Robert Mullis
PFD Report
Partially Responded
Ref: 2017-0166
1 of 2 responded · Over 2 years old
Sent To
Response Status
Responses
1 of 2
56-Day Deadline
19 Jul 2017
Over 2 years old — no identified published response
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner's Concerns AI summary
A vulnerable, partially sighted patient with dementia was able to disembark a high-speed train unaccompanied and access railway tracks directly from the end of the platform.
Responses
Response received
View full response
Dear Madam Regulation 28 Report Robert John Mullis (Decd:) refer to your report dated 23 May 2017 made under paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 in relation to the inquest into the very sad death of Robert John Mullis, who died on 6 January 2017 after going onto the railway track adjacent to platforms 5 and 6 of Ashford domestic railway station. Background As noted in your report; the conclusion of the inquest was that Robert Mullis died on the evening of 6 January 2017 from injuries sustained when he was hit by a train after disembarking from a train on Which he was travelling to London and wandering onto the railway track adjacent to platforms 5 and 6 of Ashford domestic railway station. Ashford International Station is railway station operated by London & South Eastern Railway Limited, trading as Southeastern, with trains which provide domestic and international rail services_ The station itself has six platforms and there is mixture of stopping and non-stopping services which pass through the station. Platforms 5 and 6 are domestic platforms which, together with platforms and 2 Network Rail leases to Southeastern Railway. Southeastern is the station facility owner of the domestic station and holds the Safety Certificate as Infrastructure Manager for platforms 1 2 5 and 6_ Eurostar International Ltd is similarly responsible for the international part of the station (which includes platforms 3 and 4). Netrom Rxif inlrastructure Limited Regatared Ofiice e Roorstau anc Wia e? No 254,507 busy Enolan?
Response to Points of Concern In your report;, you state that 'In my opinion action should be taken to prevent future deaths and believe your organisation has the power to take action. make this report with the knowledge that Network Rail and South Eastern are addressing the issue of track access from platforms nationally with Ashford being addressed in Autumn 2017' confirm that Network Rail is planning to install platform-end fencing and anti- trespass panels (commonly referred to as 'witches' hats) on platform 1, 2, 5 and 6 (the domestic platforms) at Ashford International Station and that these works are due to be completed by the 31st July 2017. More specifically, we have now installed platform-end fencing (in the form shown in Annex below and witches hats in the form shown in Annex 2 at both ends of platforms 2, 5 and 6 and the London end of platform 1 at Ashford International Station. We will install equivalent fencing and witches' hats at the country end of platform by the end of 2017 . Network Rail, Train Operating Companies and the British Transport Police (BTP) continue to work together to manage this type of incident on the rail network Platform-end fencing would be considered as one possible mitigation in instances where platforms ends are identified as a primary access point for repeat occurrences The platform-end fencing and witches hats being installed at Ashford International Station are part of a wider program of mitigations that are being applied to a number of locations across the South East Route to address the risks associated with trespass and access to the rail network On national basis, our approach is a risk-based one using data (including data shared by BTP) to identify trespass or access-to-the-line hot spots_ this response provides you with assurance that the advised action is taking place_ If I can be of further assistance, or if you would like further clarification, please do not hesitate t0 contact me_ Finally, on behalf of all at Network Rail, would like to take this opportunity to express my sincere condolences to the family of Mr Mullis.
Response to Points of Concern In your report;, you state that 'In my opinion action should be taken to prevent future deaths and believe your organisation has the power to take action. make this report with the knowledge that Network Rail and South Eastern are addressing the issue of track access from platforms nationally with Ashford being addressed in Autumn 2017' confirm that Network Rail is planning to install platform-end fencing and anti- trespass panels (commonly referred to as 'witches' hats) on platform 1, 2, 5 and 6 (the domestic platforms) at Ashford International Station and that these works are due to be completed by the 31st July 2017. More specifically, we have now installed platform-end fencing (in the form shown in Annex below and witches hats in the form shown in Annex 2 at both ends of platforms 2, 5 and 6 and the London end of platform 1 at Ashford International Station. We will install equivalent fencing and witches' hats at the country end of platform by the end of 2017 . Network Rail, Train Operating Companies and the British Transport Police (BTP) continue to work together to manage this type of incident on the rail network Platform-end fencing would be considered as one possible mitigation in instances where platforms ends are identified as a primary access point for repeat occurrences The platform-end fencing and witches hats being installed at Ashford International Station are part of a wider program of mitigations that are being applied to a number of locations across the South East Route to address the risks associated with trespass and access to the rail network On national basis, our approach is a risk-based one using data (including data shared by BTP) to identify trespass or access-to-the-line hot spots_ this response provides you with assurance that the advised action is taking place_ If I can be of further assistance, or if you would like further clarification, please do not hesitate t0 contact me_ Finally, on behalf of all at Network Rail, would like to take this opportunity to express my sincere condolences to the family of Mr Mullis.
Action Should Be Taken
I make this report with the knowledge that Network Rail and South Eastern are addressing the issue of track access from platforms nationally with Ashford being addressed in Autumn 2017
Report Sections
Investigation and Inquest
On 18/01/2017 I commenced an investigation into the death of Robert John MULLIS. The investigation concluded at the end of the inquest on 18th May 2017. The conclusion of the inquest was that Robert Mullis died on the evening of 6th January 2017 from injuries sustained when he was hit by a train after disembarking from a train on which he was travelling to London and wandering onto the railway track adjacent to platforms 5 and 6 of Ashford Domestic Railway Station. His reason for doing so cannot be determined but the fact that he was partially sighted and had Parkinsons and Vascular Dementia likely contributed. 1a Multiple Injuries b c
II
Conclusion: Accidental Death
II
Conclusion: Accidental Death
Circumstances of the Death
Robert Mullis who had Parkinsons, Vascular Dementia and was partially sighted was put on the South Eastern high speed train at Ramsgate in order to travel to London where he was to be met by his daughter at London St Pancras station. When he failed to arrive daughter became concerned and contacted police. Mr Mullis wore a GPS tracker which showed him to be in the vicinity of Ashford railway station. A police search was instigated and CCTV examined which showed Mr. Mullis to disembark the train shortly before it departed Ashford station and walk off the end of platform 6 onto the railway tracks at 17.45. He was thereafter struck by two trains, the latter causing the injuries from which he died.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.