Wilfred Fitchett, Jevon Hirst, Hugo Morris and Harvey Owen

PFD Report All Responded Ref: 2024-0560
Date of Report 17 October 2024
Coroner Kate Robertson
Coroner Area North West Wales
Response Deadline est. 12 December 2024
All 3 responses received · Deadline: 12 Dec 2024
Sent To
Response Status
Responses 3 of 3
56-Day Deadline 12 Dec 2024
All responses received
About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Coroner’s Concerns
Coroner's Office, Shirehall Street, Caernarfon a. Hugo was aged 18 at the time of his death following the collision and had passed his driving test on 23 May 2023. This was 6 months and 16 days prior to the collision. At the time of the collision, he was legally carrying 3 other young persons, his friends.
b. Currently, there are no legal restrictions upon the licences of young and/or newly qualified drivers and the current vehicle licensing regime permits the carrying of young persons as passengers in circumstances such as these.
c. It is noted that young drivers are exponenƟally more likely to be involved in a collision with each similar aged passengers in the car.
d. I am concerned that deaths will continue to occur or will occur into the future where younger persons are carried in motor vehicles being driven by newly qualified and/or young drivers.
Responses
Department of Transport
11 Dec 2024
The Department of Transport is developing a new road safety strategy, which will incorporate findings from the 'Driver 2020' project, to consider further measures to improve safety for young and newly qualified drivers. AI summary
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Dear Ms Robertson,

RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

Thank you for your report of 17 October 2024 made under the Coroners and Justice Act 2009 and the Coroners (Investigations) Regulations 2013, following the inquest you conducted into the deaths of Hugo Oliver Morris, Jevon Alexander Hirst, Harvey Graham Owen and Wilfred John Fitchett. I am responding as the Minister for the Future of Roads.

I am deeply saddened by the circumstances of Hugo Morris, Jevon Hirst, Harvey Owen, and Wilfred Fitchett’s deaths, and I would like to extend my condolences to their families.

I am determined that we learn from tragedies like this and that we take action to reduce those killed and injured on our roads.

I want to assure you that the Government treats road safety with the utmost seriousness. Whilst UK roads are among the safest in the world, there is no room for complacency and I have carefully considered your report and its recommendations relating to young and newly qualified drivers and young drivers carrying passengers of a similar age.

The latest statistics do show that the number of fatalities for car drivers aged 17-24 years-old on Britain’s roads is falling. However, there is still work to be done, particularly because, in terms of population and the number of miles driven, 17–24-year-olds, particularly young men, remain one of the highest fatality risk groups both as car drivers and passengers.

In partnership with the Transport Research Laboratory, the Department commissioned the largest young driver research piece, the ‘Driver 2020’ project. The research included a telematics trial, and it provides an evaluation of non-legislative interventions, such as technical and educational measures, to improve the safety of young novice drivers.

This Government takes road safety seriously, and we are committed to reducing the numbers of those killed and injured on our roads. My Department is developing our road safety strategy and will set out more details in due course.

We absolutely recognise that young people are disproportionately victims of tragic incidents on our roads. As work progresses on the new Road Safety Strategy, findings from the Driver 2020 project will feed into considerations on further measures the Department can take to improve road safety for young drivers.

