Source · Prevention of Future Deaths

Fraser Moore

Ref: 2023-0497 Date: 4 Dec 2023 Coroner: Julian Morris Area: Inner South London Responses identified: 0 / 2 View PDF

Inadequate CCTV coverage beyond station platforms and failure to immediately transmit footage to Route Control rooms increase the risk of undetected incidents in busy stations.

Date 4 Dec 2023
56-day deadline 29 Jan 2024 est.
Responses identified 0 of 2
Railway related deaths

Coroner's concerns

AI summary
Inadequate CCTV coverage beyond station platforms and failure to immediately transmit footage to Route Control rooms increase the risk of undetected incidents in busy stations.
View full coroner's concerns
The CCTV coverage/ footage ends at the end of the station concourse on both the city and country ends. Station footage does not get sent to Route Control. On a risk-based review, the chances of incidents happening in a busy cosmopolitan station must, by footfall and surrounding populations alone, increase the risk of an event. An event that should then be looked at. In order to look at an event, I accept that current CCTV is in place within the station confines but for these stations, I do not consider that I have received sufficient evidence to persuade me that the footages should not be available immediately to the Route Control Rooms or that the coverage should not extend up or down line beyond the end of the platforms.

Report sections

Investigation and inquest
On 4 May 2020 an investigation into the death of Fraser William Moore, aged 25, was opened. The investigation concluded at the end of the inquest on 15 December 2022. The conclusion of the inquest, heard before a jury was the "inappropriate handcuffing, his unnecessary arrest, inadequate supervision of his arrest and the failing to prevent his escape." He escaped firstly onto the station concourse and then onto the railway lines at London Bridge Station.

The medical cause of death was 1a. Electrocution, 1b. Contact with live rail.
Circumstances of the death
On 25 March 2020 Mr Moore had been arrested, handcuffed and was present in a carriage. He managed to exit one of the carriage doors, which was unattended and fled onto the platform. After running for a short period of time firstly up and then down the platform by moving down one side of the concourse to the other, he was running towards the country end at London Bridge Hospital. He proceeded to jump onto the track whilst still within the platform area before continuing out of the platform area towards the country. He was followed by a BTP officer. The rails were still live. The calling for the lines to be isolated occurring about the same time that maters were picked up by the signalman. Sadly, he made contact with the live rail before power could be severed. Subsequently, after the power switched off and assistance to move to his location, some distance from the platforms, he was pronounced dead at the scene.
Action should be taken
In my opinion action should be taken to look into both the extension of CCTV in busy cosmopolitan station and its passage to Route Control to help prevent future deaths and I believe you have the power to take such action.

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Report details

Reference
2023-0497
Date of report
4 December 2023
Coroner
Julian Morris
Coroner area
Inner South London

Responses identified

Responses identified 0 of 2
2 responses not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 29 Jan 2024 (estimated).

Sent to

Department for Transport
Network Rail

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