Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0235, written 23 Jun 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 Jun 2016 |
|---|---|
| Reference | 2016-0235 |
| Deceased | Michael Younghusband |
| Coroner | John Tomalin |
| Coroner area | Exeter and Greater Devon |
| 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.
ANNEX A 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. Great Western Railway - Managing Director GWR Customer Support FREEPOST RSKT-AHAZ-SLRH Plymouth PL4 6AB 4 | CORONER lam Mr, John G. Tomatin, Deputy Coroner, for the coroner area of Exeter and Greater Devon. 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. [HYPERLINKS] 3 | INVESTIGATION and INQUEST On 10" December 2015 | commenced an investigation into the death of Michael Dean YOUNGHUSBAND, aged 22. The investigation concluded at the end of the inquest on 2") June 2016, The conclusion of the inquest was given as Mr Younghusband died as a result of an accident. Medical cause of death as Multiple Injuries. 4 | CIRCUMSTANCES OF THE DEATH Mr Younghusband had attended RMB Lympstone to undertake a course. He successfully completed that course with a distinguished pass. He and others went out to celebrate the end of the course and visited various public houses in and around Exmouth and Topsham. Mr Younghusband became detached from his friends and it was believed that he was making his way back to camp along the railway, between Exmouth and Lympstone. His body was found close to a pedestrian crossing across the railway tracks. His body was hit by a train and he suffered non-survivable injuries. His blood alcohol level was 245mg/100ml of blood when the Post Mortem sample was tested by laboratory. Mr Younghusband’s family were concerned as to how someone who had been drinking a large quantity of alcohol had managed to walk the distance he did from when he’d last been seen to where his body was found. Of greater concern was the poor state of repair of the crossing very near the point where the body was struck by the train. The evidence given at the Inquest by Mr Younghusband’s brother who, with his father and others had been taken to the crossing near where Mr Younghusband’s body had been found, expressed their concerns about the poor state of repair at the crossing only one month after Mr Younghusband had been struck by the train. 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. — [BRIEF SUMMARY OF MATTERS OF CONCERN] (1) The poor state of the crossing point was oof concern to Mr Younghusband’s family as they believed it was a potential tripping hazard as they had observed a metal section, on the Lympstone side of that crossing, standing proud of the track bed. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe your organisation have the power to take such action. An investigation to ascertain whether or not any repair works may be necessary to prevent persons using the crossing from tripping or falling and potentially suffering fatal injury if they are not able to move out of the path of an oncoming train. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by ../&. (08 f 201.0 eevee |, 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 ief Coroner and to the following Interested Persons: Younghusband’s Family Oe Ministry of Defence/Defence Inquests Unit. | 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 fo 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. | . pate: 03 (etl Signed * f if enna Mr John G. Tomalin Deputy Coroner for Exeter and Greater Devon
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.
Mr John Tomalin NetworkRail Ss —| Network Rail Infrastructure Limited Deputy Coroner for the County of Devon Cottons Centre Exeter and Greater Devon Coroner’s Office Cottons Lane Room 226, Devon County Hall London Topsham Road SE1 2QG Exeter . EX2 4QD 15" August 2016 Dear Sir Michael Dean YOUNGHUSBAND Deceased D.O.D 10 December 2015 Inquest held on 2 June 2016 at County Hall, Topsham Road, Exeter Regulation 28 Report On behalf of Network Rail | write in response to your report dated 23 June 2016. Your report concerns the inquest into the death of Michael Dean Younghusband who sadly died when he was struck by a train on 10 December 2015. Your report outlined your concern that: The poor state of the crossing point was of concern to Mr Younghusband’s family as they believed that it was a potential tripping hazard as they had observed a metal section, on the Lympstone side of that crossing, standing proud of the track bed. You considered that 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. |. believe the footpath level crossing you are referring to is known as East Devon Way 1 which carries the well-used public right of way of same name over the single track Exmouth branch line. As with all crossings of this type, it is routinely inspected six-monthly by a Level Crossing Manager (“LCM”), who is responsible for reporting all defects found to maintenance colleagues. When safe to do so, the LCM carries out certain minor repairs and reports them accordingly. Network Rail infrastructure Limited Registered Office: 2 Floor, One Eversholt Street, London, NW1 2DN. Registered in England and Wales No. 2904587 There is a timber ballast retainer on the western (estuary) approach to the level crossing which forms a step up to track level including the rubber deck panels installed on the track itself. This step is very prominent and obvious to users but from time to time the ballast can wear down and so it is built up when required to minimise the stepping required. If Mr Younghusband entered the track at the level crossing it may be possible that he tripped on a metal fitting known as a deflector or chain guard which is attached to the edge of the decking panel facing the track. It is not clear if this is what his family referred to as ‘standing proud of the track bed’, but these fittings are not in the way of anyone crossing the track over the decking as intended. The last routine inspection of the level crossing prior to Mr Younghusband’s death took place on 16 September 2015. The LCM noted. that the track ballast was low to the level crossing so he built it up again. A more recent inspection took place on 4" March 2016 followed by another site check 21 June 2016 revealed that the ballast had moved again, so in late June the LCM discussed with maintenance colleagues the fitting of more substantial ‘ballast boxes’ so as to contain movement more effectively and minimise the stepping involved. | am happy to confirm that ballast surface improvement works were completed at the crossing point on 20. July 2016. Further the edges of any trip hazards have been clearly n marked in order to highlight them to the public. | hope that this response provides you with adequate assurance that the i issues you. have identified have been properly considered and addressed. If you would like any further information or aasistance please do not hesitate to contact me. Yours faithful RECEIVED 17 AUG 2016
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