Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0376, written 16 Jul 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Jul 2024 |
|---|---|
| Reference | 2024-0376 |
| Deceased | Glenn Jacques and Ben Whiteman and Callum Clark |
| Coroner | Jeremy Chipperfield |
| Coroner area | Durham & Darlington |
| Category | Railway related deaths · Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
J Chipperfield Senior Coroner HM Coroner’s Office PO Box 282 Bishop Auckland County Durham DL14 4FY 10 September 2024 Dear Sir, Northern Trains George Stephenson House Toft Green York YO1 6JT Regulation 28 - Report to prevent future deaths railway station I am writing to you as Safety & Environment Director of Northern Trains (Northern), the railway station, in response to the Regulation 28 Report to operator of railway Prevent Future Deaths of 16 July 2024, detailing your concern that station appears to be, and to be known as, a convenient location for suicide. The deaths of Glenn Jacques, Ben Robert Whiteman and Callum Clark are a tragic loss of human life and on behalf of Northern we wish to express our deepest condolences to their families. Northern’s response to the Regulation 28 Report regarding detailed in the following pages, including: station is local risk factors affecting the station suicide rate; • background information about the station; • • actions already taken by Northern and its industry partners; • actions in planning or under consideration; • actions considered but not taken forward, with supporting rationale. I hope the information provided reassures you that Northern takes very seriously its role in helping to prevent avoidable deaths on the railway. Yours sincerely, Safety & Environment Director www.northernrailway.co.uk NORTHERN TRAINS LIMITED GEORGE STEPHENSON HOUSE, TOFT GREEN, YORK, ENGLAND YO1 6JT Company No. 03076444 NORTHERN’S RESPONSE TO PREVENT FUTURE DEATHS AT STATION - September 2024 Background information station is managed by Northern Trains (Northern), the UK’s second largest passenger train operator, serving over 500 stations in the north of England. Last year 155,000 station which serves a population of journeys were made to and from 106,000 people within a 5 km (3.1 mile) radius. Just over a quarter of customers are commuters with the rest mostly travelling for leisure purposes. On 1 March 2020, Northern Trains commenced operating the Northern passenger rail franchise, taking over from Arriva Rail North. Northern Trains is a subsidiary of the Department for Transport’s operator of last resort holding company DfT OLR Holdings, known as DOHL. is what is termed an ‘unstaffed As with the majority of Northern’s stations, station’ in that it does not have staff working in a ticket office or on a ticket gateline. Northern and Network Rail provide security patrols at the station, which are described in the actions section below. station is situated 13 km (8.3 miles) south of Newcastle, on the East Coast Main Line route which runs between London and Edinburgh. Non-stopping passenger services operated by CrossCountry, Transpennine Express and LNER, of which there are around eight each hour during weekdays, travel through the station at speeds of up to 115 mph. Stopping services are operated by both Northern and Transpennine Express, with an average three trains per hour stopping at the station during weekdays. station Since 2017, there have been ten suicides or suspected suicides at and the immediately adjacent railway. Further analysis shows that there is no clear pattern of deaths happening on a particular day or at a particular time. Since February 2020, security patrols have made 33 lifesaving interventions, either at the station or surrounding areas. There are currently one to two ‘concern for welfare’ incidents a month at the station. There is no definite time pattern for these, however the majority are clustered during the daytime. The average age of persons taking their own life at station is 34, with just over half below the age of 30. The youngest was 17 years of age, the oldest 66. This compares to an average age of 48 years for all UK suicides. Of the most recent three fatalities, all lived within ten miles of station. There are no reports of the deceased having previously presented in distress at the station. Local risk factors There is no individual factor that makes other railway locations, but rather a combination of factors. These include: station a higher risk for suicide than - The frequency of high-speed trains that pass through the station without stopping; - - - the station’s location in a relatively densely populated area, which means its history is well known; the proximity to Chester Burn Viaduct to the north of the station, which has previously attracted vulnerable people; the station footbridge between the two platforms which has been in continuous use by the public for so long that many consider it a right of way. The bridge links the nearby 2 housing estate with the town centre so local residents, including non-rail users, frequently pass through the station; - an active community social media presence, where news and rumours spread quickly; - the age of the deceased, with a relatively high number in their twenties, leading to increased media interest, social media activity and large memorials; - the role of the local media and social media. Regarding the last three points, our understanding is that this combination of young age, social media activity and memorialising is leading to the local perception that the station is a place to go to by persons thinking of suicide. It has become increasingly clear from recent incidents that social media is playing a significant role in social contagion concerning station. Social contagion is a known phenomenon whereby publicity surrounding a location and means of suicide increases the likelihood of more suicides occurring at that location and by those means. The rail industry as a whole does a great deal to mitigate the