Prevention of Future Deaths reports · 2020

Clive Oxley

Regulation 28 report to prevent future deaths, reference 2020-0301, written 23 Dec 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report23 Dec 2020
Reference2020-0301
DeceasedClive Oxley
CoronerOliver Longstaff
Coroner areaCounty Durham and Darlington
CategoryRailway related deaths
Sourcejudiciary.uk record · original PDF
Responses published2

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

Regulation 28: REPORT TO PREVENT FUTURE DEATHS

REGULATION 28 REPORT TO PREVENT DEATHS

THIS REPORT IS BEING SENT TO:

LNER

1
2 Network Rail

1 CORONER

I am Oliver LONGSTAFF, Assistant Coroner for the area of County Durham and Darlington

2 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.

3 INVESTIGATION and INQUEST

On Second April 2020 I commenced an investigation into the death of Clive OXLEY aged 62. The
investigation concluded at the end of the inquest on Twenty-Third December 2020. The conclusion
of the inquest was Suicide:

I a Multiple Traumatic Injuries

I b

I c

II

4 CIRCUMSTANCES OF THE DEATH

The deceased was tracked by CCTV at and around Durham railway station as entering the station
via the main entrance on the southbound side, walking towards the viaduct along the southbound
platform, passing the barrier to pedestrians at the end of the platform, and getting onto the track.
He then scaled the viaduct parapet at a point where there is a gap between two lengths of a wire
fence which increases the height of the parapet along the short length of the parapet over which it
has been installed. The deceased then jumped from the viaduct onto North Road below.

5 CORONER’S CONCERNS

The MATTERS OF CONCERN are as follows: (brief summary of matters of concern)

1)

It is accepted that the barrier to pedestrian traffic between the southbound platform
and the viaduct makes it clear that pedestrians should not access the viaduct from
the platform (as does the automatic voice alert which is activated as the barrier is
passed). However, I am concerned that the barrier itself is not of a construction
adequate to prevent a determined pedestrian such as the deceased from
accessing the track at that particular point.

2) The impression of officers from the British Transport Police and Durham CID who
gave evidence is that the wire fence that extends the height of the viaduct parapet
wall runs along only a short length of the wall, and that there are in any event gaps
between the sections of that fence, the deceased gaining access to the parapet

 wall through one such gap.

3) Evidence was given at the inquest into two similar events (one in 2018, one in

around 2012) which resulted in the death of one individual and the sustaining of
catastrophic injuries by another.     

6 ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and I believe you (and/or 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 17 February 2021.

I, 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

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

who may find it useful or of interest.

I 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

Oliver LONGSTAFF
Assistant Coroner for
County Durham and Darlington
Dated: 23 December 2020

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 Lner (PDF)
Dear Sir, 

LNER work collaboratively with Network Rail to reduce the number of trespass and fatality incidents 
along the LNER line of route, though in practical terms, LNER operate Durham Station under a long-
term lease and are generally responsible for the day to day management of the Station. Platform end 
fencing and general boundary fencing in place to prevent unauthorised access to the track and other 
infrastructure is generally the responsibility of Network Rail.  

In  order  to  make  suicide  and  trespass  as  difficult  as  possible,  platform  end  gates  and  fencing  is 
provided,  and  prioritised  at  locations  deemed  higher  risk  to  prevent  access  to  the  line  wherever 
possible. With specific regards to Durham, this is supported by signage promoting services offered by 
the Samaritans and the warning system that is in place at the Station. In addition, LNER have trained 
a  significant  number  of  staff  in  suicide  risk  who  are  given  guidance  and  training  in  dealing  with 
vulnerable people when they are seen on the rail network.   

In respect of the platform end fencing, it should be noted that there is a requirement for maintaining 
adequate clearance between rail vehicle and adjacent structures. The amount of clearance between 
trackside infrastructure, such as fencing, and the rolling stock is determined in line with rail industry 
standards and can be affected by such as the track curvature, line speed, and those factors are used 
to determine the ‘swept envelope’ of the various types of rolling stock and the minimum  clearance 
required, so in respect of the platform end fencing, it would not be considered safe nor feasible to 
have fencing that extended to the platform edge. The ‘gap’ between the fencing on the platform and 
the platform edge is however, additionally protected by anti-trespass underfoot mitigation which is 
consistent with that in place at other Stations on the UK rail network. 

LNER have made contact with Network Rail with a view to arranging a joint site visit in order to seek 
assurance that the fencing meets the requirements of the rail industry standards. 

I hope that helps to clarify Point 1 in Section 5, and will provide an update once the site meeting has 
been arranged with Network Rail, and if you require clarification from LNER in respect of the Station 
management or operations please don’t hesitate to contact me. 

Regards 

  Security & Emergency Planning Manager

LNER  East Coast House, 25 Skeldergate, York, YO1 6DH

@353LN ER244#
Response from Network Rail (PDF)
OFFICIAL 

Oliver Longstaff  
HM Assistant Coroner for County Durham and Darlington 
HM Coroners Office 

By email only to:

Your ref: 

Re: Regulation 28 Report - Clive Oxley 

Dear Sir,  

5 March 2021 

I refer to your report dated 24th December 2020 made under paragraph 7, schedule 5, of the 
Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) 
Regulations 2013.   

