Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0207, written 19 Jan 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Jan 2017 |
|---|---|
| Reference | 2017-0207 |
| Deceased | Thomas Coyne |
| Coroner | John Pollard |
| Coroner area | Cheshire |
| Category | Railway related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The chief Executive Officer, Northern Rail,Northern House, 9, Rougier Street, York, YO1 6HZ 1 CORONER I am John Stanley Pollard,, Assistant coroner for the coroner area of Cheshire 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. 3 INVESTIGATION and INQUEST On 24th May 2016 I commenced an investigation into the death of Thomas Coyne born 8th August 1959. The investigation concluded at the end of the inquest on 18th January 2017. The conclusion of the inquest was one of Accidental Death with the medical cause being 1a Multiple Injuries. 4 CIRCUMSTANCES OF THE DEATH On the 21st May 2016 the deceased attended a stag party and consumed a quantity of alcohol. He was later making his way home when he inadvertently entered Earlestown Railway station. He wandered across all three platforms and then progressed along platform three, down the unprotected slope, and on to the lines. a short time thereafter he was struck by a passing train as he walked along the left hand cess. 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. The MATTERS OF CONCERN are as follows. – I was informed by the representative of the British Transport police who gave evidence to me , that Northern Rail own the train which struck the deceased and they also own/manage Earlestown station. Two matters of concern arose:- 1. The CCTV installed at the station and which can be monitored by the staff on duty, does not actually cover all the platform areas, and thus the member of staff could not see Mr Coyne (who was the only passenger on the station at the time) as he mistakenly wandered on to the tracks. 2. There is apparently absolutely no physical barrier of any kind at the end of 1 platform three, thus allowing unfettered access to the tracks at that point. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I 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 20th March 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 Person namely R.A.I.B. who may find it useful or of interest. (widow of the deceased). I have also sent it to 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 Dated 19th January 2017 SIGNED John Pollard. Assistant Coroner 2
~ @ARRIVA sa ev it a company 1 Admiral Way Doxford International Business Park 2 0 MAR 207 Sunderland SR3 3XP Tel +44 (0)191 520 4000 Fax +44 (0)191 520 4001 www.northernrailway.co.uk Our Ref: P| 16 March 2017 Mr J S Pollard HM Assistant Coroner The West Annexe Town Hall Sankey Street WARRINGTON WA1 1UH Dear Mr Pollard In the Inquest Touching the Death of Thomas Coyne Regulation 28 Report We are writing to respond to your Regulation 28 Report dated 19 January 2017 addressed to Northern Rail. Thank you for drawing your concerns to our attention. Your Report has caused us to review carefully the arrangements at Earlestown Railway Station, following the death of Mr Coyne on 21 May 2016. At the outset, it may assist if we clarify responsibility relating to the station. Arriva Rail North Limited manage the station as part of a network of approximately 500 stations. Network Rail are responsible for the infrastructure of the stations themselves. The CCTV system does not extend to the entirety of every platform area on all 500 stations. As the system is developed it has been necessary to prioritise extensions and this has been done by reference to the risk profile of each station, by reference to a diverse range of factors, including the incidence of suicide, vandalism, theft and antisocial behaviour. Earlestown is not considered a high risk station on this evaluation. As CCTV technology evolves, it is hoped to expend the coverage area and quality of the images produced, but this must inevitably be an incremental programme across the entire network. A further factor to be considered in relation to CCTV coverage is that the system is only monitored when booking office staff are on duty. The presence of the system itself is intended to have a deterrent effect but it is reliant upon staff observing the monitors at a time when a passenger endeavours to gain access to the rail tracks. 22% The issue raised in relation to barriers and fencing arrangements to prevent a person walking onto the tracks, properly falls to Network Rail as part of the station infrastructure. In an effort to assist the court we forwarded the Regulation 28 Report to them and understand that they were already considering installing platform end fencing at this location, having regard to the circumstances in which Mr Coyne gained access to the tracks and walked for approximately % mile before being struck by a train. The Network Rail Performance Improvement Co-ordinator has indicated that he has asked that the location at Earlestown Station be treated as a priority. It would be necessary, however, for contact to be made directly with them in order to obtain further details. We offer our condolences to Mr Coyne’s family at their tragic loss. Yours faithfully Chartered Legal Executive
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