Best wishes,

MINISTER FOR THE FUTURE OF ROADS
Clough Williams Ellis Trust
The Trust disputes responsibility for the fence, stating it was erected by Cyngor Gwynedd, not the landowner, and that fencing is the tenant's responsibility. They argue that stock fencing is not designed for highway safety and that road safety works are the responsibility of the highway authority. AI summary
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Response to Regulation 28 Report to Prevent Future Deaths, on behalf of the Trustees of the Ymddiriedolaeth Clough Williams-Ellis Foundation.
1. Introduction
1.1 The following has been prepared in response to the Coroner’s Regulation 28 Report to Prevent Future deaths issued to the Trustees of the Ymddiriedolaeth Clough Williams-Ellis Foundation as Landowners of the Brondanw Estate.
1.2 It goes without saying that the death of the four young men on 19th November 2023 is deeply upsetting and tragic.
1.3 The land upon which the vehicle ended up is owned by the Trustees, but let to the under a contract of tenancy governed by the Agricultural Holdings Act 1986.
2. The Coroner’s Report
2.1 The Coroner’s Report, in so far as the Landowner is concerned, states:
2.2 A stock fence had been erected (likely by the private Landowner) concerning the lane of the road in question. It is understood that Cyngor Gwynedd had no responsibility for this given that it was on private land. The stock fence had been damaged and had not been replaced prior to the collision on 19th November 2023.
2.3 Whilst the evidence could not determine whether or not the fence, had it been repaired and in situ at the time of the collision, would have altered the outcome the risk to road users who leave the road accidentally is that they may land in the ditch below road level.
3. The Brondanw Estate’s Position
3.1 It is extremely unlikely that the roadside fence would have been erected by the Landowner. Under the terms of the tenancy, fencing is the responsibility of the Tenant. The Tenant has confirmed to us that in this case the fence was in fact erected by Cyngor Gwynedd a number of years ago. The Tenant has further confirmed that there would be no reason to have erected a fence in that location as the ditch and embankment act as the stock proofing for the adjacent field.
3.2 In any case stock fencing is not meant to be a feature of highway safety and is not designed to withstand the force of a car hitting it at speed, and if that was its intended purpose something more robust ought to have been considered.
3.3 Over the years there have been a number of accidents on the section of road in question.
3.4 Any works on or adjacent to a public highway to enhance safety for road users are the responsibility of the relevant Authority and not the adjoining Landowner.

3.5 The below photograph shows the section of stock fencing erected by Cyngor Gwynedd behind bollards recently erected by Cyngor Gwynedd.
3.5 The below photograph shows the point where the car entered the ditch, where no stock fencing exists or existed, but now has the bollards installed by Cyngor Gwynedd.

3.6 The bollards, whilst delineating the edge of the carriageway, are of low quality and unlikely to be sufficiently strong to prevent a vehicle crashing through them and potentially ending up in the ditch below. Balfours LLP, New Windsor House, Oxon Business Park, Shrewbury, SY3 5HJ Agents to the Trustees of the Ymddiriedolaeth Clough Williams-Ellis Foundation February 2024
Cyngor Gwynedd Council
Cyngor Gwynedd Council provides a detailed explanation of its existing approach to highway safety, including the complexities and limitations of installing Road Restraint Systems (RRS) in extensive rural networks, considering factors like risk, cost, and environmental impact, and highlights driver responsibility. AI summary
View full response
Dear Coroner,

Response to Regulation 28 Report to Prevent Future Deaths (PFD)

Further to the Regulation 28 Report issued to Cyngor Gwynedd on the 24 October 2024, following the conclusion of the Inquest held on the 16 October 2024 into the tragic deaths of Hugo Morris, Jevon Hirst, Harvey Owen and Wilfred Fitchett, please find attached as Appendix 1 the Council’s response.

Yn gywir / Yours sincerely, Pennaeth Adran Cynorthwyol Assistant Head of Department

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Atodiad 1 Ymateb i’r Adroddiad Rheoliad 28 i Atal Marwolaethau yn y Dyfodol (PFD) _______________________________________________________________________________

1. CYFLWYNIAD

1.1 Mae'r canlynol wedi'i baratoi mewn ymateb i adroddiad Rheoliad 28 y Crwner i Atal Marwolaethau yn y Dyfodol (PFD) a gyflwynwyd i Gyngor Gwynedd. Mae hyn ymhellach i Gwest y Crwner ar 16 Hydref 2024 a fu'n ymdrin â marwolaethau pedwar dyn ifanc a fu farw mewn gwrthdrawiad traffig ffordd enbyd ar 19 Tachwedd 2023 ger Garreg Llanfrothen, Gwynedd.

1.2 Fe wneir cyfeiriad penodol at y pryder isod a gaiff ei godi yn yr Adroddiad:

“nad oes rhwystr neu ffens neu unrhyw beth arall i atal cerbydau modur rhag gadael y ffordd”

2. CEFNDIR

2.1 Mae'r A4085 yn Briffordd Dosbarth 1 sydd wedi'i dynodi'n Brif Ddosbarthwr CH1 yn Llawlyfr Cynnal Priffyrdd Cyngor Gwynedd. Mae'r rhain yn briffyrdd rhwng llwybrau strategol sy’n cysylltu canolfannau trefol i’r rhwydwaith strategol. Mae'r rhan o'r A4085 lle digwyddodd y gwrthdrawiad yn darparu cysylltiad rhwng Penrhyndeudraeth, Beddgelert ac ymlaen i Gaernarfon. Caiff ei defnyddio at ddibenion bob dydd gan drigolion lleol ac mae'n boblogaidd gyda thwristiaid ac ymwelwyr eraill, yn cynnig mynediad i galon Parc Cenedlaethol Eryri.

