Andrew Hanahoe

NetworkRail

lan Pears Route Managing Director LNE&EM
HM Acting Senior Coroner for Bedfordshire & Luton pees Rail
Area of Bedfordshire & Luton Coroner’s Office ec liead
George Stephenson House
The Court House Toft Green
Woburn Street York
Ampthill YO 6JT
Bedfordshire
MK45 2HX

Tel: 01904 384195

28" November 2018

Dear Sir,
Regulation 28: Report to Prevent Future Deaths — Andrew Thomas Hanahoe

| refer to your report dated 19 June 2018 made under paragraph 7, schedule 5, of the Coroners and
Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

On behalf of all at Network Rail, | would like to take this opportunity to express my sincere
condolences to the family of Mr Hanahoe.

As you noted in your report, Mr Hanahoe died by Suicide at Lindsells Level Crossing on 29"
December 2017.

| detail below Network Rail’s considered response to the matters of concern raised in your report.
Lindsells Level Crossing

Lindsells Level Crossing is a combined private bridleway and public footpath level crossing located on
the East Coast Main Line. The crossing traverses four lines with trains travelling up to 125mph.

All level crossings on Network Rail’s infrastructure are risk assessed to determine whether the risk
associated with that crossing is reduced so far as is reasonably practicable.

Network Rail always explores whether there is an option to close level crossings and if not, whether
changes can be made to make them safer. In accordance with the risk assessment for Lindsells Level
Crossing, miniature stop lights and telephones are installed to assist users to safely traverse the
crossing.

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

Proposals to close Lindsells Level Crossing

It is not within Network Rail’s power to simply close a level crossing that carries a public right of way
and this requires tiaison with stakeholders, including the relevant local authorities to progress the
necessary statutory process. Closing Lindsells Level Crossing would we believe require a large and
very expensive ramped bridleway bridge to divert the existing rights of way.

Network Rail is engaging with Central Bedfordshire Council and local residents and we understand
there is a collective desire to close various local crossings, including Lindsells Level Crossing, where
at all possible. Network Rail is continuing to work with the relevant stakeholders to consider these
options and put forward a proposal to secure funding and progress this further.

Mitigation at Lindsells Level Crossing

While the option for closing the level crossing are being pursued, our risk assessment is reviewed
regularly to identify if there are any additional mitigation measures that can be implemented to make
the crossing safer.

The latest risk assessment at Lindsell Level Crossing identified the option to install audible alarms as
an additional mitigation measure. A program of works is currently being planned to include audible
alarms and larger lensed miniature stop lights at several level crossings in the area. The target date
for completion of this work on all of the crossings, including Lindsells, is March 2019.

We have also considered the additional mitigation which you reference was identified within the Post
Incident Site Report (the "PISR”). The PISR is a site assessment undertaken by the British Transport
Police ("BTP”) immediately after an incident. While it provides valuable information the PISR is not
undertaken by specialists with detailed level crossing knowledge so the actions are not always
practicable and can actually make risk worse.

The PISR suggests that “repeater lights” should be installed on either side of the crossing. It is not
immediately clear what is meant by “repeater lights” but we assume this refers to lights facing into the
crossing. This design has been considered many times before but after detailed risk assessment, we
do not use such a design due to the risk of users becoming confused about whether it remains safe to
cross if the light changes once they were on the crossing. Miniature stop lights are therefore installed
at the near side of the railway facing towards oncoming users. The warning time gives sufficient time
to safely cross to the other side.

The PISR also suggests that anti-trespass matting should be installed on either side of the crossing.
Trespass deterrent measures of this nature are considered and installed if, for example, there is
evidence of people using the level crossing to trespass on the railway. There is no evidence of users
taking shortcuts or other such behaviour at Lindsells Level Crossing. As a result, it is not considered
that this type of deterrent is appropriate at this crossing.

Fencing at Lindsell Level Crossing
In accordance with its legal obligations, Network Rail manages its lineside boundary fencing to deter

unauthorized access. A company standard specifies the type of boundary commensurate with
assessed risks in the specific location.

The fencing in the area of Lindsells Level Crossing is a mixture of Class 1 (1.8m high, which includes
palisade fencing) and Class 3 (1.4m high, which includes post and wire) boundary measures. The
latest inspection recorded all fencing in the area of Lindsells Level Crossing to be in good condition, fit
for purpose and compliant with the current fencing standard. We understand that there is no
suggestion in this incident that access was taken to the railway as a result of failure of the boundary
measures, therefore it is not considered that further boundary mitigation is required at this time.

Further suicide prevention initiatives

The railway industry leads the way in helping to reduce the risk of suicide, working with partners such
as BTP and The Samaritans. Over 20,000 railway staff are specifically trained to intervene with people
who may be at risk, and campaigns like the hugely successful Small Talk Saves Lives initiative are
part of that work. As part of our local suicide prevention initiatives, we have funded and implemented a
team of eight patrollers in the Thameslink area to conduct suicide prevention patrols. A further
emergency intervention unit also operates in this area jointly crewed by Network Rail and BTP to
respond to potential suicide and trespass incidents as fast as possible. An embedded BTP Inspector
is funded to coordinate our patrolling and this has resulted in a joint patrolling pattern including in the
Lindsells Level Crossing area.

We have also engaged with the local authority to discuss what work can be done in the community to
reduce the risk of people taking their own lives at this and other sites.

| 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 siggerely,

Route Managing Director LNE&EM
Network Rail