Prevention of Future Deaths reports · 2017

Daniel Campbell

Regulation 28 report to prevent future deaths, reference 2017-0122, written 13 Apr 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report13 Apr 2017
Reference2017-0122
DeceasedDaniel Campbell
CoronerTony Brown
Coroner areaNorth Northumberland
CategoryRailway related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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.

Tony Brown LLM
H M Senior Coroner

17 Church Street
Berwick-upon-Tweed

North Northumberland TD15 1EE
Tel: 01289 304318
Fax: 01289 303591

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:

Operations Manager
Network Rail
Parkgate

14 Park Lane
Darlington

DL1 5AE

1 | CORONER

| | am Tony Brown, senior coroner, for the coroner area of North Northumberland

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.

3. | INVESTIGATION and INQUEST

On 24th November 2015 | commenced an investigation into the death of Daniel Campbell
aged 25 years. The investigation concluded at the end of the Inquest on 21st March 2017
with the following narrative conclusion:-

On 24.11.15 at approximately 12.00 hours, Daniel Campbell took his life by stepping into
the path of a high speed train between Spittal and Scremerston, Northumberland at a time
when his mind and capacity for rational thinking were both affected by illness, and as a
result he sustained multiple injuries from which he died instantly.

4 | CIRCUMSTANCES OF THE DEATH

As described in the above narrative.

5 | CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to concem. 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. —

Disrepair of walls, fences or other barriers:-

Photographs of the location where the death occurred, provided by British Transport
Police show that various sections of fencing and walls separating the public footpath from
the railway line were broken, missing or in disrepair. While more substantial fencing is
unlikely to prevent the trespass and death of a person who is determined to take his own
life, insubstantial fencing or barriers create an easy opportunity for persons who might not
otherwise act impulsively on fleeting suicidal thoughts after they have passed.

ACTION SHOULD BE TAKEN

| believe that action should be taken to address the concerns raised by the circumstances
of Daniel Campbell's death.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report,
namely by Friday 9th June 2017. |, 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 Chief Coroner and to the following Interested
Persons:-

| 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.

DATE = 13 April 2017

TONY BROWN
HM Senior Coroner for North Northumberland

Responses

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.

Response from National Rail (PDF)
NetworkRail

Network Rail
York Rail Operating Centre

Tony Brown LLM York Cam

HM Senior Coroner Cinder Lane

North Northumberland Off Leeman Road
York

17 Church Street Y026 4AB

Berwick-upon-Tweed
TD15 1EE

23 November 2017 t. aeaeinninaatnelshatedl |
Dear Mr Brown

Further to your request for information dated 13 April as part of your investigation into
Daniel Campbell’s death | apologise for the length of time this response has taken. This
was due to oversight as it was believed this letter had already been sent.

| can confirm that Network Rail has reviewed the active fencing proposals for upgrade
on both sides of the track in the section where the incident occurred and have included
these in our 2018 renewals plan. Stone walls are a specialist entity, which require
specialist contractors. We will aim to repair/restore the smaller sections where
possible, but large sections which have failed will be plugged with appropriate lineside
fencing to maintain integrity.

Network Rail has completed an extensive upgrade of our lineside fencing to the north of
this location in conjunction with significant trespass and another suicide incident
between Spittal and Berwick.

In May, my team walked through the section between Scremerston and Spittal, whilst
the fencing already meets Network Rail standards further works will be planned to
improve the robustness of this boundary.

If you require any further information, please do not hesitate to contact me

Sincerely,

a
a

Head of Maintenance (North)

Network Rail Infrastructure Limited Registered Office: Network Rail, One Eversholt Street, London, NW/1 2DN Registered in England and Wales No. 2904587 www.networkrail.co.uk

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