2.2 Mae'r A4085 yn lôn tua 21 milltir o hyd sy'n dolennu yma ac acw, wrth iddi ddringo'n raddol o fod bron yn lefel â'r môr ym Mhenrhyndeudraeth tuag at droed y mynyddoedd yn Eryri, ac yn ôl tua lefel y môr yng Nghaernarfon. Mae nodweddion y lôn wledig olygfaol hon yn debyg i lonydd eraill sy'n croesi'r un fath o amgylchedd a thopograffi.

2.3 Roedd y llifau traffig dyddiol cyfartalog am y cyfnod 30/10/2023-05/11/2023 yn Tŷ-Maen, Llanfrothen, tua 1.1 milltir i'r de ar yr A4085 o safle'r gwrthdrawiad, yn 511. Nid yw'r rhan hon o'r rhwydwaith yn profi tagfeydd gan fod llif y traffig yn isel, ac mae cymeriad y ffordd yn wledig gyda choed o boptu iddi am rannau helaeth, creigiau'n ymestyn allan a rhannau cul, yn ogystal â nifer o bantiau a throeon. Mae’r rhain yn ffurfio cymeriad nifer o ffyrdd gwledig yng Ngwynedd.

2.4 Mae'r Cyngor yn derbyn gwybodaeth gan y system adrodd STATS19 ar ddata gwrthdrawiadau a chan wasanaeth Heddlu Gogledd Cymru drwy Lywodraeth Cymru. O ddadansoddi data a ddaliwyd rhwng 2019 tan fis Mawrth 2024, yr unig ddigwyddiad sydd wedi'i gofnodi yn lleoliad y gwrthdrawiad yw'r gwrthdrawiad angheuol ym mis Tachwedd 2023.

2.5 Mae cofnodion mewnol y Cyngor o ymholiadau a chwynion yn cadarnhau nad oes unrhyw gofnod o unrhyw gwynion neu ymholiadau wedi'u derbyn gan yr Uned Traffig mewn perthynas â'r rhan hon o'r ffordd.

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3. SAFBWYNT CYNGOR GWYNEDD

3.1 Ar sail y ffactorau dylanwadol uchod, gan roi ystyriaeth i'r arweiniad yn y Llawlyfr Arwyddion Traffig, mae Cyngor Gwynedd yn dal i fod o'r farn fod yr arwyddion traffig a marciau ffordd oedd mewn lle yng nghyffiniau safle'r gwrthdrawiad ar adeg y gwrthdrawiad yn briodol ac yn rhesymol, yn rhoi rhybudd digonol o'r tro sydd o'ch blaen. Er bod hyn yn groes i farn y Crwner, caiff y farn hon ei chefnogi gan dystiolaeth a gyflwynwyd i'r Cwest gan Swyddog Gwrthdrawiadau Fforensig Heddlu Gogledd Cymru ynghyd ag Uwch Beiriannydd Traffig Cyngor Gwynedd.

3.2 Fodd bynnag, ar ôl y gwrthdrawiad, gan ddefnyddio pwerau sydd wedi'u breinio i Gyngor Gwynedd fel yr Awdurdod Priffyrdd yn Neddf Traffig Ffyrdd 1998 “er mwyn rheoli, gwarchod neu gynorthwyo symudiad traffig ar ffyrdd”, mae'r Cyngor wedi gweithredu'r gwelliannau a ganlyn ar sail dewisol ac anrhagfarnol.

• wedi gosod byrddau 'chevron' ar gornel y tro hir.
• wedi uwchraddio'r marciau “Araf/Slow” yn y ddau gyfeiriad ger lleoliad y gwrthdrawiad.
• wedi uwchraddio arwyddion yn rhybuddio am y tro llaw-dde.
• ⁠wedi gosod cyfres o farcwyr ymyl ffordd adlewyrchol ar ymyl y tro.

