Alun Davies
PFD Report
All Responded
Ref: 2022-0196
Response Status
Responses
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Source: Courts and Tribunals Judiciary
Coroner’s Concerns
(1) The post-incident site report presented by British Transport Police (in conjunction with the Design Out Crime Unit) and completed on 22 July 2021 identified that there was (and remains) limited staffing and CCTV surveillance at Portchester Railway Station and limited visibility of the platforms - requiring a security risk assessment with a view to increasing staffing (at the ticket office and on the platform) with increased RCO Patrols and platform surveillance and that additional CCTV installation and coverage was required (of the platforms and public areas) with real time capability.
(2) The post-incident site report further identified that Portchester Railway station is an impending ‘escalated’ location. Since 2017 there have been 2 previous fatalities in similar circumstances at the station – which is now recognised as having lower levels of surveillance – with Mr Davies’ death being the third. Although recommendations were made after the first incident, the above recommendations and identified risks (at 1) have not yet been (fully) addressed or implemented.
(3) The post-incident site report further identified the lack of public security and welfare announcements at the station (and within the station concourse) aimed at providing direction in the event of illness or of assistance being required. There is a lack of information/announcements to other members of the public as to how to obtain assistance if they are concerned by someone else’s condition or actions. It is not clear to what extent this has been further considered or addressed.
(2) The post-incident site report further identified that Portchester Railway station is an impending ‘escalated’ location. Since 2017 there have been 2 previous fatalities in similar circumstances at the station – which is now recognised as having lower levels of surveillance – with Mr Davies’ death being the third. Although recommendations were made after the first incident, the above recommendations and identified risks (at 1) have not yet been (fully) addressed or implemented.
(3) The post-incident site report further identified the lack of public security and welfare announcements at the station (and within the station concourse) aimed at providing direction in the event of illness or of assistance being required. There is a lack of information/announcements to other members of the public as to how to obtain assistance if they are concerned by someone else’s condition or actions. It is not clear to what extent this has been further considered or addressed.
Responses
South Western Railway has rejected increasing staffing levels, RCO patrols, and 24/7 CCTV surveillance at Portchester Station, stating existing measures are adequate. They have already installed trespass gates, witches hats, and anti-tread guards, and are discussing suicide risk management with Network Rail.
AI summary
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Dear Mr Wilkinson Regulation 28 Report: Alun John Davies 1 We refer to your Regulation 28 report dated 23 June 2022 (the “Report”) regarding the death of Alun John Davies (“Mr Davies”) on railway tracks at Portchester station on 4 May 2021. 2 SWR would like to take this opportunity to express its sincere condolences to Mr Davies’ family and friends. Background 3 We understand from the Report that you are concerned that there is a risk of future deaths occurring unless action is taken. You have set out in your Report three areas of concern from the post-incident site report prepared by the British Transport Police: (a) Staffing levels and CCTV; (b) Previous incidents at Portchester Station; and (c) Security and welfare announcements. 4 SWR has considered these areas of concern and sets out its response to each of them below. 5 Response to Paragraph 1: Staffing Levels: Ticket Office, Platform and RCO Patrols 6 All train stations are different. This means that there are different requirements for staffing arrangements. (a) Ticket Office 7 At Portchester Station, there is a member of staff present in the ticket office during commuter times (Monday to Friday 05:50 to 10:40 and Saturday 07:50 to 14:20). However, outside of these hours there are no staff present in the ticket office. 8 SWR has considered whether the circumstances of the incident impacts upon the need to increase ticket office staffing levels. We have concluded that there is no requirement to make adjustments to increase the number of ticket staff. (b) Platform Staff 9 SWR conducts ‘platform/train interface assessments’ which informs decisions on staffing arrangements at platforms. For example, at some stations there may be a high frequency of trains stopping at the station, a high footfall of passengers and/or special events (such as at Twickenham station on match days) which may require platform staff to be present. 10 There are no platform staff at Portchester station. This is for a number of reasons including:
