Andrew Still: Prevention of future deaths report
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Date of report: 21/02/2023
Ref: 2023-0066
Deceased name: Andrew Still
Coroner name: Caroline Saunders
Coroner Area: Gwent
Category: Road (Highways Safety) related deaths
This report is being sent to: Monmouthshire County Council
| REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: Monmouthshire County Council – [REDACTED] Chief Executive – [REDACTED] Council Leader | |
| 1 | CORONER I am Caroline Saunders, Senior Coroner for the Area of Gwent |
| 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 14/6/2022 an investigation was opened into the death of Andrew Mark STILL. The investigation concluded at the end of the inquest on: 15/02/2023. The conclusion of the inquest was recorded as: Road Traffic Collision The medical cause of death was: 1a. Multiple injuries 1b. Blunt vehicular trauma |
| 4 | CIRCUMSTANCES OF THE DEATH On 03/06/2022 Andrew Mark Still was riding his motorcycle on the A466 towards Chepstow from Tintern. Approximately 1 mile from the village of Tintern, Andrew encountered a double bend. As he rode into the second bend, Andrew was on the wrong side of the road and collided with a VW campervan travelling in the opposite direction. Andrew suffered extensive injuries and died at the scene. |
| 5 | CORONER’S CONCERNS The MATTERS OF CONCERN are as follows: There was a warning sign which alerted motorists to the forthcoming series of bends and the extended white road marking indicated a pending hazard. There was also a chevron marker closer to the bend. At the inquest I found that Andrew had overtaken vehicles prior to the bends and would have seen the warning sign and the road markings. However, I found that the chevron sign near to the bend was overgrown. Moreover there was evidence that there had previously been 3 markers but two had been removed and not replaced. I was informed that the relevant authority had been made aware of this problem by Gwent Police after Andrew’s death but there was no evidence at the inquest that any remedial action had been taken |
| 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. I should be grateful if the following information be provided to me: Confirm that plans are in place for the chevron markers to be replaced and foliage removed from the remaining chevron marker to ensure it is visible to motorists. |
| 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely 18 April 2023. I, the Coroner, may extend this 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 necessary. |
| 8 | COPIES AND PUBLICATION I have sent a copy of my report to the Chief Coroner and the following Interested Person (s) The family of Andrew Mark Still 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 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 | DATE: 21 February 2023 Caroline Saunders His Majesty’s Senior Coroner for the Area of Gwent. |