Prevention of Future Deaths reports · 2019

Carl Klimaytys

Regulation 28 report to prevent future deaths, reference 2019-0276, written 7 Aug 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report7 Aug 2019
Reference2019-0276
DeceasedCarl Klimaytys
CoronerVeronica Hamilton-Deeley
Coroner areaBrighton and Hove
CategoryRailway related deaths
Sourcejudiciary.uk record · original PDF
Responses published2

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.

VERONICA HAMILTON-DEELEY DL, THE CORONER’S OFFICE

LL.B. WOODVALE, LEWES ROAD
Her Majesty’s Senior Coroner BRIGHTON
for the City of Brighton & Hove BN2 3QB
Assistant Coroners Telephone: Brighton (01273) 292046
CATHARINE PALMER LL.B (HONS) Fax: Brighton (01273) 292047

GILVA D.J.TISSHAW, BA(LAW)HONS

CORONERS SOCIETY OF ENGLAND AND WALES
ANNEX A
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)

NOTE: This form is to be used after an inquest.

THIS REPORT IS BEING SENT TO:

1. Govia Thameslink Railways

2. Network Rail
1 CORONER
Iam Veronica HAMILTON-DEELEY, Senior Coroner, for the City of Brighton and
Hove
2 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.

3 INVESTIGATION and INQUEST

On Thirty first day of December 2018 | commenced an investigation into the death
of Carl Richard KLIMAYTYS. The investigation concluded at the end of the inquest
on 18" August, 2019.The conclusion of the inquest was MISADVENTURE.

4 CIRCUMSTANCES OF THE DEATH
See Record of Inquest

5 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: —

| found that Carl died instantly as a result of electrocution when he came in contact
with the electric rail at 0557 hrs on the 23 December, 2018.

VERONICA HAMILTON-DEELEY DL, THE CORONER’S OFFICE

LL.B. WOODVALE, LEWES ROAD
Her Majesty’s Senior Coroner BRIGHTON
for the City of Brighton & Hove BN2 3QB
Assistant Coroners Telephone: Brighton (01273) 292046
CATHARINE PALMER LL.B (HONS) Fax: Brighton (01273) 292047

GILVA D.J.TISSHAW, BA(LAW)HONS

His body was decapitated and then disrupted by a train which arrived on the line
upon which he was lying at 0611 hrs. One or two minutes later that train
departed Preston Park Station carrying Carl’s body with it for approximately 50
yards.

Whilst this occurred following Carl’s death (approximately fifteen minutes later)
the Inquest evidence indicated that there were several matters, the continuation
of which could lead to future fatalities.

In the letter accompanying this Report you will find more information about
those matters.

This Regulation Report relates to Signage on the platform.

The Inquest heard that both further north in England and Wales and overseas
the current to enable the trains is carried by overhead arrangements.

Carl and his family had come from Darlington and of course many visitors,
tourists and persons from abroad visit the Brighton area including Preston Park
Station.

It is therefore reasonable to suppose that if they think about it at all they may
assume that the electric current for the railway is carried overhead.

| should like to invite Govia Thameslink to consider and indeed the other
railways operating on ground laid electric rails to consider the question of
notification to their customers of that fact.

In addition one of the recommendations contained in British Transport Police’s
post incident site report (see page 2 — recommendation 1) there was a
suggestion that painting or otherwise installing yellow cross hatchings on the
coping stones between the platform edge white line and the tactile paving on the
platform and including the words KEEP CLEAR to be included at every 20
metres would warn passengers that non stopping services regularly pass
through stations. People on the station may stray too close to the platform edge
(without this warning).

It was discussed at the Inquest that such signage may possibly be helpful in
keeping members of the public away from the edge of the platform in any event.

This Regulation 28 Report is sent both to the Railway Company, Govia
Thameslink and to Network Rail, not because Network Rail would be carrying

_out any such works but because it is understand that Network Rail are the
‘landlords’ for GTR who would therefore need to seek their permission to carry
out these works.