South Western Railway South Bank Central 4th Floor 30 Stamford Street London SE1 9LQ (i) There are a limited number of trains which stop at the station; (ii) It is not a station where passengers make connections from one route to another; (iii) It is not a station which becomes congested with passengers and is considered to have low footfall; and (iv) The platforms are essentially straight providing good visibility along the length of the platform. 11 SWR has considered this assessment for Portchester in light of this incident and has concluded that there is no requirement to make adjustments to introduce a requirement for platform staff. (c) Railway Community Officer patrols 12 SWR undertakes an assessment to allocate the frequency of RCO Patrols. There are a number of factors which are taken into consideration during this assessment including anti-social behaviour incidents, reported criminal activity and fatalities/attempted fatalities. 13 The assessment for Porchester was carried out post incident on 13 January 2022. The output of this is that the station was categorised as a ‘green’ station and therefore considered to be of low risk. Consequently RCO patrols are not required on a regular, pre-determined basis. 14 Response to paragraph 1: CCTV 15 The purpose of CCTV at train stations is largely twofold: first, to try to deter criminal activity, and secondly to provide a record of any incidents that occur, which can be used in the course of any investigation. Given the number of CCTV cameras across the whole of the SWR network, it would not be practicable to have staff monitoring every camera 24 hours a day, and so the CCTV system cannot be used proactively to try to prevent criminal activity or other incidents. 16 CCTV footage from stations across the SWR network can also be viewed from the security desk based in the Regional Operation Centre (“ROC”) which is manned 24/7. This security desk has access to all CCTV cameras across the SWR network covering approximately 210 stations which each have multiple cameras per station. The security desk has the ability to view the feed from any camera, for example in response to a reported incident, but again it is not possible to monitor the footage from all cameras across the SWR network in real time. 17 At Portchester station, there are 6 static CCTV Cameras which cover the following areas: main area of Platform 2, main building area on Platform 1, the top of the stairs at Platform 1, the ticket office, the Portsmouth end of Platform 2 and the help point on Platform 1. The cameras are on the Nucleus analogue system resulting in good quality video footage. For the reasons explained above, the footage is not actively monitored by staff in the ROC but can be made available immediately if required, for example, if staff are notified of an on-going emergency situation. 18 Response to Paragraph 2: Previous incidents 19 SWR has considered the recommendations arising from the previous Designing Out Crime Unit Report. For the reasons set out above, SWR has not increased staffing levels at Portchester Station nor introduced 24/7 CCTV surveillance. 20 However, at Portchester Station there are a number of preventative measures in place to deter unauthorised access to the railway tracks which were put in place through 2020 and 2021 including:
South Western Railway South Bank Central 4th Floor 30 Stamford Street London SE1 9LQ
(a) trespass gates being fitted to the end of the platforms 1 and 2; (b) witches hats being fitted to the end of platforms 1 and 2; and (c) anti-tread guards being installed. 21 SWR is also currently in discussions with Network Rail to review of the status of Porchester station in relation to the management of suicide risks. 22 Response to Paragraph 3: Security and Welfare Announcements 23 The following types of security and welfare announcements are made at Portchester Station: (a) Fast train approaching; (b) See it, say it, sort it; and (c) Text contact details for Samaritans. 24 These announcements are made on an automated rolling basis. At the station, there are also help points, emergency buttons and Samaritan posters. SWR therefore considers that there are appropriate security and welfare announcements in place. 25 We trust that the above is of assistance but if you require any further information, please do not hesitate to contact us.
