Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0125, written 4 Mar 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Mar 2024 |
|---|---|
| Reference | 2024-0125 |
| Deceased | Vanessa Ford |
| Coroner | Ian Potter |
| Coroner area | Inner North London |
| Category | Railway related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
Vanessa FORD (died on 23 September 2023)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Rail –
1.
2.
, Group Safety & Engineering Director, Network
, Interim Chief Executive, London Borough
of Hackney, 1 Hillman Street, London, E8 1DY
1
CORONER
I am Ian Potter, assistant coroner for the coroner area of Inner North London.
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 2 October 2023, an investigation was commenced into the death of
VANESSA FORD, then aged 47 years. The investigation concluded at the
end of an inquest, heard by me, on Monday 26 February 2024.
The conclusion of the inquest was a short narrative conclusion, the medical
cause of death being:
1a multiple traumatic injuries
4
CIRCUMSTANCES OF THE DEATH
On 23 September 2023, Vanessa Ford consumed a significant amount of
alcohol while undergoing an acute mental health crisis. She accessed
and allowed herself to drop onto the
railway tracks below, where she was later struck by a train. There is
insufficient evidence to suggest that she intended to take her own life.
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:-
To Network Rail, in particular:
(1) I was provided with evidence that there have been three (non-fatal)
incidents in the vicinity of the Hackney Central/Dalston Kingsland
areas of the rail network in the 12 months prior to this incident on 23
September 2023 (British Transport Police Post Incident Site Report
DOCU Reference: DOCU 2023 1576 refers).
. The concern here is that there is evidence to suggest that
access to the railway tracks by members of the public may be a
frequent issue in this vicinity.
(2) Evidence provided from CCTV footage and photographic evidence
taken by the British Transport Police demonstrated that the particular
piece of wall, which was used to access the railway network on 23
September 2023, was relatively low, despite an approximate drop onto
the tracks below being 20 feet. The British Transport Police Post
Incident Site Report sets out that the “Road over rail bridge has metal
covers and hostile toppings on walls directly over the railway”;
This raises the concern that
the mitigation/safety measures in place on the wall may not have been
as effective as one might expect.
(3) The CCTV footage and photographic evidence presented to me,
demonstrated that Ms Ford’s access to the wall, and thereby the
railway network below,
. In their oral evidence during the inquest,
the Officer from the British Transport Police confirmed their view,
which I accepted, that this electrical box makes access to the wall
much easier than it should be. They also confirmed that this issue is
and
unlikely to be confined solely to the
that such items of street furniture may pose similar risks across the
railway network.
To Network Rail and the London Borough of Camden:
(4) In addition to the
mentioned at (3) above, the
evidence revealed numerous items of street furniture on the
,
all of which could be used
to facilitate easier access to the wall and the railway network. The
concern here is that the siting of items of street furniture generally on
this bridge poses risks to all manner of members of the public, from
those contemplating suicide, to young children, and may undermine
safety efforts to impede easy access to the railway network.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe
you 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 29 April 2024. 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 RESPONSE
I have sent a copy of my report to the Chief Coroner and to the following
Interested Person:
•
(Vanessa Ford’s husband)
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
Ian Potter
HM Assistant Coroner, Inner North London
4 March 2024
2 responses 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.
In the matter of a response to a Prevention of Future Deaths Report arising from the inquest into the death of Vanessa Ford 1. This is the response of the London Borough of Hackney to the Prevention of Future Deaths Report (“PFD”) issued by HM Assistant Coroner for Inner North London, Ian Potter, dated 4 March 2024 following an inquest into the death of Vanessa Ford heard on 26 February 2024. 2. The London Borough of Hackney would like to offer their sincere condolences to the family and friends of Vanessa Ford who tragically died on 23 September 2023. 3. The concerns expressed by the Coroner for this Council to consider, alongside Network Rail, were as follows: In addition to the small electrical box [on the pavement of the road bridge], the evidence revealed numerous items of street furniture on the Dalston Lane Road Bridge, such as recycling bins, all of which could be used to facilitate easier access to the wall and the railway network. The concern here is that the siting of items of street furniture generally on this bridge poses risks to all manner of members of the public, from those contemplating suicide, to young children, and may undermine safety efforts to impede easy access to the railway network. 4. Upon receipt of the PFD, Officers from the Council conducted both desk based investigations and site visits to accurately map what street furniture was present either on the road bridge or in sufficient proximity to it which might facilitate access to the railway network. 5. The Council identified the following pieces of street furniture in that location: a. Small electrical box owned by Global Communications; and b. Various recycling bins nearby on Martel Place, as described in the PFD report. 6. In respect of the electrical box, the Council has identified that the electrical box is associated with an advertisement screen located on the flank wall of 85 Dalston Lane. The site has a long history of being used for advertisements and most recently benefits from advertisement consent granted by the Council, in its capacity as local planning authority, under application reference 2024/0845. 