Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0267, written 2 Jun 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Jun 2025 |
|---|---|
| Reference | 2025-0267 |
| Deceased | Patrick Mongan |
| Coroner | Nicola Mundy |
| Coroner area | South Yorkshire (East) |
| 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.
MS N J MUNDY H M CORONER SOUTH YORKSHIRE (East District) email: CORONER'S COURT AND OFFICE CROWN COURT COLLEGE ROAD DONCASTER DN1 3HS Tel: (01302) 737135 Fax: (01302) 736365 Date: 2 June 2025 Case: REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: CORONER I am Ms N J Mundy for South Yorkshire East CORONER'S LEGAL POWERS , Chief Executive National Highways 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 20 September 2024 I commenced an investigation into the death of Patrick Anthony MONGAN. The investigation concluded at the end of the inquest . The conclusion of the inquest was Road Traffic Collision. The cause of death was: 1a Chest injuries 1b Road Traffic Collision CIRCUMSTANCES OF THE DEATH This relates to the death of an 18 year old male who died following an RTC on the 7th September 2024. The circumstances surrounding the death are as follows; At 02:26 hours, South Yorkshire Police received a report of a RTC on the Northbound carriageway of the M18 between junctions 1 & 2 where it was reported that a vehicle had left the carriageway to the nearside disappearing into trees. Staff from Highways England arrive on scene and locate the vehicle embedded deep into the trees and two males, Patrick Mongan (DOB 21/03/2006) and his brother, had been ejected from the vehicle landing next to it. Patrick Mongan, was reported to not be breathing and life was pronounced as extinct at 03:10 hours. It was later identified that the subject vehicle had struck a grassed mound of earth on the central reservation which interrupted the tarmac construction of the central reservation causing the vehicle in which the deceased was a passenger to become airborne. 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 Forensic Collison Investigator advised that the aforementioned mound of earth creates a continuing hazard to motorway users and any vehicle which might have legitimate cause to veer to the central reservation and in doing so strikes the mound, even when travelling within the speed limit, would be subjected to the same effect on the vehicle (in that control of the vehicle would be lost) with potentially catastrophic effects. The continued presence of this hazard (the mound of earth on a tarmac construction) places road users at risk of death ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you National Highways 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 28th July 2025. 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons and DWF Law. 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. 2 June 2025 Signature Ms N J Mundy LL.B (hons) HM Senior Coroner South Yorkshire East
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.
Ms N J Mundy HM Coroner South Yorkshire (East District) Coroners Court and Office Crown Court College Road Doncaster DN1 3HS Dear Ms N J Munday Regional Director Yorkshire and North East Operations Directorate 2 City Walk South Bank Leeds L11 9AR www.nationalhighways.co.uk 01 July 2025 Regulations 28 Report - After Inquest Patrick Antony Mongan Thank you for your correspondence dated 2 June 2025. National Highways has investigated the circumstances of the incident and the concerns you have raised at this location. A common feature of a carriageway outside of the normal running lanes or hard shoulder is to have soft verges, kerbs, hardened areas or a combination of these and this includes the M18 motorway. In this specific location the small section of concern you raised is a softened grassed central reservation with no kerbs, a double sided, tension corrugated vehicle restraint system and a catch pit for drainage purposes all of which are maintained to the required standards contained in the published Design Manual for Roads and Bridges of grass cutting, litter picking and drainage clearance. On the night of Thursday 12 June 2025, we undertook the action set out below, which was completed on the morning of 13 June 2025. Action taken: i) Levelled the central reservation in this specific location so that there is no deviation in level between the carriageway running lanes and the central reservation There are no other actions to be carried out at this location. Registered office Bridge House, 1 Walnut Tree Close, Guildford GU1 4LZ National Highways Limited registered in England and Wales number 09346363 The safety of everyone on our road network matters; it is an imperative for our business in what we set out to achieve and a core value of our organisation. Every death on our roads is a tragic loss of life and we offer our deepest sympathies to all those affected by Mr Mongan’s death. I trust the above is of assistance. Yours sincerely Regional Director Registered office Bridge House, 1 Walnut Tree Close, Guildford GU1 4LZ National Highways Limited registered in England and Wales number 09346363
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.