Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0621, written 11 Dec 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Dec 2025 |
|---|---|
| Reference | 2025-0621 |
| Deceased | David Langford |
| Coroner | Kate Robertson |
| Coroner area | North Wales (East and Central) |
| Category | Conwy County Borough Council |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Kate Robertson
Assistant Coroner for North Wales (East and Central)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Chief Executive, Conwy County Borough Council
1
CORONER
I am Kate Robertson, Assistant Coroner for North Wales (East and Central)
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 16 May 2024 an investigation was commenced into the death of David Paul
Langford (DOB: 31 January 1994) who died on 11 May 2024. The investigation
concluded at the end of the inquest on 8 December 2025. The conclusion of the
inquest was Road Traffic Collision.
4
CIRCUMSTANCES OF THE DEATH
The circumstances of the death are as follows :-
David Paul Langford was riding his KTM motorcycle along the A548 approximately
1.2 miles north of Llangernyw and approximately 4 miles south-west of Llanfair
Talhaiarn, Conwy, when a collision occurred with a motor vehicle emerging from
the Waterloo Hill junction which had poor visibility. David Langford was declared
deceased at the scene.
5
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 –
Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN
|
The topography at the collision scene location was considered significant. A
visibility mirror was present opposite the Waterloo Hill Junction and was, and in
fact still is, positioned as such to provide traffic exiting the junction a view of
traffic approaching on the A548 and from the Llangernyw direction.
Visibility is reduced for motorists exiting the junction to the right and those
approaching from the direction of Llangernyw on the A548 by the following:-
a. The overgrown tree foliage and hedgerow running alongside the nearside
of the Llanfair Talhaiarn bound lane of the A548 just prior to the area of
the collision; and
b. The dull nature of the visibility’s mirror’s reflective surface which hindered
the view provided, along with overgrown foliage around the mirror which
obscured the view along a section of the Llanfair Talhaiarn bound lane
c. The left hand bend for those approaching the junction on the A548 from
the Llangernyw direction
Witness evidence indicated that ‘…it is exceptionally dangerous’. The location
has excess shrubbery that limits visibility towards the junction from Abergele
direction. This is coupled with a directional mirror to assist turning onto the A548,
but again, this has excess foliage’. The witness went on to say ‘I have contacted
the local council to see what can be done to promote safety at this junction’.
It was noted by evidence from North Wales Police that the mirror had been
replaced and the excess shrubbery and overgrowth maintained around the
mirror and around the junction.
Whilst these improvements are noted there remain two concerns
1. The railings to the right of the junction are old and rusty and their position
provides a barrier from view down the road. It was noted that Conwy
County Borough Council had noted this and no action has yet been taken;
and
2. It was noted that the stretch of road in question is subject to a national
speed limit and it is a concern that this high Speed does not account for
the dangerous junction at Wterloo Hill.
I am concerned that deaths will occur into the future and/or continue to occur as
a result of these concerns.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you
have the power to take such action.
Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN
|
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this
report, namely 5 February 2026. I, Kate Robertson, 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 Family of the Deceased and to the Chief
Coroner.
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.
9
Dated 11 December 2025
Signature
Assistant Coroner for North Wales (East and Central)
Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN
|
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.
Adran Yr Amgylchedd, Ffyrdd a Chyfleusterau
Environment, Roads & Facilities Department
Pennaeth Gwasanaeth
Head of Service - Geraint Edwards, BEng(Hons) CEng FICE
Cyfeiriad Post / Postal Address: PO Box 1, Colwyn Bay, LL29 0GG
Blwch Post 1, Bae Colwyn, LL29 0GG
Mr. John Gittins
H.M. Senior Coroner North Wales (East and Central)
Coroner’s Office
County Hall
Wynnstay Road
Ruthin
LL15 1YN
Dyddiad / Date: 26/01/2026
Dear Mr. Gittins,
Coroner’s Report to Prevent Future Deaths - Inquest of David Langford
I am writing in response to your letter dated 11 December 2025 concerning the inquest into the
death of David Langford resulting from a road traffic collision at the intersection of Waterloo Hill
and the A548 near Llangernyw.
The Regulation 28 Report issued by Kate Robertson, Assistant Coroner, noted that improvements
had been made to visibility at the junction by removal of excess shrubbery and replacement of a
visibility mirror. There remained, however, two outstanding concerns, to which the Council
responds as follows:
1. The railings to the right of the junction are old and rusty and their position provides a
barrier from view down the road. It was noted that Conwy County Borough Council had
noted this and no action has yet been taken.
These railings are privately owned and located on the property known as Pentre Smithy. The
Council has approached the property owner and reached agreement to replace the railing
with a more suitable boundary treatment, at the Council’s expense. This will be carried out by
March 31st, 2026.
2. It was noted that the stretch of road in question is subject to a national speed limit and
it is a concern that this high Speed does not account for the dangerous junction at
Waterloo Hill.
The Council has conducted a route speed limit review for the A548 between Llanfair TH and
Llangernyw in accordance with national guidance (Setting of Local Speed Limits in Wales
circular 24/2009). It is proposed to reduce the speed limit on the A548 to 40mph from a point
65 metres north of its junction with Cae Llan, Llangernyw to a point 45 metres east of the
turning to Nant Mawr, a distance of approximately 4km (which includes the Waterloo Hill
junction).
Rydym yn croesawu gohebiaeth yn Gymraeg. Byddwn yn ymateb i unrhyw ohebiaeth yn Gymraeg ac ni fydd hyn yn arwain
at unrhyw oedi.
We welcome correspondence in Welsh. We will respond to any correspondence in Welsh which will not lead to a delay.
Prif Switsfwrdd / Main Switchboard: 01492 574000
www.conwy.gov.uk
Ni ddylid cyflwyno dogfennau llys drwy ffacs
Fax not to be used for serving proceedings
2
This proposal will shortly be advertised as a Traffic Regulation Order (TRO). This requires a
consultation and legal process before changes can be implemented, which may take up to 6
months, depending on any objections received.
The Council has also conducted a review of existing traffic warning signs in the area and is
proposing changes and improvements where required to improve driver information of
potential hazards. These works are programmed to be completed by March 31 st 2026.
An example of the proposals, can be seen in the attached design drawings of improved traffic
signage and road markings along the A458, in the vicinity of the Waterloo Hill junction’
I trust that the above provides assurance of our commitment to reduce the risk of future road traffic
collisions in the area and make our roads safer for all road users.
Yours sincerely,
Head of Environment, Roads and Facilities
Cc:
, Chief Executive
Rydym yn croesawu gohebiaeth yn Gymraeg. Byddwn yn ymateb i unrhyw ohebiaeth yn Gymraeg ac ni fydd hyn yn arwain
at unrhyw oedi.
We welcome correspondence in Welsh. We will respond to any correspondence in Welsh which will not lead to a delay.
Prif Switsfwrdd / Main Switchboard: 01492 574000
www.conwy.gov.uk
Ni ddylid cyflwyno dogfennau llys drwy ffacs
Fax not to be used for serving proceedings
/ 2 2
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