VERONICA HAMILTON-DEELEY DL, — THE CORONER’S OFFICE

LL.B. WOODVALE, LEWES ROAD
Her Majesty’s Senior Coroner BRIGHTON
for the City of Brighton & Hove BN2 3QB
Assistant Coroners Telephone: Brighton (01273) 292046
CATHARINE PALMER LL.B (HONS) Fax: Brighton (01273) 292047

GILVA D.J.TISSHAW, BA(LAW)HONS

6 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.

7 YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this
report, namely by 25" October 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

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

{ ER 2 solicitors)
2. British Transport Police

3. Office of Road and Rail

4. Gatwick Express Services

5. Southern Rail

| 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.

9 Date: 7 August 2019. SIGNED BY:

Isfoni Mintel

HM Senior Coroner Brighton and Hove

VERONICA HAMILTON-DEELEY DL, THE CORONER’S OFFICE

LL.B. WOODVALE, LEWES ROAD
Her Majesty’s Senior Coroner BRIGHTON
for the City of Brighton & Hove : BN2 3QB
Assistant Coroners Telephone: Brighton (01273) 292046
CATHARINE PALMER LL.B (HONS) Fax: Brighton (01273) 292047

GILVA D.J.TISSHAW, BA(LAW)HONS

CORONERS SOCIETY OF ENGLAND AND WALES
ANNEX A
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)

NOTE: This form is to be used after an inquest.

THIS REPORT IS BEING SENT TO:

1. Govia Thameslink Railways

4 CORONER

| am Veronica HAMILTON-DEELEY, Senior Coroner, for the City of Brighton and
Hove

2 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.

3 INVESTIGATION and INQUEST

On Thirty first day of December 2018 | commenced an investigation into the death
of Carl Richard KLIMAYTYS. The investigation concluded at the end of the inquest
on 18" August, 2019.The conclusion of the inquest was MISADVENTURE.

4 CIRCUMSTANCES OF THE DEATH
See Record of Inquest

5. 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: —

Three Bridges Regional Operating Centre (ROC)

A member of the public arriving at Preston Park Station saw Carl's body at Platform
2.

VERONICA HAMILTON-DEELEY DL, THE CORONER’S OFFICE

LL.B. WOODVALE, LEWES ROAD
Her Majesty’s Senior Coroner BRIGHTON
for the City of Brighton & Hove BN2 3QB
Assistant Coroners Telephone: Brighton (01273) 292046
CATHARINE PALMER LL.B (HONS) Fax: Brighton (01273) 292047

GILVA D.J.TISSHAW, BA(LAW)HONS

He used the help phone pressing the emergency button to inform of this.

The call was answered promptly by the initial call taker called a Resilience
Customer Ambassador (RCA). This person had not been given the safety critical
communication training. He had only been employed recently as an agency person
to provide cover in the RCA over the Christmas period.

The Inquest heard that when an emergency call comes in to the ROC there is a red
flashing light and a buzzer to announce that this is an emergency call.

The Inquest heard that the RCA should have picked up the telephone and handed it
to his team leader who was shadowing him and sitting opposite him doing his own
work.

At 0602 the member of the public pressed the emergency button at the help phone.

In fact the RCA answered the member of public's call, took details from him which
were correct as to the location of Carl’s body, said goodbye and terminated the call
which lasted eleven seconds.

The Inquest heard that almost immediately he passed information that the body was
not on Track 2 but on Track 1. .

The Inquest heard that the Team Leader tried to phone the member of public back
on the help phone but could not get an answer.

It was not until 0609 hrs that the Team Leaders was able to speak to the member of
public and ask for confirmation of the location of Carl’s body. This time the member
of public appears to be saying that the body is straddling Tracks 1 and 2 (in fact he
was straddling Tracks 3 and 2). .

The Team Leader should have known from the information available to him in the
ROC that for Carl’s body to be straddling Tracks 2 and 1 was a physical
impossibility since they are separated by a large island Platform.

His call to the member of public lasted nineteen seconds.

