 within 50m of the junction of Wells Street where the incident occurred was 15,345. Response to concerns Raised under Regulation 28 report. To date, the following action has been taken in response to your concerns raised: The active travel department continue to undertake a study to provide high level options for an Active Travel Link alongside the A48 between Picton Court roundabout and Laleston Roundabout. The Council reviews and updates its list of strategic transport schemes annually and will present to Cabinet later this year with further information on timelines and funding for all projects. The highway maintenance department continues to carry out highway defect inspections on this carriageway in alignment with the Code of Practise for Highway Maintenance and the County Surveyors Society (Wales) review of the 2016 code. The Traffic Management Department has undertaken an internal desktop review followed by site assessments of the A48 between Ewenny Roundabout and Pyle Roundabout with the outcome as follows: e Existing speed limits have been assessed in line with current Setting Local Speed Limit in Wales (SLSLIW) guidance. Considering the character and nature of this road the set speed limits conform with the SLSLiW criteria, and the criteria does not recommend the use of speed limits to tackle individual, isolated locations. e Speed Surveys were undertaken either side of the junction of Wells Street with the A48 in January 2025. 85%ile speeds for 2-way traffic east of the junction were recorded as 54mph, whilst 85%ile speeds for 2-way traffic just west of the junction were recorded as 53mph which is consistent with the posted speed limit. « Review of existing signs and road markings in line with current Traffic Signs Regulations & General Directions 2016 Guidance has been undertaken with no additional works being required at this time. Additionally, | can confirm that the whole section from Laleston Roundabout through to Broadlands Roundabout is in light since April/May 21 and fitted with LED lanterns, with connections regularly checked in accordance with maintenance procedures. Conclusion It should be noted that the serious collision investigation unit of the police have not raised concerns with the Council regarding the posted speed limits, road layout or vehicle speeds of the A48 during their investigations. As part of our statutory functions and commitment to our communities and road safety, Bridgend County Borough Council continues to monitor 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 across the borough. Consideration of the actions highlighted above will continue, with a view to determining if any improvements at this location are justified as a priority, over and above other schemes alongside our annual program of road safety schemes which are submitted to Welsh Government for consideration. | trust you will find the Council’s response as outlined above as proportionate to the concerns you have raised. in conclusion, the Council takes all accidents seriously, and where appropriate implements measures to make the highways network safer provided the threshold for number of road accidents on individual sites is met. Yours sincerely = Executive
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.