After a pensioner was crushed to death by trains, a coroner wrote to Sir Sadiq Khan, the mayor of London, expressing concerns about safety on the tube.
Brian Mitchell died on the Jubilee Line at London Underground station Stratford in East London on Boxing Day afternoon in 2023.
An inquest heard the 72-year-old was seen on CCTV getting off a train and sitting down before standing up, lurching towards the edge of the platform and falling onto the tracks.
East London senior coroner Graeme Irvine said Mr Mitchell moved and tried to climb back onto the deserted platform, but five minutes later, he was struck by a train – and then was hit by several more.
CCTV images caught his last moments at 2 pm as he had sat on a platform bench at the station for 48 minutes before standing up and stumbling onto the line.
Five minutes later, a train that had halted at the Jubilee line station struck Mr Mitchell.
A further three trains went over his dead body before Transport for London staff suspended services.
The coroner said of the first train that struck Mr Mitchell: ‘The impact went unnoticed.
‘The train reversed out of the station over Brian. Two further trains entered then left the platform, each moving over Brian twice.
‘A member of staff unsuccessfully tried to prevent a fourth train moving over Brian as it entered platform 13.’
The coroner deemed that in the two years since Mr Mitchell’s death there was ‘no clear evidence to demonstrate that risks of fatal harm have been mitigated’.
The coroner believed that in the two years since Mr Mitchell’s death, there was ‘no clear evidence to indicate that risks of fatal harm have been mitigated’.
The coroner has now sent his Prevention of Future Deaths report to Sir Sadiq Khan and Transport Secretary Heidi Alexander.
They have 56 days to respond, with details of the proposed action.
The coroner said Mr Mitchell, from Edinburgh, was drunk at the time of the incident.
He also told how Jubilee Line trains used Automatic Train Operation, which means drivers do not drive them, and the acceleration and braking are automated.
Mr Irvine said drivers were expected to keep a close eye on the tracks and brake if they see an object on the line.
However, in this instance, a man on the tracks was overlooked by three different drivers.
The inquest said the initial collision with Brian should have been avoided by an alert driver braking in time as the train entered the terminus.
Multiple blunt force injuries caused Mr Mitchell’s death, which was reported as an accident.
The Daily Mail contacted the Mayor of London’s office, Transport for London and the Department for Transport for comment.
Claire Mann, TfL’s Chief Operating Officer, said: ‘Our thoughts are with the family and friends of Mr Mitchell, who sadly died at Stratford Tube station.
‘We are committed to learning from this tragic incident and assisted the coroner during the inquest.
‘We will respond to the coroner’s Prevention of Future Deaths report and are taking action to prevent incidents like this from happening again.’
A Rail Accident Investigation Branch report criticised TfL last January over Mr Mitchell’s death.
The rail safety regulator said there were no other passengers or staff on the platform when Mr Mitchell fell, and the driver of the first train did not see him.
This was ‘possibly’ because the use of an automatic system to control Jubilee line trains reduced their level of attention, the report stated.
Emergency personnel discovered that Mr Mitchell, who had been residing in Hanwell in west London, had suffered fatal injuries.
A post-mortem examination discovered he had a blood alcohol concentration of 272 milligrams of alcohol per 100 millilitres of blood, which is more than three times above the drink-drive limit in England, Wales and Northern Ireland.
The report stated a driver could also have been ‘distracted’ by the presence of another staff member standing on the platform as they arrived.
The RAIB said the ‘consequences of the accident were made more severe’ because the driver of the second train also did not see Mr Mitchell.
After running over the passenger, the third train’s driver left their cab as normal and entered a staff area for a ‘personal needs break’.
They reported seeing an inflatable doll on the tracks to the control room six minutes after the train had stopped.
A customer service assistant on the platform failed to stop the fourth train despite seeing Mr Mitchell.
The train driver also realised there was a person on the tracks.
The RAIB recommended that London Underground consider the use of technology that can warn trains if it detects a passenger is in a dangerous position.
Additionally, it demanded that the organisation evaluate the potential impact of trains with automated systems on drivers.
In another event, a mother was struck by two Tube trains on her way home and lost both her right arm and leg.
PR executive Sarah de Lagarde slipped on a wet, uneven platform at High Barnet station in north London in September 2022 and fell down the gap between the train and the platform.
She broke her nose and two front teeth in the fall, but nobody heard her frantic cries for help.
After being struck by two trains, she was rushed to the hospital, where her limbs were amputated.
After TfL conducted an inquiry into Mrs. de Lagarde’s accident and alerted the Office of Rail and Road Accident Inquiry Branch, it was determined that no additional investigation was required.
Sadiq Khan sees himself above such things, so good luck getting an explanation from him, and could anyone please remind me how much these drivers are being paid for a job they apparently can’t do very well?
And this will be Sadiq Khan when challenged, ‘Eh, eh, eh… could you be more specific, I didn’t understand the question.’
This man died in the most horrific way imaginable. All platforms should have barriers with doors, but that would be far too costly – weighing up the pros and cons, preventing death is less important – saving money will always win hands down.
Evidently, drivers and staff were doing nothing. They should have been monitoring the line for any objects on it, yet no one noticed one man on the line trying to climb off it onto the platform. What were they all deaf, dumb and blind?
THE MONTHLY MOSQUITO 