Inquest Report

Inquests are under the jurisdiction of a Coroner who is often a Solicitor chosen for this role. They are assisted by a Coroner’s Officer. Their future role is being examined but at present Coroner’s have a great deal of flexibility in how they interpret their rules of operation.

For more information, please look at this website:
http://www.kcl.ac.uk/depsta/law/research/coroners/1984rules.html

If you want to know what to expect from the Coroner's Service, please read the Berkshire Coroner's Service Charter.

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About the Inquest

These notes are by no means the whole story as I am finding it hard to hear everything being said and I hope others present will add their thoughts when they feel able. It is not easy writing about such emotional issues straight away. If anyone else present believes I have made any errors in these reports, please let me know.

Setting the Scene

The Inquest is being held in a Conference Centre on the Slough Industrial estate. The hall is a massive barn-like structure akin to an exhibition hall. The acoustics aren’t that good and the temperature is controlled by blowers which make it rather cold. At least there is a nice café to go to and parking is free and relatively easy. Travel by road to the centre has not been easy, especially when there are blocks the M4. If you can travel by train, a taxi ride is needed to the venue.

The Coroner sits on a dais with his assistant, Paul Beescroft, in front. BTP Officers are to one side with all their files and papers with the chair for witnesses in front of them. The jury sit on the other side with a microphone for if they want to ask a witness a question. Facing the Coroner, there are two rows of tables and chairs for the Legal teams, representing FGW, MIB, Network Rail and some of the families. Peter Webster is representing himself and the Main family were able to gain Legal Aid so they could be represented by a barrister.

When the witnesses have been questioned by the Coroner, the advocates and the jurors are always asked if they want to question the witness. I have now discovered that anyone in the audience can ask a question if they state who they are and address it to the Coroner.

The public sit in rows beyond them with the two front rows set aside for bereaved families and Family Liaison Officers. A section of the hall is reserved for the media whose numbers have dwindled daily.

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MONDAY, 8th October 2007

The day starts at 10am and ends at different times. The jury was sworn in. According to an ITV reporter who is used to Inquests, they are a particularly good jury in the way they are asking questions. I agree and they have so far asked some very pertinent questions.

The Coroner, Peter Bedford, emphasised the purpose of the Inquest: to establish who died, where, at what time and how they died. Although the purpose is not meant to be wider than this he is allowing time for safety issues to be aired and has the power to make recommendations about safety.

Witnesses were then called, interspersed with statements for survivors. Apparently statements from two people from each carriage were used. Witnesses included the Train Manager, two passengers who are medical doctors who gave assistance to the dying, and Tommy and Brian, the marines. Five of our Network members had statements read though only knew about it through the information gained by the Network. Of course the two most harrowing witness accounts came from David Main and Peter Webster, both of whom showed great courage. It was so hard for them and their families to go through these accounts and also hard for two other of our members who were being talked about in this formal setting but had no place to tell their stories as this is an Inquest and not an Enquiry. In some cases the witness account of other on-lookers didn’t quite tie in with their own. However, it helped people to hear the similarities between experiences too – especially the accounts of the braking, swaying, the sensation of being as if in a tumble drier when carriages turned over.

The Train Manager had a tough time being questioned about why he undertook the procedure he was trained for – that is, to protect the train by immediately placing track circuit clips on the line to stop other trains. He was also questioned about why he encouraged passengers to evacuate the train as opposed to the normal advice of keeping people in the carriages. He explained that he did what he felt was appropriate given the circumstances. Survivors present felt great compassion for him because they knew only too well how hard it was to make decisions in that awful environment with little information.

I had to leave at 3pm so missed the last hour. I believed that there were only a few more statements to be read and had not heard the announcement that a computerised video was being shown, originally listed for 17th October. A phone call from a member later told me that the video was shown and, after a day of heightened emotion, it came as a shock. The video was a computerised aerial view of the crash and pointers showed where the people who died were located. From conversations I have people not on the train believe the computerised version would not affect people in the same way as real images. Those who were on the train said it didn’t make any difference – it was still emotional and real.

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TUESDAY, 9th October 2007

The journey in pouring rain and heavy traffic up the M4 was horrendous and it took nearly two hours from Newbury – and of course the proceedings started on time so some of us missed the start.

The first witness was Bryan Drysdale’s brother, Ronald, followed by statements and witnesses from Drysdale’s friends and work colleagues. The themes of interest worked out from the questions being asked were:

the state of repair of his Mazda 323 (poor, untaxed, dodgy door lock which could be opened from inside but not outside [so he could have got out but others could not have opened the door], often stalled); his state of mind and health generally (not depressed but not happy, quiet, reserved, very private, especially about his past and private life even to friends, friendly, generous to friends with loans but frivolous with money using a friend as his banker so he didn’t spend it all and asked a colleague for loans.) He had a good job as a sous chef and was reasonably well paid for the industry. Like other chefs, he got stressed in the kitchen and sometimes got cross with people. Obviously accounts varied according to the witness and he was different with different people, but he came over as a quiet, private person who had friends based on the ‘Up the Junction’ pub in Reading. He drank regularly, smoked weed from time to time and took ecstasy very occasionally but it was claimed these never affected his work and he never turned up drunk or incapacitated. He was described as a ‘man’s man’ who loved football & going to see Liverpool FC, drinking and buying old cars ‘not fit to be on the road’.

He appears to have liked his job though had a few problems with the Chief chef because he felt he was ‘picking’ on him. A colleague said the chef had to speak to him about improving his skills of communication with other kitchen staff when it was really needed. He preferred to get on with work on his own. On the 6th November, he was asked to do an extra shift on his day off and he agreed. He arrived at 4pm as agreed but then left an hour or so later as he said he wasn’t feeling well. Questions seemed to be trying to discover if he had made or received a phone call of some kind that caused him to leave suddenly. Colleagues said he was talking as if he was planning to come in the next day and all the witnesses mentioned he was looking forward to moving to his own accommodation the next week. He had been living in shared lodgings in Reading and had contributed to a deposit to share a small house with a friend. A colleague who chatted to him regularly during smoking breaks said he was jollier than usual when she last saw him on the Saturday afternoon, though she also acknowledged that some people saw him differently from others. Questions also revolved around Drysdale’s sexuality. He was gay and had known this himself since he was 13 but had never come to terms with it and did everything to hide it from other people, especially his relatives. A statement was read from his first sexual partner. They had been together for 4 years until 1982 and had kept in touch on and off as friends until their last contact in 2001.

Every friend and colleague who made a statement was surprised that Drysdale was involved in the crash, at the time and with hindsight, and no one believed he would take his own life or hurt others intentionally.

Peter Webster very generously offered sympathy to Ronald Drysdale and his family. I know this mirrored the views of other Network members who feel compassion for the family regardless of what they feel about Drysdale’s actions.

The Inquest ended at lunch time today.

Tomorrow, the two chefs senior to Drysdale will appear as witnesses, including the chef who Drysdale thought was ‘picking on him’. (A friend today said he had been much happier about this chef after he had talked things through with him).

The Coroner warned that the first two witnesses tomorrow, Wed 10th Oct, would be Doctors giving medical details of the injuries sustained by those who died and their evidence is likely to be distressing to others. It was really helpful that this warning was given so clearly.

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WEDNESDAY, 10th October 2007

The ‘Newbury ‘ contingent had a much easier journey today but those coming from the east were delayed by a block on the M4 so proceedings were delayed for 40 minutes.

The first two witnesses were forensic pathologists who gave accounts about the cause and time of death of each of the seven who died. These contained of course much horrific material but thankfully nothing that bereaved families did not already know.

I am not going to repeat any of the details here but if anyone wishes to know more then please contact me.

Much of he questioning revolved around whether laminated glass in the trains would have prevented death of the four people who were thrown out of the train and died. The pathologists said this was a very complex issue. In general, laminated glass would have prevented the type of horrendous injuries sustained by these people but they could not say that they would not have died for other reasons, for example by the force of hitting a wall of laminated glass. Seat belts would have kept people in their seats and prevented deaths by hitting the glass an dbeng thrown out, though there would still be s few cases where seat belts would not prevent death.

They explained it in terms of seat belts in a car. Generally seat belts which keep people inside a car save deaths. However, not everyone wearing a seat belt who is thrown from a car dies and there are always a few cases where people still die even if wearing a seat belt. Much depends on the details of the person and the forces at work in individual cases.

