Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0150, written 19 May 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 May 2022 |
|---|---|
| Reference | 2022-0150 |
| Deceased | Hassan Zubair |
| Coroner | Graeme Irvine |
| Coroner area | East London |
| Category | Railway 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: Prevention of Future Deaths report Hassan Zubair (died 2nd December 2021) THIS REPORT IS BEING SENT TO: 1. Chief Executive Network Rail One Eversholt Street, London, NW1 2DN 1 CORONER I am: Acting Senior Coroner Graeme Irvine The Coroner's Court 127 Ripple Road Barking IG11 7PB 2 CORONER’S LEGAL POWERS I make this report under the Coroners and Justice Act 2009, paragraph 7, Schedule 5, and The Coroners (Investigations) Regulations 2013, regulations 28 and 29. 3 INVESTIGATION and INQUEST On 3rd December 2021, this court commenced an investigation into the death of Hassan Zubair, The investigation concluded at the end of the inquest on 11th May 2022. I arrived at a narrative conclusion, “Mr Hassan Zubair was declared deceased at 14.06 on 2nd December 2021 at Goodmayes Railway station after he was . Mr Zubair deliberately at the station but it has not been possible to determine his intentions at the time.” The medical cause of death was: 1.a. Multiple injuries 2. Alcohol Intoxication CIRCUMSTANCES OF THE DEATH Goodmayes station consists of four platforms, 1-4. The station is oriented east to west, Platform 1 situated to the south, Platform 4 to the north and platforms 2 & 3 occupying a central island between the lines. At 13:40 on 2 December 2021, Network Rail was made aware of a concern for welfare by a report from the driver of train 2W34 staionary at Platform 4, who reported seeing a member of the public on Platform 3 of Goodmayes station with no shoes on, carrying a blanket. That person was later identified as Hassan Zubair. The call resulted in two actions; 1. At 13:43, the Signaller advised the driver of train 2W59 (the next train due into Goodmayes station on the Up Electric line on Platform 3) to approach at caution because of a concern for welfare. 2. The operator of Goodmayes station was contacted to alert staff at the station and the local security team of the concern. Moments later, Mr Zubair was struck at 13:45 by the 13:33 London Liverpool Street to Southend Victoria, train 1K50 on the Down Main line ( ). Critically, this train had received no warning to approach with caution and accordingly was travelling at a speed estimated to be between 80-85 mph. Mr Zubair was killed instantly. 5 CORONER’S CONCERNS During the course of the inquest, the evidence revealed matters giving rise to concern. 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 MATTERS OF CONCERN are as follows. 1. The failure of the signals controller to advise trains travelling through to proceed with caution. 6 ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and I believe that 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 15th July 2022 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 following. The Zubair family. The Rt Hon Grant Shapps MP, Secretary of State for Transport Department for Transport Great Minster House 33 Horseferry Road London SW1P 4DR United Kingdom 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 DATE 19th May 2022 SIGNED BY ACTING SENIOR CORONER GRAEME IRVINE
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 One Stratford Place Montfitchet Road London E20 1EJ Acting Senior Coroner Mr Graeme Irvine The Coroner's Court 127 Ripple Road Barking IG11 7PB 12 July 2022 Reference: Regulation 28 Report – Hassan Zubair Dear Senior Coroner Irvine Regulation 28 Report – Hassan Zubair I refer to your report dated 19 May 2022 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 Hassan Zubair on behalf of Network Rail. I hope from Network Rail's participation in the Inquest into Mr Zubair's death that you are aware that we take all incidents of this nature on the railway incredibly seriously. I have carefully considered the concern raised in your report in respect of the signaller not advising trains travelling through both Platforms 2 and 3 to proceed with caution. As was explained during the Inquest into Mr Zubair's death, when the concern for welfare report was made by a train driver, Mr Zubair was stood on on a publicly accessible platform, physically Platform 3 of separated from Platform 2 (which I address below). I understand that from the CCTV footage Mr Zubair was seen walking in the opposite direction from the end of Platform 3 towards the station exit. As a precautionary measure based upon the information provided to the Signaller and on their detailed knowledge of the station and its layout, a caution was put in place on the line interfacing with Platform 3 where Mr Zubair had been observed. In addition to the caution, timely calls were placed by Network Rail to the train operating company staff, MTR, to immediately check on the welfare of Mr Zubair. Network Rail Infrastructure Limited Registered Office: Network Rail, 2nd Floor, One Eversholt Street, London, NW1 2DN Registered in England and Wales No. 2904587 www.networkrail.co.uk OFFICIAL In terms of the layout of the station and its infrastructure, although Platforms 3 and 2 are back to back, there are a significant number of measures in place to deter members of the public from accessing Platform 2, which services non-stopping trains and is not generally accessible by the general public. Most significantly, a metal fence physically separates Platforms 3 and 2 to deter access by the public to Platform 2. The fencing mitigated the need to caution trains on Platform 2 because it is designed to prevent people from crossing from Platform 3 to Platform 2. Therefore, it was reasonable for the Signaller to caution the trains on Platform 3 only. In addition, other mitigation measures are in place to deter and/or prevent access by members of the public and these include: 1. 2. 3. 4. 5. 6. 7. White and yellow lines indicating the edge of the platform and the 'keep clear' area respectively; Electronic help points; Platform end barriers; Signs warning against trespass; Anti-trespass panels on the ground; Samaritans signs in situ; and Patrol by nine mobile security teams which specialise in reducing antisocial behaviour and suicide prevention that operate on a 24/7-hour basis. If Mr Zubair had been seen trying to access the track on platform 2, trains which would proceed over the affected portion of the line would have been cautioned or stopped in accordance with the procedure Network Rail must follow under section 18.1 of the Rail Safety and Standards Board GERT8000 Rule Book (Rule Book). A copy of section 18.1 of the Rule Book is at Annex 1. As Mr Zubair was seen heading towards the exit and we already had a number of mitigation measures in place regarding platform 2 (including, in particular, a fence physically preventing access from platform 3 to platform 2) a stop or caution was not considered for this line. We receive many calls reporting concerns in relation to the welfare of users each day and takes many measures to ensure the safety of all individuals using the railway. We are also responsible for maintaining the operation of the railway network and the safe passage of trains and passengers across the network. Signallers play a huge role on this. In response to any welfare report, Signallers will make a decision as to the most appropriate action to take based on the nature of the information reported and their detailed knowledge of the infrastructure and the location. This is done in OFFICIAL accordance with the Rule Book, which purposely provides a degree of flexibility to ensure that Signallers are empowered to make appropriate decisions based on all factors within their knowledge. Following this tragic incident, Network Rail did take action and enhanced the reporting system between Network Rail and MTR for Signallers to contact the station directly. This allows station staff to provide rapid assistance to individuals in these types of situations. Workshops have also been undertaken to train relevant staff. Network Rail takes its safety obligations incredibly seriously and we are committed to reducing opportunity for members of the public to come to harm on or near the railway. I hope that this response answers your concerns but if I can be of any further assistance please do not hesitate to contact me. Yours sincerely Route Director,
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