Christine Gould

Dear Sir,

I refer to your report dated 28th May 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 Chris Gould. We hope from Network Rail’s participation in the Inquest into Chris’s death that you are aware that we take all incidents of this nature on the railway incredibly seriously. We have carefully considered the matters raised in your report and have addressed them below.

Appropriate mitigating measures

As was explained during the Inquest into Chris’s death, Network Rail is currently carrying out a fencing renewal which will upgrade the fencing between Cherry Hinton and Teversham level crossings to 1.8m palisade fencing (a Class I boundary measure). These works are ongoing and, at the time of drafting this letter, have reached the following stage. We have separately updated the Coroner on these works but include also below for completeness:

1. The boundary from the Cherry Hinton Bypass level crossing (2m 53ch) through to the Teversham level crossing (3m 44ch), a distance of 1.48km, is currently being renewed and upgraded from Class II to Class I 1.8m Palisade fencing. The renewal covers the boundary adjacent to the public footpath that runs between the railway and the Tesco supermarket. The up side from the Cherry Hinton Bypass level crossing (2m 53ch) through to 2m 72ch (a distance of 0.38km) has now been fully constructed and installed. This covers the whole length of the footpath adjacent to the railway and Tesco as well as the hospital cemetery. The fencing on the up side beyond the Cherry Hinton Bypass level crossing (2m 50ch – 2m 53ch), a distance of 0.06km, has also been fully constructed and installed. This includes the fencing around the crossing pedestals, and the fencing around the top of the electrical cabinet.

2. Works to renew the final section of boundary on the upside from 2m 72ch through to the Teversham level crossing (3m 44ch), a distance of 1.04km, will commence during the week commencing 26 July 2021. Therefore the full boundary renewal on the up side from the Cherry Hinton Bypass level crossing through to the Teversham level crossing is estimated to be complete by 6 September 2021.

Nicholas Moss QC HM Assistant Coroner for Cambridgeshire and Peterborough 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
3. The down side is also being renewed between the Cherry Hinton Bypass level crossing and the Old Fulbourn level crossing. Works on this side of the railway commenced during the week commencing 28 June 2021, starting from the Cherry Hinton Bypass level crossing (2m 53ch) working back towards 2m 72ch (a distance of 0.38km). This is estimated to be completed by 23 July 2021.

Network Rail takes its responsibilities regarding suicide prevention very seriously and continues to work in partnership with the British Transport Police (BTP) and relevant stakeholders, including with the hospital given its proximity to the crossing. Additional mitigation measures remain under regular review as we seek to reduce the number of safety incidents. These measures have included:
1. Engagement of a 12 hour security team for the Cambridge and Fulborn area, which includes Cherry Hinton Bypass level crossing;
2. Bi-monthly meetings with the hospital and use of a Missing Service Users policy;
3. Installation of live CCTV at Cherry Hinton Bypass level crossing, including plans to replace this with Smart CCTV which alarms if it detects a person leaving the crossing and accessing the track;
4. Liaison with Cambridgeshire local authority via a Suicide Prevention Steering Group;
5. Working with Nottinghamshire University to consider technological mitigations.

Consideration of the route of access and post-incident fencing checks

Network Rail works closely with the BTP when fatalities sadly occur on the railway. In the immediate aftermath of an emergency incident, following report from a Train Driver to Network Rail Control, the duty Network Rail Mobile Operations Manager (MOM) attends site and liaises with the BTP. The BTP has jurisdiction in relation to such investigations. Initial investigations are undertaken during the emergency response to secure the area, which includes identifying any areas of the infrastructure that may require repair, including potential access points. Any immediate issues identified (such as damaged boundary fencing or potential access points as a result of branches or sagging etc) are escalated by the MOM within Network Rail fault control systems. Where an access point is not immediately clear, Network Rail attends site the following day and a Post Incident Site Report is carried out by the BTP. Following any immediate actions therefore Network Rail relies on the BTP and its investigation and conclusions following incidents of this nature.

Guidance has been shared within the Anglia Route (to the Operations Team and to the Route Crime Team) to reiterate that, following a fatality, a fence check of the area is to be carried out within 48 hours and a record of this made in the MOM report. This is an additional assurance to ensure Network Rail’s incident response is appropriately recorded, and is in addition to the BTP’s records and the Post Incident Site Report. Any faults identified during that fence check are reported to fault control for remediation.

Keeping an open mind in post-death investigations

The BTP Post Incident Site Report made the assumption that Chris entered the railway at Cherry Hinton Bypass level crossing and made her way down the lines. It is clear, with hindsight, on this occasion that nobody can be sure of the exact location at which Chris gained access to the tracks. However, assumptions about how Chris gained access to the railways were made on the basis of the investigation carried out by the BTP.

In light of this and the concerns raised in your report, Network Rail’s Route Crime teams nationally have been made aware of Chris’s case and the need to keep an open mind about access following a fatality where the point of access to the track is not definitively known. In addition, the reiteration

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 of Network Rail’s post-incident fence check process seeks to ensure that any credible route of access is picked up promptly and, where necessary, remedied as a priority.

