Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0386, written 10 Dec 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 Dec 2018 |
|---|---|
| Reference | 2018-0386 |
| Deceased | Christopher McGuffie |
| Coroner | Jeremy Chipperfield |
| Coroner area | County Durham and Darlington |
| Category | Suicide (from 2015) · 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: 1. Northern Rail Ltd 1 Ely Place, London EC1N 6RY (1 Admiral Way, Doxford International Business Park, Sunderland) CORONER lam Jeremy Chipperfield, Senior Coroner for the Coroner area of Country Durham and Darlington 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. INVESTIGATION and INQUEST On 26th July 2018, | commenced an investigation into the death of Christopher Lewis McGUFFIE (26yrs). The investigation concluded at the end of the inquest today, the 10! December 2018. The conclusion of the inquest was SUICIDE, and | found that the deceased stood on the rails of the Northbound railway line at Chester le Street station where he was struck by a London to Edinburgh service. CIRCUMSTANCES OF THE DEATH At around 19:39hrs, the deceased stood between the rails beside Platform Two where he waited for about five minutes prior to collision. During that period, members of the public (most of whom were school children) attempted to call him off the rails and raise an effective alert. One young boy left the station and knocked at the home of a local tesident to request that she alert the police. Police were notified less than two minutes prior to the collision and by making a telephone call to Network Rail achieved a block on the rail line around three minutes therafter. | was told by a DS of British Transport Police : (i) no platform staff were on duty at the time; (ii) no emergency help point exists at this station; and (iii) the station in question is “considered a hot spot for rail fatalities”. 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 could occur unless action is taken. In the circumstances it is my statutory duty to report to you The MATTERS OF CONCERN are as follows. The absence, at railway stations, of:- (1) the means to raise an immediate and effective alert regarding persons on the line; AND (2) Alternative means of detecting persons on the line and triggering appropriate response. re Te [nnn 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Wednesday 6'" February 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: | have also sent it to the Office for Rail and Road, who may find it useful or of interest. | 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:10 Dégember 2018 Signed ..../4..UA.46¢7 JEREMY HM SENIGR CORONER COUNTY DURHAM AND DARLINGTON
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.
northern by arriva Jeremy Chipperfield 5!" Floor HM Coroner for County Durham and Darlington Northern House HM Coroners Office 9 Rougier Street PO Box 282 York Bishop Auckland YO1 6HZ County Durham DL14 4FY 17 JAN 2019 11 January 2019 Dear Sir Re Inquest into the Death of Christopher Lewis McGuffie In response to your letter of 12 December 2018 and the findings of the inquest into the suicide of Mr McGuffie please find below both an explanation of the work we undertake at Arriva Rail North (ARN) to address suicides on our network and a response to some of the specific issues you raise. Addressing suicides and trespass on the Northern network are two key strands in our overall Safety Health Environment and Crime strategies. We recognise the societal impact that suicide has on the railway and in particular on our staff, customers and the communities we serve. We are committed to working together with industry partners including Network Rail (NwR), British Transport Police (BTP) and other Train Operating Companies (TOCs) to develop plans and approaches to address suicide on the railway and the trauma it can cause staff, customers, families, friends and others. | have strategic responsibility for suicide prevention at Board level. | am supported by our Workplace Health and Wellbeing Manager who acts as our suicide prevention coordinator. Ann ts a member of the National Suicide Prevention Working Group (NSPWG) and the Railway Industry Suicide Stakeholder Group (RISSG). We are actively engaging with the Samaritans in their current ‘Small Talk Saves Lives’ campaign. We have developed our Suicide Prevention Plan in line with the Rail Industry Suicide Prevention Duty Holders Group’s guidance for a 9 point plan and Leading Health and Safety on Britain's Railways. The plan sets out how staff across ARN support the delivery of our plan and initiatives including: ¢ operational and station staff in identifying vulnerable individuals, carrying out interventions and supporting Samaritan promotions; * control staff whe coordinate the response in the event of the notification of vulnerable people, attempted/actual suicides and trespass; * _ crinhe and resilience teams who deploy our 55 Travel Safe Officers (TSO) on an intelligence led basis working alongside BTP and Network Rail VITAL teams. We also have two community safety managers who work together with the local communities and schools to discourage trespass; www.northernrailway.co.uk ARRIVA RAIL. NORTH LIMITED | ADMIRAL WAY, DOXFORD INTERNATIONAL BUSINESS PARK, SUNDERLAND, TYNE AND WEAR, SR3 3XP. Company No 04337712 © operational managers who will provide support to staff following an incident; ¢ training teams to develop and deliver material to frontline