In the afternoon, the two senior chefs from Wokefield Park were questioned. Their stories about Drysdale were very similar to those already mentioned.

There were four significant pieces of information.

First, two weeks before the crash, Drysdale had told the senior chef that he had ‘enjoyed’ watching a TV documentary about the Selby train crash where a man had fallen asleep and driven his car onto the mainline rail track derailing a fast train.

Secondly, a week before the crash Drysdale had made a complaint to the Police about his ‘boss’ threatening him at his home. It was assumed his ‘boss’ was the Executive Chef who he claimed picked on him. This chef gave evidence that he had never picked on him (supported by other staff) but that Drysdale was extremely sensitive to implied or actual criticism, even if this was feedback needed to maintain standards in the kitchen. Another chef told how Drysdale made strange comments which implied he thought (wrongly) that this agency chef was ‘taking’ his job.

Third, Drysdale’s mood may have been affected by the pain he was suffering from abscesses in his mouth. He refused to get treatment and had had to be sent home a week or so before the crash because he was in such pain.

Fourth, Drysdale left work at around 5.30 pm on the 6th telling colleagues he was unwell. He did not report his departure to the Duty Manager as he should have done.

Proceedings ended at 3.30 pm

Tomorrow the Inquest will hear from witnesses from NHS Direct about a phone call Drysdale made to them just before the crash. I am unable to attend but a few of our members will be there to report back.

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THURSDAY, 11th October 2007

(This report came from Ian who was present today. When listening to him on the phone, the importance of not jumping to conclusions until the whole story had been heard really came over. Not all witnesses have accurate memories and some things said cannot be substantiated.)

Today’s witnesses were a Thames Valley Police Enquiries Officer who took a call from Bryan Drysdale at 1.36 pm on 2nd November; a Senior Patient Contact Assistant from NHS Direct who took a call from Drysdale 5 minutes after he spoke to the Police Officer; a Clinical assistant at the Reading Florey Unit for sexually transmitted diseases, and finally several staff members from the Retainer Group who had answered a call from Drysdale at about 4.20pm in which he had talked about suicide on a level crossing. The retainer Group is a company that etches car registration numbers on car windows as a security device. They are found on all Mazda cars, which also bear a sticker warning potential thieves that the car is protected in this way. Drysdale’s Mazda car had such a sticker, though with an out of date phone number for the Retainer Group.

[The previous owner of the Mazda said the sticker was not on the car when he owned it. Was it just that he did not notice it? I have only just realised we have a similar sticker on our Mazda and I had never noticed the registration numbers etched on each window – but I am a female!]

To summarise quite a complex set of information:

The call to the Police: Drysdale complained of his family being targeted and threatened after hearing voices outside his lodgings saying “We want both of you. We know where your family live”. He also said he felt he was being followed. Much of the time he spoke about his medical problems and fears that he was HIV+ve. He was rambling and the call was not taken seriously and not acted upon. He was however advised to call NHS Direct which he did immediately.

In the call to NHS Direct he was described as nervous and stressed. When asked if he was suicidal he said “Mmm – yes.” He discussed his fears about being HIV+ve and described his symptoms as “his head and bones felt as if they were cracking” and he was afraid to leave the house.

The clinical assistant from the Florey Unit saw him on Friday 5th November. He was worried about his mental health and his sexual health. She established that Drysdale last had sex with a male 5 years ago and with a female 3 years ago. A range of tests for sexual diseases, including HIV+ve were undertaken. The results were due back on Thursday 11th November – in fact all results proved to be negative.

Witnesses from the Retainer Group: An employee had received a call from Drysdale at about 4.20pm on 6th November. He asked about the nature of the business but then went on to say he felt suicidal and wanted to take his car onto a Level Crossing and let the train do the rest. This call was verified by other staff who had talked about what they should do. As they only had a name, they felt there was nothing they could do anyway, though one person offered to tell a friend who was in the Police. This wasn’t done, though Sergio Nardone who took the call thought it had been. On the Monday after the crash. Sergio heard Drysdale’s name mentioned on the radio and put two and two together and realised the significance of Saturday’s call. He told his boss and they called the Police. A phone call logging system in the company was locked away on the Saturday because carpets were being fitted and no one had access to it at the time. This log has been extensively examined. Drysdales name did not come up though his father, Keith Drysdale appeared on past logs. Confusing information came from Sergio who after his first statement kept coming out with further information until March 2005 when he gave a second statement. For example he reported that Drysdale had phoned and spoken to him on two previous occasions when he had spoken in detail about suicide using a level crossing. However other witnesses were concerned about this evidence and it has not been proven to be accurate.

Tomorrow

Further evidence in written statements about the method of analysing data logs will be heard.

The witness listed for tomorrow, Michael Hinchcliffe, a Manager in the Retainer Group, appeared today instead.

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FRIDAY, 12th October 2007

It just gets more curious by the day. The Assistant Coroner has just phoned to tell me what happened today. You remember yesterday’s witness from the ‘Retina’ Group who phoned the police about a call he claimed to have received from Drysdale an hour or so before the crash.

Today, a Professor Stewart confirmed that exhaustive checks of the phone logging system at Retina Group (in Ashford, Kent), engravers of car windows for security purposes, did not find any trace of ANY calls from or to any phones at Wokefield Park Hotel or from Drysdale’s phone. The IT Manager from Retina backed this evidence. They said the chance of a call not being logged is a million to one.

It appears everyone is at a loss, after exhaustive enquiries on several fronts, about this aspect of the case and why Drysdale would have chosen to phone this company. The name of Drysdale’s father, Keith, was found on past call records but there appears to be nothing significant about this. Keith Drysdale has died since the crash.

On Monday, the Inquest will continue with written statements from emergency and medical staff who were at the crash site and medical staff from Royal Berks hospital.

A few witnesses will be there to speak in person. I believe much of their evidence will relate to Charlie Matthews death as he died in hospital the day after the crash.

Wednesday will be a particularly important day and a reconstruction video will be shown. Please be warned that this is likely to be distressing for survivors and it is advised that you prepare yourselves in advance, have someone you trust with you and think carefully about whether you will stay in the Hall or not. You can leave any time but some may feel more comfortable watching from the back and near the exit. There have been Victim Support volunteers available for support on some days. If I am there and anyone needs specific support from me, please just tap me on the shoulder. (I sit near the front so I can hear.)

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MONDAY, 15th October 2007

Please note: there wil be no inquest sitting tomorrow, Tuesday 16th Oct, as the witesses down for tomorrow appeared today.

Another long day and I left at 4pm while the last witness, the ITU consultant at Royal Berks Hospital was still being questioned. Here is my account to the best of my ability and hearing!

Charlie Matthew’s son and daughter were seated with the Advocates asking questions about their father’s treatment.

The statements included one from Neil Marney of the Ambulance Service who was among the first to arrive and who did the first brief Triage of survivors. Details were given of how the driver was located and how other passengers who died were found and certified as dead.

Most of the day was given to the length of time Charlie lay beside the track on a make-shift stretcher (60-90 minutes). Evidence came from a police officer who had only started the job 9 weeks before. He was asked by a Fire Officer to stay with Charlie and he fully expected that someone would come and attend to him soon. He had been initially triaged as a P2 (attention needed within hours rather than minutes) and the PC cannot remember him being re-triaged though a BASICs doctor from a rapid response team thought a colleague may have done so. This Doctor described the difficulties they were working under without adequate light or equipment and with a vast site to cover stretching a long way down the line. The PC kept Charlie talking about football etc, though it was increasingly hard as he was in pain, felt sick and he found it hard to cough and had nothing under his head except the PCs arm. He told them he had a pacemaker and it is believed someone knew he was diabetic. They described how eery and quiet it was by this time as other survivors were either in the field or at the Winning Hand by now. Eventually Charlie was given the more detailed Triage (Triage Sort) and taken to the Casualty Clearance Station where other rapid response doctors were based. His injuries were assessed again and deemed to be potentially worse than first realised but he was still a P2. However, he may have had a collapsed lung so a doctor was asked to accompany him to Royal Berks where he arrived 4 hours after the crash at 22.15pm. He was assessed in A & E then taken to the CDU (1:1 care but one below ITU). During the early hours of the morning he suddenly began to deteriorate and more scans were done though this was hard as his condition became critical. Eventually in the afternoon it was decided not to use anymore invasive treatment and he died with his family around him.

