Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0291, written 10 Sep 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 Sep 2018 |
|---|---|
| Reference | 2018-0291 |
| Deceased | Darren Urquhart |
| Coroner | Geoffrey Sullivan |
| Coroner area | Hertfordshire |
| Category | Railway related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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 Juristiction Hertfordshire | REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Network Rail CORONER | am Geoffrey Sullivan Senior Coroner for Hertfordshire 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.gov.uk/ukpga/2009/25/schedule/5/paragraph, http://www. legislation gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 21" November 2017 | commenced an Investigation into the death of Darren Robert URQUHART. The investigation concluded at the end of the inquest 29th August 2018. The conclusion of the inquest was Suicide Medical Cause of death: 1a Multiple Traumatic Injuries | CIRCUMSTANCES OF THE DEATH On the 13th November 2017 Darren Urquhart was struck by a train after jumping from platform 1 of Hitchin Railway Station. Police and paramedics attended and he was confirmed dead at the scene at 21:13 hours. 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) The position of the trespass mat referred to in the report of T.Ramskill at recommendation 2 of his site report. (2) The lack of gates at the south end of platforms 1 and 2. (3) The inadequacy of the fencing shown In image 6 of T.Ramskill’s report and the position of the trespass deterrence mat low down on the ramp. The Old Courthouse, St Albans Road East, Hatfield, AL10 OES 01707 292707 | ACTION SHOULD BE TAKEN in my oplnion action should be taken to prevent future deaths and | believe you Network rail have the power to take such actlon. | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Tuesday November 27" 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: Ms R Urquhart, sister of the deceased. British Transport Police lam also under a duty to send the Chief Coroner a copy of your response. The Chlef Coroner may publish elther 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. | 10/09/2018 Signature — Geoffrey Sullivan Séni ertfordshire #DW<<corAddren>> Tel ##DW<<corTel>> | Fax ##DW<<corFax>>
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