risk of railway suicide but does not draw too much attention to this work to avoid social contagion. Unfortunately, this has become a vicious circle in that the rail industry cannot talk too openly about the prevention work it does, but then people believe that nothing is being done, become angry and post about it on social media. Each fatality is commonly posted on social media within minutes of it occurring, together with an associated outpouring of grief for the deceased. This includes complete strangers with no connection to the area, posting and re-posting large quantities of emotive material. Whilst some of these posts are available publicly, others are on private social media groups making it difficult to gauge what is being discussed. Local media and news outlets have run stories about fatalities at the station, including images of memorials. These have not always followed the media guidelines set out by Samaritans and have included news websites with the comments sections clearly visible, some of which project negative perceptions about the station. Samaritans have reached out to provide training to local media outlets and behaviours appear to be slowly changing for the better. After a railway fatality it is common to see memorials in the form of flowers and cards left at stations. These are usually a small number of items placed in a discreet part of the station. Increasingly however, when the deceased is a young person, these memorials can become very large and take up highly visible sections of the station. Memorials can also promote suicidal ideation in vulnerable people. Seeing memorials of this nature, especially large ones, increases the association between the station and suicide. Memorials can also be a distressing reminder to drivers and other rail staff involved in or affected by suicide incidents. It is the practice of rail industry partners to sensitively discourage the placing of memorials on the operational railway including suggesting more suitable temporary locations. The anniversary date of a fatality may also attract vulnerable persons to the same location or encourage mourners to the location to attend vigils, which can impact negatively upon the safety and operation of the railway. On these dates additional support is deployed at the location where necessary. 3 Actions already taken by Northern and its industry partners Following each suicide on the rail network, a joint site visit is led by the British Transport Police (BTP) Designing Out Crime Officer (DOCO). The DOCO produces a post-incident site visit report containing considerations to the industry that may help prevent further similar incidents. This report is shared with the station operator, Network Rail and the Office of Road and Rail (ORR), the safety regulator of Britain’s railways. Following the first fatality this year on 14 February, Northern received a DOCO site visit report on 29 February, with a second report received on 19 July after two further fatalities. The February 2024 DOCO report proposed the following considerations: The following considerations were proposed in the July 2024 DOCO report: 4 The table below sets out the actions already completed by Northern, Network Rail and BTP, including the DOCO report actions in relation to the security gate and station lighting. Post-incident site visits DOCO report The two most recent site visits by BTP, Network Rail and Northern following the fatalities in June and July 2024, found anti-trespass mitigations in the form of platform end fencing and anti-trespass matting to be fully in place and in good order. Samaritans’ signage was correctly displayed and visible. Following each suicide on the rail network, a joint site visit is led by the BTP Designing Out Crime Officer (DOCO). The DOCO produces a post- incident site visit report containing considerations that may help prevent further similar incidents. The considerations from the DOCO reports of February and July 2024 are detailed in the section below. Security patrols and staffing Network Rail-contracted security patrols (provided by Vital Human trained suicide prevention patrollers are Resources) comprising currently on site at station between 07.00-19.00 hours Monday-Friday, with mobile patrols taking place after this timeframe. Vital patrols have been in place at the station since August 2022. Vital patrollers have access to the station CCTV system via mobile devices. Northern TravelSafe Officers (TSOs) currently supplement Vital patrols beyond 19.00 hours, with a one-hour visit every day except Saturday. This has been in place since June 2024. Station information To install community notice boards for Public Health to update local community groups and signpost local events happening – installed July 2024. Station environment To refresh Samaritans posters across the station – completed July 2024. Samaritans and Andy’s Man Club (men’s suicide prevention charity) signage to be provided on both station ticket vending machines (TVMs) – provided July 2024. To activate help points on the station TVMs, so if someone is in distress Northern’s customer centre can be contacted who can raise the emergency services if needed – activated July 2024. To implement classical music playing on the station PA system after the Vital team finish their on-site patrols at the station. This is known to reduce loitering and antisocial behaviour, and to be calming and reduce anxiety and may therefore help dissuade persons with thoughts of suicide from waiting on the platform for a passing train – implemented July 2024. To cover up any mention of suicide on the current mural at the entrance to the station, and to work with local schools to replace the mural – covered up July 2024. Platform edge white lines have been repainted to improve their visibility – repainted June 2024. 