Prevention of Future Deaths reports · 2023

Gordon Rodger

Regulation 28 report to prevent future deaths, reference 2023-0292, written 24 Aug 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report24 Aug 2023
Reference2023-0292
DeceasedGordon Rodger
CoronerRobert Cohen
Coroner areaCumbria
CategorySuicide (from 2015) · Railway 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.

Kally Cheema LLB | Senior Coroner | Cumbria 

   Fairfield, Station Road, Cockermouth, Cumbria CA13 9PT  

Tel: 0300 303 3180 | Email: hmcoroner@cumbria.gov.uk  

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

24 August 2023 

1 

2 

THIS REPORT IS BEING SENT TO:  Network Rail Infrastructure Limited 

CORONER 

I am Mr Robert Cohen HM Assistant Coroner for Cumbria 

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. 

http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 

http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 

INVESTIGATION and INQUEST 

On 7 March 2023 I commenced an investigation into the death of Gordon Alexander 
John RODGER. The investigation concluded at the end of the inquest . The conclusion of 
the inquest was 

Suicide 

3 

1a   Multiple injuries consistent with being struck by a train 

1b    

1c    

 II 

 
 CIRCUMSTANCES OF THE DEATH 

On Thursday 02nd March 2023 at 0714hrs British Transport Police were made aware that 
the  driver  of  the  2C39  service  travelling  between Barrow  and  Carlisle  had  just  reportred 
seeing a human body in the Askam-in-Furness area of Cumbria.  

4 

The driver explained that he had earlier observed something in that area when travelling 
between  Millom  into  Barrow,  around  0625hrs,  but  had  been  unsure  what  this  was. 
Therefore, when travelling back through the Askam area he had decided to slow the train 
service  down  for  a  better  look.  On  inspection  he  noted  this  was  a  body  of  a  person.  

 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.  – 

5 

In the course of the inquest I heard that British Transport Police had recommended to Network 
Rail that they consider installing "anti trespass treads and gates to the north end of Platforms on 
Askam station if operationally possible".  

By a letter to the Court dated 5th June 2023 Network Rail indicated that they had decided not to 
take this step. They explained that Askam station is rural, that limited resources dictate which 
works are prioritised and that there is no history of trespass.  

In the course of the inquest the court heard that the line in this location is more accessible that 
might usually be expected, including by stiles in nearby fences associated with a nearby golf club. 

In the circumstances I am concerned that the line may be readily accessible to individuals who 
wish to harm themselves.  

ACTION SHOULD BE TAKEN 

6 

In my opinion action should be taken to prevent future deaths and I believe you Network 
Rail have the power to take such action. 
YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, 
namely by 19th October 2023. I, the coroner, may extend the period. 

7 

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. 
COPIES and PUBLICATION 

I have sent a copy of my report to the Chief Coroner and to the family of the deceased. 

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. 
24 August 2023 

8 

9 

Signature 

Robert Cohen HM Assistant Coroner for

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)
OFFICIAL 

Network Rail Infrastructure Limited 
Baskerville House, 1st Floor 
Centenary Square, Broad Street 
Birmingham 
B1 2ND 

Kally Cheema, Senior Coroner  
Cumbria Fairfield, Station Road,  
Cockermouth, Cumbria  
CA13 9PT  

10 April 2024 
[BY POST AND EMAIL] 

Dear Mr Cohen, 

Regulation  28  Report  to  Prevent  Future  Deaths  dated  24  August  2023  with  Case  Reference 
 concerning the death of Mr Gordon Alexander John Rodger on 2nd March 2023 in the 

Askam-in Furness area of Cumbria (the “Report”) 

I refer to your Report made under Paragraph 7 of 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 Rodger.  

I  would  also  like  to  apologise  for  the  delay  in  submitting  Network  Rail  Infrastructure  Limited’s 
(“Network Rail”) response, which, unfortunately, resulted from your Report being inadvertently sent 
to  an  incorrect  e-mail  address.  Network  Rail  receives  a  lot  of  correspondence  and  to  ensure  it  is 
routed to the proper recipient in good time please ensure requests for information from Network 
Rail are copied to the notices@networkrail.co.uk email address.   

Please  be  assured  that  Network  Rail  take  all  incidents  of  this  nature  on  the  railway  incredibly 
seriously  and  upon  being  made  aware  of  your  Report  we  have  carefully  considered  the  matters 
raised in it. 

Network Rail has a duty under the Railway Safety (Miscellaneous Provisions) Regulations 1997 to 
prevent unauthorised access to the railway line so far as is reasonably practicable (Regulation 3 – 
please see below).  

