Source · Prevention of Future Deaths

Gregory Barber

Ref: 2021-0429 Date: 24 Dec 2021 Coroner: John Hobson Area: West Yorkshire (Eastern) Responses identified: 1 / 1 View PDF

Network Rail failed to implement recommended mitigation measures to curtail access to railway tracks at a specific high-risk location, leaving a vulnerability unaddressed despite police warnings.

Date 24 Dec 2021

56-day deadline 18 Feb 2022

Responses identified 1 of 1

Mental Health related deaths Railway related deaths Suicide (from 2015)

Coroner's concerns

AI summary

Network Rail failed to implement recommended mitigation measures to curtail access to railway tracks at a specific high-risk location, leaving a vulnerability unaddressed despite police warnings.

View full coroner's concerns

In my opinion there is a risk that future deaths will occur unless action is taken. The matter of concern is as follows:

The BTP investigation identified a clear problem and recommended a mitigation measure to which there has been no meaningful response, or at all, from Network Rail within the terms of the specific request to so respond within 60 days of the incident.

On the evidence that I heard at the inquest, it would appear that the weakness identified by the British Transport Police remains as it was at the time of their investigation and I am concerned that access to the railways tracks is not sufficiently curtailed at the location identified, as recommended.

I am under a duty to report this matter upon consideration of the evidence.

Responses

1 respondent

Network Rail Private Sector

7 Mar 2022 PDF

Action Planned

Network Rail is procuring the installation of 8 metres of 2.4m palisade fencing behind a parapet wall and will close off gaps at either end of the new fence, with work expected to commence the week of March 7, 2022 and be completed within two weeks. (AI summary)

View full response

Dear Sir,

I refer to your report dated 24th December 2021 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 Mr Barber. 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.

Your report references a post incident site report undertaken by the British Transport Police (BTP) (the PISR). Network Rail works closely with the BTP following fatal accidents on the railway and participates in a post-incident site visit. The PISR is authored by the BTP.

The PISR refers to Mr Barber’s most likely access point as being over the parapet wall at the end of Wyther Lane. However, on the evening of the incident on 12 April 2021, Network Rail representatives attended the area of Kirkstall Lineside near Bridge Road, Leeds along with the BTP to undertake a post-incident site visit. During this visit, the BTP and Network Rail carried out an immediate inspection of the area and our records show that Mr Barber’s access point was agreed to have been at a Network Rail access gate further down the track towards Kirkstall Forge Station. Mr Barber’s personal possessions were found by BTP at this location.

In addition, on consideration of the PISR, Network Rail did not consider that the parapet wall was a trespass risk for the reasons explained below.

1. The parapet wall is 1.35m high and is immediately followed by a very steep embankment down to the railway, meaning it is not an easy point of access.
2. There is heavy vegetation behind the parapet wall which also serves to deter trespass and with no sign of access having been attempted or made through the vegetation.
3. Previous data held by Network Rail does not identify this location as a hot spot for trespass.
4. The area meets Network Rail’s current standards for fencing and boundaries.

Despite these findings, Network Rail is committed to maintaining a safe railway and to reducing opportunity for members of the public to harm themselves on or near the railway. As such, following further engagement with the BTP in December 2021 in relation to this incident, Network Rail remitted works at this location to address the concern raised in the BTP PISR (and since raised in your Regulation 28 report). Specifically, Network Rail is procuring the installation of 8 metres of
2.4m palisade fencing behind the wall (before the land begins to slope downwards), together with specially fabricated palisade fencing closing off the gaps at either end of the new fence. This will further deter potential access over the parapet wall and down to the railway.

John Hobson HM Assistant Coroner for West Yorkshire (Eastern) HM Coroners Office

Network Rail Infrastructure Limited Registered Office: Network Rail, One Eversholt Street, London, NW1 2DN Registered in England and Wales No. 2904587 www.networkrail.co.uk

OFFICIAL Subject to delivery of materials, work is due to commence during the week commencing 7 March 2022 and we expect it will be completed within two weeks.

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.

Report sections

Investigation and inquest

On 23 April 2021 an investigation was commenced into the death of Mr Gregory James Barber, aged 34. An inquest was opened on 29 April 2021 and the investigation completed at the conclusion of the inquest on 13 December 2021. The medical cause of death established at the inquest was that Mr Barber died from severe head injuries secondary to blunt force impact. A conclusion of suicide was recorded.

Circumstances of the death

On 12 April 2021, Gregory James Barber, who had a history of mental health difficulties and suicidal ideation, died as a result of , having lain

. Paramedics attended but his death was confirmed at 1717hours. On appraisal and consideration of the evidence at the inquest on the relevant standard of proof, a conclusion of suicide was recorded. During the course of the inquest I heard witness evidence presented in relation to an investigation undertaken by the British Transport Police. A section of a document entitled ‘Post Incident Site Report [PISV] – Lineside’ [ref: DOCU-2021-0590] contained a section entitled: ‘Considerations which could help to prevent further similar incidents/Agreed actions’ [p7 of 9]. Any such matters are set out in a table set down on a pro forma. The first column identifies a ‘Problem’, the second column is entitled ‘Mitigation Measure’. A third column refers to ‘Owner(s)’. The completed columns read as follows: Problem: ‘ is not easy and fencing is for the most part adequate. The Google image and photograph above show there is a

.’ Mitigation Measure: ‘Additional fencing along the stone parapet run up to the as indicated on the google image above. There needs to be an inner line of fencing behind the stone parapet which is far enough away from the parapet to mean that the stonework cannot be used to climb over the fencing.

Owner(s): Network Rail.

Whilst it was noted that no ‘quick time intervention/rectification was required at the location’, the report goes on to state that:

‘To support the Coroner Inquest process we respectfully request that stakeholders submit a response to the considerations detailed in the report and any other activity planned for the location using the available section below within 60 working days from the date of the incident’.

At the date of the inquest, the section of the report entitled ‘Considerations response’ had not been completed by Network Rail and returned to the British Transport Police. Upon further investigation at the inquest, it was confirmed that the report was sent to Network Rail on 7 May 2021.

The ‘Problem’ identified by BTP followed an appraisal of the scene, with the ‘weak spot’ identified as being ‘…the most likely access point and would benefit from improved fencing’ [pp6/7 of 9].

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Report details

Reference: 2021-0429
Date of report: 24 December 2021
Coroner: John Hobson
Coroner area: West Yorkshire (Eastern)

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 18 Feb 2022.

Sent to

Network Rail

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.