As well as evidence from RBH consultants in A&E, CDU and ITU, we heard evidence form a Cardio-Thoracic surgeon, Mr Tim Graham, from a Birmingham Teaching Hospital, QEH. He accepted it was much easier for him to reflect with hindsight just using paper records and it can be quite different when you have a real patient in front of you in a Major Incident situation. He was of the opinion that the delay at the track did not help and that the treatment he would have given would probably have done some things differently. He would have done more to check whether or not Charlie’s pacemaker was still working and would also have carried on invasive treatment for longer to see if it worked at all before deciding to give up. He felt a specialist Cardio-Thoracic surgeon should have been called in and said that a 72 year old man with a pacemaker in such a serious crash should have been removed from the track with more urgency. He could not say how far this would have meant Charlie would have survived. It was recognised that QEH had superior equipment and specialists in cardio-thoracic medicine whereas RBH does not (the nearest specialist units are Oxford and Harefield).

The consultant in charge of ITU on the night at RBH explained his team were used to dealing with such traumatic injuries and there were 7 in the team who all agreed with what was done. He felt Mr Graham had overplayed the chest and lung injuries because it was his specialism and that the greater factor in Charlie’s death was multiple organ failure, especially kidney failure. The post-mortem also showed significant heart disease and hardening of the arteries.

The Rest of the Week

Tuesday – not sitting

Wednesday will include evidence form people at the Level Crossing around the time of the accident. A video reconstruction will also be shown. I believe this is longer than the one shown last week so be warned this may distress you and think about your support.

Thursday: evidence about Drysdale’s state of mind from a psychiatrist and from the BTP chief, Eamon Carroll.

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WEDNESDAY, 17th October 2007

Before the jury were invited in, the Coroner considered:

A request for bereaved families to be given the opportunity to have eulogies for their loved ones to be read out. The Coroner had no objection but needs to think about the timing. He felt this should be done after the Jury has given it’s verdict so they were not unduly influenced by them.
A request from BBC South Today to have permission to use a Video Reconstruction of events at the Level crossing before the crash. After much discussion (see below) he decided to delay a decision until he and others had seen it.

Proceedings opened with a statement from a local woman who used the crossing and saw no other car or person at just after 6.00pm. Evidence was then given in person from two witnesses, Rachel Clifford who works at the stables just north of the crossing, and PC Mark Brazier who was the off-duty police officer who saw the car on the line and witnessed the crash. This took some time and a lot of detail was given.

The key points were:

Rachel saw an old, possibly blue, car driving past towards the A4 and became aware that this car turned round and came back past towards the crossing more slowly than usual. She became suspicious and was concerned about recent burglaries in stables. Her friend had left earlier in her car but then returned because of traffic problems on the A4 and she arranged to follow Rachel on the back way round the lanes. As Rachel locked up she was still keeping her eye on the suspicious old car and saw it cross the crossing, then turn round and come back slowly. She passed the car as they both crossed over the crossing. The old car cleared the crossing but she was concerned by it’s slowness and was glad when she saw another car coming towards her as she felt this would mean the other car had to move on. Her friend’s car was behind but in her wing mirror she believed she saw the reversing lights come of the old car light up. She went on and thought no more about it.
PC Brazier gave detailed evidence starting from when he drove from home down Ufton Lane to get to the A4 and Newbury. What happened next occurred in a very short space of time. As he approached the crossing, he saw a car apparently on the crossing going very slowly and veering a bit to the right. He tried to work out why the car might be there and thought perhaps there were engineering works closing the line and that the car belonged to an engineer. The car’s brake lights and reversing lights went on and off a few times and he began to think the engineer should know better. The fact that the car was moving made him believe it would soon be driven off the crossing. He flashed his lights and beeped his horn but the driver didn’t seem to respond with any urgency. Brazier then became anxious that the driver had other intentions and he reached for his mobile phone. However, he decided it would be best to take action and go to the car. It was very dark and he could not see who was in the car. On the way to the car the warning alarm and flashing lights warned him that the barriers were going down and he also became aware of the resonance of a fast train by the vibrations on the line. He saw the emergency phone and decided instead to use it. There was no emergency lighting or automatic lighting when he opened the phone box and he only had a very small torch.
NOTE: At no time did he get to the car or speak to the driver as stated in the media after the crash.
When he picked up the phone he expected to be connected immediately to a person as would happen with motorway emergency phones (He was a traffic policeman so was used to these). Instead all he heard was a dialling tone and he could not see what to do or any instructions. By this time the train had arrived and it was too late anyway. He heard a massive bang as the train struck the car and then was covered in glass and saw sparks fly as the train disappeared down the line out of sight. He used his mobile phone to call 999 and described what he saw as he moved down the track. He got as far as Coach E before assistance arrived in the form of police and ambulance. He directed some of the ‘walking wounded’ to the Winning Hand before being taken there himself to make an initial brief statement. He was still in shock so made further statements in the following days and months.

Questions from advocates and the bereaved families focussed on the inadequacy of the emergency phones and dangers of level crossings. It was felt that if someone with Mark’s experience had difficulty using one, then ordinary members of the public would find it even harder. Mark actually went back later that night with a big torch and looked in the phone box. With light, and because he was standing facing the box (not at the side as earlier), he found instructions to lift the receiver then press a red button. The button was so worn it was white not red, but it was the only one.

All the bereaved families present thanked PC Brazier for what he had done and made it clear that he had done absolutely everything he could in the difficult circumstances. Brazier himself felt that even if he had been able to speak to someone on the emergency phone it would not have averted the crash. One advocate made the point that Network Rail should really speak to PC Brazier and learn from his experience in a real-life emergency as this had never been done. It was also brought out that none of the recommendations about improving the emergency phones made in the June 2005 RSSB report had been implemented. The phone was of an old and out-of-date type, fitted in the early 1990’s.

THE VIDEO

The above evidence was then shown via a video reconstruction. The quality was poor and did not completely match what the above witnesses had said, for example the PC’s attempts to alert the car driver by flashing his lights and hooting were not included. It was probably good for the Jury to see the narrowness of the lane and isolation of the site.

The BBC’s request was then discussed in more detail. The most striking aspect was the difference in opinion between the families and the Legal representatives of the large agencies and companies. The arguments for the request being granted revolved around public interest and raising the profile of the crash in the media to alert them to important safety issues. Arguments against focussed on the dangers of copycat suicides and setting a precedent. The Coroner decided to err on the side of caution. Two of the bereaved relatives made impassioned counter arguments and they and others were left feeling extremely angry and upset. The imbalance in power was once more highlighted between the big organisations able to afford top quality legal representation and the families, some of whom had no option to represent themselves without the benefit of legal training or distance from their grief.

Tomorrow: A psychiatrist on Drysdale’s possible state of mind and the BTP chief about how the investigation was handled. A train company witness (I believe), not listed, will also appear.

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THURSDAY, 18th October 2007

The first witness to be called was Dr Philip Joseph, Consultant Forensic Psychiatrist at St Mary’s Hospital, Paddington. He had been asked to review all the written material relating to Brian Drysdale’s state of mind.

Dr Joseph emphasised that it is unusual for him to make such assessments without the benefit of ever having met the person at some point. For this reason he could only talk about possibilities and probabilities based on his professional experience.

He was also hampered by the lack of evidence about Drysdale’s past history and childhood and the fact that he was not registered with a local GP and had not seen a doctor since 1994. There was nothing in the meagre records about alcoholism, drug dependency or mental health problems. Dr Joseph said childhood problems are an indicator of adult mental health problems but these can also occur in adults without any childhood issues.

As I stated last week, the differences in reports about his personality and moods said as much about the observer, both their capacity to observe and the relationship they had with Drysdale. He clearly responded differently to different people and was more relaxed with people he trusted. Paranoia would also affect how he related to different people.

