Brian Mitchell
29 Dec 2025 · Coroner Graeme Irvine · East London
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. risk of fatal harm
“In the two years that have elapsed since [the deceased]'s death investigations have been conducted by the British Transport Police, The Rail Accident Investigation Branch ("RAIB") and TFL into the circumstances that led to this incident. There is no clear evidence to demonstrate that risks of fatal harm have been mitigated.”
2. absence of detection and alert technology
“Recommended technological measures to detect and alert staff to the presence of persons on the tracks have not been implemented at Stratford station.”
3. lack of evidence of training effectiveness
“No clear data is available to demonstrate that training provided to train operators (drivers) to ensure that they concentrate and look at the tracks before them whilst operating trains using ATO has resulted in positive improvement in performance.”
4. lack of evidence of staff training impact
“No clear data is available to demonstrate that station staff training has improved expedition or clarity of communication in emergency circumstances.”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“That there is no apparent system for staff to alert odd behaviour and then track an individual of concern on CCTV”
This report
“Recommended technological measures to detect and alert staff to the presence of persons on the tracks have not been implemented at Stratford station.”