Prevention of Future Deaths reports · 2021

Callum Evans

Regulation 28 report to prevent future deaths, reference 2021-0159, written 18 May 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report18 May 2021
Reference2021-0159
DeceasedCallum Evans
CoronerJason Pegg
Coroner areaHampshire, Portsmouth and Southampton
CategoryRailway related deaths · Alcohol, drug and medication related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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

Regulation 28: REPORT TO PREVENT FUTURE DEATHS (1)

NOTE: This from is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT DEATHS

THIS REPORT IS BEING SENT TO:

1. Managing Director Network Rail (Wessex)

1 CORONER

I am Jason PEGG, Area Coroner for the area of Hampshire, Portsmouth and Southampton

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 22nd September 2020 I commenced an investigation into the death of Callum Rhys EVANS
aged 17. The investigation concluded at the end of the inquest on 18th May 2021. The conclusion
of the inquest was: Accident

4 CIRCUMSTANCES OF THE DEATH
The deceased died on 15th September 2020 at Hinton Admiral Railway Station, Hampshire. The
deceased was on the railway tracks when he fell onto the live rail in consequence of which the
deceased was electrocuted. The deceased was intoxicated with alcohol which contributed to the
death.

5 CORONER’S CONCERNS

The MATTERS OF CONCERNS are as follows:

A friend in the company of the deceased at the railway station indicated a lack of knowledge of the
presence of a live electrified (third) rail at the railway station and stated that if it had been known
that there was a live rail they would not have gone onto the railway tracks.

The deceased and his friends had gone onto the railway tracks by dropping down from the central
part of the platform.

The railway station has an absence of signage stating the presence and risk to life of a live rail on
the railway tracks which can be seen by those entering the railway station or whilst on the central
part of the platform. The only sign referring to the live rail is at the far sloped end of the platform,
some distance from the station entrance and central part of the platform, which states “Do not
touch live rail”.

There is signage stating “No trespassing” but nothing effectively communicating the presence of a
live rail or the risk to life from that live rail.

6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you 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 13 July 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:
The parents of Callum EVANS

I have also sent it to:
interest.

(DOCU) British Transport Police who may find it useful or of

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

Jason PEGG
Area Coroner for
Hampshire, Portsmouth and Southampton
Dated: 18 May 2021

Responses

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.

Response from Network Rail (PDF)
~ 

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/2, 07.  1- 0  .:Lf 

OFFICIAL 

NetworkRail 

Mr Jason Pegg 
Area Coroner for Hampshire, Portsmouth 
and Southampton 
Coroner's Office 
Castle Hill 
The Castle 
Winchester 
S023 SUL 

9 July 2021 

Dear Mr Pegg 

Network Rail 
Basingstoke Campus 
Gresley Road 
Basingstoke 
Hampshire
RG21  LiFS 

PRIVATE  & 

CO N F f n .....  ~ ··- ·  · , 

·

Regulation 28 report - Callum Rhys  Evans 

I write in relation to the above Inquest heard on  18th  May 2021  following the sad death of 
Callum Evans on 15th September 2020 at Hinton Admiral station. This was a tragic accident 
and our thoughts and deepest sympathies go out to Callum's family and friends. 

The Regulation  28 report dated 20th  May sets out your concern about the lack of signs at 
the station entrance or  central  part of the platform directly warning  of the fatality risk  if 
you touch the live rail. 

Before specifically addressing this concern,  I wish to assure you that Network Rail  and the 
wider rail  industry are constantly working hard to discourage and prevent people accessing 
the railway and to warn of the dangers this poses not just from the presence of live electrical 
eq uipment but also the trains themselves. 

Working  with  industry  partners  including  South  Western  Railway  (SWR)  and  British 
Transport  Police,  and  other  organisations  such  as  local  authorities  and  schools,  Network 
Rail's  campaigns warn  of the dangers and  target people at risk  and  high-risk areas where 
we  believe  there  is  an  increased  risk  that member/s  of the  public  may try to  access  the 
railway. 

These  campaigns,  across  the  Internet,  broadcast,  print  and  social  media,  have  made 
significant reductions in the number of incidents and evidence demonstrates the campaigns 
make more people aware of the dangers of the railway. 

There are also practical steps we can take, and our risk assessments identify the appropriate 
types of fences along the boundary of the 20,000 miles of railway in Great Britain. However, 
certain locations such as stations must by their very nature permit people to access trains. 

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

 OFFICIAL 

How the railway is managed 

The railway industry involves many companies who collaborate to operate safely. Network 
Rail owns and operates the rail infrastructure i.e. the track, signalling, bridges, level crossings 
etc. Other companies operate the trains and most stations. The  Rail  Safety and Standards 
Board (RSSB) coordinates standards that apply across the industry. 

