Michael Younghusband

PFD Report All Responded Ref: 2016-0235
Date of Report 23 June 2016
Coroner John Tomalin
Response Deadline est. 18 August 2016
All 1 response received · Deadline: 18 Aug 2016
Coroner's Concerns (AI summary)
A railway crossing point was in a poor state, with a section standing proud of the track, presenting a significant tripping hazard for users.
View full coroner's concerns
evidence revealed matters giving rise to concern: In In the there is a risk that future deaths will occur circonistancee it is my statutory duty to report to you: [BRIEF SUMMARY OF MATTERS QF CONCERN to Mr Younghusband's The poor state of the crossing point was oof concern had observed a Tamipoas theye believed it was & potential tripping hazard asdhey section_ 00ithe Lympstone side of that crossing; standing proud of the metal track bed:
Responses
Network Rail Private Sector
23 Jun 2016
Action Taken
Network Rail completed ballast surface improvement works at the East Devon Way crossing point on 20 July 2016, and edges of any trip hazards have been clearly marked. (AI summary)
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Dear Sir Michael Dean YOUNGHUSBAND Deceased D.O.D 10 December 2015 Inquest held on 2 June 2016 at County Hall; Topsham Road, Exeter Regulation 28 Report On behalf of Network Rail write in response to your report dated 23 June 2016. Your report concerns the inquest into the death of Michael Dean Younghusband who sadly died when he was struck by a train on 10 December 2015. Your report outlined your concern that: The poor state of the crossing point was of concern to Mr Younghusband's family as they believed that it was potential tripping hazard a8 they had observed a metal section; 0n the Lympstone side of that crossing, standing proud of the track bed. You considered that action should be taken to prevent future deaths and wrote to Network Rail as the party with the power to take action_ wish to assure you that safety is core value for Network Rail; We are committed to continuously seeking to reduce risk and improve safety across the railway network believe the footpath level crossing you are referring to is known as East Devon Way which carries the well-used public right of way of same name over the single track Exmouth branch line_ As with all crossings of this type, it is routinely inspected six-monthly by a Level Crossing Manager ("LCM); who is responsible for reporting all defects found to maintenance colleagues_ When safe to do so, the LCM carries out certain minor repairs and reports them accordingly: Nelwurk Raii infrastructure Limited Registered Oflice; 2"' Fioor, Onn Evorsholt Siroet Loridor; NWVI ZON Regislered in Englarxi and Wales No. 2904587

There is a timber ballast retainer on the western (estuary) approach to the level crossing which forms a step up to track level including the rubber deck panels installed on the track itself: This step is very prominent and obvious to users but time to time the ballast can wear down and so it is built up when required to minimise the stepping required. If Mr Younghusband entered the track at the level crossing it may be possible that he tripped on a metal fitting known as a deflector or chain guard which is attached to the edge of the decking panel facing the track: It is not clear if this is what his family referred to as 'standing proud of the track bed'_ but these fittings are not in the way of anyone crossing the track over the decking as intended. The last routine inspection of the level crossing prior to Mr Younghusbands death took place on 16 September 2015. The LCM noted that the track ballast was low to the level crossing so he built it up again: A more recent inspection took place on 4th March 2016 followed by another site check 21 June 2016 revealed that the ballast had moved again sO in late June the LCM discussed with maintenance colleagues the of more substantial 'ballast boxes' s0 as to contain movement more effectively and minimise the stepping involved. am happy to confirm that ballast surface improvement works were completed at the crossing point on 20 July 2016_ Further edges of any trip hazards have been clearly marked in order to highlight them to the public. hope that this response provides you with adequate assurance that the issues you have identified have been properly considered and addressed If you would like any further information or assistance please do not hesitate to contact me_
Sent To
  • Great Western Railway
Response Status
Linked responses 1 of 1
56-Day Deadline 18 Aug 2016
All responses received
About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Report Sections
Investigation and Inquest
On 10ih December 2015 commenced an investigation into the death of Michael Dean YOUNGHUSBAND, aged 22. The investigation concluded at the end of the inquest on 2nd June 2016. The conclusion of the inquest was given as Mr Younghusband died as a result of an accident_ Medical cause of death as Multiple Injuries
Circumstances of the Death
Mr Younghusband had attended RMB Lympstone to undertake a course: He successfully completed that course with a distinguished pass_ He and others went out to celebrate the end of the course and visited various houses in and around Exmouth and Topsham. Mr Younghusband became detached from his friends and it was believed that he was making his way back to camp along the railway, between Exmouth and Lympstone: His body was found close to a pedestrian crossing across the railway tracks His body was hit by a train and he suffered non-survivable injuries: His blood alcohol level was 245mg/1OOml of blood when the Post Mortem sample was tested by laboratory: Mr Younghusband"s family were concerned as to how someone who had been drinking large quantity of alcohoi had managed to walk the distance he did from when he'd last been seen to where his body was found. Of greater concern was the poor state of of the crossing very near the where the body was struck by the train: The evidence given at the Inquest by Mr Younghusband's brother who, with his father and others had been taken to the crossing near where Mr Younghusband's body had been found, expressed their concerns about the poor state of repair at the crossing only one month after Mr Younghusband had been struck by the _train public repair point
Action Should Be Taken
action should be taken to prevent future deaths and believe your In my organisation have the power to take such action to ascertain whether or not any works may be necessary to An investigation eheicrossing from tripping or falling and potentially suffering fatal Prevent thersare uotrableecraove gutof the? of an oncoming train_ injury if they are not
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.