Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0391, written 19 Nov 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Nov 2019 |
|---|---|
| Reference | 2019-0391 |
| Deceased | James Fennell |
| Coroner | Heidi Connor |
| Coroner area | Berkshire |
| 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.
Classification: OFIICIAL-SENSITIVE
i | REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
4.
Managing Director
South Western Railway,
South Bank Central,
4" Floor, 30 Stanford Street, SE1 9L.Q.
/
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| | 2. Mrlan Prosser
: Chief Executive
The Office of Rali and Read
28 Cabot Square,
Canary Wharf,
LONDON, E14 402.
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| | rr arm Heidi J. Connor, senior coroner for (he coroner area of Berkshire.
| /
(2 | CORONER'S LEGAL POWERS
| L 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.
itis important to note the case of R (Dr Siddiqui and Dr Paeprer-Rohricht) v Assistant
| Coroner for East London, This case clarifies that the issuing and receipt of a Regulation
_ 28 report entails no more than the coroner bringing some information regarding a public |
| safety concern to the attention of the recipient. The report is not punitive in nature and
| engages no civil or criminal right or obligation on the part of the recipient, other than the
| obligation fo respond to the report in writing within 56 days.
i
1. oe ncn —— —_
(3 | INVESTIGATION and INQUEST
| | :
! i conducted an inquest into the death of James Joseph Fennell that was heard at
Reading Town Hallion 47" October 2079. | recorded a conclusion of accident.
I— - a Sy
4 | CIRCUMSTANCES OF THE DEATH
The family asked us to refer to the deceased as James at the inquest, | have reflected |
that request in this report.
Bracknell, before boarding a train from Bracknell towards Reading where the intention of -
the group was to visit a nightclub. It would appear that James had a change of heart,
and left ihe train at Wokingham Station,
back in the direction of Bracknell, where he lived) Jarnes climbed down onto the track to
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r investigations revealed that James had spent the evening drinking with friends in
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| cross to the other side.
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| Rather than using the pedestrian footbridge to get to platform 1 (in order to catch a train
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The incident happened when it was dark (between 23:00 and 24:00 hours). Therewas |
j | also snow on the tracks. itis clear from CCTV (and indeed from subsequent toxlcelogy) —
| that James was intoxicated at the time. We heard evicence that James had attempted to |
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Classification: OF FICLAL-SENSITIVE
Classification: OF FICIAL-SENSITIVE
"get on to the tracks ear
inna nenmenn
sf that evening at Bracknell Station.
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i | Tragically, although James appeared to step over the track (and third rail, he slipped,
i _ lost his footing and made contact with the third rail, resulting in his instant death. The
_ cause of death at post mortem examination was given as electrocution.
The evidence of James’ mother was that James was nol aware, and she had never
taught him, that there was a risk of electrocution in crossing the tracks. She suggested
that Janes would have known it was dangerous to cross railway lines, but only from the
point of view of oncoming trains.
an
5 CORONER'S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to concern, iy
my opinion there is a risk that future deaths could occur unless action is taken. In the
circumstances itis my statutory duty to report to you.
_ The MATTERS OF CONCERN are as follows. ~
(1) We heard that power Is supplied through the lines at this station by means of a
“third ral’. This, we heard, is not an uncommon set up in stallions nationally.
Whilst the third rail runs to the nearside of the track outside of stations, it is
positioned fo the offside of ihe track within stations.
(2) Signage was reviewed at Wokingham Station following the incident by a
Designing Out Crime Unit, and | have the report o in this respect.
No recommendations were made with regard to signage at tnis station. We
heard in evidence that there are smail signs at either end of the platform at
| Wokingham Station, indicating that the lines should not be crossed because of
| the danger of electrocution. Neither of these signs would be visible from the i
| i main area where commuters stand to wait for trains. They are small and some |
distance away. i
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(3) There is a yellow painted line indicating the safe area away from the platform |
adge, as well as a white line on the platform edge. There is no tactile paving or i
crosshatch marking between these two lines. |
(4) There is no warning of the risk of the live rail visible to commuters on the |
platform at this station. This is likely to be a situation which is replicated in many /
stations nationally.
(5) It was suggested in evidence that most people are aware of the risks of crossing |
irain tracks in this way. | accepted the evidence of James’ mother that he was
not aware of this and | am aware of other cases in recent national press in which
that was found to be the cass. ff indeed it is felt that the public Is well aware of |
{
this risk, then there seems to be little point in having signs at the ends of the
platform to warn the public of this. it seerns incongruous that the public should
need to be warned in an area where there is unlikely to be any member of the
public present, but no warning in the areas where most of the members of the
public stand to wait for trains.
(6) If the purpose of the signe at the ends of the platform is to warn the pubic of the
risk beyond the platform areas (where the “third rail” is on the nearside of the
track}, then it seems to me that this risk Is a much smaller one, given the much
higher feotfail in the platform areas ~ where there are no signs, and no
indication whatsoever of this exceptionally high tisk.
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: i (7) L cannot conceive of many (if any) scenarios in which electrical power of this |
| magnitude would be open and accessible without significant signage and |
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Classification: OFFICIAL-SENSITIVE
Classification: OPFICTAL-SENSITIVE
warnings. :
(8) Whilst James did initially step over the rail, as seen on COTY, | do not sccept
\ that is evidence that James knew of the risk of electrocution. It is human nature
to step over a rail when walking, particularly given that the third rail is somewhat
elevated.
| accept that excessive signage can carry its own risks. itis however surprising
that there is no signage visible to members of the public, warning them of this
risk, except in areas where they are unlikely fo stand, Whilst members of the
public may be aware that crossing a train line is dangerous, this may be
because of a perception of the risk of oncoming trains, rather than the risk of
electrocution,
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(10)Whilst it is undoubtedly the case that James was intoxicated at the time of these |
' events, this is not the first case of this nature. | consider that there is a risk of
i future deaths and that other members of the public are likely to be unaware of
/ the significant risk involved in crossing tracks in this way, Save in relation to the
risk of oncoming trains.
(11)| believe this is an issue which is likely to be reievarit to stations nationally, and
: not just to Wokingham Station
in my opinion action should be taken to prevent future deaths and | believe your
| organisation(s) 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 15" January 2020. |, the coroner, may extend the period
Your response must contain details of action taken or proposed fo be taken, setting out
the timetable for action. Otherwise you must explain why no action is proposed.
| COPIES and PUBLICATION
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i have sent a copy of my report to the Chief Coroner and to James’ family. | have also
| sent a copy of this report to the following organisations:
(4) Rail Accident Investigation Branch.
i iH
Lam also under a duty to send the Chief Coroner a copy of your response. |
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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 i
or of interest. You may make representations to me, the coroner, at the time of your
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response, about the release or the publication of your response by the Chief Coroner.
@ | 19 day of November 2019 __ Mrs Heidi J. Connor
neg an ~~ Senior Coroner for Berkshire
Classification: OFFICTAL-SENSITIVE
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