Gregory James Barber · Prevention of Future Deaths report

On 23 April 2021 an investigation was commenced into the death of Mr Gregory James Barber, aged 34. An inquest was opened on 29 April 2021 and the investigation completed at the conclusion of the inquest on 13 December 2021. The medical cause of death established at the inquest was that Mr Barber died from severe head injuries secondary to blunt force impact.

A conclusion of suicide was recorded.

On 12 April 2021, Gregory James Barber, who had a history of mental health difficulties and suicidal ideation, died as a result of ████████, having lain ████████.

Paramedics attended but his death was confirmed at 1717hours. On appraisal and consideration of the evidence at the inquest on the relevant standard of proof, a conclusion of suicide was recorded.

During the course of the inquest I heard witness evidence presented in relation to an investigation undertaken by the British Transport Police.

A section of a document entitled ‘Post Incident Site Report [PISV] – Lineside’ [ref: DOCU-2021-0590] contained a section entitled: ‘Considerations which could help to prevent further similar incidents/Agreed actions’ [p7 of 9].

Any such matters are set out in a table set down on a pro forma. The first column identifies a ‘Problem’, the second column is entitled ‘Mitigation Measure’. A third column refers to ‘Owner(s)’.

The completed columns read as follows:

Problem: ████████ is not easy and fencing is for the most part adequate. The Google image and photograph above show where is a ████████.

Mitigation Measure: ‘Additional fencing along the stone parapet run up to the ████████ as indicated on the google image above. There needs to be an inner line of fencing behind the stone parapet which is far enough away from the parapet to mean that the stonework cannot be used to climb over the fencing.

Owner(s): Network Rail.

Whilst it was noted that no ‘quick time intervention/rectification was required at the location’, the report goes on to state that:

‘To support the Coroner Inquest process we respectfully request that stakeholders submit a response to the considerations detailed in the report and any other activity planned for the location using the available section below within 60 working days from the date of the incident.’

At the date of the inquest, the section of the report entitled ‘Considerations response’ had not been completed by Network Rail and returned to the British Transport Police. Upon further investigation at the inquest, it was confirmed that the report was sent to Network Rail on 7 May 2021.

The ‘Problem’ identified by BTP followed an appraisal of the scene, with the ‘weak spot’ identified as being ‘…the most likely access point and would benefit from improved fencing’ [pp6/7 of 9].

The BTP investigation identified a clear problem and recommended a mitigation measure to which there has been no meaningful response, or at all, from Network Rail within the terms of the specific request to so respond within 60 days of the incident.

On the evidence that I heard at the inquest, it would appear that the weakness identified by the British Transport Police remains as it was at the time of their investigation and I am concerned that access to the railways tracks is not sufficiently curtailed at the location identified, as recommended.