Your Report stated the following two matters of concern: 

1)  “In  the  course  of  the  inquest  I  heard  that  British  Transport  Police  had  recommended  to 
Network Rail that they consider installing "anti-trespass treads and gates to the north end 
of Platforms on Askam station if operationally possible". By a letter to the Court dated 5th 
June 2023 Network Rail indicated that they had decided not to take this step. They explained 
that Askam station is rural, that limited resources dictate which works are prioritised and 
that there is no history of trespass.” 

Network Rail Infrastructure Limited Registered Office: Waterloo General Office, London, United Kingdom, SE1 8SW Registered in England and Wales No. 02904587 www.networkrail.co.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 OFFICIAL 

2)  “In the course of the inquest the court heard that the line in this location is more accessible 
that might usually be expected, including by stiles in nearby fences associated with a nearby 
golf club. In the circumstances I am concerned that the line may be readily accessible  to 
individuals who wish to harm themselves.” 

Concern 1 

Platform end barriers and anti-trespass treads can provide an effective counter measure to prevent 
individuals easily accessing the running lines from platforms. Installing physical barriers at the end 
of a platform can lead to a change in the behaviour of an individual prior to them accessing the 
infrastructure. That said the face of the platform adjacent to the line will always be exposed to easy 
access in order to allow passengers to get on and off trains, and access to the infrastructure can also 
be gained from line crossings if an individual is determined to access the infrastructure. 

There is no Network Rail or railway industry standard or requirement to have platform end gates 
and matting at stations unless a new platform or station is being built.  

Network Rail takes its safety obligations seriously and we do take additional measures beyond those 
required by internal and rail industry Standards where possible, to install additional fencing and anti-
trespass matting when budget and resource allows.  

British Transport Police made a formal consideration concerning  the “installation of anti-trespass 
treads and gates if operationally possible” to the north end of platforms on Askam station. Network 
Rail responded to that consideration explaining  this consideration would “get added to the route 
crime and suicide prevention action tracker pending future budget, resource and priorities”. Network 
Rail  informed  the  Court  by  letter  dated  5th  June  2023  that  “[a]s  this  is  a  rural  station  with  no 
identified issues of reported trespass, there are no current plans to undertake the suggested work at 
this  location”.  These  works  however  remained  under  review  on  the  route  crime  and  suicide 
prevention action tracker. Network Rail’s funding is structured into five-year delivery periods. Control 
Period 6 ended at the end of March 2024 and CP7 started in April 2024. Utilising Control Period 7 
(known as CP7) funding Network Rail intends to install platform end gates and anti-trespass matting 
at locations in Cumbria identified as potentially requiring such installations by  post incident site 
visits, including Askam station.  

This is a proactive activity that is in addition to applicable internal and external standards. Askam 
station had already been identified by Network Rail prior to the Report being received by Network 
Rail and installation of platform end gates and matting at the north end of Askam station has been 
included in the CP7 work bank. We are aiming for completion of the whole work bank by 31st March 
2026.  This  timeframe  is  necessary  given  internal  processes  for  project  delivery  which  includes  a 
scoping and deliverability review, project estimate, authority paper and panel approval, engineering 
assurance  process  in  line  with  applicable  Network  Rail  Standard  NR/L2/CIV/003  followed  by 
implementation. We will aim to accelerate this process where reasonably practicable, based on the 
risk profile of this location, however it should be noted that the installation is part of a wider work 
bank that will be prioritised by risk profile which includes a mix of locations with varying risk profiles. 
We envisage a detailed delivery programme will be available by 30th September 2024 and we will 
aim to provide a further update in due course. 

 
 
 
 
 
 
 
 
 
 
 OFFICIAL 

Concern 2 

It is the nature of the Cumbrian Coast Line that traverses rugged coastal countryside that there are 
agricultural and public right of way crossing points. Along this section of this line there are three 
established and legitimate crossing points: 

1.  Johnsons  No.2  user  worked  crossing  requiring  telephone  permission  for  agricultural  use 

consisting of a seven-bar gate at the boundary; 

2.  Dunnerholne  golf  course  public  right  of  way  foot  crossing  consisting  of  a  stile  at  the 

boundary; and 

3.  Heybank public right of way foot crossing (adjacent to Dunnerholne golf course) consisting 

of wooden gate at the boundary. 

