Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0196, written 23 Jun 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 Jun 2022 |
|---|---|
| Reference | 2022-0196 |
| Deceased | Alun Davies |
| Coroner | Christopher Wilkinson |
| Coroner area | Hampshire, Portsmouth and Southampton |
| Category | Mental Health related deaths · Suicide (from 2015) · 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: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. South Western Railway 2. Mr Davies’ family 3. CORONER – BTP Fatal Investigations Officer 1 I am Christopher Wilkinson, senior coroner for the coroner 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 5 May 2021 I commenced an investigation into the death of Alun John Davies, aged 50 years. The investigation concluded at the end of the inquest on 1 June 2022. The conclusion of the inquest was that Mr Davies had died as a result of extensive injuries consistent with being struck by a train and that he had taken his own life whilst suffering from acute anxiety and chronic depression. 4 CIRCUMSTANCES OF THE DEATH The Deceased died instantly when he jumped from the platform at Portchester railway station into the path a non-stopping train at 18.47 on 4 May 2021. The events were captured on the forward-facing CCTV camera in the cab of the train when, on approaching the station, at 18.47 he is seen at the end of the platform, closest to the oncoming train on the left-hand side to squat and then jump onto the tracks before placing himself into a position to lie on the tracks before the oncoming train. No CCTV from the station or platform was available. He was known to have left his nearby hotel at 17.17 that evening (where he was seen leaving on CCTV) and to have walked to the nearby station of Portchester. before the incident occurred. . It is believed that he had been at the station for some time The evidence established that at the time of his death he was suffering acute and heightened anxiety following a recent arrest and release on bail and a marriage breakup. He had been suffering chronic anxiety and depression related to concerns about his health, his career and family relationships. Previous use of a hair loss product, may have contributed to his lower mood, decline in his mental health and suicidal ideation. He had not disclosed the full extent of his mental health difficulties to family or professionals nor had he sought professional support. 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 could 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 post-incident site report presented by British Transport Police (in conjunction with the Design Out Crime Unit) and completed on 22 July 2021 identified that there was (and remains) limited staffing and CCTV surveillance at Portchester Railway Station and limited visibility of the platforms - requiring a security risk assessment with a view to increasing staffing (at the ticket office and on the platform) with increased RCO Patrols and platform surveillance and that additional CCTV installation and coverage was required (of the platforms and public areas) with real time capability. (2) The post-incident site report further identified that Portchester Railway station is an impending ‘escalated’ location. Since 2017 there have been 2 previous fatalities in similar circumstances at the station – which is now recognised as having lower levels of surveillance – with Mr Davies’ death being the third. Although recommendations were made after the first incident, the above recommendations and identified risks (at 1) have not yet been (fully) addressed or implemented. (3) The post-incident site report further identified the lack of public security and welfare announcements at the station (and within the station concourse) aimed at providing direction in the event of illness or of assistance being required. There is a lack of information/announcements to other members of the public as to how to obtain assistance if they are concerned by someone else’s condition or actions. It is not clear to what extent this has been further considered or addressed. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you as an 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 Friday 9 September 2022. I, the coroner, may extend the period if required. 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: 1. Mr Davies’ family. 2. British Transport Police. 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 23 June 2022 Christopher Wilkinson
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.
