Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0266, written 6 Nov 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Nov 2017 |
|---|---|
| Reference | 2017-0266 |
| Deceased | Harminder Dhillon |
| 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.
for Bedfordshire & Luton REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: THE CHIEF EXECUTIVE NETWORK RAIL 1 EVERSHOLT STREET | LONDON. NWI 2DN CORONER Jam JAN PEARS, Acting Senior Coroner, for the Coroner Area of Bedfordshire & Luton to 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 9" January 2017 | commenced an Investigation into the death of Harminder DHILLON aged | 62 years. The Investigation concluded at the end of the Inquest on 31" October 2017. The | Conclusion of the Inquest was ‘Accidental Death’. The medical cause of death was: ! I (a) Multiple Injuries a | | 4 CIRCUMSTANCES OF THE DEATH ' The deceased drove his motor vehicle around the half barrier, which was down, at the Lidlington | Level Crossing, Marston Road. Marston Moretaine in Bedfordshire and collided with a train. i The crossing was functioning appropriately. L. _ 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. ! | The MATTERS OF CONCERN are as follows. — ' | (1) The level crossing is not monitored by CCTV and it is likely that the crossing is misused | : more than is reported | H i i L f ! Senior Coroner, The Court House, Woburn Street, AMPTHILL, Bedfordshire, MK45 2HX Tet 9300-300-6559 | Fax 0300-300-8267 (2) The half barrier is not a deterrent to a road user who believes that their journey is being held up more than is necessary. (3) A full length barrier, which is used on adjacent crossings on that line, would appear to be able to prevent misuse and prevent potential future deaths 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. : | Your Response must contain details of action taken or proposed to be taken, setting out the YOUR RESPONSE You are under a duty to respond to this Report within 56 days of the date of this Report, namely | by 2" January 2018. |, the coroner, may extend the period. timetable for action. Otherwise you must explain why no action is proposed. | or the publication of your response by the Chief Coroner. COPIES and PUBLICATION I have sent a copy of my Report to the Chief Coroner and to the following Interested Persons: Tam 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 | | Dated 6th November 2017 | | : IAN PEARS : Acting Senior Coroner for the coroner area of Bedfordshire & Luton | Senior Corener, The Court House. Woburn Street, AMPTHILL, Bedfordshire, MK45 2HEX Tel 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.
Ian Pears - Acting Senior Coroner,
Bedfordshire & Luton
The Coroner’s Office
The Court House
Woburn Street
Ampthill
Bedfordshire
MK45 2HX
15th January 2018
Dear Sir
Martin Frobisher
Route Managing Director
Network Rail
Square One
4 Travis Street
Manchester, M1 2NY
Email: m
Your Ref: 42025-2017
Regulation 28 Report – Harminder Dhillon (Deceased)
I refer to your report dated 6 November 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 Harminder Dhillon. Harminder died on 3 January
2017 after driving his motor vehicle around the half barrier, which was in the down position, at
Marston Level Crossing, Marston Road, Marstone Moretaine in Bedfordshire.
Background
As noted in your report, the conclusion of the inquest was that Harminder Dhillon died on the 3
January 2017 as a result of injuries sustained when his motor vehicle collided with a train after having
driven his vehicle around the half barrier at the level crossing and in circumstances where the
crossing was functioning appropriately.
Response to matters of concern
In your report, you raise three matters of concern, which I deal with below:
1. “The level crossing is not monitored by CCTV and it is likely that the crossing is misused
more than is reported”
Currently, in the level crossing environment, CCTV equipment is generally deployed as an operational
aid rather than for security/monitoring purposes. However, where deliberate misuse is a particular
issue, then Network Rail does install cameras and recording equipment to investigate and if
necessary support the introduction of additional safety measures.
2. “The half barrier is not a deterrent to a road user who believes that their journey is being
held up more than is necessary”
The red road traffic lights provided at Automatic Half Barrier Crossings (AHBC) have specific legal
authority: no vehicle is permitted to cross them under any circumstances. Driving onto a closed level
crossing not only endangers the occupants of the road vehicle but also puts potentially hundreds of
train users at risk. In addition to the red road traffic lights, Network Rail also provides half barriers,
road signage and audible alarms which vary in tone should a second train be approaching. The
barriers at an AHBC enable vehicles to safely exit so that they are not trapped as trains approach.
They therefore discourage but cannot unfortunately prevent deliberate misuse.
Network Rail is constantly striving to improve passenger and level crossing user safety on our
network. To this end Network Rail is currently, developing additional enhancements targeting
accidental and deliberate misuse at AHBCs.
3. “A full barrier, which is used on adjacent barriers on the line, would appear to be able to
prevent misuse and prevent potential future deaths.”
AHBCs, such as installed at Marston, provide the least disruption to road users with the shortest
possible road closure times. Even where other designs are used with full barriers, Network Rail still
sees examples of deliberate misuse. Our risk assessment process takes account of all local factors
in determining the most appropriate level crossing design and seeks opportunities to provide safer
ways across the railway.
Marston level crossing is scheduled to be replaced by a vehicular road bridge in 2019; this will
eliminate the need for vehicles to traverse the crossing.
I hope this response answers your concerns but if I 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, I would like to take this opportunity to express my sincere
condolences to the family of Mr Dhillon.
Yours faithfully
Route Managing Director
London North Western
Network Rail Infrastructure Limited Registered Office: Network Rail, One Eversholt Street, London, NW1 2DN Registered in England and Wales No. 2904587 www.networkrail.co.uk
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