staff on suicide interventions and trespass; media teams to support the development of communications material: ¢ performance and planning on time champions to identify ways of reducing how suicide and trespass introduce delay onto the network. The plan also outlines how we interact with external parties such as BTP, NwR, Station Operator (where not ARN), Other TOCs, Samaritans, Local Authorities and Public Health Authorities. All frontline staff (drivers, conductors and station staff) receive training on suicide intervention as part of their initial training for their role. We are currently revising our induction training for all staff to further include a module in this area. Staff are encouraged to attend the Samaritans Managing Suicidal Contacts course. The one-day course is specifically tailored to people working within the rail industry. This course focuses on the benefits of a short conversation with someone who may have suicidal feelings and the techniques required to sensitively support that person and help begin their recovery — known as ‘emotional first aid skills.’ The courses which take place in one of our two training centres in Leeds and Manchester and are advertised on our internal Learning Management System (LMS) and through a variety of internal communication channels. These courses can also be accessed by other railway industry stakeholders. Over 300 staff have attended this training since we launched it in 2010. in addition all our TSOs have undertaken this training. We are also in the midst of a programme to train all our staff in Mental Health Awareness using a bespoke one day course. Nearly 200 managers have been trained since July 2017. Post incident support is coordinated and offered to staff and customers by station staff in conjunction with the Samaritans. Trauma Awareness training using a bespoke in house course is available to all managers- to date 79 managers have attended this training. We are also arranging a course for Trade Union representatives together with the Samaritans to provide post incident trauma support. Following a suicide or attempted trespass multi-disciplinary meetings involving NwR, BTP, ARNs station manager and the Samaritans take place to identify any local actions that need to take place. Suicide awareness briefs from NwR are distributed to station managers on the anniversary of an event. TSOs are also actively deployed to these locations at this time to assist the station managers. We actively work with NwR to implement any BTP recommended measures following an incident such as signage, platform end protection. Current initiatives we are undertaking internally and together with industry partners are as follows: ¢ Inclusion of suicides and trespass prevention measures as part of our station bow-tie risk assessment and Planned General Inspections e Using data to identify hotspot locations and identify additional measures such as CCTV coverage. In the longer term we want to upgrade our CCTV network such that a live feed could be seen in a central control room offering greater potential for proactive intervention. ¢ Exploring ways to engage the wider communities at our hot spot locations; ¢ Working with a broader group of stakeholders to identify measures to address hot spot locations such as in South Manchester and South Yorkshire. e Improving the tracking of interventions and staff recognition; ¢ Update briefings to all frontline staff using RISSG videos and presentations to staff during 2019. ¢ Development of a campaign to be deployed using a range of media- PIS screens, twitter, Facebook, multimedia screens and posters using a local poet; northern page? by arriva northern by arriva e Bespoke training for customers service controllers on how to handle calls/nelp point usage by potentially suicidal customers. Regarding the specific points you raised: 1. As with many of our stations Chester le Street is only staffed part time. Staff are located in the booking office and not on the platform. Staff are rarely located on the platform and only at those larger stations where they are involved in the despatch of trains. 2. There is a help point at the station this is the responsibility of Durham County Council. We understand that this is currently not working. We are installing Ticket Vending Machines across our network and phase 2 of the software installation includes a help point. The software is currently being trialled. 3. The station does not classify as a hot spot under British Transport Police's definition which is used nationally to focus the work of cross industry working groups. Such locations are defined as having 3 or more suicides/attempted suicides in 12 months. This is the only fatality at Chester le Street since the commencement of National data collection in 2015. 4. Unfortunately there is no technology that could detect persons on the line. | have attached the BTP report on the station following the incident for your information. We are looking to bring forward out planned installation of CCTV on the station and we will continue to work with industry groups to develop solutions to reducing suicide on the railway. | hope this provides you with the required information. Yours sincerely AUTUCAS Safety Health and Environment Director www.northernrailway.co.uk ARRIVA RAIL NORTH LIMITED | ADMIRAL WAY, DONFORD INTERNATIONAL BLSINESS P ARK SUNDERLAND, TYNE AND WEAR. SR3 XP Company No 04337712
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