Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0203, written 27 May 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 27 May 2015 |
|---|---|
| Reference | 2015-0203 |
| Deceased | Matthew Hoare |
| Coroner | Lorna Tagliavini |
| Coroner area | London Inner (South) |
| Category | Railway related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: National Rail . EE (Mother) . a (Father) . (Partner) 5. e Chief Coroner 1 2 3 4. CORONER lam Lorna Tagliavini assistant coroner, for the coroner area of Inner London - South CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. [HYPERLINKS] INVESTIGATION and INQUEST On 2™ July 204 | commenced an investigation into the death of Mathew Lee Hoare, aged 29 years, The investigation concluded at the end of the inquest on 42!" March 2015. The conclusion of the inquest was “Accidental Death” as a result of multiple injuries and severe burns. 4 | CIRCUMSTANCES OF THE DEATH In the early hours of 25" June 2014 after a night out socialising with friends, Mr Hoare was found lying on the live rail near Wandsworth Road Train Station having been seen to enter Clapham High Street Station after hours and gained access to the platforms and tracks. He fell on the live rail and electrocuted and was also hit by an oncoming train, thereby sustaining fatal injuries. 5 | CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is 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 are as follows. — (1) The lack of effective security equipment preventing access to the station and tracks after the hours of operation. (2) The ease at which Mr Hoare was able to access the station and tracks by climbing through widely spaced yellow tape. 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe your organisation] have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 22"7 July 2015. |, 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. | COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons a enc MEE the parents and partner of the decesased | am also under a duty to send the Chief Coroner a copy of your response. 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 find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. [DATE] [SIGNED 27 May 2015 LM Taglia
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Lorna Tagliavini Assistant Coroner for the Inner South District Great London HM Coroners Court Tennis Street Ber ayD RECEIVED | 07 AUG 2015 31 July 2015 ween eee ee eee Dear Ms. Tagliavini, Inquest into the death of Matthew Lee Hoare Regulation 28 Report to Prevent Future Deaths NetworkRail Route Managing Director Cottons Centre Cottons Lane London SE1 2QG | write in response to your Regulation 28 Report dated 27 May 2015 concerning the Inquest into the death of Matthew Lee Hoare who sadly died on 25 June 2014.Please accept my apologies for the delay in responding and | am grateful for the extension kindly granted whilst we considered your concerns and fiaised with London Overground Rail Operations Limited (“LOROL”). Network Rail Infrastructure Limited (“Network Rail”) owns, operates and maintains the rail infrastructure including the track and signalling equipment across the UK. Clapham High Street Station (“the Station”) is not operated by Network Rail but is managed by the operator of the majority of trains stopping at the station, LOROL. Although the station is not an asset under our management, but noting that the recommendations in your report concern access to the station and the tracks we have sought clarity from LOROL. LOROL has been able to assist with some information particularly in respect of changed practices at the Station, which we hope will assist in responding to your concerns. There is CCTV at the station which is controlled by LOROL. LOROL have confirmed that this CCTV footage shows Mr. Hoare gained access to the track after the cessation of services on the night of 25 June 2014. Due to a previous fault with the roller shutters at the entrance to the station these were not in service and were left ‘open’, however, a metal frame with yellow tape stretched across its span had been placed in the entrance to obstruct entry to the station. This was by-passed by Mr. Network Rail infrastructure Limited Registered Office: 2” Floor, One Eversholt Street, London, NW ZDN. Registered in England and Wales Ne. 2804587 Hoare, who parted the tape and entered the Station. Having gained entry to the station, Mr. Hoare then made his way to the platform and then the track. Following the incident on 25 June 2014, the roller shutters at the entrance to the station were reinstated and are now locked during non-operational hours. LOROL have advised that they are working on a system allowing their stations to be opened remotely from the central control centre. The station has had anti-trespass grids installed following the incident at the Denmark Hill end of the platforms; these are hard rubber panels which are placed on the floor, having a surface of sharp peaks that is almost impossible to walk upon. There is signage at the Wandsworth Road end of the station platform including; e a “high visibility vest required” sign (white on blue); * an anti-trespass sign (red roundel) warning of the danger of moving trains; and « a “Danger: High Voltage” sign (black on yellow) warning of the live third rail supply. This signage is clean, in good condition and is prominently displayed in the centre of the walkway. For our pari, safety is a core value for Network Rail and we are continually striving to reduce fatalities on the railway through a number of initiatives an example of which is the installation of barriers to separate rail ‘streams’ where access is not needed to Network Rail infrastructure; an example of this can be seen at the Station where the SouthEastern railway infrastructure (which does not offer services from the Station) is fully fenced from the LOROL infrastructure. | hope that this response provides you with adequate information but if you would like any further clarification, please do not hesitate to contact me. Yours sincerely; "> _. ; Route Managing Director, Network Operations
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