Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0239, written 24 Jul 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Jul 2018 |
|---|---|
| Reference | 2018-0239 |
| Deceased | Taiyah-Grace Peebles |
| Coroner | Ian Goldup |
| Coroner area | North East Kent |
| 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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: a. Network Rail 2 the: of the Deceased 1 CORONER | am lan Frank Goldup assistant coroner, for the coroner area of North East Kent 2 CORONER’S LEGAL POWERS | 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 An investigation into the death of Taiyah-Grace Sharon Peebles was commenced on the 1% August 2017 and the investigation concluded at the end of the inquest on 18" July 2018. The conclusion of the inquest was the death was the result of an accident. 4 CIRCUMSTANCES OF THE DEATH The deceased in an intoxicated state turned in the wrong direction on dismounting from a train at Herne Bay Station and instead of heading for the designated exit, stumbled down an un-barriered slope of the platform where she became disorientated and made contact with the live rail carrying the electric current that killed her 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. The absence of an end of platform barrier and the existence of a live rail at ground level that might be accessible to members of the public may in my opinion create a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The Assistant Coroner understands that a barrier has since been constructed at Herne Bay Station to help prevent deaths in similar circumstances but that other platforms in the area have no such barrier. His further understanding is that in other parts of the country trains are powered by electric current supplied by way of overhead cables rather than live rails at ground level thereby making contact with the power supply less likely 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and your organisation have the power to take such action. A YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 20" September 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. 8 COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons (mother of the deceased) and to the LOCAL SAFEGUARDING BOARD (where the deceased was under 18). | 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. Date 24" July 2018 SIGNED BY CORONER
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.
06 NOV 2018 —) NetworkRail “4 Private and Confidential Network Rail Infrastructure Limited lan Frank Goldup James Forbes House Assistant Coroner, North East Kent 27 Great Suffolk Street Coroners Service, Cantium House, London 2nd Floor, SE1 ONS Sandling Road, Maidstone, Kent, ME14 1XD 5 October 2018 Dear Sir Regulation 28 Report — Taiyah-Grace Sharon Peebles | refer to your report dated 24 July 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 Taiyah-Grace Sharon Peebles, who died on 25 July 2017 at Herne Bay railway station. Background As noted in your report, the conclusion of the inquest was that Taiyah-Grace Sharon Peebles died on the evening of 25 July 2017 when, having dismounted from a train at the station in an intoxicated state, she turned in the wrong direction, became disorientated and made contact with the live rail carrying the electric current. Response to Points of Concern In your report, you state that “The absence of an end of platform barrier and the existence of a live rail at ground level that might [be] accessible to members of the public may in my opinion create a risk that future deaths wills occur unless action is taken.... The Assistant Coroner understands that a barrier has since been constructed at Herne Bay Station to help prevent deaths in similar circumstances but that other platforms in the area have no such barrier. His further understanding is that in other parts of the country, trains are powered by eleciric current supplied by way of overhead cables rather than live rails at ground level, thereby making contact with the power supply less likely. In my opinion, action should be taken to prevent future deaths and | believe your organisation has the power to take such action.” Ground level power supply | can confirm that the majority of the South East route rail network is powered by a ground level 750V d.c. conductor rail system. The UK rail network comprises of two main forms of electric traction systems, 750V d.c. ground level conductor rail systems and 25kV a.c. overhead contact line systems. Both types of traction systems come with different risks which are key drivers of Network Rail’s asset polices and standards. The ground level conductor rail system on the South East route was installed in the 1950s and, although Network Rail has no future plans to install new conductor rail systems, it is not reasonably practicable to convert the system to an overhead contact line due to the complexity and cost to the railway industry. Whilst the ground level conductor rail cannot be replaced, Network Rail is committed to continue to develop reasonably practical solutions to improve the safety of the system wherever possibie. Platform-end fencing With regards to platform-end fencing, historically the fencing has not been installed as standard practice. The risks involved in intentlonal and unintentional accessing of the rail network were controlled via warning notices at the platform-end. The platform-end fencing and anti-frespass panels that have been installed at Herne Bay are part of a wider program of mitigations that are being applied to locations across the South East route to address the tisks associated with members of the public either intentionally or unintentionally accessing the rail network. There are currently two programmes of activity which will see platform-end gates installed at over 50 stations on the South East route. We have already completed works on 30 locations over the Kent and Sussex areas. We expect the majority of works to be completed by the end of 2018 with some being finished in early 2019. There are also programmes to improve our fencing at areas we consider to be at higher risk of intentional or unintentional public access and this includes £800,000 of work which is due to be completed by April 2019. Network Rail, Train Operating Companies (TOCs) and the British Transport Police continue to work together to manage this type of incident on the rail network. Our approach is a risk- based one using data (including data shared by the BTP) to identify areas where the public may access the line. Every week, joint BTP and Network Rail data is used to identify trends. This information is used to inform our patrolling plans which set out where the BTP, TOC or Network Rail should position their security resources throughout the week to best protect both members of the public and our infrastructure and stations from intentional or unintentional access. Monthly meetings are held with the BTP and TOCs (Southeastern and Govia Thameslink Railway (GTR)) to discuss our priorities around areas we consider to be at a higher risk of the public gaining access to the infrastructure. | hope this response provides you with assurance that addresses your concerns. 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 Miss Peebles. Yours faithfull oute Managing Director
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