I would like to take this opportunity to express my sincere condolences to the family of Mr Oxley. 
Please be assured that we take all incidents of this nature on the railway incredibly seriously and 
have carefully considered the matters raised in your report.  

Platform barrier at southbound platform 

Durham station overall and, as noted in your report, the viaduct at the station (particularly on the 
southbound track) has attracted a number of attempts by members of the public to harm 
themselves or sadly end their lives, including Mr Oxley. As a result, and to reduce the potential 
for these events, my team has extensively reviewed the possible intervention measures at this 
location. 

As part of that exercise, in December 2019, we undertook significant alteration to the end of the 
southbound platform to deter pedestrian access and to obscure the view of the viaduct from the 
platform. This was done by removing the sloped nose of the platform and installing a lockable 
gate and robust fence at the platform end. The fence itself is 1.8 metres high with a coarse infill to 
limit any view of the viaduct from the platform. The platform end also has an audible warning 
system, signage making clear that pedestrians are prohibited from passing the end of the 
platform and Samaritans signage. Anti-trespass flooring was also installed either side of the 
fencing the full width of the platform to further discourage pedestrians from passing the fence. 
Photographs showing the original platform arrangement and the works completed in December 
2019 are included in Appendix 1 to this letter. 

Decisions in relation to the location and design of these measures took into account Network 
Rail’s relevant mandatory standards. Standards prohibit fencing to be constructed the full width of 
the platform due to gauging requirements (i.e. the need to consider the potential for a train to 
come into contact with the fence when passing the platform). The fence has been placed as far 
along the platform as standards allow. Consideration was also given to a derogation from 
standards but it was recognised that a determined individual could in any event access the track 
by climbing down from the platform edge. 

Works are currently ongoing to install similar closed fencing and anti-trespass flooring to the 
northbound platform end (although the sloping nose of the platform is not being removed at that 
location due to the proximity of signalling and telecommunications equipment). 

Network Rail Infrastructure Limited Registered Office: Network Rail, One Eversholt Street, London, NW1 2DN Registered in England and Wales No. 2904587 www.networkrail.co.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 OFFICIAL 

Anti-trespass flooring 

In addition to the measures referred to above, immediately following the death of Mr Oxley, we 
installed 80 metres of anti-trespass flooring to both sides of the viaduct (i.e. northbound and 
southbound) to further prevent access to the structure. The works were completed in the week 
commencing 12 April 2020. The flooring is intended to act as both a physical and a visual 
deterrent to accessing the parapets. A photograph showing this is also included at Appendix 1. 

Parapet fencing 

Significant parapet fencing has previously been trialled at this location. However, the viaduct has 
Grade II listed status, which introduces constraints in this respect. Our mandatory fencing 
standard was therefore applied. Following receipt of your report we are liaising with relevant 
stakeholders and appropriate planning authorities to consider whether additional measures can 
be taken over and above what is required in the fencing standard. Specifically, we are 
considering whether a wire mesh fence can be installed along the parapet to restrict individuals 
from climbing over the existing structure. This is something that we have done at other Grade II 
listed structures. In the meantime, the fencing at the viaduct is compliant with and will continue to 
be maintained as required by our mandatory fencing standard. 

Further suicide prevention work 

Network Rail and the British Transport Police (BTP), together with Train Operating Companies, 
are committed to preventing suicide on the railway and are working together to actively try to 
reduce suicide attempts across the East Coast Route and specifically at Durham. 

Following successful trials, Network Rail implemented Samaritans-trained patrollers for suicide 
prevention at Durham and this has been in operation since October 2018. In October 2019, we 
increased the patrolling presence. These patrollers are present at the station 5 days per week for 
12 hours per day (based on an assessment of suicide attempts determining deployment times 
and days for maximum impact). This has sometimes been increased on a temporary basis to 16 
hours a day where risk assessments have shown an increase in incidents or risk prior to the 
normal shift pattern. Since April 2020, these teams have made four lifesaving interventions at 
Durham station.  

In addition to these patrols, we also fund a team of BTP dedicated officers who provide extra 
focus north of York on the East Coast Main Line (including Durham station). This is headed by a 
dedicated Network Rail funded BTP Embedded Inspector who works with our own suicide 
prevention lead to identify risks and provide plans for deployment of resources and liaison with 
local authorities and charities. We are also supporting LNER (who operates Durham station) to 
assess the potential for camera systems which may help to detect suicidal individuals moving into 
positions where they may harm themselves.   

I hope that this response answers your concerns but if I can be of any further assistance, or if you 
would like further clarification, please do not hesitate to contact me. 

Yours sincerely,  

Route Director, East Coast Route 

Network Rail Infrastructure Limited Registered Office: Network Rail, One Eversholt Street, London, NW1 2DN Registered in England and Wales No. 2904587 www.networkrail.co.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 OFFICIAL 

Appendix 1 

Southbound platform end – original arrangement 

Southbound platform end – current arrangement (since December 2019) 

Anti-trespass flooring viaduct installation 

Network Rail Infrastructure Limited Registered Office: Network Rail, One Eversholt Street, London, NW1 2DN Registered in England and Wales No. 2904587 www.networkrail.co.uk

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