Prevention of Future Deaths reports · 2025

Alexander Lewis

Regulation 28 report to prevent future deaths, reference 2025-0539, written 24 Oct 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report24 Oct 2025
Reference2025-0539
DeceasedAlexander Lewis
CoronerAled Gruffydd
Coroner areaSwansea Neath & Port Talbot
CategoryRoad (Highways Safety) related deaths · Wales prevention of future deaths reports (2019 onwards)
Sourcejudiciary.uk record · original PDF
Responses published3

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:  
SOUTH WALES POLICE  
CHIEF CONSTABLE JEREMY VAUGHAN  
SOUTH WALES POLICE HEADQUARTERS  
COWBRIDGE ROAD  
BRIDGEND  
CF31 3SU  

HOME OFFICE 
2 MARSHAM STREET 
LONDON 
SW1P 4DF 

1 

CORONER 

I am Aled Gruffydd, Senior Coroner, for the coroner area of SWANSEA NEATH & 
PORT TALBOT 

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 the 13th December 2022 I commenced an investigation into the death of Alexander 
Rhys Lewis. The investigation concluded at the end of the inquest on the 17th October 
2025. 

The medical cause of death is 
1a) chest injuries 
1b) road traffic collision (motorcyclist) 

The conclusion of the inquest as to how Mr Lewis came to his death was a road traffic 
collision whilst being pursued by the police. 

4 

CIRCUMSTANCES OF THE DEATH 

The deceased was Alexander Rhys Lewis and he was pronounced dead on the 2nd 
December 2025 at St Helens Road, Swansea. The cause of death was chest injuries 
caused by a road traffic collision in which he was a motorcyclist.  

The collision has occurred shortly after Alex, whilst riding a Yamaha motorcycle failed to 
stop for a South Wales Police Roads Policing Units on the Kingsway, Swansea. The 
Yamaha motorcycle has entered onto St Helens Road from the direction of the 
Kingsway roundabout where it has carried out an overtake of an unidentified white motor 
vehicle in the vicinity of the pedestrian crossing. The Yamaha motorcycle than appears 
to accelerate after completing this manoeuvre. At the same time the silver Toyota Prius 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 has been in the process of emerging slowly from the give way junction of Wyndham 
Street and turning right onto St Helens Road. On seeing the Toyota Prius the rider of the 
Yamaha motor cycle has braked heavily causing the motorcycle to go into a sideways 
skid, where the motorcycles off side has collided heavily with the off side of the Toyota 
Alex was pronounced deceased at the scene. 

5 

CORONER’S CONCERNS 

During the course of the inquest evidence was heard regarding the circumstances that 
the pursuit occurred and the events that unfolded. One such instance was that the 
pursuing police officer did not observe Alex contravening a red light due to having to 
control his vehicle as well as negotiating the other traffic and he would have had to be 
looking around to do this, whereas the dashcam fitted to the car that picked up the 
contravention of the red light continued to point straight ahead. The impact of this was 
that had he seen it, it may have raised the dynamic risk assessment to high and may 
have caused him to stand the pursuit down. The pursuing driver also stated that given 
the driving responsibilities there was no opportunity to communicate a dynamic risk 
assessment to the control centre, although he would have been undertaking a dynamic 
risk assessment throughout. 

The evidence of the officer in charge of driver training confirmed the evidence of the 
pursuing officer in that the pursuing officer would have to do a number of things 
including declaring a pursuit and negotiating the traffic. In his words “…there would be a 
lot going on in the car…”. He stated that the pursuing officer would be on their own in the 
car and as such have to undertake all the tasks involved in a pursuit themselves, and 
acknowledged that it would be safer for the crew to be double manned so the tasks can 
be shared, although you are then halving the number of TPAC trained units available to 
assist.   

I am concerned that in pursuit situations, pursuit officers are required to undertake a 
significant number of tasks on their own, and the decisions they take as a result of 
undertaking those tasks can have an impact on their safety, the subject vehicle’s safety 
as well as the safety of other road users and the general public. 

