Brian Mitchell
PFD Report
No Identified Response
Ref: 2025-0645
29 days past deadline · No identified published response
Response Status
Responses
0 of 3
56-Day Deadline
25 Feb 2026
29 days past deadline — 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
1. In the two years that have elapsed since Brian’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. Recommended technological measures to detect and alert staff to the presence of persons on the tracks have not been implemented at Stratford station.
3. 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. No clear data is available to demonstrate that station staff training has improved expedition or clarity of communication in emergency circumstances.
2. Recommended technological measures to detect and alert staff to the presence of persons on the tracks have not been implemented at Stratford station.
3. 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. No clear data is available to demonstrate that station staff training has improved expedition or clarity of communication in emergency circumstances.
Report Sections
Investigation and Inquest
On 27/12/2023 this Court commenced an investigation into the death of Brian Mitchell aged 72 years. The investigation concluded at the end of the inquest held between 15/12/2025 & 17/12/2025. The court returned a short form conclusion of, “Accidental death”
Brian’s medical cause of death was determined as; 1a Multiple Injuries 1b Blunt Force Trauma
Brian’s medical cause of death was determined as; 1a Multiple Injuries 1b Blunt Force Trauma
Circumstances of the Death
Mr Brian Mitchell was 72 at the time of his death
On 26/12/2023 at 15:20 hours, Brian was discovered on tracks at platform 13 at Stratford Underground Station. Brian was declared deceased by paramedics having sustained traumatic injuries that were incompatible with life.
CCTV was reviewed which showed the following:
• At 13:56:53 on 26 December 2023, Mr Mitchell alighted from a London Underground Jubilee line train at Stratford station and sat down on a bench on platform 13.
• At 14:45 hours Brian was seen to stand up and lurch towards the edge of the platform and fall onto the tracks.
• Brian moved and tried to climb back onto the deserted platform.
• At 14:50 hours, an incoming Jubilee Line train entered the platform and Brian was struck.
• The impact went unnoticed. The train reversed out of the station over Brian.
• Two further trains entered and left the platform each moving over Brian twice.
• A member of staff unsuccessfully tried to prevent a fourth train moving over Brian as it entered Platform 13.
The inquest heard that likely contributary factors to Brian’s death were, firstly that Brian was heavily intoxicated by alcohol.
Secondly, Jubilee Line trains use Automatic Train Operation (ATO). This means that Train Operators (TOs) do not drive the train. Acceleration and braking are automated.
The expectation of TOs is that they pay close attention to the train and the tracks before them and override the ATO system and apply brakes if they observe an object on the tracks.
In this case, at least 3 separate TOs failed to notice a man before them on the tracks or to override the automatic system.
The court heard that the initial collision with Brian was likely to have been avoidable. The track layout would have allowed Brian’s presence to have been noticed by an attentive TO. Additionally, it was asserted that a TO would have had sufficient time to react and bring the train to a stop many metres before Brian’s location.
The court heard that these omissions may have resulted from the fact that Platform 13 is a terminus platform which could result in a lowered level of attention on the part of TOs.
On 26/12/2023 at 15:20 hours, Brian was discovered on tracks at platform 13 at Stratford Underground Station. Brian was declared deceased by paramedics having sustained traumatic injuries that were incompatible with life.
CCTV was reviewed which showed the following:
• At 13:56:53 on 26 December 2023, Mr Mitchell alighted from a London Underground Jubilee line train at Stratford station and sat down on a bench on platform 13.
• At 14:45 hours Brian was seen to stand up and lurch towards the edge of the platform and fall onto the tracks.
• Brian moved and tried to climb back onto the deserted platform.
• At 14:50 hours, an incoming Jubilee Line train entered the platform and Brian was struck.
• The impact went unnoticed. The train reversed out of the station over Brian.
• Two further trains entered and left the platform each moving over Brian twice.
• A member of staff unsuccessfully tried to prevent a fourth train moving over Brian as it entered Platform 13.
The inquest heard that likely contributary factors to Brian’s death were, firstly that Brian was heavily intoxicated by alcohol.
Secondly, Jubilee Line trains use Automatic Train Operation (ATO). This means that Train Operators (TOs) do not drive the train. Acceleration and braking are automated.
The expectation of TOs is that they pay close attention to the train and the tracks before them and override the ATO system and apply brakes if they observe an object on the tracks.
In this case, at least 3 separate TOs failed to notice a man before them on the tracks or to override the automatic system.
The court heard that the initial collision with Brian was likely to have been avoidable. The track layout would have allowed Brian’s presence to have been noticed by an attentive TO. Additionally, it was asserted that a TO would have had sufficient time to react and bring the train to a stop many metres before Brian’s location.
The court heard that these omissions may have resulted from the fact that Platform 13 is a terminus platform which could result in a lowered level of attention on the part of TOs.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.