Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016 – 0294, written 4 Aug 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Aug 2016 |
|---|---|
| Reference | 2016 – 0294 |
| Deceased | Susan Hamlett |
| Coroner | Ian Pears |
| Coroner area | Bedfordshire and Luton |
| Category | Railway related deaths · Suicide (from 2015) |
| 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.
Ian Pears
Assistant Coroner for Bedfordshire and Luton
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
The Chief Executive
Network Rail
1 Eversholt Street
London NW1 2DN
CORONER
| am lan Pears, Assistant Coroner for Bedfordshire and Luton
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.
http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
| http:/Avww.legislation.gov.uk/uksi/2013/1629/part/7/made
INVESTIGATION and INQUEST
On 9 March 2016 | commenced an Investigation into the death of Susan
Elizabeth HAMLETT, aged 66 years. The Investigation concluded at the end of
the Inquest on 04 August 2016. The Conclusion of the Inquest was ‘suicide; the
medical cause of death was ‘Multiple Severe Traumatic Injuries’.
CIRCUMSTANCES OF THE DEATH
On the 8 March 2016 the driver of a train travelling at 115 mph saw the
deceased walk from behind the bridge pillar and lay down across the tracks
looking at the train. The deceased was killed instantly.
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.
Senior Coroner, The Court House, Woburn Street, AMPTHILL, Bedfordshire, MK45 2HX
Tel 0300-300-6559 | Fax 0300-300-8267
The MATTERS OF CONCERN are as follows. —
(1) The British Transport investigation revealed that the deceased gained
access to the railway line through an access gate at Lower Farm Road,
Bromham, Bedfordshire. The gate is of wooden construction and
provides little deterrence or hindrance to someone wanting to gain access
to the railway. The gate has a wooden fence around it of a similar height.
(2) The investigation identified that the area around the wooded track access
gate, at the western side of the bridge, should be removed and replaced
with a more significant fence as a matter of urgency. It is understood that
this has not been undertaken.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you
Network Rail 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 01 November 2016. |, the Assistant 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
Po — husband of the deceased.
| 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.
Senior Coroner, The Court House, Woburn Street, AMPTHILL, Bedfordshire, MK45 2HX
Tel 0300-300-6559 | Fax 0300-300-8267
Dated 04 August 2016
Assistant Coroner for Bedfordshire and Luton
Senior Coroner, The Court House, Woburn Street, AMPTHILL, Bedfordshire, MK45 2H1X.
Tel 0300-300-6559 {| Fax 0300-300-8267
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 HM Coroners Office Mr Tom Osborne HM Senior Coroner The Court House Woburn Street Ampthill Bedfordshire MK45 2HX 3 November 2016 Dear Sir Inquest touching the death of Susan Elizabeth HAMLETT held on the 4” August 2016 at Coroners’s Court, Ampthill | refer to your report dated 18" August 2016 and the very sad death of Susan Elizabeth Hamiett, In respect of the matters of concern raised, being the wooden gate and the fencing, we respond as follows: ¢ in relation to the wooden gate, this gate will be upgraded by the 2 December 2016, as part of a comprehensive upgrade to the fencing at this site. ° A multi-agency site visit was organised at the location of this fatality which scoped the site for additional fencing. We will be installing over S00 metres of Class 1 patisade anti-trespass fencing. So far 385 metres of fencing of this has been delivered. The project end date for this is also 2" December 2016 Bedford to St Pancras has been recognised for special attention and is one of four Focus Areas where we are working with the British Transport Folice, Samaritans and Rail industry partners along the entire line- of- route to seek to reduce incidents of suicide. We have invested significantly in preventing unauthorised access in this line- of- route through physical mitigations such as piatform end barriers, mid-platiorm fences at stations and ‘ineside fencing. The attached document shows some of the work that we have done so far. We have four joint projects with the British Transport Police and loca! authority engagement is being stepped- up at points within this area of railway. We continue to explore what other Opportunities can be realised. | trust this answers your concerns but please advise if you require further information. 1 Yours faithfully, i Rob Nicintosh Route Managing Director Network Rail infrastructure Limted Registered Office: Network Rell, 250 Foor, One Evorshoit Street, Leagan, NWT 20N Registered inErg anc and Wales No. 2904587 wen retworkal co uk Bedford to St Pancras: Suicide Prevention & Route Crime NetwrorkRai/ Briefing Note ie / | Authors: Alex Sullivan-Wilson 7 | Date: 16/09/2016 To Derby via EAST MIDLANDS TRAINS Leicester and | AX) Bevrorn y "10 Sheffield Flitwick iii Platform 3 Issues with anti-trespass guard south, i —— Being Progressed for smart camera/hybrid MPF Problem Solving Plan Palisade Scoping Harlington Leagrave & moreno ‘cu,LOCation Identified ~ ~ 4m Palisade, ev LUTON i completed : a : i eee ee | \ Palisade Scoping | LUTON _—— i AIRPORT itl Location Identified | Problem PARKWAY Palisade Scoping i Solving ~ 7 Location Identified H Plan . More palisade underway i 250m Palisade / completed : Harpendon i tt 205m Palisade V — ST ALBANS @ completed : a Rotaspike to prevent i station trespass request ti He : : : Elstree & Borehamwood : ii he g : : Mill Hill Broadway i he) : Problem i Solving Hendon @ 33 ii te] : : Pian : Cricklewood (2 | ft i | i : _._ Trespass Issues : - | West : — == = Palisade Scoping : Hampstead ging Location Identified | Thameslink | naan © High Risk of Suicide f] Platform End Gating Kentish Town = Mid Platform fencing GOVIA ttl Palisade fencing THAMESLINK ST Damaged Platform End Gating RAILWAY PANCRAS Fixed P10
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