Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0213, written 9 Jun 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Jun 2015 |
|---|---|
| Reference | 2015-0213 |
| Deceased | Lewis Ghessen |
| Coroner | Andrew Walker |
| Coroner area | London (North) |
| Category | Railway related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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.
: North London Coroners Court, Her Majesty's Coroner for the 29 Wood Street, Northern District of Greater London ——Bamet ENS 4BE (Harrow, Brent, Barnet, Haringey and Enfield) Telephone 0208 447 7680 Fax 0208 447 7689 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: RSSB, Enquiry Desk, 1 Torrens Street, London EC1V INY 1 | CORONER lam Andrew Walker, senior coroner, for the coroner area of Northern District of Greater London 2 | 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. 3. | INVESTIGATION and INQUEST On the 21% May 2013 | opened an inquest touching the death of Lewis Philip Ghessen , 22 years old. The inquest concluded on the 10” April 2015, The conclusion of the inquest was “Narrative’, the medical case of death was 1a Multiple Injuries _— 4 | CIRCUMSTANCES OF THE DEATH On the 25" September 2011 Lewis Philip Ghessen was chased on to railway tracks at Harrow and Wealdstone Railway Station, where, at a short time after 20.37 he was struck and killed by a fast train that was passing through the section of track where Mr Ghessen was. a 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. — That the RSSB Rule Book allows trains to be stopped only in circumstances where that person may cause damage to a train, but does not allow for trains to be stopped where the person may be in danger form a train. 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you LIAND/OR your organisation] have the power to take such action, Her Majesty’s Coroner for the Northern District of Greater London (Harrow, Brent, Barnet, Haringey and Enfield) YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Tuesday 4" August 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;- Representatives of the family. Network Rail |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, abdgut\the release or the publication of your response by the Chief Coroner. 9™ June 201
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