Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0077, written 26 Feb 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Feb 2016 |
|---|---|
| Reference | 2016-0077 |
| Deceased | Jakovas Fofonovas |
| Coroner | Andrew Harris |
| 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 Re Jakovas Fofonovas, 01397-15 (died 23,05.15) (MM) THIS REPORT IS BEING SENT TO: 1. RE Director, Network Strategy and Planning, Network Rail Kings Place, 90 York Way, London, Ni 9AG CORONER I am Andrew Harris, Senior Coronet, London Inner South 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. INQUEST On 28" May 2015 I opened an inquest into the death of Mr Jakovas Fofonovas, who died on 23" May 2015 on the rails near Abbey Wood railway station. T concluded the inquest at a full hearing on 7° January 2016. The medical cause of death was 1a Multiple injuries 1b Struck by train The coroner concluded he committed suicide CIRCUMSTANCES OF THE DEATH The deceased accessed the railway. The British Transport Police Post Fatality Survey Report [I found that at Bridge No 614A, Bostall Manorway, Abbey Wood: i) The stairs to the footbridge had low railings that enabled easy access to the track ii) There were temporary mesh extensions and fencing in poor condition iii) The mid elevation turn back was of great concern due to possible access to railway land iv) There are no measures in place to mitigate against the railings being climbed over v) Building materials under the bridge offer aids to climbing down re CORONER’S CONCERNS The MATTER OF CONCERN is as follows. - Recommendations in The BTP Post Fatality Report to create a safer environment at the bridge and restrict public access to the railway had not been effected by the time of the inquest. The court did not have the benefit of Network Rail spokesperson in court to provide evidence of future plans ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that that if the Network Rail is in a position to do so. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Monday 25" April 2016. 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. If you require any further information about the case, please contact the case reams you require further information about the process of responding to this report my whom your response should be sent. COPIES and PUBLICATION Thave sent a copy of my report to the following Interested Persons: SE (wife). I am also sending a copy to the | Coroners Liaison for London South British Transport Police. Tam 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 BY CORONER] Written: 26.02/16 dy Sent: 3 OK &
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 Mr A Harris Network Rail infrastructure Limited Senior Coroner Cottons Centre Inner London South Coroner's Court Cottons Lane 1 Tennis Street London Southwark SE1 2QG $E11YD 25 April 2016 Jakovas Fofonovas Decd Regulation 28 Report | refer to your report dated 26 February 2016 sent in accordance with paragraph 7, schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 in relation to the very sad death of Jakovas Fofonovas who died on 23 May 2015 on the railway tracks near Abbey Wood Station. Background The footbridge at Bostall Manor Way is owned and maintained by the Royal Borough of Greenwich. As part of the works currently being carried out by Network Rail and Balfour Beatty on behalf of Crossrail at Abbey Wood Station the original footbridge has now been demolished. it has been replaced with a completely new and much improved specification footbridge which accommodates the additional railway tracks which have been laid at Abbey Wood. The new footbridge | attach 2 photographs one of the old footbridge and the other of the new footbridge during construction. | also attach plans of the new footbridge detailing the specification. The footprint of the bridge on the north side of the railway now extends over Mottisfont Road. The benefit of this is that pedestrians using the footbridge no longer exit close to the railway tracks but directly onto the pedestrian pavement next to the road. The section of the new footbridge which spans the live railway is completely encased which improves the safety of pedestrians using the footbridge by preventing accidents and intentional acts. The new structure has been designed with ramps (on both the north and south sides) which improves accessibility for wheelchair users, cyclists and parents with young children in pushchairs. The area around the new footbridge will be fully landscaped and it is proposed to install improved lighting. Once this structure is fully brought into use, it will be handed back to the Royal Borough of Greenwich who are the asset owner and who will be responsible for the ongoing maintenance of the footbridge. In response to the specific points raised in your regulation 28 report | set out below my response below your questions and confirm that: i. The stairs to the footbridge had low railings that enabled easy access fo the track. The new footbridge railings are at the current industry standard height of 1250mm. Further, as set out below we are in the process of installing acoustic fencing along both sides of the track at a height of 3m. Additionally this will have anti-climb extensions fitted at certain sections. This fencing is designed to prevent access to the railway tracks. ii. There were temporary mesh extensions and fencing in poor condition We are in the process of installing acoustic fencing on both sides of the track at a height of 3m. This will also have anti-climb wire extensions fitted as an additional deterrent at certain sections. iii. The mid elevation turn back was of great concern due to possible access to railway tand This refers to the old structure which is no longer in situ and there is no longer a mid- elevation turn back in the new design. Further the installation of the acoustic fencing alongside the south side of the track and alongside the Mottisford Road, with anti- climb wire extensions, prevents access to the railway tracks from the footbridge steps and ramps. iv. There are no measures in place to mitigate against the railings being climbed over At the shoulder of the steps/ramps and the main span there is an anti-climb guard at a greater height than the railings as further mitigation. In addition there is the acoustic fencing and anti-climb wire extensions to prevent anyone accessing the track if they were to climb over the railings. v. Building materials under the bridge offer aids to climbing down 1 confirm that the old building materials under the bridge have now been removed from this site. | hope this response provides you with adequate information and assurance that the issues you identified have been considered and addressed. If | can be of any further assistance or you would like any further clarification please do not hesitate to contact me. Yours sincerely, Route Managing Director
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