5 CCTV The mid-platform pedestrian gate on platform 1 has been padlocked in response to the DOCO report, as it allowed people to bypass areas likely to have people present. Now those visiting the station must walk past Vital’s office and CCTV, eliminating a blind spot. The security of the gate is checked daily by the Vital patrols. The station historically has never had a permanent CCTV system, principally because of a lack of supporting infrastructure on site. Northern has mitigated this by using a portable analytical CCTV system, supplied by Marlowe Fire & Security - installed November 2023. Vital patrollers have access to view camera footage via a monitor in the old taxi office in the station building, which is used as their base. Northern has recently upgraded this office space to maintain its continued suitability for use by Vital staff when patrolling at the station. Station lighting Although mentioned in the July 2024 DOCO report, lighting on the station platforms is fully operational and of a suitable quality to capture CCTV images at night. This is illustrated by the clarity of the image below, taken by the current CCTV system at 00:59 hours on 13 August 2024, which shows all platform lighting working. Community engagement Multi-agency working Northern has engaged with local high schools on community artwork and with the local residents’ association to encourage station adoption. Northern, Network Rail and LNER colleagues are also working with the local Men’s Sheds Association on community volunteering at the station. Northern is an active participant in two forums with key stakeholders concerning station. These include a joint industry meeting chaired by Network Rail and attended by representatives of BTP, Durham Council Public Health and passenger train operators Northern, LNER, Transpennine Express and Lumo. There is also a multi-agency meeting attended by local councillors, Public Health, Samaritans, Northern and Network Rail. Memorials It is rail industry practice for Network Rail, train operators and BTP fatality investigation officers to work sensitively with the families of the 6 deceased to educate why memorials are best sited in discreet locations and removed within a short timescale. Actions in planning or under consideration CCTV CCTV at station is to undergo a full upgrade to a permanent system. The station is identified as a priority location with installation work anticipated to start before year end. The new CCTV system will have monitoring and some smart capabilities. This will make it easier to search for particular incidents in recorded footage and can enable geo-fencing to be applied to boundaries such as platform ends to deter persons venturing onto the track. It is generally understood that the presence of CCTV cameras may not prevent suicides per se, as railway deaths often occur in full view of platform and level crossing cameras. Some persons with suicidal thoughts may also act quickly and without prior warning, which CCTV cannot prevent. Most station CCTV systems like are not monitored, but act to deter criminal activity and to assist with post- incident investigation and review. The proposed CCTV system design is complete and currently with Network Rail for design approval and landlord’s consent. Estimated dates for completion of each stage of work is as follows: Design approval and landlord’s consent – 7 October 2024. Completion of procurement, order placement – 6 December 2024. CCTV system on-site installation – 31 January 2025. Station environment ‘Stand behind’ yellow line and cross hatchings on both platforms to be repainted to maintain visibility – by 30 November 2024. Industry engagement Northern will be working with other train operating companies to raise station – to awareness of the current issues affecting be delivered through ongoing activity arising from the joint industry meeting. Communications Northern are seeking opportunities to showcase the roles of traincrew and train drivers in particular, helping the public see them as real people with important jobs to do, through feature news stories and social media – ongoing as opportunities arise. Northern, working in conjunction with industry partners, will develop a ‘stay behind the yellow line’ safety campaign, to raise awareness of the dangers at the platform-train interface – by 31 December 2024. Northern plan to engage with Samaritans to explore whether they can engage with social media group admins to request the removal of harmful content – to be delivered through liaison with Samaritans at the joint industry and multi-agency meetings. Community engagement Northern are planning a community day with its North East team, working with ISS (Northern’s facilities management provider), Network Rail and Samaritans to improve the station waiting room and platform 7 areas. Northern are currently investigating the possibility of involving local schools and Scout groups as part of the ‘Platforms for Change’ campaign in conjunction with Community Rail Network – planned for 10 October 2024. Northern are working to establish a ‘Friends of’ group to adopt station and undertake work such as refreshing the planters with flowers. These would be tended by local groups to give the station a more community feel and afford greater opportunity to recognise vulnerable persons who may present on the station – the initial response has been very limited, but Northern will continue to engage with the local groups to try and establish a viable group of volunteers. Northern is seeking opportunities to partner with local health agencies to ensure that local people feeling vulnerable and in need of support know what services are available to them, so they can seek help before they start to feel suicidal – to be delivered through ongoing discussion and liaison at the multi-agency meetings. Actions considered but not taken forward Security patrols and staffing The DOCO report of July 2024 recommends the following mitigation measures: The station should always be staffed with active patrols when members of the public can access the station, which may be 24/7 if it is decided that access cannot viably be