 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.  There was no opportunity for the pursuing driver to communicate a dynamic risk 

assessment to the control centre, to assist the control centre in making a 
decision to authorise or stand down the pursuit. the control centre indicated that 
such information would go towards authorising the pursuit as opposed to 
standing it down in the present case 

2.  The number of tasks having to be undertaken by the pursuing driver meant that 
vital information as to the risks involved in continuing the pursuit were missed, in 
the present case that being a contravention of a red light 

3.  The officer in charge of driver training confirmed that from a safety perspective, 
it would be safer to have the crew in a pursuit situation “double manned”. 

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.  

2 

 
 
 
 
      
 
 
 
 
  
 
 
 
 
 
 
 7 

YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, 
namely by 19th December 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. 

8 

COPIES and PUBLICATION 

I have sent a copy of my report to the Chief Coroner and to the following Interested 
Persons 

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 

24 October 2025 …

……..…………………. [SIGNED BY CORONER] 

3

Responses

3 responses 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 Department of Transport (PDF)
From the Parliamentary  
Under Secretary of State 

Great Minster House 
33 Horseferry Road 
London 
SW1P 4DR 

Aled Gruffydd 
Senior Coroner 
Swansea and Neath Port Talbot 
Coroner's Office, The Guildhall 
Swansea 
SA1 4PE 

      18 November 2025 

Dear Aled, 

Thank you for your letter of 4 November about mandatory distance 
regulations for parking. 

I should note that there is no specific statutory guidance or mandatory 
distance regulations that stipulate the minimum distance single yellow lines 
must be situated from a junction. 

Ultimately, it is for the local authority to assess that the visibility of the junction 
is sufficient and to determine how much they want to protect with yellow lines. 

As you may be aware, traffic signing is now devolved and would be a matter 
for the Welsh Government.  

Best wishes, 

MINISTER FOR LOCAL TRANSPORT
Response from Minister of State for Policing and Crime (PDF)
Minister of State for Policing and 
Crime 

2 Marsham Street 
London SW1P 4DF 
www.gov.uk/home-office 

 5 January 2026 

Aled Gruffydd 
Senior Coroner 
Swansea Neath and Port Talbot 
The Guildhall 
Swansea  
SA1 4PE 

Dear Aled, 

Thank you for sending your report concerning the investigation into the death of Mr 
Alexander Rhys Lewis. I am replying as the Minister of State for Policing and Crime, and I 
apologise for the delay in responding. 

My sincere sympathy is with Mr Lewis’s family. I was deeply saddened to read about the 
circumstances of his death and the impact on his family and those close to him. 

I understand the importance of the concerns you have raised and I will respond to each in 
turn. 

Police drivers operate in high-pressure situations to urgently respond to incidents and to 
pursue drivers who pose a danger to the public. The Government recognises the vital role 
police drivers play and is committed to ensuring they are trained to high and consistent 
standards to ensure their safety and that of the public. The Government works closely with 
the National Police Chiefs’ Council (NPCC) and the College of Policing to ensure police 
driver training meets these high and consistent standards, as set out in the Road Traffic 
Act 1988 (Police Driving: Prescribed Training) Regulations. These regulations prescribe 
minimum standards of police driver training in line with the Police Driving Standards 
measures in the Police, Crime, Sentencing and Courts Act 2022.  
The Police, Crime, Sentencing and Courts Act 2022 is a legislation that enhances police 
powers and reforms the criminal justice system.  

This Act amended the Road Traffic Act 1988 to require that an assessment of whether a 
constable or other ‘designated person’ has driven carelessly or dangerously compares 
their standard of driving against that of a competent and careful constable who has 
undertaken the same prescribed training, rather than with a member of the public, as was 
the case previously.  

The prescribed minimum requirements for police driver training form part of a standardised 
programme, which is developed, maintained, and implemented by the NPCC and the 
College of Policing. This training is aligned with the College of Policing’s Authorised 
Professional Practice, Roads policing, police pursuits guidelines for managing pursuits, 
and the national police driver training curriculum. Officers engaging in pursuits must 
complete both levels of practical police pursuit driver training: Initial Phase Pursuit  and the 
Tactical Phase Pursuit standard, as set by the College of Policing and within the College’s 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Police Driving National Policing Curriculum. Police officers should also take account of the 
College of Policing’s Authorised Professional Practice guidance on whether a pursuit is 
appropriate. The College introduced licensing in April 2024 for police driver training 
providers to further professionalise police driving standards. These high standards of 
training are intended to ensure officers do not fall below the professional standards 
expected of them and to safeguard the public. 

