Investigation and inquest
On the 18th December 2014 I 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 13th February 2017 through to Thursday 16th 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 the 10th December 2014 was running with a fellow pupil to catch 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.
Coroner’s concerns
(1) The evidence revealed clear deficiencies in relation to the design of the “service road” leading up to the school. This included the construction of a “bus bay” which was inadequate for the number of vehicles required to transport children from the school at the end of the school day. As a direct result of this buses were parked outside the designated bus bay on the service road necessitating children to cross the road which was, at the time of the accident, being used by other vehicles such as staff vehicles, visitors vehicles and school vehicles. This created a highly dangerous situation 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 at the end of the school day. Given the issues with the site, which the evidence indicated had been raised when the school was still under construction and before it opened in 2008, the number and position of staff was inadequate to ensure children boarded their buses safely.
(3) The wider investigation revealed that there was a clear lack of accountability between the various stakeholders in the design and construction of the school premises to ensure that a safe facility was constructed. Appropriate Safety Advice at an early stage, the evidence showed, would have reduced the likelihood of injury or death.