Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-01202, written 23 Apr 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 Apr 2025 |
|---|---|
| Reference | 2025-01202 |
| Deceased | Martin Saunders |
| Coroner | Kerrie Burge |
| 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:
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
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, Rhondda Cynon Taf County Borough Council
Welsh Government, Cathays Park, Cardiff
CORONER
1
I am Kerrie Burge, H. M. Coroner, for the coroner area of South Wales Central.
CORONER’S LEGAL POWERS
2
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 26 June 2023, I commenced an investigation into the death of Martin Robert SAUNDERS.
The investigation concluded at the end of the inquest on 23rd. April 2025.
The conclusion of the inquest was Road Traffic Collision.
The medical cause of death was
1a Blunt Head Injury, including Basal Skull Fracture
CIRCUMSTANCES OF THE DEATH
These were recorded as follows:
3
4
Martin Robert Saunders, aged 48, died on A4059 New Road Mountain Ash, on 17th. June
Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW
Phone/Ffôn (01443) 281100 Fax/Ffacs (01443) 485862
2023, which is a 60 mph road, with laybys and bends, locally described as a dangerous
road. Martin’s motorbike collided with a coach which had been making a right turn from a
layby / parking area. A sweeping bend approaching the layby reduces visibility for those
approaching or exiting it. Martin’s motorbike was not visible to the driver when he began
his manoeuvre and Martin’s reaction time when faced with the coach was further reduced
because he had been overtaking other vehicles on the approach to the layby. Despite best
resuscitation efforts, Martin was declared 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.
The collision occurred on the A4059, New Road, Mountain Ash near the exit of a parking
bay located on the east side of the carriageway. The parking area can be busy. At the time
of the collision, the speed limit on the road was 60 mph and there was no prohibition on
making right turns from the layby. The combination of reduced visibility due to the bends in
the road, speed and right turns across the carriageway increases the risk of road traffic
collisions.
Changes are in progress to reduce the maximum speed limit but even allowing for this, I
remain concerned there is a risk of future deaths occurring along this route unless action is
taken, due to vehicles turning right across the carriageway from the layby on this stretch of
road.
ACTION SHOULD BE TAKEN
5
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
7
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 18th. June 2025. I, the Coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out the
Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW
Phone/Ffôn (01443) 281100 Fax/Ffacs (01443) 485862
timetable for action. Otherwise, you must explain why no action is proposed.
COPIES and PUBLICATION
I have sent a copy of my report to family who may find it useful or of interest.
8
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.
She may send a copy of this report to any person who she 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.
23 April 2025
9
SIGNED:
Kerrie Burge, H. M. Coroner for South Wales Central Coroner Area
Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW
Phone/Ffôn (01443) 281100 Fax/Ffacs (01443) 485862
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.
From: To} Sent: Fri May 09 2025 08:33:15 BST Subject: FW: Gohebiaeth Llywodraeth Cymru / Welsh Government Correspondence - [i Hi Kerrie, This is in relation to the case of Martin Saunders. | can see that the Reg 28 went to the Chief Exec of RCTCBC anyway. Clare I acoso CES Sent: la : To: Subject: Gohebiaeth Llywodraeth Cymru / Welsh Government Correspondence FY Rhybudd: E-bost allanol yw hwn - sy wedi dod o sefydliad/unigolyn y tu allan i'r Cyngor. Byddwch yn wyliadwrus wrth glicio ar ddolenni neu agor atodiadau. Caution: This is an external email and did not originate from within the Council. Please take care when clicking links or opening attachments. Yr Economi, Ynni a Thrafnidiaeth Economy, Energy and Transport WE, Llywodraeth Cymru Weish Government Ein cyf / Our ref: in Dear Ms Everett Thank you for your letter. The Welsh Government and its Ministers are the Highway Authority responsible for the Motorway & Trunk Road Network in Wales. The A4059 is a local road and the responsibility of Rhondda Cynon Taf County Borough Council (RCTCBC) as the local Highway Authority. We would therefore ask that you forward the report's recommendations to RCTCBC. Details of how to contact the council can be found online at Contact us | Rhondda Cynon Taf County Borough Council. Yours sincerely Pennaeth Gweithrediadau / Head of Operations Is-adran y Rhwydwaith Ffyrdd Strategol / Strategic Road Network Division Cysylitedd Trafnidiaeth a Digidol / Transport and Digital Connectivity Yn Economi, Ynni a Thrafnidiaeth / Economy, Energy and Transport Llywodraeth Cymru / Welsh Government Rydym yn croesawu derbyn gohebiaeth yn Gymraeg. Byddwn yn ateb gohebiaeth a dderbynnir yn Gymraeg yn Gymraeg ac ni fydd gohebu yn Gymraeg yn arwain at oedi. We welcome receiving correspondence in Welsh. Any correspondence received in Welsh will be answered in Welsh and corresponding in Welsh will not lead to a delay in responding. Pare Cathays » Cathays Park Canolfan Cyswilt Cyntaf / First Point of Contact Centre Caerdydd + Cardiff 0300 0604400 CF10 3NQ Sganiwyd y neges hon am bob feirws hysbys wrth iddi adael Llywodraeth Cymru. Mae Llywodraeth Cymru yn cymryd 0 ddifrif yr angen i ddiogelu eich data. Os cysylltwch 4 Llywodraeth Cymru, mae ein hysbysiad preifatrwydd yn esbonio sut rydym yn defnyddio eich gwybodaeth a sut rydym yn diogelu eich preifatrwydd. Rydym yn croesawu gohebiaeth yn Gymraeg. Byddwn yn anfon ateb yn Gymraeg i ohebiaeth a dderbynnir yn Gymraeg ac ni fydd gohebu yn Gymraeg yn arwain at oedi. ----------------- On leaving the Welsh Government this email was scanned for all known viruses. The Welsh Government takes the protection of your data seriously. If you contact the Welsh Government then our Privacy Notice explains how we use your information and the ways in which we protect your privacy. We welcome receiving correspondence in Welsh. Any correspondence received in Welsh will be answered in Welsh and corresponding in Welsh will not lead to a delay in responding.
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