4. ASESIAD RHWYSTR FFORDD AR GYFER SAFLE PENODOL

4.1 Oherwydd:

1. Natur drasig, proffil uchel a sensitif y sefyllfa.
2. Bod cyfeiriad penodol yn cael ei wneud at y pryder a godwyd yn Adroddiad Rheoliad 28 y Crwner:

“nad oes rhwystr neu ffens neu unrhyw beth arall i atal cerbydau modur rhag gadael y ffordd”

4.2 Fe gynhaliwyd asesiad ar gyfer darparu System Rhwystr Ffordd (RRS – road restraint system) yn y safle.

4.3 Roedd yr asesiad yn seiliedig ar yr arweiniad sydd wedi'i amlinellu yng Nghanllaw Dylunio a Chynnal a Chadw'r Adran Drafnidiaeth ar gyfer Ffyrdd Awdurdodau Cyhoeddus, Darparu Systemau Rhwystr Ffordd ar Ffyrdd Awdurdodau Cyhoeddus.

4.4 Dewiswyd y Canllaw hwn oherwydd y lefel isel o draffig sy'n defnyddio'r A4085. Mae’r Canllaw yn rhoi fframwaith, ond nid yw'n gyfarwyddol. Cydnabyddir y bydd nifer o ffactorau yn dylanwadu ar briodoldeb a chyfiawnhad system RRS ac mae'r rheiny'n cynnwys natur a defnydd y ffordd, data gwrthdrawiadau, perchnogaeth tir, ystyriaethau peirianyddol, amgylcheddol ac esthetig yn ogystal â chost (costau cyfalaf ar gyfer gosod y system, a chostau refeniw parhaus ar gyfer ei harchwilio a'i chynnal a chadw wedi hynny).

4.5 Mae'r Canllaw yn cynnwys diffiniadau ac eglurhad mwy manwl ynghylch yr hyn y cyfeirir atynt fel Dull A (Asesu Damweiniau) a Dull C (Sgorio Risg). Mae’r isod yn rhoi crynodeb:

• Mae Dull A yn ystyried data ar wrthdrawiadau i asesu'r tebygolrwydd o ddamwain ddifrifol yn digwydd.

• Mae Dull C yn ystyried natur y ffordd a'r peryglon sy'n bresennol yn fwy na'r tebygolrwydd.

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4.6 Fel sydd wedi'i nodi yn y Canllaw, nid asesiad Dull C fyddai'r prif ddull o asesu risg os oes data gwrthdrawiadau ar gael ac felly mae modd defnyddio dull A. Fodd bynnag, at ddibenion yr asesiad hwn fe ddefnyddiwyd Dull A a Dull C.

4.7 Mae Casgliad yr asesiad a wnaed i'w weld isod.

Casgliad Wrth ddefnyddio'r asesiadau a amlinellir yng Nghanllaw Dylunio a Chynnal a Chadw'r Adran Drafnidiaeth a'r UK Roads Liaison Group ar gyfer Ffyrdd Awdurdodau Cyhoeddus, Darparu Systemau Rhwystr Ffordd ar Ffyrdd Awdurdodau Cyhoeddus:

• Daw Dull A i'r casgliad fod y safle yn safle blaenoriaeth isel yn seiliedig ar amlder damweiniau hanesyddol.
• Daw Dull C i'r casgliad fod y safle yn safle blaenoriaeth ganolig uchaf yn seiliedig ar nodweddion y ffordd.

Mae'r canllaw ar gyfer safleoedd blaenoriaeth ganolig yn datgan efallai fod cyfiawnhad am system rhwystr ffordd, fodd bynnag mae'n bosib y byddai dull nad yw'n defnyddio RRS i leihau'r risg yn ddigonol i negyddu’r angen am RRS.

Oherwydd diffyg ymyl ffordd gwastad, nid oes modd gosod system rhwystr ffordd yn hawdd heb waith sylweddol i greu ymyl ffordd, a fyddai'n golygu costau helaeth.

Byddai tynnu'r peryglon presennol hefyd yn gofyn am waith sylweddol a byddai yna ganlyniadau amgylcheddol yn ei sgil.

