Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate fencing allowing unauthorized railway access
The earlier warning
Ashley Matthews · 23 Jul 2015 · David Urpeth, Black Country
“(1 During the course of the inquest, evidence suggested that access to the site was gained by insecure fencing.”
judiciary.uk/prevention-of-future-death-reports/ashley-matthews
What was promised
Stated action 1 · response to Ashley Matthews (23 Jul 2015) · stated timescale: none stated
“There has been an extension to the palisade fencing to prevent access by climbing around the side of the fencing to the over bridge that carries the disused line from which [the deceased] climbed down.”
Stated action 2 · response to Christine Gould (28 May 2021) · stated timescale: none stated
“Following notification of the Regulation 28 report, a member of the Investigation Review Team within the British Transport Police was commissioned to review the investigation of [the deceased], the scope of this review was limited to the matters of concern. This review offered recommendations of which a number are included within this response.”
What recurred
- 28 May 2021 · Christine Gould · Nicholas Moss QC
- 28 Mar 2024 · Daniela Pani · Robert Simpson · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Christine Gould · 28 May 2021
“In [name redacted]' case, earlier consideration to the fence boundary being a credible route of access may have led to the fence boundary being improved more quickly after her death.”
Later · Daniela Pani · 28 Mar 2024
“Car park line side fencing being too low. The proposed mitigation was replacement of the fencing.”
What happened next
No web check of the stated actions has been published for this chain.