Detailed information around how Network Rail manages level crossing safety can be found at this 
website: www.networkrail.co.uk/communities/safety-in-the-community/level-crossing-safety 

In relation to the concern raised in your Report we instructed the Network Rail Delivery Maintenance 
Unit  for  the  Askam  area  to  undertake  a  full  boundary  inspection  to  verify  the  integrity  of  the 
boundary from Askam station to Heybank footpath crossing (between the points marked on the 
map extract below) being a distance of 1,430 yards including the boundary on both sides of the 
tracks. 

Network  Rail  Standard  reference  NR/L2/OTK/5100  on  the  Management  of  Fencing  &  Other 
Boundary  Measures,  has been  created  to ensure Network  Rail  complies with  its  legal  obligations 
regarding fencing and boundaries, including its obligation under Regulation 3 of the Railway Safety 
(Miscellaneous Provisions) Regulations 1997 to, so far as is reasonably practicable, where and to the 
extent necessary for safety, prevent unauthorised access to rail infrastructure. 

 
 
 
 
 
 
 
 
 
 
 
 
 OFFICIAL 

Fencing in the Askam station area was last inspected in June 2023 in accordance with Network Rail 
Standard reference NR/L2/OTK/5100.  Under this Standard Network Rail undertakes inspections and 
remediation works identified as necessary are carried out following such inspections.  

The Boundary Inspector’s report provided this month has found that all boundary fencing is in good 
condition  and  there  is  no  evidence  of  trespass,  or  damage  to  the  boundary  fencing.  This  recent 
inspection undertaken w/c 11 March 2024 confirms that the fencing is in the same condition as the 
last inspection undertaken as per the NR/L2/OTK/5100 Standard in June 2023. 

These inspections confirm that the majority of fencing along this section of line is a class 3 boundary 
(see below for boundary classification type details) that is consistent with the predominant adjacent 
land use in this area that is agricultural/livestock/woodland. There is a small section to both sides 
having  a  class  1  boundary  (see  below  for  boundary  classification  type  details)  where  there  is 
industrial use (on the one side) and where there is a road at Askham station level crossing.  

The Network Rail Boundary Standard defines the fencing classification types as follows: 

Class  I  fencing  -  Steel  palisade,  mesh  panel  and  decorative  metal  railings,  and  non-
conductive alternatives installed to a minimum height of 1800mm. Brick and mortar walls 
installed to a minimum height of 2000mm. 

Class  2  fencing  -  Weld  mesh,  chain  link,  closeboarded  timber  and  brick  and  mortar  walls 
installed to a minimum height of 1800mm. 

Class 3 fencing - Post and wire fence, livestock fence, post and rail or weld mesh fencing, dry 
stone or brick/stone and mortar walls installed to a minimum height of 1350mm. 

This Standard requires Network Rail to inspect boundary fencing in the required timescales and if 
any deficiencies are identified to rectify via either repair or renewal in a timely manner. 

Network Rail can confirm after checking the inspection download and reviewing the photos taken 
during  the  additional  inspection  undertaken  in  March,  that  the  boundary  fencing  in  the  area 
inspected meets the requirements of the applicable Network Rail Standard and that there are no 
outstanding  items  of  works.  On  this  basis  Network  Rail  does  not  believe  that  the  line  is  readily 
accessible by means of deficient fencing nor by unauthorised crossing points and does not therefore 
believe further action is required in relation to boundary integrity in the area inspected (as defined 
above). 

Network Rail manage the risks of rail suicide and vulnerable presentations in partnership with the 
wider rail industry and British Transport Police. We also work closely with suicide prevention experts, 
national agencies such as Public Health England and charities such as the Samaritans, Chasing the 
Stigma and Shout.  Our activities aim to reduce rail suicide and vulnerable presentations. In recent 
years,  the  rail  industry  has  made  significant  strides  in  understanding  rail  suicide  and  vulnerable 
presentations  and  in  deploying  measures  to  mitigate  the  risk.   We  continue  to  see  suicide 
interventions,  with  rail  employees,  the  Police  and  public  intervening  in  more  than  2,034  suicide 
attempts  on  the  railway  in  2022/23.  Central  to  our  programme  is  the  belief  that  suicide  is  not 
inevitable and we can work collectively to reduce the traumatic loss of life and devastation that 
suicide causes.  

 
 
 
 
 
 
 
 
 
 
 
 OFFICIAL 

If there is any further information or clarification that Network Rail can provide in relation to the 
contents of this letter please let us know soonest.  

Yours sincerely  

– Route Director North West Route 
for and on behalf of Network Rail Infrastructure Limited

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