As a result of this incorrect and impossible information it was believed that Carl’s
body would not be disrupted by the train 9T90 approaching from Brighton and due
to arrive in Preston Park Station on Line 2 at 0611.

The plan was to prevent the train stopping at the station for reasons which were
explained at the Inquest, but because of the inputting of the wrong headcode and
the fact that the train describer system was down the driver of 9T90 was not
contacted, came into Preston Park Station arriving on the track where Carl’s body
was lying, decapitating and then disrupting it, stopping at the station for
approximately two minutes before leaving carrying Carl's body with it.

The other matter which caused concern from the point of view what was going on in
the ROC was that they apparently did not have up to date contact details for

VERONICA HAMILTON-DEELEY DL, — THE CORONER’S OFFICE

LL.B. WOODVALE, LEWES ROAD
Her Majesty’s Senior Coroner BRIGHTON
for the City of Brighton & Hove BN2 3QB
Assistant Coroners Telephone: Brighton (01273) 292046
CATHARINE PALMER LL.B (HONS) Fax: Brighton (01273) 292047

GILVA D.J.TISSHAW, BA(LAW)HONS

Bronze.

Having set out these facts the purpose of this Regulation 28 Report is to refer to the
failings in the ROC and to request that actions are taken regarding appropriate
training and use of resources for those who work in that operating centre.

6 ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and I believe you
AND 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 25" October 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

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

(via Solicitors)
Network Rail
British Transport Police
Office of Road and Rail
Gatwick Express Services
Southern Rail

Oakwn =

| am also under a duty to send the Chief Coroner a copy of your response.

VERONICA HAMILTON-DEELEY DL, THE CORONER’S OFFICE

LL.B. WOODVALE, LEWES ROAD
Her Majesty’s Senior Coroner BRIGHTON
for the City of Brighton & Hove BN2 3QB
Assistant Coroners . Telephone: Brighton (01273) 292046
CATHARINE PALMER LL.B (HONS) Fax: Brighton (01273) 292047

GILVA D.J.TISSHA W, BA(LAW)HONS

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.

fe) Date: 7 August 2019 SIGNED BY:

far Ninoy

HM Senior Coroner Brighton and Hove

Responses

2 responses 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 Gtr (PDF)
GTIX

Head of Independent Assurance
Govia Thameslink Railway Limited
Go-Ahead House

26 — 28 Addiscombe Road
Croydon

CR9 5GA

Veronica Hamilton-Deeley, DL. LL.B.
Her Majesty's Senior Coroner

The Coroner's Office

Woodvale, Lewes Road

Brighton

BN2 3QB

Your Ref: VHD/TS/INQ 01212-2018
31st December 2019
Dear Madam,

RE: The late Carl Richard KLIMAYTYS

nS PR AA BT

Thank you for your Regulation 28 report dated 7th August 2019 addressed to Patrick Verwer,
Chief Operating Officer for Govia Thameslink Railway (GTR), who has asked me to respond on
his behalf and on behalf of GTR.

The first of your Regulation 28 reports, expresses a concern in relation to signage on the
platform at Preston Park station to (1) warn customers of the existence of ground laid electric
rails and (2) to keep customers away from the edge of the platform. The second report refers to
facts presented to the inquiry, that identified areas of improvement in the call handling of the
Rail Operating Centre.

GTR is Station Facility Owner at 235 stations, including Preston Park and is responsible for
ensuring that each operate safely and in compliance with industry standards. These stations
include those with traction current supplied by 3° Rail (Conductor Rail), Overhead Lines and
some non-electrified lines. Staff working at stations are trained and are familiar with the specific

Govia Thameslink Railway
Monument Place, 24 Monument Street, London, EC3R 8AJ
Registered in England under number: 7934306. Registered office: 3rd Floor, 41-51 Grey Street, Newcastle upon Tyne, NE1 6EE

GTIk

risks at their locations, pertaining to electrification.

