“(brief summary of matters of concern) Concerns regarding the train station After…”

The coroner’s concerns

(brief summary of matters of concern) Concerns regarding the train station After Daniela’s death British Transport Police (BTP) prepared a ‘Post Incident Site Report’. I understand that this report was undertaken in conjunction with the station operator; in this case South Western Railways, and Network Rail. This report detailed a number of potential problems at and proposed mitigation measures. These included: 1. A lack of Samaritan signs on the platforms or within the stations. The mitigation proposed was conspicuously placed posters and/or additional signage. 2. Car park line side fencing being too low. The proposed mitigation was replacement of the fencing. The report was submitted on the 25th July 2023. Despite the passage of nearly 9 months from submission of the report to the date of the inquest the BTP officer giving evidence could not inform me whether these changes had been actioned. I was advised that this information had been requested from South Western Railways but had not been provided. On the 18th March 2024 I requested an update from BTP about the actions taken Regulation 28 – After Inquest Document Template Updated 30/07/2021 and invited them to attend the final hearing on the 25th March 2024. No information was submitted and no-one from BTP attended the final hearing. I am therefore concerned that measures to mitigate the risk of future suicides at the train station have not been implemented. Concerns regarding the 72 hour review meeting I heard evidence from a number of members of the CMHT regarding the policies, procedures and training around the completion of this important review meeting. During the course of this I heard that training and guidance did not specifically address how to deal with service users declining a visit or meeting. This is a complex area with competing demands of the duty of care, mental capacity and the autonomy of an individual to make decisions about their own care and treatment. The evidence from the CMHT Joint Service Manager was that guidance and/or training would be important for staff seeking to deal with this challenging area. This gap had not been identified by the NHS Trust in their Serious Incident Report in 2023. Following the evidence at inquest the matter has been raised internally but no changes have yet been introduced. I am concerned that the staff not being able to carry out face to face assessments in all possible cases gives rise to the risk of future deaths.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2024-0664

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0