South Western Railway South Bank Central 4th Floor 30 Stamford Street London SE1 9LQ (i) There are a limited number of trains which stop at the station; (ii) It is not a station where passengers make connections from one route to another; (iii) It is not a station which becomes congested with passengers and is considered to have low footfall; and (iv) The platforms are essentially straight providing good visibility along the length of the platform. 11 SWR has considered this assessment for Portchester in light of this incident and has concluded that there is no requirement to make adjustments to introduce a requirement for platform staff. (c) Railway Community Officer patrols 12 SWR undertakes an assessment to allocate the frequency of RCO Patrols. There are a number of factors which are taken into consideration during this assessment including anti-social behaviour incidents, reported criminal activity and fatalities/attempted fatalities. 13 The assessment for Porchester was carried out post incident on 13 January 2022. The output of this is that the station was categorised as a ‘green’ station and therefore considered to be of low risk. Consequently RCO patrols are not required on a regular, pre-determined basis. 14 Response to paragraph 1: CCTV 15 The purpose of CCTV at train stations is largely twofold: first, to try to deter criminal activity, and secondly to provide a record of any incidents that occur, which can be used in the course of any investigation. Given the number of CCTV cameras across the whole of the SWR network, it would not be practicable to have staff monitoring every camera 24 hours a day, and so the CCTV system cannot be used proactively to try to prevent criminal activity or other incidents. 16 CCTV footage from stations across the SWR network can also be viewed from the security desk based in the Regional Operation Centre (“ROC”) which is manned 24/7. This security desk has access to all CCTV cameras across the SWR network covering approximately 210 stations which each have multiple cameras per station. The security desk has the ability to view the feed from any camera, for example in response to a reported incident, but again it is not possible to monitor the footage from all cameras across the SWR network in real time. 17 At Portchester station, there are 6 static CCTV Cameras which cover the following areas: main area of Platform 2, main building area on Platform 1, the top of the stairs at Platform 1, the ticket office, the Portsmouth end of Platform 2 and the help point on Platform 1. The cameras are on the Nucleus analogue system resulting in good quality video footage. For the reasons explained above, the footage is not actively monitored by staff in the ROC but can be made available immediately if required, for example, if staff are notified of an on-going emergency situation. 18 Response to Paragraph 2: Previous incidents 19 SWR has considered the recommendations arising from the previous Designing Out Crime Unit Report. For the reasons set out above, SWR has not increased staffing levels at Portchester Station nor introduced 24/7 CCTV surveillance. 20 However, at Portchester Station there are a number of preventative measures in place to deter unauthorised access to the railway tracks which were put in place through 2020 and 2021 including:
South Western Railway South Bank Central 4th Floor 30 Stamford Street London SE1 9LQ
(a) trespass gates being fitted to the end of the platforms 1 and 2; (b) witches hats being fitted to the end of platforms 1 and 2; and (c) anti-tread guards being installed. 21 SWR is also currently in discussions with Network Rail to review of the status of Porchester station in relation to the management of suicide risks. 22 Response to Paragraph 3: Security and Welfare Announcements 23 The following types of security and welfare announcements are made at Portchester Station: (a) Fast train approaching; (b) See it, say it, sort it; and (c) Text contact details for Samaritans. 24 These announcements are made on an automated rolling basis. At the station, there are also help points, emergency buttons and Samaritan posters. SWR therefore considers that there are appropriate security and welfare announcements in place. 25 We trust that the above is of assistance but if you require any further information, please do not hesitate to contact us.
Report Sections
Investigation and Inquest
On 5 May 2021 I commenced an investigation into the death of Alun John Davies, aged 50 years. The investigation concluded at the end of the inquest on 1 June 2022. The conclusion of the inquest was that Mr Davies had died as a result of extensive injuries consistent with being struck by a train and that he had taken his own life whilst suffering from acute anxiety and chronic depression.
Circumstances of the Death
The Deceased died instantly when he jumped from the platform at Portchester railway station into the path a non-stopping train at 18.47 on 4 May 2021. The events were captured on the forward-facing CCTV camera in the cab of the train when, on approaching the station, at 18.47 he is seen at the end of the platform, closest to the oncoming train on the left-hand side to squat and then jump onto the tracks before placing himself into a position to lie on the tracks before the oncoming train. No CCTV from the station or platform was available. He was known to have left his nearby hotel at 17.17 that evening (where he was seen leaving on CCTV) and to have walked to the nearby station of Portchester.
. It is believed that he had been at the station for some time before the incident occurred.
The evidence established that at the time of his death he was suffering acute and heightened anxiety following a recent arrest and release on bail and a marriage breakup. He had been suffering chronic anxiety and depression related to concerns about his health, his career and family relationships. Previous use of a hair loss product, may have contributed to his lower mood, decline in his mental health and suicidal ideation. He had not disclosed the full extent of his mental health difficulties to family or professionals nor had he sought professional support.
. It is believed that he had been at the station for some time before the incident occurred.
The evidence established that at the time of his death he was suffering acute and heightened anxiety following a recent arrest and release on bail and a marriage breakup. He had been suffering chronic anxiety and depression related to concerns about his health, his career and family relationships. Previous use of a hair loss product, may have contributed to his lower mood, decline in his mental health and suicidal ideation. He had not disclosed the full extent of his mental health difficulties to family or professionals nor had he sought professional support.
Copies Sent To
2. British Transport Police
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.