Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0645, written 29 Dec 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 Dec 2025 |
|---|---|
| Reference | 2025-0645 |
| Deceased | Brian Mitchell |
| Coroner | Graeme Irvine |
| Coroner area | East London |
| Category | Railway related deaths |
| 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.
MR G IRVINE
SENIOR CORONER
EAST LONDON
124 Queens Road Walthamstow, E17 8QP
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1.
Commissioner, Transport for London (“TFL”)
2. The Mayor of London,
3.
, Secretary of State for Transport
1
CORONER
I am Graeme Irvine, senior coroner, for the coroner area of East 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.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
3
INVESTIGATION and INQUEST
On 27/12/2023 this Court commenced an investigation into the death of Brian Mitchell
aged 72 years. The investigation concluded at the end of the inquest held between
15/12/2025 & 17/12/2025. The court returned a short form conclusion of, “Accidental
death”
Brian’s medical cause of death was determined as;
1
1a Multiple Injuries
1b Blunt Force Trauma
4
CIRCUMSTANCES OF THE DEATH
Mr Brian Mitchell was 72 at the time of his death
On 26/12/2023 at 15:20 hours, Brian was discovered on tracks at platform 13 at
Stratford Underground Station. Brian was declared deceased by paramedics having
sustained traumatic injuries that were incompatible with life.
CCTV was reviewed which showed the following:
• At 13:56:53 on 26 December 2023, Mr Mitchell alighted from a London
Underground Jubilee line train at Stratford station and sat down on a
bench on platform 13.
• At 14:45 hours Brian was seen to stand up and lurch towards the edge
of the platform and fall onto the tracks.
• Brian moved and tried to climb back onto the deserted platform.
• At 14:50 hours, an incoming Jubilee Line train entered the platform and
Brian was struck.
• The impact went unnoticed. The train reversed out of the station over
Brian.
• Two further trains entered and left the platform each moving over Brian
twice.
• A member of staff unsuccessfully tried to prevent a fourth train moving
over Brian as it entered Platform 13.
The inquest heard that likely contributary factors to Brian’s death were, firstly that Brian
was heavily intoxicated by alcohol.
Secondly, Jubilee Line trains use Automatic Train Operation (ATO). This means that
Train Operators (TOs) do not drive the train. Acceleration and braking are automated.
The expectation of TOs is that they pay close attention to the train and the tracks before
them and override the ATO system and apply brakes if they observe an object on the
tracks.
In this case, at least 3 separate TOs failed to notice a man before them on the tracks or
to override the automatic system.
The court heard that the initial collision with Brian was likely to have been avoidable. The
track layout would have allowed Brian’s presence to have been noticed by an attentive
TO. Additionally, it was asserted that a TO would have had sufficient time to react and
bring the train to a stop many metres before Brian’s location.
The court heard that these omissions may have resulted from the fact that Platform 13 is
a terminus platform which could result in a lowered level of attention on the part of TOs.
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.
In the two years that have elapsed since Brian’s death investigations have been
2
conducted by the British Transport Police, The Rail Accident Investigation
Branch (“RAIB”) and TFL into the circumstances that led to this incident. There
is no clear evidence to demonstrate that risks of fatal harm have been mitigated.
2. Recommended technological measures to detect and alert staff to the presence
of persons on the tracks have not been implemented at Stratford station.
3. No clear data is available to demonstrate that training provided to train operators
(drivers) to ensure that they concentrate and look at the tracks before them
whilst operating trains using ATO has resulted in positive improvement in
performance.
4. No clear data is available to demonstrate that station staff training has improved
expedition or clarity of communication in emergency circumstances.
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 25th February 2026, 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 PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons the family of Brian Mitchell.
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 other 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.
9
[DATE] 29/12/2025 [SIGNED BY CORONER]
3
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