Gordon Rodger: Prevention of future deaths report
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Date of report: 24/08/2023
Ref: 2023-0292
Deceased name: Gordon Rodger
Coroner name: Robert Cohen
Coroner Area: Cumbria
Category: Suicide (from 2015) | Railway related deaths
This report is being sent to: National Rail Infrastructure Limited
| REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: Network Rail Infrastructure Limited | |
| 1 | CORONER I am Mr Robert Cohen HM Assistant Coroner for Cumbria |
| 2 | CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made |
| 3 | INVESTIGATION and INQUEST On 7 March 2023 I commenced an investigation into the death of Gordon Alexander John RODGER. The investigation concluded at the end of the inquest . The conclusion of the inquest was Suicide 1a Multiple injuries consistent with being struck by a train |
| 4 | CIRCUMSTANCES OF THE DEATH On Thursday 02nd March 2023 at 0714hrs British Transport Police were made aware that the driver of the 2C39 service travelling between Barrow and Carlisle had just reported seeing a human body in the Askam-in-Furness area of Cumbria. The driver explained that he had earlier observed something in that area when travelling between Millom into Barrow, around 0625hrs, but had been unsure what this was. Therefore, when travelling back through the Askam area he had decided to slow the train service down for a better look. On inspection he noted this was a body of a person. |
| 5 | CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. In the course of the inquest I heard that British Transport Police had recommended to Network Rail that they consider installing “anti trespass treads and gates to the north end of Platforms on Askam station if operationally possible”. By a letter to the Court dated 5th June 2023 Network Rail indicated that they had decided not to take this step. They explained that Askam station is rural, that limited resources dictate which works are prioritised and that there is no history of trespass. In the course of the inquest the court heard that the line in this location is more accessible that might usually be expected, including by stiles in nearby fences associated with a nearby golf club. In the circumstances I am concerned that the line may be readily accessible to individuals who wish to harm themselves. |
| 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you Network Rail have the power to take such action. |
| 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report,namely by 19th October 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. |
| 8 | COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the family of the deceased. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner |
| 9 | 24 August 2023 Robert Cohen HM Assistant Coroner |