Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0301, written 15 Nov 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Nov 2013 |
|---|---|
| Reference | 2013-0301 |
| Deceased | Andrew Phrydas |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Railway related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
Andrew PHRYDAS (died 04.06.12)
THIS REPORT IS BEING SENT TO:
1.
Managing Director
London Underground
Palestra
197 Blackfriars Road
London SE1 8NJ
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 6 June 2012, my predecessor, Shirley Anne Radcliffe, commenced an
investigation into the death of Andrew Phrydas (aged 23 years). The
investigation concluded yesterday.
The medical cause of death was 1a multiple injuries, and the jury
returned a narrative conclusion, a copy of which I attach.
4
CIRCUMSTANCES OF THE DEATH
Andrew Phrydas died when he was struck by a London Underground
train on the line just outside Finsbury Park Station. He had jumped off
the platform and run into the tunnel, then crossed over from the Victoria
Line onto the Piccadilly Line, which is where the collision took place.
1
5
CORONER’S CONCERNS
During the course of the inquest, the evidence revealed matters giving
rise to concern. There may be a risk that future deaths will occur unless
action is taken. In the circumstances, it is my statutory duty to report to
you.
The MATTERS OF CONCERN raised by the jury are contained in their
narrative as follows.
Three minutes and 49 seconds passed between Andrew leaving the
platform and him being struck by the train.
Although a person in the tunnel was an unprecedented event, there was
a failure by London Underground to have a process in place to shut down
both lines simultaneously at a station where two lines intersect.
There was also a failure by London Underground to alert the driver in the
most direct and effective method about Andrew’s presence on the track.
6
ACTION SHOULD BE TAKEN
I believe that you and London Underground have the power to take action
that may prevent future deaths.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 20 January 2014. I, the coroner, may extend the
period.
Your response must contain details of action taken or proposed to be
taken, setting out the timetable for action. Otherwise you must explain
why no action is proposed.
8
COPIES and PUBLICATION
I have sent a copy of my report to the following.
HHJ Peter Thornton QC, the Chief Coroner of England & Wales
Barnet Enfield & Haringey MentalHealth Trust
I am also under a duty to send the Chief Coroner a copy of your
response.
2
The Chief Coroner may publish either or both in a complete or redacted
or summary form. He may send a copy of this report to any person who
he believes may
interest. You may make
representations to me, the Senior Coroner, at the time of your response,
about the release or the publication of your response by the Chief
Coroner.
it useful or of
find
9
DATE SIGNED BY SENIOR CORONER
15.11.13
3
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