College Authorised Professional Practice guidelines set out that officers should give due 
regard to the purpose and justification of their actions and ensure any decision to pursue is 
necessary, proportionate, and balanced against threats, risks and the possibility of harm to 
the person being pursued, the officers involved and any others who may be affected. Any 
decision on whether to undertake a pursuit is an operational one and  Authorised 
Professional Practice sets out the factors for officers to consider when planning and 
running an operation.   

Your report sets out your concerns that the officer had no opportunity to communicate a 
dynamic risk assessment to the control room for it to take a decision on whether to 
authorise or stand down the pursuit; the number of tasks the officer had to undertake 
meant risks involved in continuing the pursuit were missed; and from a safety perspective, 
double-crewing is safer.  

Authorisation of pursuits 
While officers should seek authorisation where possible, in accordance with Authorised 
Professional Practice, to engage in a pursuit, that Practice sets out that this may not 
always be possible, depending on the operational circumstances of an incident. Officers 
performing any role in pursuit management must be trained to the standards set out by the 
College of Policing and police drivers should not be authorised to pursue if they are unable 
to meet the required level of competence during training. The College of Policing’s  
Authorised Professional Practice sets out that, in some circumstances, the time available 
between recognising the need for action and the deadline for taking action may be too 
short to acquire authorisation from a control/communications room. Officers, in these 
circumstances, may self-authorise so long as they can justify the decision at a later time, in 
line with the National Decision Model. The National Decision Model is a used by everyone 
in policing. It encourages officers to act in accordance with the Code of Ethics (Ethical 
policing principles | College of Policing) It encourages them to use their discretion where 
appropriate and should reduce risk aversion. In a fast-moving incident, it makes clear that  
decision makers should adhere to their overarching mission to act with integrity to protect 
and serve the public.  

Following each pursuit, reflective and lessons-learned meetings are held where forces 
review and analyse the decision to pursue and examine whether training protocols were 
followed. 

Managing risks  
As set out above, College of Policing training requirements must be undertaken and met 
by officers before they can be qualified to engage in pursuits. This includes officers being 
trained to demonstrate competence in applying effective decision making from the initial 
phase to the tactical phase of a pursuit and the need to carry out dynamic risk 
assessments throughout.    

Before engaging in pursuits, officers must be familiar with pursuit considerations and use 
the intelligence at hand to assess the level of risk posed by the pursued driver and the 
seriousness of the offence being committed, or suspected, in accordance with the National 
Decision Model. This allows officers to make decisions where many short-duration pursuits 
might not allow time for specific guidance to be communicated by a control room and 
communications room staff. 

 
 
 
  
 
 
 
 Crewing   
Decisions on crewing are operational matters and at the discretion and judgement of Chief 
Constables who determine how to deploy available resources to deal with issues for which 
the force is responsible, considering specific local problems and demands. 

Any pursuit that results in a fatality is taken very seriously and referred to the Independent 
Office for Police Conduc, a statutory body with powers and duties to investigate under the 
Police Reform Act 2002 and associated legislation. The Independent Office for Police 
Conduct has the authority to independently investigate cases where there has been a 
death or serious injury following police contact, public complaints against police, and 
conduct matters where a member of the public has been adversely affected and/or public 
interest requires it. Following its investigations, the  Independent Office for Police Conduct 
may direct disciplinary proceedings for persons serving with the police and/or refer them to 
the Director of Public Prosecutions for a charging decision. Following the  Independent 
Office for Police Conduct investigation into Mr Lewis’ death, I note they concluded that the 
investigation was not subject to special procedures and the decision-maker found the 
service of the police to be acceptable. 

I hope this response is helpful in responding to the concerns raised in your report. On a 
personal note, I wish again to extend my condolences to the family and friends of Mr 
Lewis, and to thank you for bringing this issue to my attention. 

