Prevention of Future Deaths reports · 2018

Kevin Sherwood

Regulation 28 report to prevent future deaths, reference 2018-0289, written 11 Sep 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report11 Sep 2018
Reference2018-0289
DeceasedKevin Sherwood
CoronerGeoffrey Sullivan
Coroner areaHertfordshire
CategoryRailway related deaths · Suicide (from 2015)
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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.

Signed by Geoffrey Sullivan
Title Senior Coroner
Jurisdiction Hertfordshire

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO: Network Rail _|

CORONER

lam Geoffrey Sullivan Senior Coroner for Hertfordshire

wi!

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.

http://www. legisiation.zov.uk/ukpga/2009/25/schedule/S/paragraph/7

http://www legislation.gov.uk/uksi/2013/1629/part/7/made

INVESTIGATION and INQUEST

On the 27” February 2018 | commenced an investigation into the death of Kevin Philip SHERWOOD. The
Investigation concluded at the end of the inquest 6th September 2018. The conclusion of the Inquest was

Sulcide
Medical Cause of Death:

1a Severe Multiple Injuries

CIRCUMSTANCES OF THE DEATH

On the morning of the 20th February 2018 a passenger train from Edinburgh to London Kings Cross was
approaching Hitchin Station. The driver of the train saw Kevin Sherwood standing on the train line facing
the oncoming train. The driver applied the brake and sounded the horn but Mr Sherwood did not move
and was struck by the train. Police and paramedics attended and his death was confirmed at 11:47 hours

at the scene

CORONER'S CONCERNS

During the course of the inquest the evidence revealed matters giving rise to concern. The matters
outlined below were not found to have caused or contributed to the death. In my opinion, however
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) Only post and wire fencing at the rallway boundary In this area. The areas on both sides off the
ickneild Way, particularly to the west of the railway, are used by dog walkers and others.

The Old Courthouse, St Albans Road East, Hatfield, AL10 OES
01707 292707

6

| ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe you Network Rall 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, namely by
Wednesday 28" November 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.

"| COPIES and PUBLICATION

| have sent a copy of my report to the Chief Coroner and to the following Interested Persons

partner of the deceased
British Transport Police.

| 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 senda
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.

11/09/2018

>
Signature F
Geoffrey Sullivan Hertfordshire

##DW<<corAddress>>
Tel ##DW<<corTel>> | Fax ##DW<<corFax>>

Responses

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.

Response from Network Rail (PDF)
Geoffrey Sullivan

NetworkRail
reas

Route Managing Director LNE&EM

HM Senior Coroner for Hertfordshire — Rail
i , loor 4B
Area of Hertfordshire Coroner's Office Georpe Stephenson House
The Old Courthouse Toft Green
St Albans Road East York
Hatfield YO1 6JT
Hertforshire
AL10 OES
~—s PY
Dear Sir,

Regulation 28: Report to Prevent Future Deaths — Kevin Phillip Sherwood

| refer to your report dated 11™ September 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 Sherwood.

As you noted in your report Mr Sherwood died as the result of Severe Multiple Injuries
sustained when he was struck by a train on the railway near Hitchin on 20" February 2018.
The conclusion at the end of the inquest on 6" September 2018 was Suicide.

| detail 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 NR/L2/TRK/5100 Issue 2 (2008) - Management of Fencing and other Boundary
Measures, which applies to all Network Rail controlled infrastructure (a copy of this document
can be provided if required).

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.

Network Rail infrastructure Limited Registered Oftice: Network Rail, One Eversholt Street, London, NW/1 2DN Registered in England and Wales No. 2904587 www networkraill co.uk

To comply with the standard, annual inspections are undertaken, noting and scoring against
stipulated criteria:

1) Likelihood of unauthorized access (Risk score 1-4)
2) Consequence of unauthorized access (Risk score 1-4)
3) Condition of existing boundary (Rating score 0, 2 or 4)

Low scores = Low risk

The overall risk score is derived using the equation:

Risk = (Likelihood x Consequence) + Condition
The overall risk score informs the boundary management measures that are appropriate for
the given location.

Fencing in the Ickneild Way, Hitchin area

At the time of the incident the boundary measure in the Ickneild Way, Hitchin area had been
assessed as 3 (Likelihood) x 3 (Consequence) + 0 (Condition) = 9 and, as such, deemed
medium risk. The class 3 (1.4m high) boundary measure on both sides of the track was
installed twelve years ago. The inspection prior to the incident on 15" February 2018
recorded the fence as ‘good condition’ and regarded as compliant to the Fencing Standard.

As a result of this incident, the site was re-assessed (in line with the Fencing Standard) and
the likelihood score increased from 3 to 4 as there was now “recorded evidence of trespass
or vandalism within the last twelve months”. The consequence score was also increased
from 3 to 4 as a result of the increase in numbers of trains through this section of railway.
The revised score, therefore, became 4 (Likelihood) x 4 (Consequence) + 0 (Condition) = 16.

The mitigation for the increased risk score is a requirement to increase the frequency of
inspection from annual to three monthly. The standard also requires that, at the point where
the current fence becomes life expired, it will be replaced by a class 1 (1.8m high) fence. A
fence line may be renewed prior to life expiry in some circumstances due to operational
requirements or route enhancement projects (subject to funding).

Renewal of the fencing in the Inckneild Way, Hitchin area is currently scheduled for
2019/2020. In the meantime the fencing remains compliant with our Fencing Standard, and
will continue to be monitored via three-monthly inspections.

Further Suicide Prevention Work

Network Rail and the British Transport Police (BTP), together with Train Operating
Companies, are working together to actively mitigate against suicidal intent along the line of
route from Peterborough to Kings Cross and Bedford to St Pancras (which includes Hitchin),
together known as the Thameslink route.

Specifically, Platform End Anti-trespass measures have been added to Hitchin Station to
deter access on to the track. In addition to existing Mobile Operations staff who patrol the
area, the Route has been supported by BTP Emergency Interventions Units and BTP
Embedded Inspectors. Network Rail has also introduced a team of ‘roving patroliers’ whose
focus is suicide prevention on this line of route and providing rapid response to incidents. We
continue to work closely with industry partners to prevent loss of life in the Hitchin area as
part of our strategy for the Thameslink route.

| 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.

Route Managing Director LNE&EM
Network Rail

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