Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0330, written 1 Jul 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Jul 2025 |
|---|---|
| Reference | 2025-0330 |
| Deceased | Jody Robb |
| Coroner | Crispin Oliver |
| Coroner area | County Durham and Darlington |
| Category | 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: Network Rail East Coast Route Director George Stephenson House Toft Green York YO1 6JT 1 CORONER I am Crispin OLIVER, Senior Assistant Coroner for the coroner area of County 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. 3 INVESTIGATION and INQUEST On 14/04/2025 12:38an investigation was commenced into the death of Jody Lee ROBB 30/04/1993. The investigation concluded at the end of the inquest on 26/06/2025 11:15. The conclusion of the inquest was that Died at 23.03 on 08 April 2025 on the carriageway of Station Approach, life having taken deliberate steps to end her own . 4 CIRCUMSTANCES OF THE DEATH Died at 23.03 on 08 April 2025 on the carriageway of Station Approach, having taken deliberate steps to end her own life . 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: (brief summary of matters of concern) I read and heard evidence from the investigating CID officer who had reviewed all available CCTV in relation to the incident. She reported that Jody had arrived on the south bound platform just over an hour before she jumped. She sat on a bench for a few minutes before making her way onto . She was on the for about one hour before she actually did so. A total of 11 trains passed her, north and southbound, during that hour. No report was made or received of her presence there by train crews of station staff attending on the station platforms for arrivals and departures. . My concerns are: Regulation 28 – After Inquest Document Template Updated 30/07/2021 from the platform is not sufficiently barred or impeded to the 1. Access to the public. It is clear by means of signage that the public must not go beyond the end of the platform. There are what appear to be some sort of wheeled access stoppers on the platform at and around the fence at its end. But there is nothing to prevent even a moderately mobile person from going around the fence and resource preventing access is human by means of station staff intervention, which is necessarily reliant on their presence at the relevant time; 2. attempts at suicide are not ones designed to prevent, impede or discourage . The main . ; 3. Eleven trains passed Jody, from north and south, while she was on during the hour before she jumped. No reports were made by any train crew of her presence. It would be exceeeding the available evidence and unfair to infer that train crews and/or station staff deliberately or negligently ignored her presence there. More likely is that she was simply not visible. It was dark, being at night in April, and Jody was wearing relatively dark clothing. However, she seems to have been discernible on CCTV and from the British Transport Police images I have seen taken from approximately where a driver might have been placed, it is plausible to suggest that she might have been visible, even laterally, from the cab of a train either slowing to stop at the station or pulling out from it, with even moderately enhanced lighting on the viaduct. Obviously, had a report been made of her presence, some type of intervention could have been attempted . 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your 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 August 27, 2025. 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. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons , Jody’s Mother , Jody’s Aunt who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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 Dated: 01/07/2025 Regulation 28 – After Inquest Document Template Updated 30/07/2021 Crispin OLIVER Senior Assistant Coroner for County Durham and Darlington Regulation 28 – After Inquest Document Template Updated 30/07/2021
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 Crispin Oliver Senior Assistant Coroner for County Durham and Darlington HM Coroners Office By email only to: hmcoroner@durham.gov.uk Re: Regulation 28 Report – Jody Lee Robb Dear Sir, 22 August 2025 I refer to your report dated 1 July 2025 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 Robb. 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. Network Rail Infrastructure Limited (“Network Rail”) owns, operates and maintains the railway infrastructure in England, Scotland and Wales. At Durham Station, as infrastructure owner, Network Rail is responsible for the railway track and the viaduct. London North Eastern Railway Limited (“LNER”) is the Station Facility Owner and responsible for the operational running of the station, including staffing and CCTV. 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 viaduct from the platform. Your report suggests that access is not sufficiently barred or impeded to the public, and that the main resource preventing access is human by means of station staff intervention. We understand that Ms Robb accessed the viaduct from the platform. Over the last 6 years or so, the station and the viaduct have been the subject of significant investment, introducing multiple anti-suicide and trespass measures. At various points throughout the station, there is Samaritans signage to encourage individuals to seek help, if needed. The end of the platform is fitted with a locked gate, and beyond this, there is a drop off the edge of the platform to track level, to deter individuals from walking beyond the platform’s edge and onto the track. Access via the locked gate is granted only for authorised personnel. The gate is the standard design and has pointed tops, to make it difficult for individuals to climb over the gate. The gate does not extend to the platform edge, as this is in compliance with Network Rail’s national standards. Near the end of the platform and at the side of the gate referred to above there are anti-trespass rubber pyramid mats (“witches hats”) which extend along the edge of the railway track onto the viaduct for approximately 60 metres, on each side of the station platform. This is beyond what is required by Network Rail’s standards. The intention of the witches hats is to make access difficult for anyone intending to trespass by acting as both a physical and visual deterrent. There is an automatic voice message released from a speaker, when individuals get within 14 metres of the end of the platform. This tells people to move away from the platform end. Network Rail Infrastructure Limited Registered Office: Network Rail, Waterloo General Office, London, SE1 8SW Registered in England and Wales No. 2904587 www.networkrail.co.uk OFFICIAL Near the end of the platform, there is also a yellow cross-hatched box. The main intention is to deter individuals from going within the box, as well as making anyone within the box more visible. Network Rail has also funded training for station staff, led by the Samaritans, to help them engage with persons presenting at the station in distress. This training is offered not just for employees of LNER, but also employees of businesses within the station. (2) The railings on the viaduct You have suggested that the railings are not designed to prevent, impede or discourage attempts at suicide by means of jumping. As the viaduct is a Grade 2 listed structure, Network Rail is required to submit a listed building consent application and prior approval planning application before it can undertake any work to physically alter the existing viaduct structure. Without the Council’s approval, we would be unable to carry out any works to the existing viaduct structure which alter its appearance Prior to the incident taking place, Network Rail submitted an application to improve the parapet across the full length of the viaduct on both sides by putting in place mesh safety panels. We have received the approved listed building consent from the Council, but there is one final planning approval that is required before final permission is granted (prior approval). We expect a further update on this application in August 2025. Should permission be granted, the planned works intend to increase the height of the parapet, which will also be curved inwards, by installing the safety barrier to make it harder to climb. The aim of this barrier is to deter individuals from climbing, and even if they did try, it would be much more difficult to climb over and sit on the parapet. Whilst we do not have a confirmed start date for the physical works, the design stage is underway and it is hoped that the works can be completed by the end of this financial year, subject to planning permission being forthcoming. (3) Lighting on the viaduct Finally, you indicate that eleven trains passed by Ms Robb whilst she was on the viaduct, and that no reports were made by any train crew of her presence. You have offered that Ms Robb may have been visible with even moderately enhanced lighting on the viaduct. Network Rail cannot comment on the actions of the drivers of trains who passed the area in question. In respect of the lighting on the viaduct, I can confirm that temporary lighting is only used where works to the railway are taking place; however, it is not usual to permanently light the railway. There are various safety reasons for this, including lighting potentially inhibiting driver’s vision and ability to see signals. In addition, there are concerns that lighting the structure may increase trespassing incidents as access may become more visible. As such, whilst we do not consider it appropriate to install lighting on the viaduct, we remain committed to restricting trespassing on the railway infrastructure as far as reasonably practicable, and will therefore continue to monitor the steps which have been implemented as described above. 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, East Coast Route Network Rail Infrastructure Limited Registered Office: Network Rail, Waterloo General Office, London, SE1 8SW Registered in England and Wales No. 2904587 www.networkrail.co.uk
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