Luke James LYONS · Prevention of Future Deaths report

I write following the Inquest into the death of Luke James Lyons who died on 25th January 2013 at the scene of the accident just past Cove on the A396 when his vehicle hit a patch of black ice which had formed overnight.

I enclose a copy of the record of findings of Inquest, a recording and copies of the map of the location and scale plan of the incident for information; along with the data contained in C5, C6 and C7 regarding the gritting of the area.

Luke James Lyons died on 25th January 2013 at the scene of the accident just past Cove on the A396 when his vehicle hit a patch of black ice which had formed overnight.

I received evidence that the area in question was subject to water egress from the land at the side of the road which flowed from the higher ground across the road, thereby washing away any salt gritting put down by the Highway Department in anticipation of bad weather.

It was clear that procedures were followed, gritting undertaken which it was anticipated would have satisfied the need for gritting in the area in question in the absence of the localised water problem.

I received evidence that a number of vehicles going through this area also lost control despite the gritting but had managed to counteract the loss of control.

I understand that the Highways Department have since placed a drain at the location in order to combat the problem but it appears that it is inadequate (from information received from ████████ of Devon and Cornwall Constabulary). Clearly a repetition of Luke’s death in the forthcoming winter would be a disaster if it could be avoided by further action.