It was clear to Dr Joseph that the underlying issue was the fact that Drysdale was tormented by his homosexuality which he tried to repress and keep from others, including his brother. However, his sexuality in itself was unlikely to trigger his suicidal thoughts. What appears to have caused his change in behaviour and possibly his deterioration towards paranoid psychosis was his fear about having HIV+ve. Though it appears he told his parents he was homosexual he may have feared them knowing if he proved to be HIV+ve. The fear of this, possibly brought on by symptoms which he may have concluded were signs of HIV+ve (though they were also symptoms of stress), may have been enough to trigger his paranoia and suicidal thoughts, which he divulged to the Florey Clinic nurse when asked directly if he had them.

While his friends had called him ‘paranoid’ (though some said not in a clinical sense), several changes in behaviour in the weeks before his death were significant and suggested this was becoming more serious. Several people described his behaviour as weird, especially an agency chef who felt Drysdale must have thought was after his job. In particular his call to Thames Valley Police complaining about his boss and his hearing voices outside his flat threatening him were seen as evidence of paranoia of a more clinical kind, though there is doubt about whether the voices were real or in his head. There was no evidence from anyone that anyone was shouting threats outside his home.

The apparent difference in his ‘normal’ behaviour just before the crash, such as sorting out a deposit for his new home and chatting about football to his mother an hour before, contrasts with his apparent inner turmoil. Dr Joseph said this was quite usual for people who had decided on taking their lives when they often relaxed knowing their decision had been made. He did however also say that even where an intent to suicide had been made, people still often wavered about actually doing it.

The question was discussed of the influence of his comments to his boss 2 weeks before the crash about having enjoyed a documentary about the Selby train crash on TV. However, in this case the driver was not trying to take his life and ended up with a prison sentence for manslaughter. It did however suggest that it would have given him some idea of the fact that such an incident caused the deaths of passengers.

There was a consideration of the three possibilities about his intentions towards others than himself being harmed:

Ignorance of them
Indifference towards others who may be harmed, but aware there might be some
Intent to harm others.

All were thought possible but the last would be the most unlikely as it was rare for people to kill others with intent in this way. Usually such actions would be more personal and take place in situations such as a family massacre. There would also be more evidence in someone’s past to suggest this scenario. Dr Joseph felt the first two options equally likely but that his behaviour may have also been reckless.

More weight would be given to the second and possibly the third option if the evidence given by Sergio Nardone (last Thursday) was proven to be true. As yet a great deal of uncertainty remains over the truth of his assertion that Drysdale called the Retaina Group prior to the crash and, even more so, to the assertion that other calls were received a few months before when he was alleged to have told Sergio that he would kill himself on a level crossing and wouldn’t care about passengers who might be harmed. No records on the phone logs can be found after extensive searching. There is also evidence of this witness having given similar evidence at an Inquest in Dover. Another member of staff will be giving more evidence on this matter on her return from abroad next week.

It was clear that the full story can never really be known because of the limited information Dr Joseph had to work on and the fact he never met him nor heard the telephone conversations. However, the probability is that his recently brought on fears had triggered a state of paranoid psychosis which affected his behaviour in some situations. He was still able to keep up a normal appearance to most people who saw him regularly and his history of ’being private’ meant he was well practised at this. However, he had said to the Florey Unit nurse, “I’m waiting for myself to die” and his fear of being diagnosed with HIV+ve had perhaps made him wish to end it all sooner.

BT Investigation

Detective Chief Superintendent Eamon Carroll gave a very detailed account of the Police investigation, illustrated with graphic images of the interior of the carriages and a reconstruction of what happened to the train second by second after the crash.

It is too detailed for me to outline this now and I shall add more details later.

The most striking image however was of Coach E where most deaths occurred. The interior was virtually intact EXCEPT for the number of broken windows through which four passengers were thrown. Coaches D and F were far more damaged and the only fatality here was Charlie Matthews who was not thrown from the train and died the next day in hospital.

Braking of the train

Finally a Mechanical Engineer gave evidence about the ‘Black Box’ recorder which showed the train was travelling at 101 mph. It was difficult to be sure whether or not the brakes had been applied by the driver and at which point. It is expected more evidence will emerge on this later.

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FRIDAY, 19th October 2007

Friday’s business was very technical. Checks on the Ufton Nervet Level Crossing were considered in a statement from a Network Rail Operations Manager who reported that the Crossing had no faults at the annual check on 28th July 2004, and a brief examination of Richard Stevens, a Signal’s Technician covering the day-to-day management of the Theale area track. On 6th November he called at the Crossing at 3.00pm as part of his investigation of a reported track circuit failure. There was no fault at Ufton and he reported back using the emergency phone, which was working. This was the same phone used later by PC Brazier who tried to avert the crash.

A further statement from a Network rail Duty Control Manager was used to show that the computer based control system, which gives a schematic view of all train movements, was working and so too ws the detection signal an eighth of a mile from the Ufton crossing.

A statement by HM Chief Inspector of Railways in what is now called the Office of Rail Regulators (ORR) explained all the plethora of acronyms for the many rail industry bodies. I didn’t get them all down but the impression I was left with was that there seem to be many committees monitoring each other and all seem to have had their names and responsibilities changed since 2004!

Most of the day was taken up with evidence from Mr John Tilly, a Railway Signal Engineer employed by HM Inspectorate of Railways (now the ORR). It was tedious listening so I shall sum up as best I can.

Mr Tilly examined the crossing and site soon after the crash. First he showed pictures of the deep score marks left by the car on the concrete on the Level Crossing. There was also damage to the train position detector caused by ballast.

To summarise,

It appears that the train was travelling at or possibly just above the speed limit for this part of the line (100mph). There was no time for the driver to respond once he saw the obstacle on the line.
All rail equipment was in working order and the condition of the level crossing was acceptable.
The car would have been seen by the train driver at between 76 an d18m to the east of the crossing. At 100mph the train would only be 10-12 seconds away from the crossing and it would have been impossible for the driver to stop in time.
The car was almost sideways on to the train across the down-line. On impact it was dragged down the line and thrown to one side landing not far from the crossing. The car ignition keys were found near the car.
On impact, the leading wheels of the front power car (driver’s end) were derailed.
The train carried on for another 91m. He said the Sunday Express report that a small car cannot derail a train was incorrect.
There, it crossed the points where the side-line goes off the main line and this caused a catastrophic derailment. Mr. Tilly said there are ‘too many variables’ to say if the train would have stayed on the track but for the points but the points are a big factor and the outcome is likely to have been very different if they hadn’t been there.
A computer reconstruction showed second by second what happened to the train and each carriage after it hit the points. The train formed a wave and then Coach E jackknifed and turned over, ending up beyond the coach in front. Coach F buckled in half around the bogie and Coach D was very badly damaged and rolled over (indicated by soil on the roof). All other carriages tilted to varying degrees.
Coach bodies detached from each other, breaking power transmission, and from bogies. Windows in most coaches remained intact except for Coach E, some in D and some on the left side of H. Mr Tilly said he could not tell which windows had been broken on impact or during the rescue.
The front power car’s side window broke and soil and ballast were scooped up as the car slid along the bank. The front windscreen remained intact.
He said there was no evidence of errors by rail staff. If the speed limit was indeed broken by 1.6mph, this was, in his opinion, not significant.

Safety Issues

Mr Tilly went into safety issues in some detail and outlined the investigations he had made since the crash. Some of these were in response to research undertaken by Peter Webster into safety equipment used in other parts of the world, for example, he had travelled to Germany and Netherlands to investigate Obstacle Detection Systems. He also said that all calls after the crash from the public and manufacturers with ideas for improving safety were investigated and a few are being researched.

Obstacle Detection Systems These are not widely used world-wide. German research found that obstacle detectors are only effective on full barrier operated crossings and the cost of installation is very high (100,000 Euro, making it cheaper to hire staff). Netherlands crossings are very complex and totally different. Warning systems caused too many other problems and were set off for the wrong reasons. He said that the Honeywell radar system is the one most likely to be used in the UK and trails of these will begin first at crossings in need of renewal.

Automatic Half Barrier Crossings (AHBs) provide the weakest points regarding safety on the railways. He would welcome the closure of any of them and has put forward the recommendation to West Berks Council that the Ufton crossing has more trains than cars and could be closed without too much inconvenience to the local population. (The alternative idea of building a bridge over the railway was not mentioned). West Berks had refused this request.

