Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0166, written 23 May 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 May 2017 |
|---|---|
| Reference | 2017-0166 |
| Deceased | Robert Mullis |
| Coroner | Patricia Harding |
| Coroner area | Central and South East Kent |
| Category | Railway related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Central and South East Kent Coroners The Archbishops Palace Mill Street Maidstone Kent ME15 5YE Telephone: New and Current Cases: 03000 410804 General Enquiries: 03000 410805 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Group General Counsel Network Rail 2. Managing Director South Eastern Railway 1 CORONER I am Patricia Harding Senior Coroner for Central and South East Kent 2 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 INVESTIGATION and INQUEST 3 On 18/01/2017 I commenced an investigation into the death of Robert John MULLIS. The investigation concluded at the end of the inquest on 18th May 2017. The conclusion of the inquest was that Robert Mullis died on the evening of 6th January 2017 from injuries sustained when he was hit by a train after disembarking from a train on which he was travelling to London and wandering onto the railway track adjacent to platforms 5 and 6 of Ashford Domestic Railway Station. His reason for doing so cannot be determined but the fact that he was partially sighted and had Parkinsons and Vascular Dementia likely contributed. 1a Multiple Injuries b c II Conclusion: Accidental Death CIRCUMSTANCES OF THE DEATH Robert Mullis who had Parkinsons, Vascular Dementia and was partially sighted was put on the South Eastern high speed train at Ramsgate in order to travel to London where he was to be met by his daughter at London St Pancras station. When he failed to arrive daughter became concerned and contacted police. Mr Mullis wore a GPS tracker which showed him to be in the vicinity of Ashford railway station. A police search was instigated and CCTV examined which showed Mr. Mullis to disembark the train shortly before it departed Ashford station and walk off the end of platform 6 onto the railway tracks at 17.45. He was thereafter struck by two trains, the latter causing the injuries from which he died. 4 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action. I make this report with the knowledge that Network Rail and South Eastern are addressing the issue of track access from platforms nationally with Ashford being addressed in Autumn 2017 YOUR RESPONSE 7 You are under a duty to respond to this report within 56 days of the date of this report, namely by 19th July 2017. 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: I 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. 9 23/05/2017 Signature: Patricia Harding Senior Coroner Central and South East Kent
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.
Private and confidential Patricia Harding, Senior Coroner, Central and South East Kent NetworkRail Network Rail Infrastructure Limited Cottons Centre Cottons Lane London The Archbishops Palace SE1 2QG Mill Street Maidstone T: 07515 619374 Kent ME15 5YE 19 July 2017 Dear Madam Regulation 28 Report - Robert John Mullis (Decd.) | refer to your report dated 23 May 2017 made under 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 inquest into the very sad death of Robert John Mullis, who died on 6 January 2017 after going onto the railway track adjacent to platforms 5 and 6 of Ashford domestic railway station. Background As noted in your report, the conclusion of the inquest was that Robert Mullis died on the evening of 6 January 2017 from injuries sustained when he was hit by a train after disembarking from a train on which he was travelling to London and wandering onto the railway track adjacent to platforms 5 and 6 of Ashford domestic railway station. Ashford International Station is a busy railway station operated by London & South Eastern Railway Limited, trading as Southeastern, with trains which provide domestic and international rail services. The station itself has six platforms and there is a mixture of stopping and non-stopping services which pass through the station. Platforms 5 and 6 are domestic platforms which, together with platforms 1 and 2, Network Rail leases to Southeastern Railway. Southeastern is the station facility owner of the domestic station and holds the Safety Certificate as Infrastructure Manager for platforms 1, 2, 5 and 6. Eurostar International Ltd is similarly responsible for the international part of the station (which includes platforms 3 and 4). Response to Points of Concern In your report, you state that “/n my opinion action should be taken to prevent future deaths and | believe your organisation has the power to take such action. | make this report with the knowledge that Network Rail and South Eastern are addressing the issue of track access from platforms nationally with Ashford being addressed in Autumn 2017”. | confirm that Network Rail is planning to install platform-end fencing and anti- trespass panels (commonly referred to as ‘witches’ hats) on platform 1, 2, 5 and 6 (the domestic platforms) at Ashford International Station and that these works are due to be completed by the 31st July 2017. More specifically, we have now installed platform-end fencing (in the form shown in Annex 1 below and witches’ hats in the form shown in Annex 2 at both ends of platforms 2, 5 and 6 and the London end of platform 1 at Ashford International Station. We will install equivalent fencing and witches’ hats at the country end of platform 1 by the end of July 2017. Network Rail, Train Operating Companies and the British Transport Police (BTP) continue to work together to manage this type of incident on the rail network. Platform-end fencing would be considered as one possible mitigation in instances where platforms ends are identified as a primary access point for repeat occurrences. The platform-end fencing and witches’ hats being installed at Ashford International Station are part of a wider program of mitigations that are being applied to a number of locations across the South East Route to address the risks associated with trespass and access to the rail network. On a national basis, our approach is a risk-based one using data (including data shared by BTP) to identify trespass or access-to-the-line hot spots. | hope this response provides you with assurance that the advised action is taking place. If | can be of further assistance, or if you would like further clarification, please do not hesitate to contact me. Finally, on behalf of all at Network Rail, | would like to take this opportunity to express my sincere condolences to the family of Mr Mullis. Yours faithfully, St Habel John Halsall Route Managing Director Annex 1 — Illustrations of Works: Platform-end Fencing Annex 2 — Illustration of Works: Witches’ Hats
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