The risk of trespass onto the railway track is a widely recognised industry wide issue; one which
nationally accounts for hundreds of people each year unintentionally injured or killed. We
recognise that the railway is full of hidden dangers, which includes the risk of being hit by an
unexpected train or encountering lethal current in rails and power lines. To help publicise and
manage these risks the industry recently launched the ‘You vs. Train’ campaign.

This campaign, based on extensive research, targets specific groups identified as more
vulnerable from trespassing onto the railway track; it is accessible in several ways including TV,
Poster and Social Media specific to the risk at varying locations. One of the messages and
accompanying video focuses on the dangers of the 3° Rail. The campaign having received a
high degree of visibility has received an award from the Institute of Occupational Safety and
Health (IOSH).

Yous. rain

‘The third rail is probably the hardest danger to see. It
looks just like an ordinary rail, but i carries 750 volts -
easily enough to kill you.

I's designed to send power to the train, bul you are 70
per cent water and the perfect conductor for this
electricity. If you touch the rail, you vill “stick” to it. The
DC current that flows through it wit pull you in. and not
fet go unti! the emergency services are able to switch
the power off.

Nearly haif of the UK rail nelwork is now electrified ~
and more than 30 per cent uses a third rail to power
the train. The only way to avoid stepping on this
hidden danger is not to step on the track.

http:/Awww. youvstrain.co.uk/

Govia Thameslink Raitway
Monument Place, 24 Monument Street, London, EC3R BAI
Registered in England under number: 7934306, Registered office: 3rd Floor, 41-51 Grey Street, Newcastte upon Tyne, NE1 6EE

GTI

GTR continues to work with groups such as the industry Trespass Risk Group to learn and
promote good practice, monitor the effectiveness of current trespass management and be
involved and sponsor work in this area to raise public awareness. This broader approach is
combined with the local notifications at specific locations to reduce the likelihood of trespass.

Preston Park Station

In recent years there has been significant investment in anti-trespass measures at stations. This
includes barriers and anti-trespass matting at platform ends, in addition to the trespass warning
and danger of live rail signs. These signs are compliant with Railway Group Standard
GI/RT7033 in both design and positioning (CBO1 — Electrical Hazard: Warnings to the Public;
CA03 — Danger — No Unauthorised Access). To supplement our planned general inspection
regime, GTR are currently surveying all its sites to access anti-trespass and suicide measures,

Govia Thameslink Railway
Monument Place, 24 Monument Street, London, EG3R 8AJ
Registered in England under number: 7934306. Registered office: 3rd Floor, 41-51 Grey Street, Newcastle upon Tyne, NEt 6EE

including Samaritans signage.

We recognise the significant risks associated with heavy drinking in how it potentially impairs
judgement and the increased risk of death on the railway for those affected. In preparation for
this year’s festive season, GTR made use of the Respect the Edge campaign messaging to
keep people and staff safe.

Respect the Edge Social Media graphic (2019)

The festive socialising campaign was used as a timely reminder to take extra care during the
festive season, when we see more people out socialising, to the extent where they are more
likely to have an accident. This campaign was supported by posters at stations that have a high
frequency of slips, trips, falls was heavily pushed to GTR’s 333,000 Twitter followers and in
briefing to staff. It's key messages for customers are to not let alcohol affect you and your

Govia Thameslink Railway
Monument Place, 24 Monument Street, London, EC3R 8AJ
Registered in England under number: 7934306. Registered office: 3rd Floor, 41-51 Grey Street, Newcastle upon Tyne, NE? 6EE

GTI

friends’ ability to keep a clear head and to stay safe on the platform. Key messages for staff
were to pay extra attention during the festive season as some customers may be affected by
alcohol and may be vulnerable; be on the look-out for anyone who needs help on the platform
or while getting on or off the train. As well as advice on how to manage people who may be
under the influence.

Consideration for the use of cross-hatching to demark the platform edge is a recommendation
made regularly by the Designing Out Crime Unit and is based on a theoretical basis that it could
influence people in suicide crisis to not cross the psychological barrier. However, there is no
evidence to support that this either influences the behaviours of those in crisis or travelling
passengers generally.

