Source · Prevention of Future Deaths

Daniel O’Mahony

Ref: 2018-0258 Date: 30 Aug 2018 Coroner: Geoffrey Sullivan Area: Hertfordshire Responses identified: 1 / 1 View PDF

Inadequate railway anti-trespass measures, including missing gates, gaps in fencing, and unreviewed signage, increase access to railway lines and the risk of future deaths.

Date 30 Aug 2018
56-day deadline 21 Nov 2018 est.
Responses identified 1 of 1
Railway related deaths Suicide (from 2015)

Coroner's concerns

AI summary
Inadequate railway anti-trespass measures, including missing gates, gaps in fencing, and unreviewed signage, increase access to railway lines and the risk of future deaths.
View full coroner's concerns
_ (1) Samarltan Signage has not been reviewed and updated around the station.

(2) Anti-trespass measures have not been installed at the end of platforms, to prevent ready access from the end of the platform to the rallway lines: (3) Cross hatching vellow paint is not present on the fast line platforms 1 and 2. To clearly demark the area (4) Anti-trespass Slgnage has not been replaced at the end of platforms to be more visible: (S)There are gaps in the mid-section fencing between platforms 2 and 3. (6)There are no gates at the access polnt to platform 2 and 3 at the top of the stairs, to prevent any unauthorised access to platform 2. Old Courthouse; St Albans Road East, Hatfleld, ALIO OES 01707 292707 The

Responses

1 respondent
West Midlands Railway
14 Nov 2018 PDF
Action Planned

West Midlands Railway (operated by West Midlands Trains) removed an outdated Samaritans sign and will install new signs at the Hemel Hempstead Railway Station. Network Rail have submitted a remit to install fencing and a swing gate, and to fill gaps between platforms 2 and 3 with sliding gates. (AI summary)

View full response
Dear Sir, London North Western Railway have been requested to respond to a Regulation 28 report to prevent future deaths issued by Geoffrey Sullivan HM Senior Coroner for Hertfordshire in relation to the death of Daniel James 0' Mahony on the 18th December 2017 at Hemel Hempstead Railway Station. The report had 6 matters of concern that London North Western Railway have been asked to respond to by the 16th November 2018.
1) Samaritans signage has not been reviewed and updated around the station Samaritans signage is displayed at stations in line with the Industry Guidance for using Samaritans Communications Materials on the Rail Network as issued by the Rail Industry Suicide Stakeholder Group. A review undertaken in October 2018 concluded that there were 10 signs containing the current Samaritans "Talk to Us" campaign and 116123 number: These signs are displayed at each platform end and 2 are displayed between platforms 2/3 in line with Industry Guidance. The review found that 1 outdated Samaritans sign was displayed on a lighting column between platforms 2/3. This has now been removed. The review also identified that other parts of the station area could benefit from additional Samaritans posters and signs_ lx metal Samaritans sign will be installed by the night entrance, Ix Samaritans metal sign will be installed on the brick wall by the cycle racks, 2x new poster cases and Samaritans posters will be installed in the subway: These have been planned in with the West Midlands Trains Property Team for action.
2) Anti-trespass measures have not been installed at the end of the platforms, to prevent ready access the end of the platform to the railway lines Platform end measures normally fall under the responsibility of Network Rail. Network Rail have advised that there are no standard requirements to have platform end measures, such as fencing, a and a form of tactile or rubber mat but are installed when particular risk is identified and when specific funding becomes available_ West Midlands Railway and London Northwestern Railway are operated by West Midlands Trains Ltd: Head Office: 134 Edmund Street; Birmingham, B3 2ES. Registered number: 9860466. VAT number: 278 2688 49. Midlands Trains Ltd is owned by Abellio, East Japan Railway Company, Mitsui & Ltd and Mitsui & Co:, Europe: from they gate Co;, West

