South Western Railways
Other
Noted
SWR expresses condolences and explains a miscommunication regarding inquest information. They describe existing measures at Bracknell Train Station such as staffing, training, signage, and tactile paving. They also note that Network Rail is responsible for the lineside fencing issue. (AI summary)
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Dear Assistant Coroner Simpson Regulation 28 Report: Daniela Vitalia Pani We refer to your Regulation 28 report dated 28 March 2024 (the “Report”) regarding the death of Daniela Vitalia Pani (“Ms Pani”) on the railway tracks at Bracknell Train Station on 29 June 2023. SWR would like to take this opportunity to express its sincere condolences to Ms Pani’s family and friends. 1 SWR ENGAGEMENT
1.1 Within section 5 of the Report, you have made reference to the difficulties you experienced in seeking confirmation regarding what steps had been taken following the preparation of a ‘Post Incident Site Report’ into Ms Pani’s death undertaken by the British Transport Police (“BTP”). There is reference to SWR failing to provide information about whether recommendations made by the Report had been actioned.
1.2 SWR would like to assure you from the outset that it takes its engagement with Coronial investigations seriously and is committed to assisting Coroners where SWR holds relevant information. SWR would like to start by providing you with an explanation for any confusion or miscommunication which may have impacted your investigation and prevented SWR from assisting you.
1.3 SWR were involved in the immediate response to the incident and fully cooperated with BTP’s post incident investigations. This included having an SWR Representative, RCO Barry Osborne, present at the post incident site visit (the investigation which preceded the post incident site report) conducted by BTP.
1.4 BTP sent the post incident site report to SWR following the investigation, but SWR were not informed of the commencement of the Inquest. It has come to SWR’s attention that BTP tried to contact SWR about the Inquest using an incorrect email address, but due to the error in the contact address used this was not received by SWR. As a result, SWR were unaware of the Inquest and the subsequent request for information.
1.5 SWR has taken steps to make sure that BTP has the correct contact details. We would also ask that if any further contact is needed, correspondence is sent to SWR’s Head of Security and Safety Assurance, Mr O’Riordan, who has provided his contact details to your office separately. Mr O’Riordan will act as a single point of contact and will be able to assist if information is required in any future investigations. 2 THE REPORT
2.1 Within section 5 of the Report, which sets out the basis for your concern that there is a risk that future deaths could occur unless action is taken, you have set out areas of concern regarding Bracknell train station, specifically two areas of concern arising from the post-incident site report prepared by BTP: (a) A lack of Samaritan signage; and (b) Car park line fencing being too low.
2.2 SWR has considered these areas of concern and sets out its response to each of them below. 3 SAMARITAN SIGNAGE
3.1 Signage at the station
3.2 There are 4 Samaritan signs on the platform at Bracknell train station. These are in prominent locations, including on all platform end gates and on a lamppost.
3.3 SWR have included photographs of these signs for your consideration at Annex A.
3.4 There is 1 Samaritan sign situated within the station, which is located near the ticket office. The station itself is staffed by means of a gate line between 06.00 and 22.00 hours, meaning there is a member of either SWR or contracted staff always present at the station between these times.
3.5 Since this incident, no additional signs have been placed at Bracknell station and there is currently no intention to place any additional signs at Bracknell station. The signage has been reviewed and has been assessed as appropriate. SWR have set out the background to that conclusion below to assist you in understanding what steps have been taken following this incident.
3.6 Consultation with the Samaritans
3.7 A risk analysis is undertaken by the Samaritans at every station to determine the level of signage to implement. There are various human and psychological factors which must be measured when considering the number of signs and the placement of the signs across the station. This assessment is necessary to balance the provision of information and support to deter suicide and suicide attempts against the unwanted advertisement of the suicide potential of a site. The risk of deliberate unauthorised access to the tracks must also be balanced against the control measures required to mitigate the risks of unintentional/accidental unauthorised access to the tracks.
3.8 SWR work with the Samaritans to place signage where both parties consider it to have the most effective engagement. SWR cannot, however, unilaterally increase the number of signs at a station without consultation and the consent of the Samaritans.
3.9 As a result, the Samaritan signage is as listed at paragraph 3.1 above and no additional signage has been added. Bracknell train station was not considered a priority location for trespass and welfare concerns. The station has not experienced a prevalence of unauthorised access (either into the confines of the station itself by those not authorised to be in the station or from those within the station gaining access to prohibited areas such as the tracks) nor has it experienced a prevalence of suicide or suicide attempts. Please see paragraph 4 below for more details as to how SWR manages the risk of unauthorised access.