This recommendation has been selected by the report author, a member of BTP’s Designing
Out Crime Unit, from an industry document which has subsequently been formally reviewed by
the industry (published in May 2018 (ref: T1118 Optimising the design and position of platform
markings to keep people away from the platform edge)). The aim of this review was to develop
good practice guidance on the design and position of platform markings for keeping people
away from the platform edge. This included an appraisal of the efficacy of platform markings
such as the yellow line and cross hatching. The research concluded that platform marking are a
weak control method and any strong safety benefits should not be attached to them. To try and
maximise their effectiveness as a weak control, a consistent approach to the location of the
yellow line should be adopted, but could be modified considering local risks and constraints,
and other markings should be avoided. It can be observed in the report (CRU 2018 2255) that
the consistent approach endorsed in T1118 of tactile paving and painted yellow lines is in place
at Preston Park Station.

The Resilience Customer Ambassador (RCA) role provides a valuable interface for our
customers which can respond directly to their questions about live network operations. Where
we anticipate greater demand, agency staff will supplement the normal establishment.
Temporary staff are subject to the same training and competency assessment regime as
permanent staff. This now includes safety-critical communications training, which is assessed
as part of the Customer Ambassador standard, so there is no longer a reliance on a Team
Leader to establish a clear understanding about an emerging situation.

Govia Thameslink Railway
Monument Place, 24 Monument Street, London, EC3R 8AJ
Registered in England under number: 7934306. Registered office: 3rd Floor, 41-51 Grey Street, Newcastle upon Tyne, NE1 GEE

GTIk

The new training for Help Point Assessment includes functional tasks such as launching and
logging into the system, answering calls and making calls back to the help point. This enhanced
competency development cycle includes a ‘Quiz’ which tests personal knowledge and was
established in February 2019 as an action from the learnings from this tragic incident.

Competencies, are managed through a Competency Management System (CMS), as used for
other safety critical roles; this establishes an assessment cycle and maintains records of
assessments, which are subject to audit.

Information resources now include access to a ‘Track Access’ system that can be viewed on
line with video and associated track map, and the Stations Made Easy section of National Rail
Enquiries, to provide an interactive view of the station and its facilities such as ticket offices etc.

‘AGUISCS

Track Access © image

Govia Thameslink Railway
Monument Place, 24 Monument Street, London, EC3R 8AJ
Registered in England under number; 7934306, Registered office: 3rd Floor, 41-51 Grey Street, Newcastle upon Tyne, NE1 6EE

area natiorateail couksesnicrs Pt,

ding iv the north of England (1)

Biany Use hg.

1am ot

‘eum 2) seaeme
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Hr Be Stem

| Sttions made cssy Shaw PAPI nite:

National Rail Enquires
We at GTR express our deepest condolences to the family for their tragedy and we appreciate

their unimaginable loss. Our thoughts remain with them.

Yours sincerely,

>

Govia Thameslink Railway
Monument Place, 24 Monument Street, London, EC3R 8AJ
Registered in England under number: 7934306. Registered office: 3rd Floor, 41-51 Grey Street, Newcastle upon Tyne, NE1 6EE
Response from Network Rail (PDF)
NetworkRail

25 October 2019 Sam Chessex
Network Rail
27 Great Suffolk Street
London
SE1 ONS

T 07702 911 907

Ms Veronica Hamilton-Deeley

H M Senior Coroner Brighton and Hove
The Coroner's office

Woodvale

Lewes Road

Brighton BN2 30B

Dear Ms Hamilton-Deeley,
THE LATE CARL RICHARD KLIMAYTYS

Thank you for your Regulation 28 report dated 7th August 2019 addressed to John Halsall, Regional
Managing Director Southern Region, who has asked me to respond on his behaif and on behalf of
Network Rail. | am the Support Services Director of the Southern Region, which includes Preston
Park Station.

Your Regulation 28 report expresses a concern in relation to signage on the platform at Preston Park
station to (1) warn customers of the existence of ground laid electric rails and (2) to keep customers
away from the edge of the platform.

