Recurance · prevention of future deaths reports
Pre-inquest brief
Stopping trains for unwell trespasser on line
The earlier warning
Daniel Maurice McMahon · 21 Nov 2013 · Andrew Walker, London
“The Rule book be amended to require that trains stop, (signals are set to danger), when a person who is identified as being unwell or there is reason to believe might be unwell is trespassing on the line.”
What was promised
Stated action 1 · response to Daniel Maurice McMahon (21 Nov 2013) · stated timescale: none stated
“The LAS have reviewed the matter and I hope that you find the following explanation helpful: Purpose of needle chest decompression Needle Chest Decompression forms an important part of the management of chest trauma in the pre hospital environment by paramedic staff.”
judiciary.uk/wp-content/uploads/2013/12/2013-0271-Response-R.pdf
What recurred
- 13 Sept 2016 · Lauris Kodors · Andrew Walker · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Daniel Maurice McMahon · 21 Nov 2013
“The Rule book be amended to require that trains stop, (signals are set to danger), when a person who is identified as being unwell or there is reason to believe might be unwell is trespassing on the line.”
Later · Lauris Kodors · 13 Sept 2016
“That the RSSB Rule Book allows trains to be stopped only in circumstances where that person may cause damage to a train, but does not allow for trains to be stopped where the person may be in danger form a train.”
What happened next
No web check of the stated actions has been published for this chain.