Mae'r lefelau traffig ar yr A4085 yn isel iawn i ffordd A ac mae'r cyflymderau a fesurwyd hefyd yn llawer is na'r 60mya a ganiateir oherwydd aliniad y ffordd.

Mae'r arwyddion ar y tro eisoes wedi cael eu gwella yn dilyn y ddamwain angheuol, ac wedi cynyddu'r rhybudd i fodurwyr am y tro sydd o'u blaen, a bydd hyn yn lleihau'r tebygolrwydd ymhellach o gerbyd yn gadael y ffordd ar y tro. Mae'n bosib iawn y bydd hyn yn ddigonol i negyddu'r angen am system RRS.

4.8 Fe nodir yn y Canllaw, mewn sawl achos y gellir ystyried RRS fel y 'dewis olaf', gyda mesurau lliniaru eraill yn cael eu hystyried i fod yn ddigon priodol. Mae'r rhain yn cynnwys y canlynol sydd eisoes wedi cael eu gweithredu yn safle'r gwrthdrawiad:

• Gosod byrddau chevron ac arwyddion rhybuddio, yn cynnwys arwyddion sy’n cael eu rhoi ymlaen gan gerbydau.
• Gosod nodweddion ymyl-ffordd goddefol fel awgrym gweledol o berygl e.e. pyst adlewyrchol hyblyg (deformable reflective posts).

4.9 Mae'r Canllaw hefyd yn nodi:

Mae'r penderfyniad i ddarparu system RRS mewn sefyllfa llif isel neu gyflymder isel yn un anodd oherwydd y costau uchel a'r risg isel posib o ddamweiniau mewn lleoliad penodol. Gall un ddamwain sy'n cynnwys cerbyd yn gadael y gerbyd-lon fod yn ganlyniad i nifer o ffactorau priffordd, ond gall arwain at gryn bwysau gan y cyhoedd i ddarparu system RRS.

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Ni ddylai'r sawl sy'n gwneud y penderfyniad fod ofn gwneud dim byd, os mai gwneud dim yw'r casgliad priodol a ddaw o'r broses asesu sydd wedi'i hamlinellu yn y Canllaw.

4.10 Ar sail yr uchod, gan ystyried y gwelliannau sydd eisoes wedi cael eu gweithredu, mae opsiynau yn y tymor byr i osod RRS yn gyfyngedig o ran y sgôp a'r cyfiawnhad. Fodd bynnag, fe gaiff hyn ei adolygu gan fod yna ffactorau eraill a allai ddylanwadu ar hyn. Gallai'r rhain gynnwys gwaith cynnal a chadw yn y dyfodol a/neu welliannau ehangach a mwy sylweddol i'r briffordd a allai effeithio ar yr ystyriaethau sy'n pennu a ddylid gosod RRS ai peidio.

4.11 O safbwynt sawl peth, gan gynnwys y gost, y safbwynt amgylcheddol a pherchnogaeth tir, efallai y byddai darpariaeth RRS fel rhan o gynllun ehangach yn fwy hyfyw a chyfiawnadwy na chynllun unigol i osod RRS oherwydd yr ystyriaethau a chyfyngiadau sy'n benodol i'r safle dan sylw.

4.12 Bydd Cyngor Gwynedd hefyd yn ystyried pa ymyraethau pellach, ac os oes yna unrhyw ymyraethau pellach ar wahân i RRS, fydd efallai'n cael eu gweithredu i liniaru ymhellach y risgiau sy'n gysylltiedig â'r gwrthdrawiad hwn ac amgylchiadau'r marwolaethau trasig.

5. CASGLIAD

5.1 Fe all fod yna gyfleoedd i wneud newidiadau i'r briffordd mewn ymdrech i gael dylanwad positif ar ymddygiad gyrwyr, lleihau pa mor ddifrifol yw gwrthdrawiadau posib, neu wneud newidiadau dyluniad i'r ffordd er mwyn lleihau'r risg o wrthdrawiadau.

5.2 Fodd bynnag, mae yna gyfyngiadau cyllidol, adnoddau, ffisegol, peirianyddol, cyfreithiol ac eraill sy'n golygu bod yna gyfyngiadau ar yr hyn y gall, ac y gellir disgwyl i, Awdurdodau Priffyrdd ei wneud i wella diogelwch y rhwydwaith priffyrdd ymhellach.