7. Existing planning policy does not explicitly cover the 'location of street furniture in proximity to road bridges over railway lines'. The National Planning Policy Framework (NPPF”) refers to ‘street clutter’ at paragraph 116(c) where it refers to applications for development creating “places that are safe, secure and attractive – which minimise the scope for conflicts between pedestrians, cyclists and vehicles, avoid unnecessary street clutter, and respond to local character and design standards” but is otherwise silent on the topic of the location of street furniture. 8. Apparatus such as electrical boxes like this which are often associated with advertisement screens which are themselves subject to the Town and Country Planning (Control of Advertisements) (England) Regulations 2007. The NPPF states that “advertisements should be subject to control only in the interests of amenity and public safety, taking account of cumulative impacts”. The Council’s own planning policy - LP33, LP7 - Advertisements - provides that advertisements must not cause a physical obstruction to the public realm with the supporting text stating that should not “add clutter to an already busy street scene thus adversely affecting the local environment blocking the public realm and in some cases affecting highway safety”. 9. Discussions have taken place, and will continue, between the highways team and the local planning authority to see whether an effective mechanism could be put in place through the planning process to identify and flag up electrical apparatus and street furniture at locations such as this one. 10. In respect of the various recycling bins nearby on Martel Place, the Council has taken steps to remove those bins and this action was completed on 8 May 2024. 11. The Council has also been in contact with Network Rail to coordinate actions and ensure clear ownership of responsibilities. The Council has received confirmation from Network Rail that further measures to address specific concerns around the access gate at Martel Place and the wall more generally are underway. London Borough of Hackney 21 November 2024
OFFICIAL Ian Potter HM Assistant Coroner for Inner North London HM Coroners Office 29 April 2024 Re: Regulation 28 Report – Vanessa Ford Dear Sir, I refer to your report dated 4 March 2024 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 Ms Ford. 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 identifies a number of matters of concern on which you request Network Rail’s response. I have taken each of these matters in turn. (1) Access to the railway tracks in the vicinity of Hackney Central/Dalston Kingsland In your report you refer to three (non-fatal) incidents in the vicinity of the Hackney Central/Dalston Kingsland areas of the rail network in the 12 months prior to this incident on 23 September 2023. You also refer to the British Transport Police Post Incident Site Report (DOCU Reference: DOCU 2023 1576) which refers to these incidents. Though 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. I can confirm that the three incidents referred to each occurred at the Hackney Central and Dalston Kingsland railway stations. These are publicly accessible locations and in each instance access was taken from the public station areas directly onto the track. Management of the stations and relevant access mitigations is the responsibility of London Overground as Station Facility Owner. The three incidents referred to therefore do not suggest that access to the railway tracks by members of the public may be a frequent issue in this vicinity.We have no other records of unauthorised access at this location. (2) Mitigation measures The specification, inspection and maintenance of railway boundary measures, including the particular piece of wall which was used to access the railway network on 23 September 2023, is specified in Network Rail standard NR_L2_OTK_5100 Boundary Measure Management Manual. All boundaries to the rail network are assessed in accordance with Network Rail standards. This includes assessing the likelihood of trespass and the adequacy of boundary measures, which includes consideration of the risks associated with the adjoining land use including ancillary features of a location (such as the presence of street furniture) which may exacerbate a risk or require further mitigation. I can confirm that all relevant inspection records were up to date and the boundary at this location was confirmed to meet Network Rail standards on its last inspection on 17 January 2023. 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 I note the evidence referred to in your report regarding the nature of the wall at this location, specifically the wall along Martel Place referred to in the Post Incident Site Report. The wall has reviewed again following receipt of your report as part of Network Rail’s continuous boundary asset management approach. Although the boundary is assessed as compliant to Network Rail standards, we are working with the Local Authority to explore if further measures can be implemented to address the specific concerns identified by this incident. Works have already been scheduled to be undertaken on during early May to the access gate at Martel Place so that it matches the height of the adjacent palisade fencing and the gap underneath the fence and the climbing foothold will be removed. We are working with the Local Authority to consider options to add additional measures to the wall which may include the installation of Vanguard anti-climb rollers, planting Hawthorne or similar and installation of signage to warn people of the risks of the drop to the railway at the other side of the wall. It is anticipated that the selected option will be installed by early May 2024. (3) Street furniture Street furniture such as the recycling bins or electrical boxes referred to in your report are managed by the Local Authority. In relation to specific issues on Dalston Lane Road Bridge and Martel Place, Network Rail is liaising with the Local Authority and understand that its Streetscene department is looking to re-locate some of the recycling bins. Though this is outside of Network Rail control we continue to support the exploration of any improvements that can be made at this location, alongside the physical mitigations being explored as detailed above. We consider that the mitigation works referred to above to add additional measures to the boundary will also address the concerns raised in your report regarding the electrical box. 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, Anglia 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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