Emergency phone design could be improved as technology has progressed beyond the Ufton phone. The lights lighting up the button that has to be pressed to connect to an operator dims when the receiver is lifted (which is why PC Brazier could not see the instructions as he lifted the receiver first – if the phone is left off the hook or vandalised an alarm is sent to the Signal box at Theale and an engineer is sent out. The phone on the other side of the crossing continues to operate. The phone power supply is independent of other circuits in the system)

Track lay-out in relation to crossings could be investigated as the points close to the crossing are what turned this into a catastrophic derailment.

The shape of the front of the train – it is possible that a flatter shape might have pushed the car out of the way.

Train windows that did not break so easily should be considered.

Concrete apron on the level crossing – did this affect the behaviour of the car (some are steel framed, some polymer)

Bogies and door to driver’s cab – Mr Tilly was not qualified to comment on these.

Three possible options relating tot Drysdale:

1. The car stalled

2. He was doing a 3-point turn on the crossing (this has been known in previous incidents, but Drysdale had already appeared to turn twice before in the lane, according to Ms Clifford’s evidence)

3. Drysdale intentionally parked on the crossing as has happened in two incidents before the crash and one since the crash (and another possibly)

Statistics quoted by Mr Tilly:

There have been 3 major level crossing incidents in 30 years, the last at Lockington on Humberside in July 1986 where 9 people died. (Liz says, a few years later I met the Probation Officer who set up the Lockington survivor/bereaved families group a year after the crash because they had not received much help. This memory influenced me when deciding to set up UNTCN)

There are on average 20 incidents a year of cars striking trains at level crossings.

25% of these incidents involve Automatic Half Barriers

[An advocate said that Near-misses are not included in this figure. When they were, RSSB has reported 68 in the first 5 months of 2007 (equivalent of 166/year)]

The Advocate representing David Main put Mr. Tilly under intensive cross-examination about the speed of the train and the other advocates objected to this.

By this time, my head was splitting and I decided to leave as there was at least an hour until the session closed but I shall try and find out what happened on Monday. Mr Tilly may be back again if the Adovcates and jury did not finish their questioning of him.

Next week there will be more technical evidence an dsubmissions from Dr Anton Jack of the RSSB. An important witness is appearing on Friday, a member of staff from the Retaina Group who may be able to shed light on the intriguing contradictions over evidence about alleged phone calls by Drysdale just before the crash and two calls several months.

The Jury are due to go out on Wednesday 31st October. The bereaved relatives will have the opportunity to read out eulogies about their loved ones after they return (either that day or the 1st November if they take a long time to come to a decision). The Coroner will make his Recommendations at the end.

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MONDAY, 22th October 2007

The Coroner made his displeasure known about an article that appeared in The Times this morning about train safety issues.

All of the morning was taken up with the continued cross-examination of Friday’s witness, Mr. John Tilly, a Railway Signal Engineer employed by HM Inspectorate of Railways (now the ORR) to clarify the issues I listed yesterday. He was unable to answer a lot of questions because he didn’t have the correct tables to work things out or because there were too many variables for him to be definite.

Tim Webster asked for an opinion on whether a camera based obstacle detection system could have made a difference if it had been in place on 6th November. Could the train have slowed down enough to have made a difference to the outcome? He had done some complex maths to try and work out the speed of the train. Mr Tilly said he couldn’t answer the question. (The next witness, Mr Wally, guessed that had the driver been aware of the obstacle on the line as soon as was possible then the speed of the train could have been reduced to 70-80 mph)

The point of this question related to the questions being pursued by Peter Webster to highlight the existence of alternative obstacle detection systems which he believed the industry was ignoring or didn’t know about. He referred to a company called Nomad whose experts believe that the electronic advertising systems being fitted in trains now can be used for obstacle detection at no extra cost to the train companies. Arguments against this system came from FGW that this system would mean that drivers would have to give too much attention to screens conveying this information and would be distracted. Mr Webster stated that the Rail Driver’s Union was in favour of this system. The train companies, according to Mr Tilly, are most likely to adopt the Honeywell Radar system. He said that in Germany this was used on some crossings but more to cut the costs of labour than for safety. Later, I believe someone said that there would be no cost benefits as they were too expensive to install.

After lunch, Mr Wally, an ORR Inspector, was called to give evidence on braking systems. Again it was very technical and hard to hear but essentially he said the driver could have done nothing to avert the accident. They deduced from records that the brakes were applied for the first time just seconds before the crash.

Mr Wally mentioned a statement from a passenger in coach B2 in which it was stated that there were 2 periods of braking. Mr Wally said the railway data showed this did not happen but that there were plausible reasons why a passenger might think this, for example the loss of power when the coach was derailed would feel like braking. There were in fact 3 separate points of deceleration – possibly when the emergency brakes were applied, then when the train hit the car and ballast, and finally when the train jack-knifed and got tangled up in itself. Drysdale’s may also have hit an ‘angle cock’ which would have applied the brakes. The force of the braking was 10 times greater than the maximum normal braking.

Other points:

Every coach has it’s own independent braking system so that the braking system can adjust according to the weight of passengers and luggage in each car.
Deceleration happens in a non-linear way and is dependent on variables such as frequency of braking, temperature and damp.
Braking is designed so that in normal circumstances it is not so sudden that passengers are thrown around.
Once the train had broken apart, speed is only measured in the ‘black box’ in the rear power car. All trains are now fitted with these in both front and back power cars.

Mr Wally was released at 3.30 and the Coroner decided it would be better to leave the next witness until tomorrow.

Other timetable adjustments were made, for example Anson Jack of RSSB will now be called on Monday, not Friday.

An extra witness has been located and will be called on Friday at the request of the Jury. He is Keith Hopkins, the man who was due to share accommodation with Bryan Drysdale.

Tuesday: evidence will be heard from Mr. Randall of ORR; a Police Investigator and Mr David Price from the Transport Research Lab who has information on the condition of Drysdale’s car.

No sittings on Wednesday 24th & Thursday 25th October.

Please note that a great deal of technical detail has been left out.

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TUESDAY, 23th October 2007

Three witnesses presented their evidence:

1. Peter Randall (HSE, now ORR) He spoke about many of the safety issues discussed before and about his role in encouraging the industry to take up safety measures. The low number of incidents made it difficult for conclusions to be drawn. What improved safety or caused problems in one incident might not do the same in another (later the FGW Advocate said FGW had been criticised at the Ladbroke Grove Inquest for not making windows easier to break and escape from). It was emphasised that every crash has its own unique features which can give different outcomes.

He said ORR believed change was implemented more effectively through a process of education and persuasion of the rail Operating Companies than through enforcement. However, mandatory requirements are enforced through the Standards and compliance agreements which operators must sign up to as part of their Franchise agreements.

He made clear the distinction between the different needs during a crash to prevent deaths from the needs of passengers to escape after a crash. The Companies really had to revisit their policies on evacuation procedures which at present many believe revolve around escape via windows. He prefers the escape route to be via doors where possible. He recognised the need for public education as it was counter-intuitive for many to have windows that cannot be released even though research has found these significantly reduce fatalities (as shown in the Greyrigg incident in February).

He said the rolling stock at Ufton Nervet performed reasonably well, though more modern stock would have performed better.

There are 2 means of containment of passengers:

In the seat using seat belts: in research into 7 crashes, 11 deaths were caused by lack of seat belts, but 88 more would have been caused by seat belts due to the way bodies would react in a crash at speed. Seat belts only stop forward, not sideways or vertical movement and would not prevent people being thrown through a window.
Laminated glass windows would significantly reduce deaths, even though they can’t stop all deaths. He said there were no cases of deaths caused by people not being able to escape the train. However, as this is counter-intuitive to most people, other ways of escape, e.g. via doors, must be found and public education about these was vital. (But in lesser crashes, he said it is always safest to stay where you are or move to another carriage – but he recognised the Ufton situation made this difficult!)

Other safety points:

Air-line style seats are safer than being thrown into a table.
Backward facing seats are safest as the seat absorbs the force
Seats now are designed to absorb energy
Tables have 2” thick edges designed to absorb shock.
Sitting near ‘escape windows’ is best avoided
Hammers (prone to be used by vandals) are being replaced by some Operators along with escape windows
Laminated windows can now be made thinner to fit old stock frames and can be broken by emergency services with their cutting equipment in emergency evacuation
The thinner glass makes it easier for them to be replaced in old stock without replacing the whole window frame. The incompatibility of new glass to old frames was given as one reason for the cost and delay in replacing the old windows.
A major problem is that different Operators have different evacuation policies so there is a need for CONSISTENCY so the public understand what to do whatever train they are on.