A Train dispatch and platform safety risk assessment carried out on 20th April 2018 under section 8 "Items considered but not deemed a risk" noted that the platform ends were not fitted with anti-trespass but that there were no reported incidents attributed to this It is recognised that a fence or can offer both a visual and physical barrier to anyone wishing to access the track unlawfully, but access can be gained from any of the platform if someone is determined to do so. Network Rail undertook a review of Anti-trespass measures at stations between Rugby and London Euston and as a result Network Rail advise that a remit for this work has been submitted as part of a suite of fencing enhancements across the London North Western Route utilising funding source that has become available and it is still in the design and planning stage, we are not able to give any timescales at present for this work:
3) Cross hatching yellow paint is not present on the fast line platforms 1 and 2. To clearly demark the area Network Rail advise that there is no requirement for cross hatching in any Network Rail standard. It has been used in isolation where there is a passenger train interface issue or risk identified such as overcrowding around stairs and where fast trains pass through narrow platforms This is not an issue at Hemel Hempstead on these 2 platforms as Platform where fast trains pass through is fenced and gated off to the public when trains are running normally as per the timetable. These allow access a5 and when Platform 1 is needed for stopping trains such as during engineering works, in perturbation such as a track blockage, or an infrastructure failure on the slow railway lines Platform 2 the other fast line platform has had a barrier fence installed between it and Platform 3 to separate the 2 Platforms If work is completed as covered under concern 5 and 6 then there would be no access to the fast line platform 2 when trains are running normally as per the timetable
4) Anti-trespass signage has not been replaced at the end of platforms to be more visible To prosecute for an offence of trespass there must be displayed at the nearest passenger station to where the offence took place, at least 1 red trespass warning sign on public display anywhere at the station: Hemel Hempstead is therefore compliant with this requirement: A Train dispatch and platform safety risk assessment carried out on 20th April 2018 under "Passenger Behavioural Risk" , identified as Low Risk the faded additional trespass warning signage on Platform 4. This has been raised with Network Rail on the gth November 2018 to install a new sign. There is a mixture of additional passenger warning signage on display at the platform ends. West Midlands Trains has requested that Network Rail update and standardise these signs and install them as part ofthe remit for the platform end fencing and if installed under concern number 2_ gates gate point gates gates

5) There are gaps in the mid-section fencing between platforms 2 and 3 Previously work was undertaken between Network Rail and London Midland to install the fencing between platforms 2 and 3. The funding for this work was supplied by Network Rail, but project managed by London Midland due to the station lease agreement: This ceased at the end of the franchise and funding agreement that was in place. Network Rail advise that the outstanding work to fill the gaps with sliding gates has been submitted as a remit as part of a suite of fencing enhancements across the London North Western Route utilising a funding source that has become available and it is still in the design and planning stage: We are not able to give any timescales at present for this work The work if completed will prevent passengers from accessing the fast line platform 2 when trains are running normally as per the timetable. The sliding will allow access when required for stopping trains such as during engineering works or in perturbation such a5 a track blockage or an infrastructure failure on the slow railway lines.
6) There are no at the access point to platform 2 and 3 at the top of the stairs, to prevent any unauthorised access to platform 2 In conjunction with concern 5 and the remit to install sliding in the gaps Network Rail advise us that a remit to install fencing and a swing like that installed on Platform 1 has been submitted as a remit as part of a suite of fencing enhancements across the London North Western Route utilising a funding source that has become available and it is still in the design and planning stage We are not able to give any timescales at present for this work this information addresses the concerns that you raised in your report but if / can be of further assistance, or if you would like further clarification, please do not hesitate to contact me Yours Sincerelv Suicide Prevention Co-ordinator West Midlands Trains gates gates gates gate hope

Report sections

Investigation and inquest
On the 44 January 2018 commenced an Investigatlon into the death of Daniel James 0'Mahony: The investigation concluded at the end of the inquest 22nd August 2018. The conclusion of the inquest was Suicide: Medical cause of death: 1a) Multiple Traumatic Injuries
Circumstances of the death
On the 18th December 2017 the drlver of the 11.1Shrs Manchester to London Euston service was on the approach to Hemel Hempstead Rallway Station, where he was not due to stop. Ahead he saw Danlel 0'Mahony approxlmately half way down the platform: As the traln neared Mr O'Mahony Jumped from the platform onto the track and sat down facing the train. Mr O'Mahony was struck by the traln: Police and paramedlcs attended and his death was conflrmed at 13.20 hours_
Action should be taken
In my oplnion action should be taken to prevent future deaths and belleve you London North Western Railway have the power to take such action

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Report details

Reference
2018-0258
Date of report
30 August 2018
Coroner
Geoffrey Sullivan
Coroner area
Hertfordshire

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: 21 Nov 2018 (estimated).

Sent to

London North Western Railways

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