Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0341, written 6 Nov 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Nov 2018 |
|---|---|
| Reference | 2018-0341 |
| Deceased | Ryan Williams |
| Coroner | Ian Pears |
| Coroner area | Bedfordshire & Luton |
| 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.
for Bedfordshire and Luton REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | THIS REPORT IS BEING SENT TO: Mr Andrew Haines Chief Executive Network Rail 1 Eversholt Street London NW1 2DN CORONER | am lan Pears, Assistant Coroner, for the Coroner Area of Bedfordshire & Luton 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. _ INVESTIGATION and INQUEST On 27" May 2018 | commenced an Investigation into the death of Ryan John James WILLIAMS, aged 26 years. The Investigation concluded at the end of the Inquest on 1st November 2018. The Conclusion of the Inquest was ‘Accidental Death’ following his sustaining muitiple severe traumatic injuries. CIRCUMSTANCES OF THE DEATH Ryan was born on 25" Aprif 1992 and on the evening of 26 April 2018 | he went out to Stevenage, Hertfordshire, to celebrate his birthday. He returned by train to Sandy Railway Station in the early hours of 27" April 2018. At the time Sandy Station was unmanned, but it was possible for the public to gain access. About an hour after Ryan had arrived at the Station he was run over by a train. CORONER’S CONCERNS | During the course of the Inquest the evidence revealed matters giving | report to you. 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 The MATTERS OF CONCERN are as follows : 1. It is of concern that a member of the public was able to be on the Station premises for an hour without any supervision from a member of staff. 2. Itis not uncommon for members of the public to be vulnerable due to intoxication. It is a concern that if stations do have to be kept open, but unmanned, that there is no means of supervising the use of the station by the public. i |6 ACTION SHOULD BE TAKEN | In my opinion action should be taken to prevent future deaths and | believe your organisation have the power to take such action. | / 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 11th January 2019. |, 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 '1 am also under a duty to send the Chief Coroner a copy of your | have sent a copy of my report to the Chief Coroner and to the following Interested Person a --: mother of Ryan). Response, The Chief Coroner may publish either or both in a complete or redacted oF 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 6 November 2018 IAN PEARS Assistant Coroner for the Coroner Area of Bedfordshire & Luton
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