3.10 SWR’s senior security manager, Matthew Smith, has also recently undertaken a full review of Samaritan signage across all stations on the SWR route. This was to check correct placement, wear and tear (fading), and the display of the correct information and phone numbers. Bracknell did not require any replacement signs as their signage in place was sufficient. As set out above, this did not include the provision for new signage as this is an agreed process with the Samaritans themselves. 4 CAR PARK LINE FENCING
4.1 The car park perimeter fencing at Bracknell train station is the responsibility of Network Rail (“NR”), not SWR. Responsibility for management of the station infrastructure is governed by the lease agreement between SWR and
NR. If it assists the Coroner, SWR has provided further detail in the next paragraph on the general delineation of responsibilities between NR and SWR across the rail network.
4.2 NR is responsible for the operation and management of railway infrastructure. They own, operate, maintain and develop the main rail network in Great Britain including the railway tracks, junctions, bridges, tunnels and level crossings. NR is also the landlord for almost all stations on the national network. SWR and other train-operating companies (“TOCs”) lease train stations from NR and manage them in accordance with lease agreements. Each specific agreement determines responsibility for the management of each site, but NR retains responsibility for aspects of the infrastructure (which often includes fencing) at the majority of stations. Bracknell train station is leased to SWR in this way.
4.3 SWR is responsible for site management at the stations it leases from NR, including ticket barriers/ticket office, staffing and security. SWR has the following arrangements in place relevant to both the management of unauthorised access and the risks associated with the platform train interface which are designed to mitigate the risks of both deliberate and accidental unauthorised access to the tracks at Bracknell train station: (a) The station can only be accessed via the ticket office and is staffed from 06:00 – 22:00 seven days a week. (b) Between these hours, there is a staffed gate to access the station. Outside of these hours, there is a night gate which allows passengers to enter and leave the station when their trains arrives or depart. (c) All SWR staff at the station are trained to look out for passengers in distress or who may be a concern for welfare. Managing Suicide Contact is a course delivered both in house and by the Samaritans that is now mandatory for all new employees of SWR, it is also a course that all third-party suppliers contracted to SWR must now deliver to their front facing staff. It is specifically in place to identify those in crisis. (d) The placement of Samaritan signage as set out above at paragraph 3 and Annex A. (e) Tactiles at the platform edge to assist vulnerable passengers in locating the platform edge. (f) The platforms include signage relating to platform/train interface (e.g. the yellow line and the instructions to stand back). (g) There are automated tannoy announcements asking passengers to stand behind the yellow line, announcing scheduled arrivals and warning of through trains (non-stop services). (h) There are electronic timetables indicating the scheduled arrivals and which also display written warnings alongside the tannoy announcements at (g) regarding through trains (non-stop services).
4.4 A representative from NR was present at the post incident site visit and NR were identified by BTP in the post incident site report as the ‘Owner’ of action 6 which relates to car park lineside fencing. NR are therefore best placed to respond to this concern.
4.5 Nevertheless, SWR work closely with NR and have flagged the issue raised by you of the lineside fencing. We trust that the above is of assistance but if you require any further information, please do not hesitate to contact us.
1.1 Within section 5 of the Report, you have made reference to the difficulties you experienced in seeking confirmation regarding what steps had been taken following the preparation of a ‘Post Incident Site Report’ into Ms Pani’s death undertaken by the British Transport Police (“BTP”). There is reference to SWR failing to provide information about whether recommendations made by the Report had been actioned.
1.2 SWR would like to assure you from the outset that it takes its engagement with Coronial investigations seriously and is committed to assisting Coroners where SWR holds relevant information. SWR would like to start by providing you with an explanation for any confusion or miscommunication which may have impacted your investigation and prevented SWR from assisting you.
1.3 SWR were involved in the immediate response to the incident and fully cooperated with BTP’s post incident investigations. This included having an SWR Representative, RCO Barry Osborne, present at the post incident site visit (the investigation which preceded the post incident site report) conducted by BTP.
1.4 BTP sent the post incident site report to SWR following the investigation, but SWR were not informed of the commencement of the Inquest. It has come to SWR’s attention that BTP tried to contact SWR about the Inquest using an incorrect email address, but due to the error in the contact address used this was not received by SWR. As a result, SWR were unaware of the Inquest and the subsequent request for information.
1.5 SWR has taken steps to make sure that BTP has the correct contact details. We would also ask that if any further contact is needed, correspondence is sent to SWR’s Head of Security and Safety Assurance, Mr O’Riordan, who has provided his contact details to your office separately. Mr O’Riordan will act as a single point of contact and will be able to assist if information is required in any future investigations. 2 THE REPORT
2.1 Within section 5 of the Report, which sets out the basis for your concern that there is a risk that future deaths could occur unless action is taken, you have set out areas of concern regarding Bracknell train station, specifically two areas of concern arising from the post-incident site report prepared by BTP: (a) A lack of Samaritan signage; and (b) Car park line fencing being too low.
2.2 SWR has considered these areas of concern and sets out its response to each of them below. 3 SAMARITAN SIGNAGE
3.1 Signage at the station
3.2 There are 4 Samaritan signs on the platform at Bracknell train station. These are in prominent locations, including on all platform end gates and on a lamppost.
