Christine Gould
28 May 2021 · Coroner Nicholas Moss QC · Cambridgeshire and Peterborough
This report repeats 2 earlier warnings, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. unmitigated railway access points
“Following completed suicides on the railway network BTP and Network Rail are both involved in considering further mitigating measures that may be appropriate at the location to guard against further fatalities”
2. delayed fence improvement
“In [name redacted]' case, earlier consideration to the fence boundary being a credible route of access may have led to the fence boundary being improved more quickly after her death”
3. assumption of single access point
“I am concerned that your investigation into, and consideration of, [name redacted]' death did not keep a sufficiently open mind that she may have climbed the boundary fence to access the railway line”
4. missed mitigating measures
“there is a risk that mitigating measures will be missed if BTP and Network Rail too readily assume that one point of access to the railway was used when the evidence permits of credible alternative routes of access”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“Evidence suggested that some parts of the perimeter fencing were secured with cable ties”
This report
“In [name redacted]' case, earlier consideration to the fence boundary being a credible route of access may have led to the fence boundary being improved more quickly after her death.”
Identical hazardConfidence 0.90 · high
Earlier report
“(2) The fencing at the scene of Mr [name redacted] death was a low wooden fence which was easy to climb over.”
This report
“(3) I am concerned that your investigation into, and consideration of, [name redacted]' death did not keep a sufficiently open mind that she may have climbed the boundary fence to access the railway line.”
Closely relatedConfidence 0.90 · high
This report
“In [name redacted]' case, earlier consideration to the fence boundary being a credible route of access may have led to the fence boundary being improved more quickly after her death.”
Later report
“Car park line side fencing being too low. The proposed mitigation was replacement of the fencing.”
Responses
2021-0185-Response-from-BTP_Published.pdf ↗· British Transport Police
Stated action
“Following notification of the Regulation 28 report, a member of the Investigation Review Team within the British Transport Police was commissioned to review the investigation of [the deceased], 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.”
2021-0185-Response-from-Network-Rail_Published.pdf ↗· Network Rail