Very best wishes, 

Minister of State for Policing and Crime
Response from South Wales Police (PDF)
Mr Aled Gruffyd 
Senior Coroner 
Swansea Neath & Port Talbot 

Dear Senior Coroner Gruffyd, 

09 January 2026 

South Wales Police offer its sincerest sympathies to Mr Lewis’ family on this case. South Wales Police 
also acknowledge the concerns raised regarding the crewing of Road Policing Unit (RPU) officers during 
pursuits and specifically in relation to the case of Alexander Rhys Lewis. Our current operational model 
and  training  standards  are  designed  to  ensure  public  safety,  officer  competence,  and  compliance  with 
national guidance. 

Training and Operational Practice 
Police  pursuit  training,  as  delivered  under  the  College  of  Policing’s  Police  Driving  National  Policing 
Curriculum  (PDNPC)  to all  national forces, reflects  real-world  operational  conditions.  During  both Initial 
Phase Pursuit (IPP) and Tactical Phase Pursuit (TPP) training, officers operate single-crewed, even when 
accompanied by an instructor, so that they replicate day-to-day working practices. This approach ensures 
officers are fully prepared for the responsibilities they will assume in live operations. 
While single-crewed, officers are trained to: 

•  Receive and process intelligence to build a dynamic picture of the subject vehicle and driver. 

•  Deliver  accurate  commentary  using  the  National  Surveillance  Glossary,  enabling  other  units  to 

position effectively for tactical intervention. 

•  Manage the Tactical Phase, which includes high-speed driving, commentary, tactical use of lights 

and sirens, and implementation of pursuit resolution tactics. 

•  Continuously  apply  the  eight  pursuit  considerations  and  produce  Dynamic  Risk  Assessments 

(DRAs) that reflect evolving circumstances. 

•  Make  real-time  decisions  on  proportionality  and  justification  for  continuing  or  terminating  the 

pursuit. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 National Standards and Professional Guidance 
The  prescribed  minimum  requirements  for  police  driver  training  are  set  by  the  NPCC  and  College  of 
Policing  and  aligned  with Authorised  Professional  Practice  (APP).  Officers  engaging  in  pursuits  must 
complete both IPP and TPP training. Since April 2024, the College has introduced licensing for training 
providers  to  further  professionalise  standards.  These  measures  ensure  officers  meet  the  highest 
professional standards and safeguard the public. 
APP  guidance  requires  that  any  decision  to  pursue  is  necessary,  proportionate,  and  balanced  against 
threat,  risk,  and  harm  to  all  parties.  Decisions  remain  operational  and  must  consider  risk  factors  and 
proportionality throughout. 

Resourcing and Operational Realities  
Adopting a default position of double-crewing vehicles for pursuits would significantly reduce South 
Wales Police’s ability to maintain specialist roads policing coverage across the wider network. Our 
challenge is to fully address the concerns raised in the Reg 28 notice while safeguarding our statutory 
duty to serve the broader South Wales community and manage wider risk. 
When setting crewing models, we must strike a balance between operational effectiveness and resource 
availability. To sustain a strong capability for pursuits and TPAC tactics across the road network, single 
crewing remains the most practical option given the number of vehicles and trained officers required. This 
approach enables us to respond effectively to both planned and spontaneous incidents while maintaining 
public safety and operational resilience. 
As a force, we continually assess resources to ensure capability and capacity are maintained across the 
area. We are confident in the national training both initial and refresher undertaken by our officers, which 
equips them  to  carry  out  Dynamic  Risk Assessments  and make  informed  decisions,  including  standing 
down when risk outweighs benefit. We fully support officers in exercising this professional judgment. 

Post-Pursuit Review and Continuous Learning 
South Wales Police have robust post-pursuit review processes, bringing together the Driving Training Unit 
(DTU) and operational teams to examine tactics and circumstances and embed learning. This ensures 
continuous improvement and reinforces our commitment to public safety and officer professionalism. 
In  addition,  following  the  Independent  Office  for  Police  Conduct  investigation  into  Mr  Lewis’  death,  the 
investigation  was  not  subject  to  special  procedures,  however  we  will  continue  to  focus  on  continuous 
improvement in relation to pursuits as highlighted above.  

Yours sincerely 

Temporary/Assistant Chief Constable

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