3.3 SWR have included photographs of these signs for your consideration at Annex A.
3.4 There is 1 Samaritan sign situated within the station, which is located near the ticket office. The station itself is staffed by means of a gate line between 06.00 and 22.00 hours, meaning there is a member of either SWR or contracted staff always present at the station between these times.
3.5 Since this incident, no additional signs have been placed at Bracknell station and there is currently no intention to place any additional signs at Bracknell station. The signage has been reviewed and has been assessed as appropriate. SWR have set out the background to that conclusion below to assist you in understanding what steps have been taken following this incident.
3.6 Consultation with the Samaritans
3.7 A risk analysis is undertaken by the Samaritans at every station to determine the level of signage to implement. There are various human and psychological factors which must be measured when considering the number of signs and the placement of the signs across the station. This assessment is necessary to balance the provision of information and support to deter suicide and suicide attempts against the unwanted advertisement of the suicide potential of a site. The risk of deliberate unauthorised access to the tracks must also be balanced against the control measures required to mitigate the risks of unintentional/accidental unauthorised access to the tracks.
3.8 SWR work with the Samaritans to place signage where both parties consider it to have the most effective engagement. SWR cannot, however, unilaterally increase the number of signs at a station without consultation and the consent of the Samaritans.
3.9 As a result, the Samaritan signage is as listed at paragraph 3.1 above and no additional signage has been added. Bracknell train station was not considered a priority location for trespass and welfare concerns. The station has not experienced a prevalence of unauthorised access (either into the confines of the station itself by those not authorised to be in the station or from those within the station gaining access to prohibited areas such as the tracks) nor has it experienced a prevalence of suicide or suicide attempts. Please see paragraph 4 below for more details as to how SWR manages the risk of unauthorised access.
3.10 SWR’s senior security manager, Matthew Smith, has also recently undertaken a full review of Samaritan signage across all stations on the SWR route. This was to check correct placement, wear and tear (fading), and the display of the correct information and phone numbers. Bracknell did not require any replacement signs as their signage in place was sufficient. As set out above, this did not include the provision for new signage as this is an agreed process with the Samaritans themselves. 4 CAR PARK LINE FENCING
4.1 The car park perimeter fencing at Bracknell train station is the responsibility of Network Rail (“NR”), not SWR. Responsibility for management of the station infrastructure is governed by the lease agreement between SWR and
NR. If it assists the Coroner, SWR has provided further detail in the next paragraph on the general delineation of responsibilities between NR and SWR across the rail network.
4.2 NR is responsible for the operation and management of railway infrastructure. They own, operate, maintain and develop the main rail network in Great Britain including the railway tracks, junctions, bridges, tunnels and level crossings. NR is also the landlord for almost all stations on the national network. SWR and other train-operating companies (“TOCs”) lease train stations from NR and manage them in accordance with lease agreements. Each specific agreement determines responsibility for the management of each site, but NR retains responsibility for aspects of the infrastructure (which often includes fencing) at the majority of stations. Bracknell train station is leased to SWR in this way.
4.3 SWR is responsible for site management at the stations it leases from NR, including ticket barriers/ticket office, staffing and security. SWR has the following arrangements in place relevant to both the management of unauthorised access and the risks associated with the platform train interface which are designed to mitigate the risks of both deliberate and accidental unauthorised access to the tracks at Bracknell train station: (a) The station can only be accessed via the ticket office and is staffed from 06:00 – 22:00 seven days a week. (b) Between these hours, there is a staffed gate to access the station. Outside of these hours, there is a night gate which allows passengers to enter and leave the station when their trains arrives or depart. (c) All SWR staff at the station are trained to look out for passengers in distress or who may be a concern for welfare. Managing Suicide Contact is a course delivered both in house and by the Samaritans that is now mandatory for all new employees of SWR, it is also a course that all third-party suppliers contracted to SWR must now deliver to their front facing staff. It is specifically in place to identify those in crisis. (d) The placement of Samaritan signage as set out above at paragraph 3 and Annex A. (e) Tactiles at the platform edge to assist vulnerable passengers in locating the platform edge. (f) The platforms include signage relating to platform/train interface (e.g. the yellow line and the instructions to stand back). (g) There are automated tannoy announcements asking passengers to stand behind the yellow line, announcing scheduled arrivals and warning of through trains (non-stop services). (h) There are electronic timetables indicating the scheduled arrivals and which also display written warnings alongside the tannoy announcements at (g) regarding through trains (non-stop services).
4.4 A representative from NR was present at the post incident site visit and NR were identified by BTP in the post incident site report as the ‘Owner’ of action 6 which relates to car park lineside fencing. NR are therefore best placed to respond to this concern.
4.5 Nevertheless, SWR work closely with NR and have flagged the issue raised by you of the lineside fencing. We trust that the above is of assistance but if you require any further information, please do not hesitate to contact us.