restricted. and, The station should be staffed and patrolled when trains are running through the station, which may be 24/7 if there are freight or sleeper trains throughout the night. Northern and its partners do not have plans to staff the station 24/7 at present. Fatalities have still occurred when the station has been staffed and patrolled proactively. This has included persons accessing the railway not through the station itself, but via the lineside up to 100 metres north and south of the station. station was staffed by a third party who ran the former booking office until 2016 when the lease ended. There was also a café facing onto the station platform that was open until the start of the COVID pandemic in early 2020, together with a dance space on the top floor of the station building holding classes in the evening. Incidents have occurred despite railway staff and other persons being present on site. Northern is aware of the station becoming a focal point for persons in distress, so any initiatives need to be mindful not to exacerbate the situation. For example, a female was on hold on the phone with a crisis line for two hours before she decided to come to the station to speak to Vital staff in order to access mental health support. The message to 8 vulnerable people must be to seek help elsewhere through other agencies rather than from the station. Station environment The DOCO report of July 2024 also recommends the following mitigation measure: The station should have all access points secured against entry except for between 10 minutes before and 5 minutes after every stopping train, staff restricting access and the use of the footbridge between platforms to be used only by people intending to travel and not to be used as a right of way for pedestrians, who should be encouraged to use other road and path links. Northern and its industry partners do not recommend implementing this recommendation, as when the station was undergoing previous refurbishment, the footbridge was taken out of commission. During this time trespass incidents onto the track significantly increased within the station environs. People were seen to cross the tracks as the easier option instead of detouring 200 metres to use the nearest subway via Avondale Terrace to get from one side of the station to the other. Restricting access to the bridge has the potential to inadvertently increase the likelihood of trespass onto the main line, increasing the chance of accidental death. Summary station are a tragic loss of human life. Northern and its The fatalities at industry partners take very seriously their role in helping to prevent avoidable deaths on the railway. Northern has already taken a number of actions to help mitigate the risk of future deaths, with more in planning and under consideration, as detailed above. These actions are commensurate with the considerations and outputs of the DOCO report. Where these are not considered proportionate or appropriate to take forward, Northern has provided commentary to explain why. Progress on completion of the remaining actions will be reported at Safety Executive Group, Northern’s four-weekly senior safety meeting attended by Northern Directors. station make this The particular factors affecting the incidence of suicides at a particularly complex issue to resolve. It points to issues of mental and physical health that exist outside of the railway in the wider community, which require a joined-up multi-agency approach to help address. Northern is committed to playing its part by continuing to work through the above action plan and by being proactive in working with industry partners, other agencies and the wider community. Safety & Environment Director Northern Trains 10 September 2024 9
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (Before Inquest) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Managing Director Northern Railway 5th Floor Northern House 9 Rougier Street York YO1 6HZ 1 CORONER I am Jeremy Chipperfield, senior coroner for the coroner area of Durham and Darlington 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. https://www.legislation.gov.uk/ukpga/2009/25/schedule/5 https://www.legislation.gov.uk/uksi/2013/1629/contents/made made 3 INVESTIGATION I have commenced investigations into the deaths of the following persons: Collision and death Investigation commencement Glenn Jacques 14-Feb-24 15-Feb-24 Ben Robert Whiteman 03-Jun-24 05-Jun-24 Callum CLARK 05-Jul-24 08-Jul-24 . The investigations have not yet concluded and the inquests have not yet been heard. 1 4 CIRCUMSTANCES OF THE DEATH Each of the deceased persons died after being struck by a train travelling through railway station, County Durham; in each case, the person is reported to have put himself into the path of the train by deliberate, intentional action. 5 CORONER’S CONCERNS During the course of the investigation my inquiries 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 – railway station appears to be, and to be known as, a convenient location for suicide. In response to a Prevention of Future Deaths Report dated 10-Dec-18, (which followed a death by suicide at railway station), you stated that “the station does not classify as a hot spot under British Transport Police’s definition which is used nationally to focus the work of cross industry working groups. Such locations are defined as having 3 or more suicides/attempted suicides in 12 months”. The incidents referred to herein took place within 12 months. 6 7 ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe you or your organisation has 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 10-Sep-24I, 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 and to Interested Persons to these investigations. 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. She may send a copy of this report to any person whom she 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 16-Jul-24 2 3
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