5.3 Nid gwneud newidiadau i'r rhwydwaith priffyrdd yw'r unig fodd o leihau nifer y damweiniau ar y rhwydwaith. Mae swyddogion Cyngor Gwynedd yn gweithio'n barhaus mewn partneriaeth â Heddlu Gogledd Cymru ac mae'r ymdrechion cydweithio yma wedi bod hanfodol wrth gael dylanwad positif ar nifer y gwrthdrawiadau ar ein rhwydwaith.

5.4 Mae'r penderfyniad a'r cyfiawnhad i ddarparu system RRS mewn sefyllfa llif isel a/neu gyflymder isel yn un anodd ar rwydwaith priffyrdd gwledig enfawr. Mae hyn yn rhoi ystyriaeth i ac yn adlewyrchu cymesuroldeb a phriodoldeb ymyraethau o'r fath o safbwynt risg (tebygolrwydd a difrifoldeb), cyfyngiadau peirianyddol, ystyriaethau amgylcheddol ac esthetig, cost a chysondeb. O ran costau mae hyn yn cynnwys y costau gosod cyfalaf sylweddol ynghyd â'r costau cynnal a chadw parhaus wedi hynny.

⁠5.5 Yn ei hanfod, pwrpas RRS yw cadw cerbydau oddi fewn i derfynau'r briffordd lle mae ongl yr ardrawiad yn berthnasol. Fe allai system RRS mewn lleoliad fel safle'r gwrthdrawiad fod yn wrthrych disymud sydd wedyn yn creu perygl ynddo'i hun petai, er enghraifft, cerbyd yn ei daro wrth deithio'n gyflym a allai beri'r cerbyd i droi drosodd ac/neu arwain at ardrawiadau/gwrthdrawiadau gyda cherbydau eraill.

5.6 Nid yw cyflwyno system RRS yn gwneud sefyllfa yn gwbl ddiogel bob tro, a byddai gosod system sy'n cydymffurfio â'r canllaw yn y lleoliad hwn yn golygu costau sylweddol. Bob blwyddyn, mae yna anafiadau sy'n cael eu hachosi pan fydd cerbydau yn taro systemau RRS ac mae'r Canllaw yn cydnabod bod elfen o risg ymhlyg mewn unrhyw system RRS. Mae'n rhaid cydbwyso’r risg hwn yn erbyn y budd o liniaru difrifoldeb unrhyw ddamwain am gost fforddiadwy.

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5.7 Mae Rheolau’r Ffordd Fawr (The Highway Code) yn pwysleisio'r pwysigrwydd bod modurwyr yn parhau i ganolbwyntio ar y ffordd sydd o'u blaen, a bod ganddynt rôl a chyfrifoldeb sylweddol yn niogelwch y ffordd.

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Appendix 1 Response to Regulation 28 Report to Prevent Future Deaths (PFD) _______________________________________________________________________________

1. INTRODUCTION

1.1 The following has been prepared in response to the Coroners’ Regulation 28 Report to Prevent Future Deaths (PFD) issued to Cyngor Gwynedd. This is further to the Coronial Inquest of 16 October 2024 touching the deaths of four young men who died in a tragic road traffic collision on the 19 November 2023 near Garreg Llanfrothen, Gwynedd.

1.2 Specific reference being made to the concern raised in the Report that:

“there is no barrier or fence or otherwise to prevent motor vehicles leaving the road”

2. BACKGROUND

2.1 The A4085 is a Class 1 Highway designated a CH1 Main distributor in the Cyngor Gwynedd Highways Maintenance Manual. These are highways between strategic routes and linking urban centres to the strategic network. The section of the A4085 where the collision occurred provides a link between Penrhyndeudraeth, Beddgelert and onwards to Caernarfon. It is used for everyday purposes by local residents and is popular with tourists and other visitors affording access to the heart of the Eryri National Park.

2.2 The A4085 is an approximate 21-mile route that is meandering in nature as it climbs gradually from near sea level at Penrhyndeudraeth towards the foothills of the mountains in Eryri and back towards sea level at Caernarfon. Features of this scenic route are similar to others traversing the same kind of environment and topography.

