Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0250, written 10 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 | 10 Jul 2018 |
|---|---|
| Reference | 2018-0250 |
| Deceased | Bartholomew Coleman |
| Coroner | Brendan Allen |
| Coroner area | Dorset |
| 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 (1) NOTE: This form fs to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. FY Wessex Route Managing Director, Network Rail, Basingstoke Campus, Gresley Road, Basingstoke RG21 4HG 1 | CORONER Iam Brendan Joseph Allen, Assistant Coroner, for the Coroner Area of Dorset. 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 the 1% February 2018, an investigation was commenced into the death of Bartholomew Patrick Coleman, who was born on the 12" March 1945. The investigation concluded at the end of the Inquest on the 18" July 2018. The Medical Cause of Death was: Ia Multiple Injuries The conclusion of the Inquest was Bartholomew Patrick Coleman took his own life while the balance of his mind was disturbed. 4 | CIRCUMSTANCES OF THE DEATH On 24" January 2018, Mr Coleman accessed the train track near to his home address. He lay on the track as a train approached. Mr Coleman was struck by the train and died instantly. 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. During the inquest evidence was heard that: i. The likely point at which Mr Coleman accessed the railway line was a bridge on Sandecotes Road, Poole, near to his home address. The bridge has a low brick wall separating the pavement from the area adjacent to the railway track. There is a trodden path through the undergrowth from the wall to the train track, indicating that that this is a route that has been used by others to access this area. 2. Ihave concerns with regard to the following: i. Tunderstand children of school age cross the bridge to and from school. There is evidence to suggest that the area has been used by either groups or individuals to consume alcohol: there are discarded drinks containers in the area beyond the bridge and close to the train track. I am concerned that the railway track is easily accessible to members of the public from this bridge. In addition, there appears to be no warning as to the dangers presented by accessing this area. ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe you and/or your organisation have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, 20% September 2018. 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (1) Mrs Bridget Coleman, the wife of Mr Bartholomew Patrick Coleman; (2), «Coroners Enquiry Co-Ordinator for British Transport Police. 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. Dated Signed. Brendan J Allen 10* July 2018
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 Mr BJ Allen Network Rail Infrastructure Ltd. H M Assistant Coroner for Dorset Basingstoke Campus The Coroner’s Office for the County of Dorset Gresley Road Town Hall Basingstoke Bournemouth hi BH2 6DY Hampshire RG21 4FS 13" September 2018 Dear Sir Regulation 28 Report — Bartholomew Patrick Coleman | refer to your report dated 25 July 2018 sent in accordance with 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 Bartholomew Patrick Coleman, who died on 22 January 2018. Background The bridge that you have identified in your report is a masonry arch bridge that supports a highway (Sandecotes Road) over a two track railway that runs from London Waterloo to Weymouth, with steep wooded embankments on both the Down and Up-sides. The bridge is in an urban area, on the northern edge of Parkstone town. There is also a well-used public footpath that runs from just north of Parkstone Station, parallel to the Up road along the top of the embankment that then joins Sandecotes Road at the bridge at the northern parapet (low wall). This footpath is currently closed due to retaining wall works on an adjoining property. A bungalow and a house both join the Network Rail boundary on the Up-side. Site assessment Following your report, three members of our route staff (Infrastructure Maintenance Delivery Manager, Head of Maintenance and an Asset Engineer (Structures)) attended the site for an inspection and to make an assessment. There is evidence of access being achieved by members of the public by scaling the wall on the northern parapet on the north side of the bridge, and walking down a very steep embankment to the track side. There is evidence of litter, sign of footfall and graffiti. It is likely that Mr Coleman, as assessed in your report, may have used this path to access the track, due to the evidence of access by members of the public. An additional access point has also been identified on the southern parapet on the same side of the line, although there is less evidence of its use by members of the public. It is also possible that this path was used by Mr Coleman to access the track. On the opposite side of the bridge (the south side where the track runs to Poole and Weymouth), both parapet walls have a chain-link fence topped with barbed-wire, and there is no obvious or visible evidence of access down that side of the embankment. Network Rail Infrastructure Limited Registered Office: Network Rail, 2nd Floor, One Eversholt Street, London, NW1 2DN Registered in England and Wales No. 2904587 www.networkrail.co.uk Addressing your concerns Noting your concerns identified in your report, and following the Network Rail staff site assessment, Network Rail is planning to apply mitigation measures (wire mesh panels with base plated fence posts fixed to the top of the parapet walls) to the parapet walls to further deter access to the track below. An order has now been placed with Network Rail’s framework contractors in respect of these works, with an anticipated completion date of the end of September 2018. Network Rail will also erect a warning sign of the dangers presented and that the land belongs to Network Rail and therefore access beyond is trespass. Safety is of paramount importance at Network Rail. It is a core value of our organisation and we strive to continuously reduce risk to passengers or members of the public. We want to learn any lessons we can from this very sad death to prevent similar circumstances arising in the future. | hope this response provides you with adequate information and assurance that the issues you identified have been considered and addressed. If | can be of further assistance, or you would like further clarification, please do not hesitate to contact me. Yours faithfully LEsluulock_ P| Route Managing Director, Wessex Route Py a oF AAA aN snna Network Rail infrastructure Limited Registered Office: Network Rail, 2nd Floor, One Eversholt Street, London, NW1 2DN Registered In England and Wales No. 2904587 www.networkrail.co.uk
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