Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0429, written 24 Dec 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Dec 2021 |
|---|---|
| Reference | 2021-0429 |
| Deceased | Gregory Barber |
| Coroner | John Hobson |
| Coroner area | West Yorkshire (Eastern) |
| Category | Railway related deaths · Suicide (from 2015) · Mental Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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 FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
, Area Customer Service and Performance Manager, Network Rail.
1 CORONER
I am John Hobson, an Assistant Coroner for the coroner area of West Yorkshire
(Eastern).
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 23 April 2021 an investigation was commenced into the death of Mr Gregory James
Barber, aged 34. An inquest was opened on 29 April 2021 and the investigation
completed at the conclusion of the inquest on 13 December 2021. The medical cause of
death established at the inquest was that Mr Barber died from severe head injuries
secondary to blunt force impact.
A conclusion of suicide was recorded.
4 CIRCUMSTANCES OF THE DEATH
On 12 April 2021, Gregory James Barber, who had a history of mental health difficulties
and suicidal ideation, died as a result of
, having lain
.
Paramedics attended but his death was confirmed at 1717hours. On appraisal and
consideration of the evidence at the inquest on the relevant standard of proof, a
conclusion of suicide was recorded.
During the course of the inquest I heard witness evidence presented in relation to an
investigation undertaken by the British Transport Police.
A section of a document entitled ‘Post Incident Site Report [PISV] – Lineside’ [ref:
DOCU-2021-0590] contained a section entitled: ‘Considerations which could help to
prevent f urther similar incidents/Agreed actions’ [p7 of 9].
Any such matters are set out in a table set down on a pro forma. The f irst column
identifies a ‘Problem’, the second column is entitled ‘Mitigation Measure’. A third column
ref ers to ‘Owner(s)’.
The completed columns read as follows:
Problem: ‘
is not easy and fencing is for the most
part adequate. The Google image and photograph above show there is a
.’
1
Mitigation Measure: ‘Additional fencing along the stone parapet run up to the
indicated on the google image above. There needs to be an inner line of
f encing behind the stone parapet which is far enough away from the parapet
to mean that the stonework cannot be used to climb over the fencing.
as
Owner(s): Network Rail.
Whilst it was noted that no ‘quick time intervention/rectification was required at the
location’, the report goes on to state that:
‘To support the Coroner Inquest process we respectfully request that
stakeholders submit a response to the considerations detailed in the report
and any other activity planned for the location using the available section below
within 60 working days from the date of the incident’.
At the date of the inquest, the section of the report entitled ‘Considerations response’ had
not been completed by Network Rail and returned to the British Transport Police. Upon
f urther investigation at the inquest, it was confirmed that the report was sent to Network
Rail on 7 May 2021.
The ‘Problem’ identified by BTP followed an appraisal of the scene, with the ‘weak spot’
identified as being ‘…the most likely access point and would benefit from improved
f encing’ [pp6/7 of 9].
5 CORONER’S CONCERNS
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 matter of concern is as follows:
The BTP investigation identified a clear problem and recommended a mitigation measure
to which there has been no meaningful response, or at all, from Network Rail within the
terms of the specific request to so respond within 60 days of the incident.
On the evidence that I heard at the inquest, it would appear that the weakness identified
by the British Transport Police remains as it was at the time of their investigation and I am
concerned that access to the railways tracks is not sufficiently curtailed at the location
identified, as recommended.
I am under a duty to report this matter upon consideration of the evidence.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe your
organisation has 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 18 February 2022. I, John Hobson, 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, to the family who were an Interested
Party at the inquest and to British Transport Police.
2
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
f orm. 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
24 December 2021
John Hobson (Assistant Coroner)
3
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.
OFFICIAL John Hobson HM Assistant Coroner for West Yorkshire (Eastern) HM Coroners Office 7 March 2022 Re: Regulation 28 Report – Gregory James Barber Dear Sir, I refer to your report dated 24th December 2021 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 Barber. 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. Your report references a post incident site report undertaken by the British Transport Police (BTP) (the PISR). Network Rail works closely with the BTP following fatal accidents on the railway and participates in a post-incident site visit. The PISR is authored by the BTP. The PISR refers to Mr Barber’s most likely access point as being over the parapet wall at the end of Wyther Lane. However, on the evening of the incident on 12 April 2021, Network Rail representatives attended the area of Kirkstall Lineside near Bridge Road, Leeds along with the BTP to undertake a post-incident site visit. During this visit, the BTP and Network Rail carried out an immediate inspection of the area and our records show that Mr Barber’s access point was agreed to have been at a Network Rail access gate further down the track towards Kirkstall Forge Station. Mr Barber’s personal possessions were found by BTP at this location. In addition, on consideration of the PISR, Network Rail did not consider that the parapet wall was a trespass risk for the reasons explained below. 1. The parapet wall is 1.35m high and is immediately followed by a very steep embankment down to the railway, meaning it is not an easy point of access. 2. There is heavy vegetation behind the parapet wall which also serves to deter trespass and with no sign of access having been attempted or made through the vegetation. 3. Previous data held by Network Rail does not identify this location as a hot spot for trespass. 4. The area meets Network Rail’s current standards for fencing and boundaries. Despite these findings, Network Rail is committed to maintaining a safe railway and to reducing opportunity for members of the public to harm themselves on or near the railway. As such, following further engagement with the BTP in December 2021 in relation to this incident, Network Rail remitted works at this location to address the concern raised in the BTP PISR (and since raised in your Regulation 28 report). Specifically, Network Rail is procuring the installation of 8 metres of 2.4m palisade fencing behind the wall (before the land begins to slope downwards), together with specially fabricated palisade fencing closing off the gaps at either end of the new fence. This will further deter potential access over the parapet wall and down to the railway. 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 Subject to delivery of materials, work is due to commence during the week commencing 7 March 2022 and we expect it will be completed within two weeks. 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, North & East 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
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