Brian Davies: Prevention of future deaths report
Other related deathsWales prevention of future deaths reports (2019 onwards)
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Date of report: 17/09/2025
Ref: 2025-0631
Deceased name: Brian Davies
Coroner name: Aled Gruffydd
Coroner Area: Swansea Neath & Port Talbot
Category: Other related deaths | Wales prevention of future deaths reports (2019 onwards)
This report is being sent to: South Wales Police | HSE
| REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: SOUTH WALES POLICE CHIEF CONSTABLE [REDACTED] SOUTH WALES POLICE HEADQUARTERS COWBRIDGE ROAD BRIDGEND CF31 3SU HSE LEGAL SERVICES DIVISION REDGRAVE COURT MERTON RD BOOTLE L20 7HS | |
| 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 21st March 2023 I commenced an investigation into the death of Brian Lyn Davies. The investigation concluded at the end of the inquest on the 15th September 2025. The medical cause of death is 1a) chest and neck injuries The conclusion of the inquest as to how Mr Davies came to his death was a narrative conclusion and is as follows:- It is not possible to determine the cause of the explosion, due to a lack of preserved material evidence, it cannot be determined how the explosion came about or occurred. |
| 4 | CIRCUMSTANCES OF THE DEATH The deceased was Brian Lyn Davies who was pronounced dead on the 13th of March 2023 at his home address [REDACTED], Swansea. The cause of death was chest and neck injuries sustained following an explosion at his home address.  The explosion occurred shortly after 11:00am on the above date, and the result of the explosion was that there was complete destruction of [REDACTED], and partial destruction of [REDACTED] resulting in a significant amount of rubble and debris. In order to undertake the search and rescue operation debris needed to be cleared to allow access to areas of the property, and to ensure that the search and rescue team operated in a safe environment. Brian was discovered beneath the rubble in the area that used to be the kitchen approximately 6 hours after the explosion occurred. Enquiries revealed that the gas service pipe to the property had been severed during the explosion and there was a compete circumferential crack to the gas main that ran adjacent to the property resulting in leaking gas. The investigation into the cause of the explosion undertaken by the HSE could not attribute the cause of the explosion to a gas leak since the clean up had removed vital evidence from the scene. They were unable to rule out other potential causes such as an internal gas leak or the explosion of other potential combustibles within the property. As such a gas leak was one of several possible theories, with none of them being able to be advanced as a probable cause of the explosion. Although the main gas appliances consisting of the gas cooker, the gas boiler and the gas meter had been secured, inspected, and eliminated as the cause, other items such as internal pipework and the internal walls were not available for inspection and the Police had not given instructions for those items to be secured as evidence. |
| 5 |  CORONER’S CONCERNS During the course of the inquest it was established that the cause of the explosion could not be ascertained since the clean up operation removed debris from the scene which was subsequently disposed of. It was confirmed that evidence ascertaining the cause of that explosion was not secured and as such was disposed of without an exercise to determine its significance to the investigation. The HSE’s Principal Gas Engineer commented that on viewing the television footage of the incident prior to attending the scene he feared that any investigation would be compromised due to evidence having been lost or disposed of. He also noted that the Police may not have come across a scene like this since gas explosions are rare. If the HSE are not involved then decisions made by Police in the interests of search and rescue that then hinder the investigation process and he would not expect them to understand the intricacies of what he would be looking for as part of his investigation. It is acknowledged that in search and rescue operations the preservation of life has to take precedence, however there should be an understanding by the Police as to what evidence should be preserved due to them having the initial primacy of investigation, and the information to fuel that understanding as to what evidence should be preserved where possible should come from the HSE who have the experience of investigating such events. I am concerned that without thorough investigations into the causes of domestic explosions then those causes cannot be determined and steps put in place to prevent future deaths by way of recurrence. The MATTERS OF CONCERN are as follows. 1. There was no understanding of what evidence was required to be preserved for the purposes of an investigation as to the cause of the explosion; 2. There was no order given to secure such evidence; 3. There was no memorandum of understanding or protocol between the Police and the HSE to provide information on what the HSE would need to be able to identify the cause of the explosion as far as practicable without impacting upon the primary objective of preserving life undertaken by the search and rescue operation |
| 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. |
| 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 12 November 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 [REDACTED] 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 | 17 September 2025 [REDACTED] |