Chances missed to save man killed walking across M4

The coroner said that there was a 'catalogue of missed opportunities" that may have prevented Thavarajah Sasikaran's death

14:03, 12 Jun 2025

Opportunities were missed to safeguard a man who was fatally hit by a car while walking across a motorway, a coroner has concluded.

Thavarajah Sasikaran was allowed to discharge himself from Morriston Hospital half an hour before the collision on the westbound carriageway of the M4 in Swansea[1]. The 41-year-old -- referred to as Sasi during the Swansea coroner's court hearing -- had been experiencing paranoia and acute alcohol withdrawal in the lead-up to the accident at 8.34pm on February 18, 2022.

The three-day inquest had heard he was struck by a Nissan Qashwai while "casually" crossing the carriageway on foot.

A police investigation found the driver was blameless[2]. No alcohol was in Sasi's system at the time of the crash between junctions 46 (Llangyfelach) and 47 (Penllergaer).

In the hours before the collision Sasi had been in a confused state while experiencing withdrawal at the hospital -- where he had been admitted at 4.30pm the day before -- but due to communication failures a nurse allowed Sasi to discharge himself without realising he was in a mental health crisis.

"There was a catalogue of missed opportunities that, if implemented, may have prevented death," said coroner Aled Gruffydd.

Sasi, a dad-of-one who struggled with alcohol addiction, had been living in supported accommodation on Tontine Street run by the Goleudy homelessness charity.

On February 17 he had a mental health episode and told staff he was hearing voices and seeing spiders and slime on walls.

No ambulance was available so staff called a taxi to take him to Morriston A&E, where he was assessed as being in acute alcohol withdrawal. Senior house officer Dr Amy Noble told the inquest that Sasi had "ideas to harm himself and paranoid thoughts".

Agitated and twitching, Sasi told staff he drank half a litre of whisky each day as well as some beer. He was administered diazepam and kept in overnight to be assessed the following day.

At 10.35am the next day he had a serious seizure and afterwards appeared confused, wandering around the hospital and displaying erratic behaviour like mixing a main meal with a dessert.

In its serious incident review, Swansea Bay Health Board found a series of failings.

Staff did not observe Sasi's alcohol withdrawal symptoms every 90 minutes as they should have done.

This was because of an "extremely busy" period in the emergency department and Sasi's own reluctance to respond to assessment, said the coroner.

At 6.30pm, nurse Annemarie Morris observed Sasi was still confused and lacking capacity to discharge himself. He required a mental health assessment before he could be safely discharged.

But shortly afterwards Sasi told a security guard, Ian Gough, he wanted to go home. The guard took him to see nurse Tristan Taylor, who found the patient to appear "rational", with no "red flags".

Sasi said he planned to go home as he would be travelling the following day to see family in London.

Nurse Taylor allowed Sasi to discharge himself and Mr Gough walked him out of the hospital grounds at around 8pm.

When the guard asked if he knew his way home, Sasi was able to give "adequate directions" to the city centre, said the coroner.

The serious incident review found the unsafe discharge took place because of failings in "handover" information between staff, which meant nurse Taylor was aware of the seizure but "had no knowledge that this was a mental health matter", said Mr Gruffydd.

"Nurse Taylor was unaware of the medical history," the coroner went on. "The case was overtaken by the seizure, but the original admission was for a mental health matter. By his own admission, had he been aware of the recommendation for a mental health assessment, nurse Taylor would have got a doctor to have a discussion with Sasi."

The health board accepted errors including that there was no attempt to persuade Sasi to stay in hospital and see a doctor, no contact with his supported accommodation on discharge, and no offer to arrange a taxi.

CCTV footage showed Sasi walking westbound along the hard shoulder of the M4's eastbound carriageway before the crash. "He has then crossed the eastbound carriageway and climbed over the central reservation barrier," the police report read. "He has then attempted to cross the westbound carriageway and was narrowly missed by a roads policing vehicle which was attending an unrelated emergency.