Randall suggested that implementation of window replacement did not really take off after the 1993 recommendations were made because there were no significant crashes. It was the Potters Bar crash in 2002 where people were also thrown out of windows and killed which triggered action.

He said that research programmes have to include lengthy consultation with stakeholders in the industry and other interested parties, such as survivors to reduce the risk of unintended consequences and resistance to implementation. Issues of cost have to be considered and for this reason certain routes and higher speed trains will be targeted in window replacement programmes. Research finished a year ago and he said that implementation began immediately. FGW are in the process of replacing windows in the old Intercity 125 trains which they are bringing back into service.

Obstacle deflectors were discussed in some detail and the problems highlighted, especially if they cause objects to get between the bogies and train body. This happened in a Glasgow crash where the carriage went head over tail as it was ripped form the bogie by an obstacle. In a crash 6 months ago with a vehicle on a crossing, the first carriage passed over the vehicle but the second coach was derailed. At Ufton, it was probably the heavy, rigid car engine that caused the power car to derail.

(Lifeguards are old devices attached to the leading wheels to knock small obstacles out of the way.)

The usefulness of deflectors is open to debate, though at Ufton one may have just pushed the car to one side and reduced the consequences. However, Randall said that the chances of a derailment are always high at 100mph. Forward fitting deflectors are impossible to fix to HSTs. Whether the shape of the front of the train would make any difference is open to debate but it would require a major re-engineering programme. The current shape is for aero-dynamic reasons only – there is no structure of any importance in the wedge shaped section.

Another research interest is driven by the need for retention of bogies. At Ufton, the detachment of carriages contributed to the forces exerted on the badly damaged centre coaches. They need to strengthen fittings on bogies down the train to cope with progressively greater forces as deceleration occurs. However, he believes current standards are about right because if the bogies are strengthened and don’t break then the forces are exerted on the train body itself leading to greater risks.

The Driver’s Door The detachment of the door was a crucial factor in the death of the driver as it allowed the cab, which otherwise remained intact, to fill with debris. Randall said this was a rare occurrence but noted that the death of the driver in the Selby (Great Heck) crash in 2001 was similar, though in that case it was the windscreen that gave way. This is the subject of on-going research.

The next section is disjointed as the points came out from questioning of the witness:

Questions about past delays in implementing safety recommendations were blocked by the Coroner as he said these were about the past and he had to concern himself with what could be done in the future to prevent deaths. “My job is to look to the future not the past”. Others tried to argue that in order to move forward quickly, reasons for past delays had to be understood.

Randall re-iterated the fact that 2 out of 3 Operating Companies were now fitting laminated glass windows and one would be doing so now that the last Operator had lost the Franchise. He insisted that Operators were co-operating and this was preferred to making implementation mandatory, though this was to some extent done through them having to meet certain standards before they were given their Franchise. It was now a matter of being a mechanical exercise for the replacement programmes to be completed. At the time of the Ufton Nervet crash there was no technology to enable HSTs to be fitted with laminated glass but this has changed. He made it clear that even laminated glass could not withstand every force as some objects may still be able to penetrate it. In the Greyrigg crash, even with laminated glass, 2 windows were broken through penetration of objects (from the outside or inside – not yet known). One window detached from its frame (so there is a need to address how windows are anchored), another was found intact on the inside.

Randall agreed that research into laminated glass has gone on apace but there have been many fluctuations in opinions in the industry. There has been scepticism over the removal of ‘egress’ windows for escape. FGW were criticised in the Ladbroke Grove crash for lack of escape windows. The “What if.." argument is hard to counter. He believed the industry was now being pro-active so that the delay in completion of implementation because of the need to wait for the Greyrigg report does not worry him. It would if they were resistant.

FGW have changed their evacuation policy.

Research on emergency lighting (better described as red mode lighting) is also in progress. At Ufton none would have worked because the power supply was broken. Research is being done on battery operated lighting.

A great deal of work is being done on how injuries occur.

Where stock is leased to Train Operators, some aspects of the construction are the responsibility of the manufacturer, some of the leaser and some of the Operating Company. However, Operators will not lease trains that do not reach the requirements laid down in their Franchise agreement.

Reports and consultation of survivors I have asked Mr Randall if he can give the Network details of all the reports mentioned, especially the report on how injuries are incurred.

I have also asked how survivors can contribute to their bank of knowledge. I am only aware of one survivor who took part in the Cranfield survey & they did not feel the final report represented their experience adequately.

2. The next witness was PC Tony Reading, the first officer to arrive on the scene. He gave a brief factual account of what he found.

3. He was followed by Mr David Price, in 2004 of the Road Transport Research Laboratory, but now a Consultant. He gave a detailed account of the condition of Drysdale’s car when found and what his team could deduce from the wreckage.

Key points:

The rear lights had been on seconds before the crash
The headlights and tail lights were off
The ignition lock was in the off position
The seat belts had been in the lock position strapping him in.
No evidence of him trying to drive forward off the crossing
The steering showed he was turned to the left
The car key was found under the train – it may have been out of the ignition or thrown out by the impact
The handbrake was almost fully on and it appeared he had braced himself against them.
There was enough petrol and there were no problems with the car that could have prevented him from moving forward off the crossing had he wished to do so.
His spare wheel was of no use so he would not have been changing a tyre on the crossing
The control car of the same make had similar problems with the door as mentioned by earlier witnesses – it is a problem with the make of car.

His overall conclusion was that being on the crossing was the deliberate act of the driver.

The Inquest resumes again on Friday with evidence from a member of Retaina Group staff and possibly Drysdale’s friend who was about to share a house with him.

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FRIDAY, 26th October 2007

Before the Jury arrived, the Webster’s took up their case for more information about procedures for families and how difficult it has been for them to ask questions at the Inquest. Anjanette’s sister Eleanor stood up and supported them. One of the Advocates suggested the problems could be solved by inviting Tim to sit by his father with the Advocates as everyone else was represented by 2 people.

Once the Jury arrived, there were 3 witnesses until the end of the day:

Keith Hopkins, a drinking associate of Drysdale’s from ‘Up The Junction’ pub in Cemetery Road, Reading. Keith explained how he only knew Drysdale from the pub and knew very little about him otherwise. He had spoken in the pub about moving into a house adjacent to another pub and owned by a Brewery. Drysdale had asked if he wanted anyone to share and Hopkins agreed as it would help him pay the rent. He confirmed that Drysdale had paid his part of the deposit, got the keys and had arranged to move in on the 7th Nov as he was working on his day off on the 6th Nov). Hopkins knew about Drysdale’s problems with the car and with the Executive Chef. He said Drysdale was happier once he had advised him about how to deal with the chef. Hopkins could not remember much else except that he last saw Drysdale when they both left the pub on the Friday evening. He could not remember any of the brief calls made between them on the 5th which were recorded by the phone log. Replying to a question from a Juror, he said he had no relationship of any kind with Drysdale and did not feel he had any designs on him as he is not gay.

Christy Clark, previously employed at the Retaina Group call centre. Christy had been called in relation to the claims by her colleague, Sergio Nardone, that he had received a call from Drysdale an hour or so before the crash and on two occasions a few months before. She gave a convincing account of her memories of the day and the call on the 6th and one previous call. On the 6th she became aware of a call being taken by Sergio that seemed to be causing him distress as his voice was getting higher and he was turning pale. She heard him ask the caller ‘Why would you want to do that?’ and she was told later that the caller replied , “Because I am waiting for myself to die”. Sergio was also heard to say, “I am not qualified. You’d better call the Samaritans. They told their Supervisor about the call but as they only had the surname Drysdale and did not have a key to the room where the phone logs were being kept while carpets were being re-laid, they did not take further action.

When asked about the lack of electronic evidence for the calls and any other computer work she had done that afternoon, Christy said she could not explain it, unless it had something to do with the equipment being moved that weekend while carpets were being laid. [There was no record of any calls from any relevant phones or the area where Drysdale was known to be]. These calls therefore remain a mystery. The possibilities remain: that several people have made up a fantastic story or there is some unexpected; that there is an unexplained problem with the equipment which a top expert said was working; or there is another solution that no one has yet thought of.