2.3 Daily average traffic flows for the period 30/10/2023-05/11/2023 at Tŷ-Maen, Llanfrothen, approximately 1.1 mile south on the A4085 from the site of the collision, was 511. This part of the network is not subject to congestion as the traffic flows are low, and the character of the road is rural with extensive tree coverage, rocky outcrops and narrow sections as well as numerous dips and bends. These form the character of many rural roads in Gwynedd.

2.4 The Council receive information from the STATS19 reporting system on collision data and from the North Wales Police Service via the Welsh Government. From analysing data captured between 2019 and March 2024, the only incident that has been recorded at the collision location is the tragic fatal collision in November 2023.

2.5 The Council’s internal enquiries and complaints records confirm that there is no record of any complaints or enquiries received by the Traffic Unit relating to this section of road.

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3. CYNGOR GWYNEDD’S POSITION

3.1 On the basis of the above influencing factors, giving consideration to the guidance within the Traffic Signs Manual, Cyngor Gwynedd maintains the position that the traffic signs and road markings in situ in the vicinity of the collision site at the time of the collision were appropriate and reasonable giving adequate warning of the upcoming bend. While this is contrary to the opinion of the Coroner this position is supported by evidence presented to the Inquest by both the North Wales Police Forensic Collision Officer as well as Cyngor Gwynedd’s Senior Traffic Engineer.

3.2 However, post collision, applying powers vested to Cyngor Gwynedd as the Highway Authority in Section 39 of the Road Traffic Act 1988 “for controlling, protecting or assisting the movement of traffic on roads”, the Council have implemented the following enhancements on a discretional and non-prejudicial basis:

• installed chevron boards on the corner of the sweeping bend.
• upgraded the road “Araf/Slow” markings in both directions near to the collision location.
• upgraded warning signage of the right-hand bend.
• installed a series of reflective verge markers on the edge of the bend.

4. SITE SPECIFIC ROAD RESTRAINT ASSESSMENT

4.1 Due to:

1. The tragic, high profile and sensitive nature of the situation.
2. Specific reference being made to the concern raised in the Coroners’ Regulation 28 Report that:

“there is no barrier or fence or otherwise to prevent motor vehicles leaving the road”

4.2 an assessment for the provision of a Road Restraint System (RRS) at the site has been undertaken.

4.3 The assessment was based on the guidance outlined in the Department of Transport, Design and Maintenance Guidance for Local Authority Roads, Provision of Road Restraint Systems on Local Authority Roads.

4.4 This Guidance was selected due to the low volume of traffic using the A4085. The Guidance provides a framework but is not prescriptive. It is acknowledged that a number of factors will influence the appropriateness and justification for RRS which includes the nature and usage of the road, collision data, land ownership, engineering, environmental and aesthetic considerations as well as cost (capital costs for installation and ongoing revenue costs for inspection and maintenance thereafter).

4.5 The Guidance includes more detailed definitions and explanations with regards what are referred to as Method A (Accident Assessment) and Method C (Risk Scoring). The following provides a summary:

• Method A considers collision data to assess the probability of a serious accident occurring.

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• Method C considers the nature of the road and hazards present more than the probability.

4.6 As set out in the Guidance, a Method C assessment would not be the primary method of assessing risk where collision data is available and Method A can therefore be applied. However, for the purposes of this assessment both Method A and Method C were applied.

4.7 The Conclusion of the assessment undertaken is provided below.

Conclusion When using the assessments outlined in UK Roads Liaison Group and Department of Transport, Design and Maintenance Guidance for Local Authority Roads Provision of Road Restraint Systems on Local Authority Roads document:

• Method A concludes that the site is of low priority site based on historic accident frequencies.
• Method C concludes that the site is of top medium priority based on the road features.

The guidance for medium priority sites state that a road restraint system may be justified however a non- RRS approach to reducing the risk may prove sufficient to negate the need for a RRS.

Due to lack of level verge a new restrain system cannot be easily installed without major works to create a verge which would have significant costs.

Removing the existing hazards would also require significant works and have environmental consequences.

The traffic volumes on the A4085 are very low for a A road and the measured speeds are also far lower than the permitted 60mph due to the alignment of the road.

The signage on the bend has already been improved following the fatal accident and has enhanced the warning to motorists of the bend which will further reduce the probability of a vehicle running off the bend. This may well prove sufficient to negate the need for a RRS.

