Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0284, written 17 Jul 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Jul 2015 |
|---|---|
| Reference | 2015-0284 |
| Deceased | Adam Connelly |
| Coroner | Rachael Griffin |
| Coroner area | Manchester (West) |
| 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: 1. Chief Executive of Network Rail, 1 Eversholt Street London, NW1 2DN 2. Chief Superintendent [EE of the British Transport Police, Force HQ, 25 Camden Road, London, NW1 9LN 1 | CORONER I am Rachael Clare Griffin, Assistant Coroner, for the Coroner Area of Manchester West 2 | CORONER'S LEGAL POWERS I 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 13th March 2015 I commenced an investigation into the death of Adam Lee Connelly, born on the 13" June 1992. The investigation concluded at the end of the inquest on the 10™ July 2015. The Medical Cause of Death was 1a Multiple Fatal Injuries. The conclusion of the inquest was that Adam Lee Connelly was found deceased on a railway track with injuries consistent with being struck by a train. The circumstances as to how those injuries came about are unclear. 4 | CIRCUMSTANCES OF THE DEATH At around 7.00am on the 10™ March the train driver of the Northern Train Service travelling from Manchester Victoria to Wigan, reported a body lying at the side of the railway line between Walkden and Atherton, near to foot bridge number 57, which is located between Engine Lane and Peel Lane, Atherton. The body was later identified to be Adam Lee Connelly and evidence confirmed that he had been struck by a train causing injuries that resulted in his death. Unfortunately despite a thorough investigation by the British Transport Police, the train which struck Adam was not identified, nor were the exact circumstances as to how Adam Lee Connelly came about his death. 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. During the inquest evidence was heard that: i. On the 9" March 2015 Mr Connelly was seen to leave his home address in Tyldesley at around 8pm. His subsequent actions are not known until tragically he was found deceased by the side of the railway tracks, at around 7am on the 10° March. Following a thorough investigation by the British Transport Police it is believed that it is most likely Mr Connelly had gained access to the railway tracks by climbing over the wall of the steps leading to the footbridge 57, which was near to where his body was found. The evidence given at the inquest was that this footbridge and the access to it, namely the steps and the walls, are owned by Network Rail. iii. a the British Transport Police gave evidence that the wall of these steps is approximately 5 feet in height and that a person of reasonable athletic ability would be able to climb over the wall onto the railway tracks. There are identical steps on the other side of the footbridge with a public footpath or track running along each side of the railway line and the bridges. iv. | gave evidence that there was a risk of public access to the railway track at this section due to the height of the wall and that to reduce the risk of future fatalities, it would be beneficial if action was taken to restrict access to the railway track at this location, explained that due to the steps the wail is easily accessible and he was able to climb over the wall several times during his investigation. It was explained that the bridge itself had a wall of approximately 8 feet in height which would be extremely difficult to climb over. 2. Ihave concerns with regard to the following: i. Due to the height of the walls of the steps which are used to access footbridge 57 on the railway line between Walkden and Atherton train stations, a person of reasonable athletic ability could gain access to the railway track, which could lead to future fatalities at this location on the railway ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe you and/or 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, 11" September 2015. 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. COPIES and PUBLICATION T have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (1) Mr Connelly’s father, Ps on behalf of the family I 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. Dated Signed " 17" July 2015 Rachael C Griffin
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.
NetworkRail a / Ms Rachel C Griffin Mark Carne H M Assistant Coroner, Manchester West, Chief Executive Paderborn House Network Rail Infrastructure Ltd Howell Croft North, One Eversholt Street Bolton London BL1 1QY NW1 2DN 15 September 2015 Dear Madam Inquest touching the death of Adam Lee Connelly | write in response to your report dated 17 July 2015 concerning the inquest into the death of Adam Lee Connelly who sadly died when he was struck by a train and was found at the side of the railway tracks on 10 March 2015. Your report outlined your concern that: “Due to the height of the walls of the steps which are used to access footbridge 57 on the railway line between Walkden and Atherton train stations, a person of reasonable athletic ability could gain access to the railway track which could lead to future fatalities at this location on the railway.” You considered that urgent action should be taken to prevent future deaths and wrote to Network Rail as the party with the power to take action. | wish to assure you that safety is a core value for Network Rail. We are committed to continuously seeking to reduce risk and improve safety across the railway network. We will always seek to learn all the lessons we can from tragedies such as the death of Mr Connelly. | thought it may be helpful to provide some detail in respect of the bridge structure and measures we currently have in place to prevent entry onto the operational infrastructure: e The bridge is estimated to have been constructed around 1900. It is a 30m single span which carries a footbridge over two non-electrified lines. The main span is supported from two engineering brick and stone masonry stair trestles. Network Rail Infrastructure Limited Registered Office: Network Rall, 2nd Floor, One Eversholt Street, London, NW12DN Registered In England and Wales No. 2904587 www.networkrail.co.uk NetworkRail a / | e On the structure itself a parapet 1.4 - 1.5m high is in place to prevent access from the upper and jower flights of the downside stair trestle. There are 2m high trusses/edge beams on the bridge deck to prevent access. e A palisade fence approximately 1.8m high is in position on both sides of the track on either side of the structure. The bridge is not known to Network Rail as being used by members of the public to gain access to the infrastructure. However, as a consequence of this event, | can confirm that we intend to undertake the following works: e Lower Flight — install shorter palisade pales to connect into the existing boundary fence line. The additional pales are to be installed flush with the internal face of the existing parapet and will raise the overall height of the parapet to a minimum of 2m; and e Upper Flight — raise the height of the stepped parapet with engineering brick, capped with bull nose units to remove the potential to scale the wall at this level and climb down behind the lower flight palisade up stand. We expect to have completed the works by the end of October 2015.The time frame for undertaking the works is driven by site access which is extremely limited due to the remote location of the structure. The materials required will have to be delivered by rail under possession (i.e. closure of the railway) and installed lineside during the week. | hope that this response provides you with adequate information and assurance that the issues you have identified have been properly considered and are being addressed. If | can be of further assistance, or if you would like any further clarification, please do not hesitate to contact me. Yours sincerely Mark Carne Chief Executive
See every Prevention of Future Deaths report matching Railway related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.