Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0297, written 23 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 | 23 Jul 2015 |
|---|---|
| Reference | 2015-0297 |
| Deceased | Ashley Matthews |
| Coroner | David Urpeth |
| Coroner area | Black Country |
| Category | Railway related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Axis House, 10 Holliday Street, Birmingham BI IUP , British Transport Police, 1st Floor, South Wing, 1. CORONER I am Mr David Urpeth, Assistant Coroner, for the coroner area of Black Country. 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 23.6. 2015, I commenced an investigation into the death of Mr Ashley Aaron Matthews. The investigation concluded at the end of the inquest on 23 July 2015. The conclusion of the inquest was Death by Misadventure 4 CIRCUMSTANCES OF THE DEATH 1. On the 18.6.15, Ashley Matthews and friends accessed Bescot Traction Maintenance Depot in Wednesbury, via a gap in fencing. 2. He climbed over a railway bridge ( Bridge 26) and attempted to drop into a good wagon. 3. Whilst attempting to do so, he was electrocuted after making contact with a high voltage cable. 4. He was taken to hospital but his injuries were thought to be incompatible with I ife. 5. Hediedl9.6.15 6. The medical cause of death was given as: Ia. Extensive full thickness burns incompatible with life 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 wit occur unless action is taken. In the crcumstances t s my statutory duty to report to you. The MATTERS OF CONCERN are as fotows. (1 During the course of the inquest, evidence suggested that access to the site was gained by insecure fencing. (2) After the death of Ashley Matthews, the family were able to gain access to the site unchallenged by security. i3The family ctressed the segggyj Ja has1eep in mc ncr — [iLl: PROTECT] (4) Others had gained access and placed flowers on Bridge 26 5) The family witnessed someone on the site walking with their dog nd placing flowers on bridge 26 6I Evidence suggested that some parts of the perimeter fencing were secured with cable ties ç7) Evidence suggested there were no warning signs on Brioge 26 warning of toe dangers posed by high voltage cabling In light of the inquest findings, you may wish to consider he pnyscal security of the site including fencing as well as the security patrols in place (8) 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 19.9.2015 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. 8 COPIES and PUBLICATION have sent a copy of my report to the Chief Coroner and to the following Interested Persons Mr Matthews famly, 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 oublicatior of yor &pesbythGlief Cororer 9 237.2O1 5
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.
BRITISH TRANSPORT POLICE Coroners Liaison Office British Transport Police 1st Floor, South 10 Holliday Streei Birmingham BI lup Axs House Inquest into the late Ashley Mathews Sir, With reference to your request for clarification of points made under the regulation 28 notice issued, I have the following to report. Approximately 2 weeks after the inquest I attended the scene of this fatality with liaison officer with Network Rail, from Network Rail and British Transport Police As well as the areas mentioned by the family, a number of other potential access points were visited as part of a full review of the site safety. has prepared a report of work already completed and work to be done. With regards to points 1-6. There has been an extension to the palisade fencing to prevent access by climbing around the side of the fencing to the over bridge that carries the disused line from which Ashley climbed down. (See the bottom middle photo on third page of report). The site is regularly subject to damage to fencing and and repair as soon practicable when any holes in fencing are found. has assured me that there is constant inspection The construction site for the adjacent distribution deport was well underway, it has been established that the security officer mentioned by the family was for this site and not associated in any way with Network Rail. No cable ties were found on Network rail fencing, visit, however there are some cable ties securing temporary fencing that sounds the construction site. The two lower photographs on page 2 of the report show the area where the family placed their flowers. They fence they attached them to can now clearly be seen to be a new public footpath that passes very close to the over bridge which is shown at the top right hand side of the second photo. Running along side this is a river and consideration has been given to placing palisade fencing on the other side of the river on Network Rail land. However, as can be seen in the top two photos on page 2 a ladder has been fixed at the time of construction which is there as a means of escape should a person find themselves trapped in the river during flooding. from network rail is carrying out investigation to see if the placing of fencing on the riverside would interfere with this means of escape. Point 7, although this is not a public area Network rail have already placed signs warning of the dangers of electrocution on the over bridge (See photo on final pages of the report). Point 8. Network rail have never employed a security officer at the depot. It is currently used as a marshalling yard for trucks carrying low value railway ballast. I have discussed point 8 with effective. He has mentioned that the site where this fatality took place is not actually within the area of the marshalling yard but is on the access line that runs towards it. who will be speaking with Network Rail to see if a security officer would be cost Finally, the liaison officer for this case has spoken with the family about the points that they raised. He has supplied a statement of their conversation and in this he confirms that the family did not access the rail yard at any time. They have also clarified that the security guard found asleep was from a nearby haulage yard and was nothing to do with Network Rail. I hope that I have answered the points raised, however if you need any further information I will be please to help. BRITISH TRANSPORT POLICE Pau(Simmon& Fatality Investigation &Coroners Liaison Officer British Transport Police 1st Floor, South Wing, Axis House 10 Holliday Street Birmingham BI IUP Ext No 0121 781 1165 Tel 0300 123 9100 Office Ext 7811165 DX 702861 Coroners Liaison Officer Ext No 0121 781 1165 Tel 0300 123 9100 Office Ext 7811165
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.