Prevention of Future Deaths reports · 2025
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 report | 24 Oct 2025 |
|---|---|
| Reference | 2025-0539 |
| Deceased | Alexander Lewis |
| Coroner | Aled Gruffydd |
| Coroner area | Swansea Neath & Port Talbot |
| Category | Road (Highways Safety) related deaths · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
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
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.
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
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
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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