Why is this evidence important? As far as I can discern, this mystery is important as I guess it will affect the kind of verdict given. If Drysdale can be shown to have killed and injured passengers with intent because, as implied in Nardone’s statement, he had been made aware of the consequences of his actions by being asked to consider the impact on train passengers of parking his car on a level crossing. Nardone claim she replied that Drysdale answered he didn’t care about them, then had he lived he could have been charged with murder or manslaughter. If he acted with ignorance or indifference, then I guess it could be manslaughter. But remember there appears to be no conclusive evidence to prove that Drysdale made these calls or said was reported.

In an Inquest, only the cause, place and time of death has to be established and the verdict can be unlawful killing, an open verdict, accidental death or natural causes. Narrative verdicts can now be given where an account of what is believed to have happened can be given.

The final evidence came from a Network Rail engineer, Mr Jones. He gave evidence on safety systems previously considered in the evidence of others, such as John Tilly of ORR and covered some questions that Mr Tilly could not answer about what had happened to the Everton trials on Honeywell Obstacle Detection Systems. He confirmed that these trials had been stopped because of all the technical problems that cropped up in these trials (given consent in 2000). He also confirmed that Network Rail did not have to inform anyone at ORR about the abandonment of the trials. This formed the basis of a recommendation by David Main’s advocate to the Coroner that in future such information should be passed to ORR and be the subject of sanctions if they are abandoned. Network Rail said they would be happy to pass details of trials to ORR if they wanted them and ORR said they would welcome regular contact about such issues.

Mr. Jones also announced that a commitment by Network Rail to begin trials into Radar Operated Obstacle Detection Systems has been made but he was unable to give the date on which that decision had been taken and he could not give a timetable for the completion for the non-operational trials and, if these were successful, for the operational trials. They were still negotiating with suppliers of equipment and contractors and once non-operational trials began there could be many unknown technical issues to resolve making it hard to give dates. When pressed by the Coroner he said he was talking months and a few years rather than decades. They wanted to look at other systems apart from the Honeywell system mentioned earlier by Mr Tilly. The Honeywell system had lots of benefits, a high level of integrity and was already in operation in Germany and Holland, hence their experience of the systems could be used. It must be remembered that these systems are only suitable for Full Barrier Crossings, not Automatic Half- Barrier crossings as at Ufton. It would be unlikely that a crossing used by as few cars as at Ufton would be up-graded to a Full Barrier system, though risk assessments are undertaken annually when decisions to upgrade can be made.

Other points:

It appears Network Rail is looking for alternatives to CCTV cameras and employees at Crossings. CCTV cameras are not so good in adverse weather conditions.
Mr. Jones highlighted the cost implications of every one of the 7000 driver cabs having to be installed with new detection screens and systems. It would also be hard to find space and there primary duty had to be in watching signals.
The HSE Report issued just after the UN crash highlighted the fact that there is no single body overseeing the safety of Level Crossings.
After the crash, 290 suggestions were received from the Public and all were evaluated.

In the questioning of Mr Jones that followed, it was suggested that lack of technical knowledge about radar systems was an excuse as other countries with comparable systems were already using them. Mr Jones was pressed on this issue and the lack of having to inform the ORR but the Coroner intervened to say this was going beyond his Rule 43 responsibilities for making recommendations about how similar fatalities could be prevented.

Mr Jones said that in the end all crossings were safe if they were used correctly by the public. Peter Webster asked about research into improving the public’s use of them. Mr Jones said they had tested out red light enforcement cameras, new flashing lights and countdown indicators to show how long people had to wait before the train came. None of these had worked well and countdown indicators were rejected because people took risks if think they know how much time they have left to cross. Research had found that drivers overestimate the time they have to wait before the train arrives at the crossing from when the barrier comes down as 1½ to 2 minutes. In fact it is only 27 seconds. Waiting time is kept to a minimum, otherwise drivers become impatient and risk crossing. This time lag is the same as other European countries and more than some Scandinavian countries.

[I had to leave at this point]

NEXT WEEK: I have been told that there is a possibility that the Inquest will go on beyond the 31st October as planned and may not end until Friday 2nd. I’ll keep you informed.

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MONDAY, 29th October 2007

There were 2 witnesses today - I had to leave at 3pm during the questioning of the 2nd. The morning session was taken up with evidence from Anson Jack, Director of RSSB, who sent the RSSB report to UNTCN in July. Both witnesses covered most of the safety issues discussed by previous witnesses but allowed Advocates to question them on areas of their specific interest and responsibility.

The Coroner’s questions to Mr Jack were initially geared to establishing the independence of RSSB from the rail industry and Mr Jack explained the various checks and balances to ensure this – for example the Board’s non-executive directors from the rail industry can be outvoted by those independent of the industry and The Department of Transport and the ORR have the right to inspect all their papers.

Main points to come out:

80% of the RSSB’s recommendations to the industry are accepted and taken up. Sanctions if needed include intervention by the ORR and the use of the Health and Safety at Work regulations. There is no presumption by RSSB that recommendations will be taken up. This is because the practical difficulties often get in the way or cost too much.
There has been a major shift in the type of issues researched in the last few years as a result of the Potters Bar and Ufton crashes and because the design of trains has improved. In the old days, deaths in Mark 1 trains were usually due to poor interior design features whereas now ejection from windows is more prevalent. Previously the concern for windows was about the penetration of objects from outside.
RSSB prefer closure of any Level Crossings and UN in particular
RSSB recommend that the risk assessment procedure for Level Crossings should in future have integrated into it the proximity of track features such as the points which caused the catastrophic derailment of the train.
RSSB are working closely with Network Rail on Obstacle Detection Systems.
RSSB are satisfied with N R’s reasons for refusing to take up their recommendations for changing the road surface of crossings.
RSSB recognise that nothing can be done with the shape of the fronts of the power cars on existing stock but modifications may be recommended for new stock
RSSB recommend laminated glass, do not recommend the fitting of seat belts and are accelerating research into means of emergency escape for passengers. (All of these points are in the July 2007 report)
There is on-going research into bogie retention (some think it better that they split, others that they are retained) and research into the driver’s cab door and entry of ballast will have results by the end of the year.
Each crash is unique with unique forces and unique circumstances which result in variable train behaviours on impact. It is hard to generalise from such unique situations.
Consultation on recommendations has been held up until the results of the Rail accident Investigation (RAIB) Report on the Greyrigg crash. As crashes are rare they want to take full account of the information from this crash as it is the first on a train of new design with laminated glass windows.
Level crossing safety in the UK is better than that in other parts of the world, except Ireland.

Questions focussed on:

Delays to research – how it took so long in the past and how can similar delays be prevented in the future.
The need for mandatory recommendations and implementation of recommendations on old stock when being refurbished (and what is the real definition of refurbishment)
Is the rail industry only informed by disasters – isn’t the evidence for change already there.
Shouldn’t AHB level crossings all be up-graded on lines with high speed trains? The UN crossing was given a D4 risk rating meaning that it was not risky enough for up-grading.
Have cost/benefit analyses been done for various recommendations e.g. the retrospective fitting of laminated glass – if they haven’t been done in the past, will they be done in the future? Shouldn’t one be undertaken now, 3 years after the UN crash?. (Often costs against benefits are quoted as a reason for not taking up recommendations but the suggestion was being made that C/B analyses have not always been undertaken.)
The issue of emergency lighting was taken up by Peter Webster. It’s importance was contested by the Coroner. Peter argued that he was the only person in the room who was actually in the crash and he knew that it was important to survival during the crash as well as to evacuation after the crash. Mr Jack said it was important to passenger’s feelings of security after the crash. A member of the Jury took up this point as something that would be valued if they were on a train tomorrow and it crashed.

The afternoon session consisted of evidence from David Ward, Group Director of Network Rail (West).