South Western  Railway  is  responsible  for the station  at Hinton Admiral  under a franchise 
agreement. They are responsible for the signs at the station and applying standards set by 
the RSSB. 

Network  Rail  is  responsible  for  the  infrastructure  serving  the  station,  including  placing 
statutory  signs  warning  people  that  it  is  an  offence  to  access  the  infrastructure  and 
determining  whether  barriers  are  required  at  the  platform  ends.  Network  Rail  is  also 
responsible  for applying the relevant standards set by RSSB.  RSSB  has  by way of example 
produced a Rail  Industry Standard for Station Infrastructure RIS-7700-INS; Railway Group 
Standard  GI/RT7033  relevant  to  Lineside  Signs;  Rail  Industry  Standard  RIS-7016-INS 
Interface between Station Platforms, Track, Trains and Buffer Stops and many more which 
include the requirements for the specification and positioning of safety signs and platform 
safety features. 

Turning now to the specific concern: 

You  have stated that "the railway station has an absence of signage stating the presence, 
and risk  to life, of a live rail on  the railway tracks which  can  be seen  by those entering the 
railway station or whilst on the central part of the platform". 

Signage on the railway is set out in the industry standards. These state that we have a "do 
not trespass"  sign  at all  locations.  We  also  have signs  at the ends  of the platform, which 
were  in  place at Hinton Admiral, to prohibit unauthorised access and warn of the dangers, 
including  of  electrocution.  The  signs  displayed  at  the  station  warn  of  the  danger  of 
electrocution and comply with the Railway Group Standard GI/RT 7033. To avoid confusion 
at different locations, there is safety benefit in consistent and clear signs that meet British 
Standard ISO  386Li - 1.2011: 'Graphical symbols' and the Health and Safety (Safety Signs 
and  Signals)  Regulations  1996. Network  Rail's  own  company  standard  NR/L2/ELP/21131 
applies the industry and  national standards and  follows appropriate risk  assessments. The 
signs provided by Network Rail at Hinton Admiral remain compliant with those standards. 

The signs at the ends of the platform state that passengers must not go onto the track or 
cross  the line; a sign  giving the contact number for the Samaritans; and a graphic 'electric 
bolt'  sign  with  large words  stating "Danger do  not touch  the  live  rail".  Research  evidence 
highlights the benefit of clear and simple communication of risks  - extra words are  more 
likely to dilute the message impact. Adding additional words suggesting a "risk to life" may 
have  other  impacts  such  as  increasing  the  risk  to anyone  with  mental  health  issues  and 
suicidal  thoughts. As  a  national  and  world  leader  in  combatting  suicide  on  the  railway 
Network Rail works with other industry parties to consider its signage so that it reduces risk 
and  does  not have any  knock  on  effects on  those  who  are  struggling  with  mental  health 
issues. 

 OFFICIAL 

That said we do understand that awareness of our risks needs to be continually refreshed 
and needs to be a combination of hard mitigations, key messages and signage so we are 
now planning to trial under platform warning signage.  This will be at 10 locations across 
the Wessex region with Hinton Admiral being one of the trial locations, and will feature 
warning signs underneath the platform which will be visible to passengers standing on the 
opposite platform. 

In addition, we  target  areas  where we  know there is  a higher risk  of the public accessing 
the  infrastructure  with  additional  measures  to  help  further  deter  access,  such  as  the 
installation of platform end gates, yellow hatching warning lines and anti-trespass matting. 
Within the  Wessex  region  of Network Rail  we  are just completing  a  programme of works 
that sees these additional safety measures installed at the majority of our stations, Hinton 
Admiral already being one of them. 

I would also like to take this opportunity to highlight the work we do with schools and other 
organisations to raise  awareness  of the dangers of accessing  the railway,  including from 
electrification risks. 

Network Rail  works with schools and community partners such as the Scouts Association to 
educate  young  people  about  hidden  dangers  on  and  around  the  railway.  Our  schools' 
partner Learn Live has reached over ten million children in the past two years. 

Underpinning  all  this  work  is  our  social  media  campaign  branded  "YouVsTrain".  The 
material used  in  that campaign  and on  the YouVsTrain.co.uk website specifically features 
the dangers from electrification with three dramatic films reconstructing real events. Those 
films  have  been  seen  by  many  millions  of  people and  have  won  awards  for  effective 
community engagement. Other work with Fun  Kids Radio and a book featuring Thomas the 
Tank Engine target younger age groups. 

In two years this combination of activity has reduced overall trespass incidents by 20 % and 
incidents involving young people particularly by 30 % . 

I  hope  my  letter  addresses  the  concerns  raised  but  would  be  happy  to  provide  further 
information about our extensive work to prevent people accessing the railway and to warn 
of the dangers the railway environment poses if that would help. 

i :n:eire~ 

Y 

Head of Operations Network Rail Wessex 
On behalf of 

Route Director Network Rail  Wessex

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