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.

Dear Sir write in reply to the Regulation 28: report to prevent future deaths dated 287 2021 which followed the inquest into the death of Christine Elizabeth Gould (Chris). This letter details the British Transport Police response to the raised matters of concern as listed below: Following completed suicides on the railway network BTP and Network Rail are both involved in considering further mitigating measures that may be appropriate atthe location to guard against further fatalities. In Chris' case, earlier consideration to the boundary being a credible route of access may have led to the fence boundary being improved more quickly after her death. am concerned that your investigation into, and consideration of, Chris' death did not keep a sufficiently open mind that she mayhave climbed the boundary fence to access the railway line. If similar assumptions are made in other investigations, there is a risk of future fatalities: there is a risk that mitigating measures will be missed if BTP and Network Rail too readily assume that one point ofaccessto the railwvay was used when the evidence permits of credible alternative routes of access Following notification of the Regulation 28 report; a member ofthe Investigation Review Team within the British Transport Police was commissioned to review the investigation of Christine Gould, the scope of this review was limited to the matters of concern. This review offered recommendations of which a number are included within this response BTP investigative response_tonon {Uspicious fatalities Since Chris' death, the British Transport Police has undertaken organisational change in the management of non- suspicious fatalities. In April 2020 single Fatality Investigation Team was created, from a position where there was the opportunity for regional differences across the Force in the management of such investigations, the BTP implemented standardised structure. The structure includes two teams covering Enzland and Wales, they are divided into North and South regions. Each team is supervised by a Detective Sergeant. Their role is to assess and formulate an investigative strategy at the outset identifying relevant lines of enquiry- In turn, the Detective Sergeants report into the Fatality Investigation Team Detective Inspector and a Detective Chief Inspector. All Child Death investigations are overseen by BTP Detective Inspector, and it will be for them to again set the investigative strategy- All non-suspicious deaths are subject to Fatality ad Serious Injury Review meeting chaired by the Detective Superintendent, (Major, Serious ad Organised Crime) This structure provides specialised oversight into all non-suspicious investigations. May fence

Scene Assessment Inining and Continuous Professional Development The BTP Disruption Team review the Force's frontline response to non-suspicious fatalities, through their assessments they identify areas of improvement practice. The Disruption Team have commenced a programme of regular "bite-sized" continuous professional development training sessions for police officers one of these specifically targets scene assessments at railway fatalities Following the prevention of future deaths report, this training nOw incorporates renewed focus on attending officers comprehensively documenting their rationale following a scene assessment training also seeks to remind staff of how to use static railway infrastructure and modern technology such as the geolocation application What3Words, to provide precise positional locations for evidential material (ie. possible access points/recovered property from scenes). All this additional detail will enhance the ability of investigators and the Designing Out Crime Unit (DOCU) when mal assessment on how an individual may have accessed the railway network, and crucially what considerations could be made t0 prevent future access Post Incident Scene Visitf The BTP Designing Out Crime Officer (DOCO) who completed the Post Incident Site Visit (PISV) at Cherry Hinton on Ilth February 2019, from the available information assumed that Chris had travelled from the Fulbourn Hospital as opposed t0 the Darwin Unit, where it was later found she had in fact travelled from. There is no criticism of the initial DOCU action as the role is not to investigate and establish the of entry for any death but to be directed to a location The Cherry Hinton Bypass Level Crossing at this time was identified asthe access point and the location was as the basis for the PISV report BTP has now implemented a procedural change for PISV visits whereby the DOCO will ensure the full incident log is read prior to a site visit; and liaison will take place prior to deployment with the Fatality Investigator (or SIO if unexplained or a child fatality) assigned to the investigation team when the access point isn t immediately clear. This is to ensure the location subject to the PISV is the one established to have been used, or potentially include multiple points of entry if unknown Ifat point following completion of a PISV report;a location(s) other than that visited and referenced in the report is established to have been the point of entry; a second site visit to the correct location will be made and a new report issued Though the PISV for Cherry Hinton was completed with a representative from Network Rail it is now standard practice that all DOCU visits are conducted with railway representatives ensuring collaborative approach The PISV report which includes considerations for improving an access point(s) will be provided to the attending Network Rail representative (or other railway infrastructure owning organisation; such as a Train Operating Company) and forwarded to Network Rail' s suicide prevention programme email. Conversation between BTP $ Designing Out Crime Unit and Network Rail is taking place with the aim of establishing regular meetings where considerations from previously submitted PISV report will be discussed. Conclusion Through the changes that have been implemented to the structure of non-suspicious fatalities, the ongoing training of frontline staff around scene assessment andthe preparing; production and submission of PISV reports, BTP has implemented robust procedures which significantly reduce the risk of mitigating measures being missed by the BTP post-incident site visits There is a structured process for the PISV reports to be passed on to Network Rail, whose responsibility it is to decide on any appropriate and proportionate action around the proposed improvement considerations highlighted by BTP - and good The key aking point , used any during

understand that this response may be shared with the interested persons and would like to take this opportunity to express my condolences to Chris' family on behalf of BTP.