You identify that these concerns are matters for consideration by the train operator, namely, Govia
Thameslink Railway Ltd (GTR) and a copy of your report is sent to Network Rail in its capacity as
landlords for GTR who may need to seek Network Rail’s permission to carry out works at the station.

Firstly, we confirm that GTR is the lessee and Station Facility Owner of a number of stations within its
area of franchise, including the station at Preston Park.

In keeping with other stations identified within GTR’s lease, the station at Preston Park is specified to
be used for or in connection with the provision of the services for the carriage of passengers by railway
provided by the Station Facility Owner pursuant to its Franchise Agreement with the Department for
Transport. Part It of the Landlord and Tenant Act 1954 does not apply.

Under the terms of its lease, GTR has the responsibility for all signage at the station and does not
require Network Rail’s permission for it. GTR is required to keep such signage in good order, clear and
clean, while in all other regards GTR is obligated to respond to industry standards and to be compliant
with them.

By way of background it is perhaps appropriate to identify that the railway is made up of many

Network Rait infrastructure Limited Registered Office: Network Rait, 2nd Floor, One Eversholt Street, London, NW1 20N Registered in England and Wales No. 2904587
wow. networkeail.co.uk

NetworkRail

companies and organisations delivering different parts of the railway. Those parts need to collaborate
to make the railway work and to ensure it is safe. This means there is no single organisation which
leads. Instead, different aspects of leadership are provided or supported from different places with
the aim of delivering a consistent and safe railway benefiting from wider railway knowledge.

One such part is the Rail Safety and Standards Board (RSSB) which is a membership-based rail industry
body designed to help the railway become safer and more sustainable. Its work helps to reduce risk
and cost for passengers, the workforce and the wider public. It enables and informs safety leadership,
assesses whole system risk, provides tools, guidance, standards, analysis, and research, informs on
progress against strategy, facilitates safety collaboration and advises on good safety management.

Your investigation received evidence that RSSB provides the industry standards including Railway
Group Standards, Rail Industry Standards, Codes of Practice, Guidance Notes and National Safety Rules
etc. drafted with the benefit of collaboration, safety research, risk assessment and inter-operational
working.

RSSB has, by way of example, produced:
Rail Industry Standard for Station infrastructure RIS-7700-INS;
Railway Group Standard GI/RT7033 relevant to Lineside Signs; and
Rail Industry Standard RIS-7016-INS for the Interface between Station Platforms, Track, Trains
and Buffer Stops.

There are many more standards which include the requirements for the specification and positioning
of operational safety signs. In this regard GTR is expected to be compliant with all those standards and
does not require Network Rail permission.

We care about making sure passengers and members of the public understand how to stay safe and
we support a number of safety awareness programmes, including the You vs Train film about the
dangers of the third rail.

A key part of our work in the community is education and we regularly attend schools and community
events to promote safety on the railway. Educational resources have also been developed with
teachers and pupils about electrification on the railway, level crossings and railway safety. A life-size
indoor train station has even been built at Sutton Life Educational Centre to bring home safety
messages to young people and is a part of our safety outreach programme for young people.

We note from the Record of inquiry that the presence of alcohol is listed under the medical causes of
death. The inherent dangers of the railway are of course exacerbated by excessive alcohol intake.
Anything you, as one of Her Majesty’s Senior Coroners, could do to draw attention to the significant
risks associated with heavy drinking and impaired judgements and the significant risk of death on the
railway — whether being struck by a train or by electrocution — would be very much appreciated.
Network Rail regularly runs seasonal publicity campaigns warning the public of the risks of excessive
alcohol intake and travelling on the railway.

Network Rail has expressed its deepest condolences to the family for their tragedy and we appreciate
their unimaginable loss. Our thoughts remain with them.

Network Rail infrastructure Limited Ragistered Office: Network Rail, 2nd Floor, One Eversholt Street, Landon, NW1 2DN Registered in England and Wales No. 2904587
wa networkrail.co.uk

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