Mr Ward spoke mainly about Level Crossings and the side-track, the presence of which so close to the Crossing caused the second catastrophic derailment. Key points were:

Network Rail is responsible for all aspects of 21 000 miles of track and 7 000 level crossings of all types.
If a car is trapped between the gates of a Full Barrier Crossing, the presence nearby of staff or via CCTV to a signal box, trains could be stopped unless this happened after the all clear signal had been activated.
There are 470 Automatic Half Barrier crossings in the UK, with 131 on lines carrying high speed trains.
The reasons against closure of the UN crossing given by West Berks Council were accepted by NR. There are width and weight restrictions on the alternative routes
Drivers who zig-zag through AHBs usually do so when they approach just as the barrier is coming down, rarely once they have stopped.
Each crossing has a unique Specification Order and is checked using a strict procedure annually with lower-level inspections every 4 weeks.
Closing Crossings is a complex procedure, up-grading them is easier but only happens if there are significant changes in road lay-out or traffic use. An AHB is appropriate fro UN as few vehicles use it.
The side-track is needed to maintain service operation at its current level of 1000 trains pa and especially to keep up freight usage.
Trials of new emergency phones with better operating mechanisms, lighting, instructions and signage are planned with a view to rolling them out in 2008.
NR don’t accept RSSB’s recommendations for concrete pads at the crossing because ‘it wouldn’t work for 7 000 crossings’, all with different road surfaces – timber, steel, concrete, rubber – which have to be hard-wearing, not cause cars to ground and be able to take road markings. (I understand another witness will argue that the concrete surface at UN did make a difference to the derailment).

Tuesday: witnesses from First Group PLC and another technical agency covering much the same topics as above.

Wednesday: Submissions to the Jury from Advocates and the Coroner

Thursday: Jury out. The Coroner is consulting families on whether the eulogies are read out while the Jury is out or in their presence after the verdict is given. Depending on how long the Jury take, the verdict is most likely to be given today.

Friday: The Coroner will use his Rule 43 powers to give his recommendations as to how similar deaths can be prevented in the future.

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TUESDAY, 30th October 2007

Tim Webster reports:

The first witness today, Hawkins from FGW, confirmed beliefs that FGW knew about the dangers of toughened glass in 1993, but did not even bother to contact the glass manufacture until 2005 to see whether they might be able to fit laminated glass onto trains. The witness from AEA technologies was useful for us in that he acknowledged the usefulness of level crossing lighting, CCTV and obstacle detection in helping to reduce the likelihood or impact of such an accident.

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WEDNESDAY, 31th October 2007

The legal representatives were consulted by the Coroner about the kind of options he could give in his direction to the Jury.

[This exercise again showed how important it is that the bereaved have representation considering all the others are associated witht the rail industry].

The options that the Jury would be asked to consider are first UNLAWFUL KILLING, then if this was not proven, an OPEN VERDICT then ACCIDENT

When the Jury arrived, the Coroner gave a very detailed summary of the evidence over the last 4 weeks, demonstrating to the Jury the type of questions they had to consider an dhow they had to make up their minds about the plausibility of witnesses, even those described as experts, and their evidence. The evidence was split into 5 sections:

The circumstances of the crash
Focus on Drysdale
Focus on the death of Charlie Matthews
Events on the Level Crossing before and during the crash
Evidence on the condition and use of the car

Direction of the Jury by the Coroner

He explained how they had to complete for each of the deceased an Inquisition form stating name; medical cause of death; time, place and circumstances; conclusion. Every statement had to be factual and based only on the evidence heard in the court. It must not contain opinion or any suggestion of blame or challenge. They had to reach a unanimous agreement about what should be written on the forms fo reach person. They were directed to use the words of the Pathologist for the medical causes of death except for Drysdale.

The different standards of proof were explained: the highest level is ‘Beyond reasonable doubt’ and the second is ‘On the balance of probability”

The Jury were asked to deal with Drysdale first as the outcome would then affect their conclusions about the others.

The options given were:

Suicide (a rider about the state of mental health is possible)
Accidental death
Open verdict

For the other deaths the options given were:

Unlawful killing (based on actual evidence not supposition)
Accidental death
Open verdict

The Jury went out at c 2.30 and were called back at 4.00pm. No decision had been reached so they will be called back t 10,00am tomorrow to resume their deliberations.

THURSDAY

Jury out.

While they are out, eulogies in tribute to the dead by the families will be presented. These must not contain any statements or opinions about any other issues.

Verdict

FRIDAY

Rule 43 – Recommendations by the Coroner to prevent similar deaths in the future

NOTE: Media interest is likely to peak tomorrow

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THURSDAY, 01th November 2007

The Jury took all day to deliberate and left everyone feeling apprehensive about the verdict.

They finally returned at 3.30 and the Coroner read out their Inquisition reports. Along with the medical causes of death as given by the pathologists, they gave the verdicts of:

Suicide in respect of Bryan Drysdale and the words, ‘misuse of the level crossing’ were used. There was no mention of his state of mind.
Unlawful killing –the words by ‘involuntary ejection from the train’ were used for the four people thrown from the train.

Following the verdict, moving eulogies were given by the Rossi/Main; Webster and Martin families. The Strevens family decided not to do so as their tribute revolved around a short DVD tribute to Barry for which permission to use this was refused.

The Coroner went on to consider whether he would use his discretionary power under Rule 43 to write letters to any relevant organisation able to take action to prevent similar deaths happening again. He had considered all the written and oral submissions already given by the Advocates.

He argued that there was no need to write any letters to the various sectors of the Rail Industry as he was persuaded that this was not necessary after hearing the progress they had made on research and implementation of various issues.

The only letter he was prepared to write was to Dr Simon Brown, the Rapid Response GP, to pass to any appropriate body dealing with policy for emergency response. The suggestion was that each rapid response team should have an extra doctor who oversees the whole operation. This was in the light of Charlie Matthews’ experience of being left by the track for such a long time without a faster review of his condition.

In making his decision on whether to use Rule 43 in relation to rail/train safety he was swayed by the submission of the neutral and independent body, Passenger Focus who didn’t think anything needed to be done. (See footnote)

After this, everyone thanked everyone else and said what a good job everyone had done – and we were left to go home to reflect.

AFTER FOUR WEEKS OF FORMAL PROCEEDINGS PLEASE GIVE A MOMENT’S THOUGHT TO ALL WHO DIED AND ALL WHO HAVE BEEN SO AFFECTED BY DEATH, TRAUMA and INJURY.

Please also reflect on the fact that, but for the deaths, many important questions would never have been asked and information important for psychological recovery would not have been heard. Please also reflect that there is no forum in which the survivors of this crash who were not bereaved, many of whom still suffer pain and injury, still have no place in which they can find the answers they need to help them understand the cause of their suffering. The Inquest has helped but of course it’s purpose relates only to the dead and many survivors will not even have heard that it has happened.

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John Cartledge of Passenger Focus has sent a copy of the full text of the relevant part of their written submissions, plus our oral statement regarding the use to be made of Rule 43 as they felt the Report did not do justice to their position. He states that, “The written submission is an attempt objectively to survey where the evidence led. The oral submission was a clarification of our understanding of the purpose of Rule 43. You will see that we were explicitly neutral as to whether the current position was such that any use of Rule 43 powers was called for, so the conclusion that it wasn’t was the Coroner’s alone.
Nothing in the attachment is confidential, so feel free to use it as you think best, or not at all. But if you wish to post it on your site, please use it intact, and do not simply publish extracts (which could then be read out of context)."

Anyone wishing to have a CD Rom of the Inquest should make it known to the Coroner’s Office in Reading. There is no written transcript of the proceedings. The Inquest reports above were taken from notes recorded at the Inquest. Matthew Clement of the RSSB has asked us to point out that the official Verdicts given by the Coroner were as follows. These were obtained by their Legal Representative from the Coroner.

The jury verdict for all except Mr Drysdale was:"Unlawfully killed as a result of the misuse of a railway level crossing by a road vehicle"

The wording at Para 3 of the Inquisition was: "Deceased sustained fatal injuries as a result of the derailment of a train following a collision with a car on the level crossing at Ufton Nervet on 6/11/2004 at or around 18.11 hours."

For Mr Drysdale the verdict was: "Suicide"

The wording at Para 3 of the Inquisition was: "The deceased sustained fatal injuries while in a car involved in a collision on the level crossing at Ufton Nervet on 6/11/2004 at or around 18.11 hours."

Peter Bedford
(Coroner)

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Liz Capewell

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