Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0345, written 20 Dec 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Dec 2017 |
|---|---|
| Reference | 2017-0345 |
| Deceased | Scott Rayner |
| Coroner | Edward Solomons |
| Coroner area | Hertfordshire |
| 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.
i
CORONER’S OFFICE
AREA OF HERTFORDSHIRE
Assistant Coroner Mr Edward SOLOMONS
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: Network Rail Gompony Secretary, | Eversholt St. London
CORONER
| am Edward B Solomons Assistant Coroner for Hertfordshire
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.
http://www. legislation.gov.uk/ukpga/2009/25/schedule/S/paragraph/7
http://www. legisiation.gov.uk/uksi/2013/1629/part/7/made
INVESTIGATION and INQUEST
On the 28" April 2017 | commenced an investigation into the death of Scott RAYNER. The
investigation concluded at the end of the inquest 20th December 2017. The conclusion of the inquest
was Misadventure. On the 16th April 2017 Scott Rayner trespassed on the railway track near
Watford Junction Station, where he was struck by a train.
la. Multiple Traumatic Injuries
CIRCUMSTANCES OF THE DEATH
On the 16" April 2017 the driver of the 19:19 train from Oxonholme to London Euston saw Scott
Rayner standing in the middle of the track at Watford Junction Station. Mr Rayner was facing the
train holding his arms out to the side. Although the driver applied the emergency brakes his train
struck Mr Rayner. Mr Rayner had been suffering from long term mental health problems. Paramedics
confirmed death at the scene. BTP SOCO confirmed {D via fingerprints.
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 uniess action is taken. in the circumstances it is my
statutory duty to report to you.
The MATTERS OF CONCERN are as follows.
British Transport Police investigating revealed that fencing beside the railway track was inadequate
especially at the rear of a scrap metal dealer located off St Albans Road and Bedford Street, jeading
toa risk that adults and children may trespass on the line where the speed limit is 100mph.
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
Rad March 2018. |, 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. |
ir COPIES and PUBLICATION
| have sent a copy of my report to the Chief Coroner and to the following Interested Persons, Mr
Rayner’s family and the Railway Health & Safety Board.
[am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both ina 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 | 20/12/2017 i
Signature. Li BE -—>
Edward B Solomons Assistant Coroner Hertfordshire
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
Martin Frobisher
Route Managing Director
Square One
4 Travis Street
Manchester
M1 2NY
Mr Edward Solomons
HM Assistant Coroner
Area of Hertfordshire Coroner’s Office
The Old Courthouse
St Albans Road East
Hatfield
Hertfordshire
AL10 OES
5th March 2018
Dear Sirs
Regulation 28: Report to Prevent Future Deaths — Scott RAYNER {Deceased}
| refer to your report dated 20 December 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 Scott Rayner.
On behalf of ail at Network Rail, | would like to take this opportunity to express my sincere condolences to the family
of Mr Rayner.
As noted in your report, Scott Rayner died as a result of multiple traumatic injuries sustained when he was struck by a
train on the railway track near Watford Junction Railway Station on 16 April 2017. The conclusion of the end of the
inquest on 20 December 2017 was misadventure.
| have detailed below Network Rail’s considered response to the matter of concern raised in your report.
Network Rail’s Fencing Standard
In accordance with its legal obligations, Network Rail implements a mandatory fencing standard “Management of
Fencing and Other Boundary Measures” which applies to the boundary of Network Rail controlled infrastructure (the
Fencing Standard}.
The purpose of the Fencing Standard is to specify the boundary management measures commensurate with assessed
risks posed by the adjacent environment and the railway and to incorporate a method of assessing these risks. A copy
of the Fencing Standard can be provided on request.
Fencing around St Albans Road and Bedford Street
To comply with the Fencing Standard, an annual condition inspection is undertaken and any defects found are then
prioritised for repair based upon a risk assessment that takes cognisance of adjacent land characteristics (likelihood)
and rail characteristics (consequence). The inspection also checks that the adjacent land usage (likelihood) is
unchanged from the previous inspection.
The last annual inspection of the St Albans Road and Bedford Street area, including the area to the rear of the H&D
Motors, prior to April 2017 was undertaken on 26 June 2016. This inspection identified that there was no repair work
required in the area and the boundary fencing was compliant with the Fencing Standard.
Following the accident involving Mr Rayner on 16 April 2017, the British Transport Police conducted a Post Incident
Site Report on 24 April 2017 which was issued to Network Rail. The report included recommendations to inspect and
repair any gaps in the boundary fencing around St Albans Road and Bedford Street.
in line with this recommendation, an inspection was undertaken by Network Rail’s local operations team on 17 May
2017 to establish ownership and condition of the boundary fencing.
Although no faults were identified in the boundary fencing around St Albans Road and Bedford Street, the local
operations team planned a further multi stakeholder inspection of the wider Watford area in order to investigate
trespass incidents where specific locations of access were unknown. This took place on the 30 May 2017 in
conjunction with the British Transport Police. A number of lineside locations in the Watford area were inspected and
identified for additional enhancement work to prevent access to the railway. Work to implement this enhancement
work was completed on 22 February 2018, which included installing additional palisade fencing in the St Albans Road
and Bedford Street area.
| hope this response answers your concerns but if | can be of further assistance, or if you would like further
clarification, please do not hesitate to contact me.
Yours faithfully
Wi Se
Martin Frobisher
Route Managing Director
Network Rail Infrastructure Limited Registered Office: Network Rail, One Eversholt Street, Londen, NW1 2DN Registered in England and Waies No. 2904587 veww.networkrail.co.uk
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