"A very short time after this near miss he has been struck by a Nissan Qashqai. There is no evidence of any excess speed of the Nissan Qashqai, and the driver David Newman would have had only 40 metres to react, leaving very little time to avoid the collision."

The officer who narrowly avoided crashing into Sasi was PC Ian Ranford, who said the pedestrian was dressed all in dark clothing on an unlit section of motorway and "casually" stepped from the central reservation into the path of the police car, appearing "oblivious" to his surroundings.

After PC Ranford swerved to prevent a collision, Sasi continued walking across the carriageway and was knocked down in the next lane by the Nissan, which was travelling at 50mph in accordance with road signs.

The PC and two off-duty nurses stopped to perform CPR on the motorway but he was pronounced dead at the scene with severe injuries to his neck, chest, pelvis and legs.

Mr Gruffydd said there was not enough evidence to show the hospital's missed opportunities were "causative of death".

Recording a conclusion of death by road traffic conclusion, he said: "I do not consider it was his intention to end his own life."

The coroner noted that Sasi had spoken about self-harm but not suicidal ideation. "Furthermore, the CCTV footage showed that when he saw the police car he hurried forward to avoid it," he added. "That doesn't accord with the actions of a person who intended to take his own life. In my view this was a tragic accident."

Sasi had a happy childhood in Sri Lanka before moving to the UK at the age of 20, said his brother Thavarajah Shanthakumaran in a statement.

"He settled in London and was talented in arts and had a natural ability. However, he struggled with alcohol, so much so that we as a family paid for him to go to rehab and get his life back on track."

Sasi married and became a father but he again battled with alcohol addiction after the marriage ended.

He moved to south Wales in 2018 and got a job at a store run by his brother. Following a period in rehab he found supported accommodation in Swansea.

"We are a close family and Sasi was never without money or food," his brother added. "We were always able to speak to him daily. As a family we are truly lost and heartbroken by Sasi's death.

My parents will never get over losing him."

What the health board says

A Swansea Bay health board spokesman said: "The health board expresses its sincere condolences to Mr Sasikaran's family and apologises for the missed opportunities as outlined by the coroner. These missed opportunities were identified during the health board's own investigation following Mr Sasikaran's tragic death in 2022.

"As a result of the lessons learnt, a series of measures, including additional training and improved procedures, has since been introduced. These relate to the failure to follow the CIW-AR regime for monitoring and rating the severity of alcohol withdrawal; failure in relation to the safe discharge of a patient who wants to self-discharge; and failings in communication and handover.

"We acknowledge the coroner's comments that he could not find the missed opportunities were probable in Mr Sasikaran's death and it was unforeseeable that he would be a pedestrian on the M4.

Nevertheless, the health board would like to assure the family it is doing everything possible to prevent a similar incident occurring in future."

Join the WalesOnline WhatsApp community

WalesOnline has launched a new breaking news and top stories WhatsApp community. From the biggest court stories to the latest traffic updates, weather warnings and breaking news, it's a simple way to stay up to date with what's happening in Wales.

Want to join? All you have to do is click on this link[3], select 'Join Community' and you're in.

We will not spam your feed with constant messages, but you will receive updates from us daily.

If for some reason you decide you no longer want to be in our community, you can leave by clicking on the name at the top of your screen and clicking 'Exit Group'.

We occasionally treat our community members to special offers, promotions, and adverts from us and our partners.

You can read our Privacy Notice here.[4]

Join our WhatsApp community here[5]

References

1. ^ M4 in Swansea (www.walesonline.co.uk)
2. ^ found the driver was blameless (www.walesonline.co.uk)
3. ^ click on this link (chat.whatsapp.com)
4. ^ Privacy Notice here. (www.reachplc.com)
5. ^ Join our WhatsApp community here (chat.whatsapp.com)