Matthew Hoare
PFD Report
All Responded
Ref: 2015-0203
All 1 response received
· Deadline: 22 Jul 2015
Coroner's Concerns (AI summary)
Ineffective security equipment allowed easy access to the station and tracks after operational hours, with individuals able to climb through widely spaced yellow tape.
View full coroner's concerns
_ (1) The lack of effective security equipment preventing access to the station and tracks after the hours of operation.
(2) The ease at which Mr Hoare was able to access the station and tracks by climbing through widely spaced yellow tape.
(2) The ease at which Mr Hoare was able to access the station and tracks by climbing through widely spaced yellow tape.
Responses
Action Taken
Network Rail reports that following the incident, the roller shutters at the station entrance have been reinstated and are now locked during non-operational hours, and anti-trespass grids have been installed at the Denmark Hill end of the platforms. LOROL are working on a system allowing their stations to be opened remotely from the central control centre. (AI summary)
Network Rail reports that following the incident, the roller shutters at the station entrance have been reinstated and are now locked during non-operational hours, and anti-trespass grids have been installed at the Denmark Hill end of the platforms. LOROL are working on a system allowing their stations to be opened remotely from the central control centre. (AI summary)
View full response
Dear Ms. Tagliavini;, Inquest into the death of Matthew Lee Hoare Regulation 28 Report to Prevent Future Deaths write in response to your Regulation 28 Report dated 27 2015 concerning the Inquest into the death of Matthew Lee Hoare who sadly died on 25 June 2014.Please accept my apologies for the delay in responding and am grateful for the extension kindly granted whilst we considered your concerns and liaised with London Overground Rail Operations Limited ("LOROL"): Network Rail Infrastructure Limited ("Network' Rail") owns, operates and maintains the rail infrastructure including the track and signalling equipment across the UK Clapham High Street Station ("the Station") is not operated by Network Rail but is managed by the operator of the majority of trains stopping at the station, LOROL Although the station is not an asset under our management; but noting that the recommendations in your report concern access to the station and the tracks we have sought clarity from LOROL. LOROL has been able to assist with some information particularly in respect of changed practices at the Station, which we hope will assist in responding to your concerns_ There is CCTV at the station which is controlled by LOROL. LOROL have confirmed that this CCTV footage shows Mr , Hoare gained access to the track after the cessation of services on the night of 25 June 2014. Due to a previous fault with the roller shutters at the entrance to the station these were not in service and were left 'open' , however, a metal frame with yellow tape stretched across its span had been placed in the entrance to obstruct to the station_ This was by-passed by Mr: Netvronk: Rail infrastrucfure Limitec Registered (Hlice: 2" Flkror, (ne Everstiolt Shreut, Lersckor NWI 20N Rerlslereci ir1 Eniglao; akf Wales No 2910415017 May entry
Hoare, who parted the tape and entered the Station: Having gained to the station, Mr: Hoare then made his way to the platform and then the track Following the incident on 25 June 2014, the roller shutters at the entrance to station were reinstated and are now locked during non-operational hours. LOROL have advised that are working on a system allowing their stations to be opened remotely from the central control centre_ The station has had anti-trespass grids installed following the incident at the Denmark Hill end of the platforms; these are hard rubber panels which are placed on the floor, having surface of sharp peaks that is almost impossible to walk upon: There is signage at the Wandsworth Road end of the station platform including; "high visibility vest required" sign (white on blue); an anti-trespass sign (red roundel) warning of the danger of moving trains; and "Danger: High Voltage" sign (black on yellow) warning of the live third rail supply. This signage is clean, in condition and is prominently displayed in the centre of the walkway_ For our part; safety is a core value for Network Rail and we are continually striving to reduce fatalities on the railway through a number of initiatives an example of which is the installation of barriers to separate rail 'streams' where access is not needed to Network Rail infrastructure; an example of this can be seen at the Station where the SouthEastern railway infrastructure (which does not offer services from the Station) is fully fenced from the LOROL infrastructure_ hope that this response provides you with adequate information but if you would like any further clarification, please do not hesitate to contact me_ Yours sincerel Route Managing Director, Network Operations entry the they good
Hoare, who parted the tape and entered the Station: Having gained to the station, Mr: Hoare then made his way to the platform and then the track Following the incident on 25 June 2014, the roller shutters at the entrance to station were reinstated and are now locked during non-operational hours. LOROL have advised that are working on a system allowing their stations to be opened remotely from the central control centre_ The station has had anti-trespass grids installed following the incident at the Denmark Hill end of the platforms; these are hard rubber panels which are placed on the floor, having surface of sharp peaks that is almost impossible to walk upon: There is signage at the Wandsworth Road end of the station platform including; "high visibility vest required" sign (white on blue); an anti-trespass sign (red roundel) warning of the danger of moving trains; and "Danger: High Voltage" sign (black on yellow) warning of the live third rail supply. This signage is clean, in condition and is prominently displayed in the centre of the walkway_ For our part; safety is a core value for Network Rail and we are continually striving to reduce fatalities on the railway through a number of initiatives an example of which is the installation of barriers to separate rail 'streams' where access is not needed to Network Rail infrastructure; an example of this can be seen at the Station where the SouthEastern railway infrastructure (which does not offer services from the Station) is fully fenced from the LOROL infrastructure_ hope that this response provides you with adequate information but if you would like any further clarification, please do not hesitate to contact me_ Yours sincerel Route Managing Director, Network Operations entry the they good
Sent To
- National Rail
Response Status
Linked responses
1 of 1
56-Day Deadline
22 Jul 2015
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 2nd July 204 commenced an investigation into the death of Mathew Lee Hoare, aged 29 years, The investigation concluded at the end of the inquest on 12th March 2015. The conclusion of the inquest was "Accidental Death" as a result of multiple injuries and severe burns
Circumstances of the Death
In the early hours of 25th June 2014 after a night out socialising with friends, Mr Hoare was found Iying on the live rail near Wandsworth Road Train Station having been seen to enter Clapham High Street Station after hours and gained access to the platforms and tracks_ He fell on the live rail and electrocuted and was also hit by an oncoming train, thereby sustaining fatal injuries
Action Should Be Taken
Inmyopinion action should be_taken to prevent future deaths and believe your To The organisation] have the power t0 take such action_
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.