Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0304, written 23 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 | 23 Aug 2016 |
|---|---|
| Reference | 2016-0304 |
| Deceased | Stephen Cahill |
| Coroner | Ian Pears |
| Coroner area | Bedfordshire and Luton |
| 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.
Tan Pears Assistant Coroner for Bedfordshire and Luton REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | THIS REPORT IS BEING SENT TO: 1 | The Chief Executive Network Rail 1 Eversholt Street London NW1 2DN CORONER | am lan Pears, Assistant Coroner for Bedfordshire and Luton see weenie ner tener crater enn one 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. htto:/Awww.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www. legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST | On 1 April 2016 | commenced an Investigation into the death of Stephen Sean CAHILL aged 55 years. The Investigation concluded at the end of the Inquest on 18 August 2016. The Conclusion of the Inquest was that he died as a result of ‘Multiple Injuries’. | CIRCUMSTANCES OF THE DEATH On the 29" March 2016 the 2P49 Peterborough to London Kings Cross train was approximately half mile north of Sandy Railway Station when the driver saw the deceased walk from the left side of the track and lay face down on the track : with his body over the rail. The train at this time was travelling at 75 miles per hour leaving the driver no time to stop. The train struck the deceased and his death was subsequently confirmed at the scene. A witness had earlier seen the | deceased climb over a gate to walk on the track and lay down across the rail. | Senior Coroner, The Court House, Woburn Street, AMPTHILL, Bedfordshire, MK45 2HX. Tel 0300-300-6559 | Fax 0300-300-8267 i | | / 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 will occur unless action is taken. In the circumstances it is my statutory duty to report to you. i | H 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. Both the gate and fence provide little deterrence or hindrance to someone wanting to gain access to the railway. (2) The Investigation recommended a review of the fencing and access gates be undertaken at the location as it is relatively easy to access the track from both sides of the line. It is understood that this has not been undertaken. 6 | ACTION SHOULD BE TAKEN | In my opinion action should be taken to prevent future deaths and | 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 15 November 2016. I, 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. 8 | COPIES and PUBLICATION | have sent a copy of my Report to the Chief Coroner and to the following | Interested Persons Po — wife of the deceased. | am also under a duty to send the Chief Coroner a copy of your response. i 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 | Senior Coroner, The Court House, Woburn Street. AMPTHILL, Bedfordshire, MK45 2HX Tel 300-300-6559 | Fax 0300-300-8267 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 23 August 2016 _— Se A J IAN PEARS Assistant Coroner | Bedfordshire and Luton Senior Coroner, The Court House. Woburn Street, AMPTHILL, Bedfordshire, MK45 2HX Tet 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 4 HM Coroner's Office Mr Tora Osborne HM Senior Coroner The Court House Woburn Street Ampthill Bedfordshire MK45 2HX 10 November 2016 Dear Sir Inquest touching the death of Stephen Sean CAHILL Inquest held on the 18th August 2016 at Coroners’s Court, Ampthill i refer to your report dated 23rd August 2016 and the very sad death of Stephen Sean Cahill. In respect of the matters of concern raised in your letter we respond as follows: e We have commissioned works to enhance the fencing and gates in this area. These works will be delivered by 15" January 2017 and will be to install over 600m of fencing and upgrade the gate height and construction to deter unauthorised access to the railway in the area. ¢ Our internal standard mandates that after unauthorised access has been detected that our “Off Track” team (who maintain our boundary) perform an inspection to fix any damage or recommend investment in upgrades to prevent access where necessary. Their assessment is based on trained assessment of risks at the site. In this instance we decided that this site required an upgrade as detailed above. We take the issue of suicide very seriously. On the route from Peterborough to Kind Cross we have invested significantly in removing the opportunities for unauthorised access to the railway. We have done this primarily through physical mitigation such as platform end barriers, mid-platform fences at Stations and lineside fencing at our boundary line. As part of this work we currently have four joint projects with the British Transport Police and have recently engaged with several local authorities at points within this area of railway. We continue to explore what other opportunities can be realised together with our partners the British Transport Police, Train Operators and Samaritans. Nationally we have been working with the Samaritans since 2010 supporting campaigns aimed at reducing suicides on the railway as well as training our staffto be. better preparedto recognise and-~ respond to members of the public who may be considering ending their lives. | trust this answers your concerns but please advise if you require further information. Route Managing Director Network Rail infrasinccture Limited Registered Office: Network Rati, 2nd Floor, One Evershott Steet London, NW1 2DN Registered in England and Weles No. 2904587 www .netwarkrall,.co.uk
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