Prevention of Future Deaths reports · 2020
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 report | 23 Dec 2020 |
|---|---|
| Reference | 2020-0301 |
| Deceased | Clive Oxley |
| Coroner | Oliver Longstaff |
| Coroner area | County Durham and Darlington |
| Category | Railway related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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
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.
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#
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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