Ashley Talbot

PFD Report All Responded Ref: 2017-0051
Date of Report 22 February 2017
Coroner Andrew Barkley
Response Deadline est. 19 April 2017
All 2 responses received · Deadline: 19 Apr 2017
Coroner's Concerns (AI summary)
Poor design of the school service road and bus bay, coupled with insufficient staff supervision, created a highly dangerous situation for children crossing the road, stemming from a lack of accountability in the school's construction.
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In the circumslances It IS my statutory duty to report to you [BRIEF SUMMARY OF MATTERS OF CONCERNJ (1) The evidence revealed clear deficiencies in re ation to the design of the service road" leading up to the school This Included the construction of a "bus which was inadequate for the number of vehicles required to transport children from the school at the end of the school As a direct result of this buses were parked outside the designated bus on the other side of the road The bay day: bay necessitating children t0 cross the road which was at the time of the accident used by other vehices such as staff vehicles visitors vehicles and school vehicles This created a highly dangerous situalion which resulted in the loss of life The evidence also revealed that there had been several "near misses which appeared to have gone unreported (2) At the time of the accident there was insufficient staff supervision of children boarding buses al the end of the school Given the Issues with the site which the evidence indicated had been raised when (he school was still under construction and before it opened in 2008 the number and position of slaff was Inadequate t0 ensure children boarded their buses (3) The wider Investigalion revea ed that (here was a clear lack of accountability between the various stakeholders in the design and construction of the school premises t0 ensure that a safe facilily was constructed Appropriate Safety Advice at an early stage the evidence showed would have reduced the likelihood of injury or death ActioN SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to lake such action
Responses
Ashley Talbot
19 Apr 2017
Action Taken
The bus bay has been extended to accommodate seven buses, and the school site is now subject to a lockdown, with no vehicles allowed to enter or move around the site until the children have boarded/alighted. A new drop-off area has been developed approximately 200m from the school gates. (AI summary)
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Dear Mr Barkley Thank you for your letter and Regulation 28 report dated 22 February 2017 following the inquest into the death of Ashley Talbot: This was a tragic accident and the Council would like to express its sincere condolences to Ashley's family: In accordance with Regulation 28, we have considered the concerns you have raised and will respond as follows: 1 Road layout Following this incident; the traffic management arrangements at all schools in the Borough were observed by Health and Safety Officers and Road Safety Officers. Both internal and external arrangements at the school were observed and documented Advice was provided to all headteachers at their forum meetings and a checklist was developed to assist them in monitoring their current arrangements. A programme of works was identified for physical environment which is currently being implemented: Examples of work undertaken at these locations included extra crossings, the installation of additional barriers and bollards. Works were also carried out at Maesteg Comprehensive School. The bus bay has been extended and can now accommodate seven buses. If there are changes to the number of buses required, this will be reviewed to ensure the space remains sufficient: The school site is now also subject to a lockdown, with no vehicles allowed to enter or move around the site until the children have alightedlboarded the buses_ Buses are only permitted to arrivelleave under controlled operation. A new drop-off area has been created on the access road (Ffordd Dysgu): The Corporate Health and Safety Team has promoted near-miss reporting within the current accident procedure across the Council, This was promoted with all headteachers at their forum meetings.
2. Staff supervision The supervision of the children falls under the responsibility of the school: The Council has monitored all schools' supervision arrangements during their observations by health and safety Ffonltel: 01656 643643 Facsifax: 01656 668126 EbostIEmail: talktous@bridqendgovuk Negescuon SMSI SMS Messaging: 07581 157014 TwltterdbridgendcBc GwefanWWebslte: WWwbrldgendgov-uk Cytnewid'testun: Rhowch 18001 flaen unrhyw un 0nrhifau fon ar y gwasanaeth (rosglwyddo testun Text rolay: Put 18001 before any of our phone numbers for the text relay service Rydym yn icroesawu goheblaeth yn y Gymraeg: Rhowch wybod Ini 05 yw eich dewis Ialth ywr Gymraeg We welcome correspondence In Welsh; Please lct u5 know If your language cholce (s Welsh Cyeor Ogwrs 1 F the being gyier

and road safety officers. The traffic management checklist provided to all schools includes a question on staff supervision during the start and end of the school day:
3. Design and construction The design project board for any new school build is now a multi-discipline team including designers, clients, highways road safety staff and health and safety officers. The project is now planned more strategically and with a holistic view: Early consideration is given to traffic management arrangements both internal and external for any new schools Advice is sought at an options appraisal stage to ensure any potential highway issues are identified prior to a site being chosen. Infrastructure costs, including works to highways and on-site parkingldrop- off arrangements, are now included in the overall costs of the budget: Once a site is identified and design is underway, the project board maintains a link with the on-site management of the build. hope the above reassures you that Bridgend County Borough Council has taken appropriate steps to respond to the events at Maesteg Comprehensive School, and has also considered the actions that are needed throughout the Borough: The Council is committed to improving health and safety within the schools and will continue to work with the governing bodies and headteachers to ensure the situation at all schools is monitored and actions taken as necessary_ If you have any further queries, please do not hesitate to contact us
Maesteg School
Action Taken
The bus bay has been extended, a school lockdown occurs during bus loading, staff supervision has increased, a speed limit is in place, and a vehicle drop-off point has been created. (AI summary)
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Dear sir , reply regarding the regulation 28 notice and the concerns raised by the coroner. (1) The bus being inadequate for the no. of vehicles: The bus bay has now been extended and now provides adequate parking for all buses, there is now no parking of buses outside of the designated bay: There is a lockdown of the school premises prior to and during pupils exiting the school and loading onto the buses, there is no vehicle movement this period_ (2) Staff supervision has been increased and there are now adequate nos. in place when children are boarding the buses at the end ofthe day: (3) While agree with the lack of accountability regarding the construction of a safe facility school governors would have had no input regarding the design or construction: (4) Additional measures now in place include a Smph speed limit within the school grounds. Staff managed pedestrian crossing points where pupils access the school via our safe routes to school pathways: (5) A vehicle drop off approximately 200 metres from the main gates which allows children to access the school via steps leading to the back of the school lessening the vehicle nos. which caused congestion outside the main gates: The governing body has worked closely with HSE representatives since the time of this tragic accident and all their recommendations have been carried out
Sent To
  • Bridgend County Borough Council
  • Maesteg Comprehensive School
Response Status
Linked responses 2 of 2
56-Day Deadline 19 Apr 2017
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

Report Sections
Investigation and Inquest
On the 18h December 2014 commenced an investigation into the death of Ashley Daniel Talbot aged 15. The investigation concluded at the end of an inquest held at the Aberdare Coroners Court between Monday 13" February 2017 through to Thursday 16" February 2017 The conclusion of the inquest was Accidental Death"
Circumstances of the Death
The deceased was a pupil at the Maesteg Comprehensive school and shortly after 3pm on Ihe 10"n December 2014 was running with a fellow pupil t0 calch his bus home when he was struck by a school minibus being driven In the school grounds as he entered the carriageway from between 2 parked buses He suffered extensive injuries to his head and chest and was confirmed deceased at the scene
Related Inquiry Recommendations

Public inquiry recommendations addressing similar themes

Out-of-school settings guidance update
Southport Inquiry
School Estate Management Failures
School monitoring and filtering systems guidance
Southport Inquiry
School Estate Management Failures

Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.