South Western Railway South Bank Central 4th Floor 30 Stamford Street London SE1 9LQ Strictly Private and Confidential For the attention of Christopher Wilkinson Senior Coroner for Hampshire, Portsmouth and Southampton Coroners Dear Mr Wilkinson Regulation 28 Report: Alun John Davies 1 2 We refer to your Regulation 28 report dated 23 June 2022 (the “Report”) regarding the death of Alun John Davies (“Mr Davies”) on railway tracks at Portchester station on 4 May 2021. SWR would like to take this opportunity to express its sincere condolences to Mr Davies’ family and friends. Background 3 4 5 6 7 8 9 We understand from the Report that you are concerned that there is a risk of future deaths occurring unless action is taken. You have set out in your Report three areas of concern from the post-incident site report prepared by the British Transport Police: (a) (b) (c) Staffing levels and CCTV; Previous incidents at Portchester Station; and Security and welfare announcements. SWR has considered these areas of concern and sets out its response to each of them below. Response to Paragraph 1: Staffing Levels: Ticket Office, Platform and RCO Patrols All train stations are different. This means that there are different requirements for staffing arrangements. (a) Ticket Office At Portchester Station, there is a member of staff present in the ticket office during commuter times (Monday to Friday 05:50 to 10:40 and Saturday 07:50 to 14:20). However, outside of these hours there are no staff present in the ticket office. SWR has considered whether the circumstances of the incident impacts upon the need to increase ticket office staffing levels. We have concluded that there is no requirement to make adjustments to increase the number of ticket staff. (b) Platform Staff SWR conducts ‘platform/train interface assessments’ which informs decisions on staffing arrangements at platforms. For example, at some stations there may be a high frequency of trains stopping at the station, a high footfall of passengers and/or special events (such as at Twickenham station on match days) which may require platform staff to be present. 10 There are no platform staff at Portchester station. This is for a number of reasons including: (i) There are a limited number of trains which stop at the station; South Western Railway South Bank Central 4th Floor 30 Stamford Street London SE1 9LQ (ii) It is not a station where passengers make connections from one route to another; (iii) (iv) It is not a station which becomes congested with passengers and is considered to have low footfall; and The platforms are essentially straight providing good visibility along the length of the platform. 11 SWR has considered this assessment for Portchester in light of this incident and has concluded that there is no requirement to make adjustments to introduce a requirement for platform staff. 12 13 14 15 16 17 18 19 20 (c) Railway Community Officer patrols SWR undertakes an assessment to allocate the frequency of RCO Patrols. There are a number of factors which are taken into consideration during this assessment including anti-social behaviour incidents, reported criminal activity and fatalities/attempted fatalities. The assessment for Porchester was carried out post incident on 13 January 2022. The output of this is that the station was categorised as a ‘green’ station and therefore considered to be of low risk. Consequently RCO patrols are not required on a regular, pre-determined basis. Response to paragraph 1: CCTV The purpose of CCTV at train stations is largely twofold: first, to try to deter criminal activity, and secondly to provide a record of any incidents that occur, which can be used in the course of any investigation. Given the number of CCTV cameras across the whole of the SWR network, it would not be practicable to have staff monitoring every camera 24 hours a day, and so the CCTV system cannot be used proactively to try to prevent criminal activity or other incidents. CCTV footage from stations across the SWR network can also be viewed from the security desk based in the Regional Operation Centre (“ROC”) which is manned 24/7. This security desk has access to all CCTV cameras across the SWR network covering approximately 210 stations which each have multiple cameras per station. The security desk has the ability to view the feed from any camera, for example in response to a reported incident, but again it is not possible to monitor the footage from all cameras across the SWR network in real time. At Portchester station, there are 6 static CCTV Cameras which cover the following areas: main area of Platform 2, main building area on Platform 1, the top of the stairs at Platform 1, the ticket office, the Portsmouth end of Platform 2 and the help point on Platform 1. The cameras are on the Nucleus analogue system resulting in good quality video footage. For the reasons explained above, the footage is not actively monitored by staff in the ROC but can be made available immediately if required, for example, if staff are notified of an on-going emergency situation. Response to Paragraph 2: Previous incidents SWR has considered the recommendations arising from the previous Designing Out Crime Unit Report. For the reasons set out above, SWR has not increased staffing levels at Portchester Station nor introduced 24/7 CCTV surveillance. However, at Portchester Station there are a number of preventative measures in place to deter unauthorised access to the railway tracks which were put in place through 2020 and 2021 including: South Western Railway South Bank Central 4th Floor 30 Stamford Street London SE1 9LQ (a) (b) (c) trespass gates being fitted to the end of the platforms 1 and 2; witches hats being fitted to the end of platforms 1 and 2; and anti-tread guards being installed. SWR is also currently in discussions with Network Rail to review of the status of Porchester station in relation to the management of suicide risks. Response to Paragraph 3: Security and Welfare Announcements The following types of security and welfare announcements are made at Portchester Station: (a) (b) (c) Fast train approaching; See it, say it, sort it; and Text contact details for Samaritans. These announcements are made on an automated rolling basis. At the station, there are also help points, emergency buttons and Samaritan posters. SWR therefore considers that there are appropriate security and welfare announcements in place. We trust that the above is of assistance but if you require any further information, please do not hesitate to contact us. 21 22 23 24 25 Yours sincerely Head of Crime and Security
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