Malcolm James Ernest Potter · Prevention of Future Deaths report

On 9 October 2013 I commenced an investigation into the death of Malcolm James Ernest Potter aged 76 years. The investigation concluded at the end of the inquest on 6 February 2014. The conclusion of the inquest was that:

1. The medical cause of death was:

1(a) Multiple injuries predominantly neck fracture
2 Diabetes mellitus, coronary artery atherosclerosis, hypertension

2. Narrative Conclusion:

On 3rd October 2013 Mr Potter took his regular walk across the Dernford Crossing, "a user-worked crossing". After the South bound train passed Mr Potter proceeded to cross but was struck by a North bound train at around 0920hrs. He had no opportunity to see the light change from red when triggered by the arrival of the North bound train. This was due to configuration of the crossing. Life was pronounced extinct at 0948hrs.

Mr Potter was a regular walker in his local area. On 3.10.13 he approached the Dernford railway crossing while out walking. He waited for a south bound train to pass then he crossed the track and was struck by a north bound train which he did not apparently see or hear.

(1) The warning light for pedestrians is positioned before the gate through which the pedestrian passes before crossing the track. A red light is triggered by a train coming towards the crossing and turns green once it passes. The warning light system relates to individual trains and is not synchronised to take account of another train about to arrive. It is therefore possible for a pedestrian to see a red light turn green, and pass through the gate to cross the track oblivious to the light having turned red again due to an approaching train.
(2) It is the view of British Transport Police that this death could have been prevented by positioning the light on the opposite side of the track. Pedestrians would then see that another train was coming even after they have passed through the gate. A horn or some similar noise was recommended as an additional safeguard as provided on other crossings.
(3) The type of crossing is more suited to a quiet rural line than a very busy commuter and freight line as this one is, running between London and Cambridge.
(4) While there have been no previous accidents there is nothing to prevent this accident reoccurring at any time.