4.8 It is noted in the Guidance that in many cases RRS can be considered as a ‘last resort’ with other mitigating measures considered sufficiently appropriate. These include the following which have already been implemented at the collision site:

• Installation of chevron and warning signs, including vehicle activated signs.
• Installation of passive roadside features as a visual cue to a hazard e.g. deformable reflective posts.

4.9 The Guidance also notes:

The decision to provide a RRS in a low flow or low speed scenario is a difficult one due to the high costs and the potentially low risk of accidents at a particular location. The occurrence of one accident involving a vehicle leaving the carriageway may be a result of numerous highway factors but can result in considerable public pressure to provide an RRS.

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The decision taker must not be afraid of doing nothing, if to do nothing is the proper conclusion of the assessment process outlined in the Guidance.

4.10 On the basis of the above, taking into account the enhancements already implemented, options in the short term to install a RRS are limited in respect of both scope and justification. However, this will be subject to review as there are other factors which may influence this. These could include future maintenance and/or wider and more significant improvements to the highway which may affect the determining considerations in relation to installing a RRS.

4.11 From a number of perspectives, including cost, environmental and land ownership, RRS provision as part of a wider scheme may be more viable and justifiable than a stand-alone scheme to install RRS due to the site-specific considerations and constraints.

4.12 Cyngor Gwynedd will also consider what, and if, there are any further interventions, other that RRS, which may be implemented to further mitigate risks associated with this collision and the circumstances of the tragic deaths.

5. CONCLUSION

5.1 There can be opportunities to make changes to the highway as an effort to positively influence driver behaviour, reduce the severity of a potential collisions, or make design changes to the road layout to reduce the risk of collisions.

5.2 However, there are funding, resource, physical, engineering, legal and other constraints which mean there are limitations to what Highway Authorities can, and can be expected to do, to further improve the safety of the highway network.

5.3 Making changes to the highway network is not the only way to reduce the number of accidents on the network. Cyngor Gwynedd Officers work on an ongoing basis in partnership with North Wales Police and these collaborative efforts have been instrumental in having a positive influence on the number of collisions on our network.

5.4 The decision and justification to provide a RRS in a low-flow and / or low-speed scenario is difficult on what is an extensive rural highway network. This takes into account and reflects the proportionality and appropriateness of such interventions from the perspective of risk (likelihood and severity), engineering constraints, environmental and aesthetic considerations, cost and consistency. In terms of costs this includes the considerable capital installation costs as well as the subsequent ongoing maintenance costs.

5.5 The purpose of a RRS is, essentially, to keep vehicles within the confines of the highway where the angle of impact is relevant. A RRS at a location such as the collision site could be an immovable object creating a hazard in its own right which if, for example, it was hit at speed could cause a vehicle to flip and / or could result in impacts/collisions with other vehicles.

5.6 The introduction of a RRS does not always make a situation totally safe and the installation of a compliant system, in this location, would come at significant expense. Every year, there are injuries caused when vehicles hit RRSs and the Guidance recognises that any RRS has an inherent element of risk. This risk must be balanced by the benefit of mitigating the severity of any accident at an affordable cost.

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5.7 The Highway Code emphasises the importance of motorists staying focused on the road ahead and that they have a significant role and responsibility to play in road safety.
Report Sections
Investigation and Inquest
On 27 November 2023 I commenced an investigation into the deaths of Wilfred John Fitchett, Jevon Alexander Hirst, Hugo Oliver Morris and Harvey Graham Owen. The investigation concluded at the end of the inquest on 16 October 2024. A Road Traffic Collision conclusion was recorded with deaths for all four young men resulting from drowning.
Circumstances of the Death
The circumstances of the death are as follows :- Hugo Morris was aged 18 at the time of his death. On 19 November 2023 he was driving a motor vehicle and carrying three passengers who were aged 17 (Wilfred), 16 (Jevon) and 17 (Harvey), along the A4085 Garreg, Llanfrothen having been on a camping trip when the motor vehicle in quesƟon veered onto the nearside grass verge and entered into a water-filled drainage ditch which led to the deaths of all four young men, where the exisƟng signage would not have given adequate warning of the upcoming bend. The motor vehicle with the four young men was not found unƟl 21 November 2023.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.