Coroner to warn Transport for London further lives could be at risk following man’s death at Stratford tube station

It follows the conclusion by a jury that Brian’s death was accidental. 

The jury added that after falling onto the tracks while intoxicated, Brian could not reach a place of safety. The jury concluded that following his fall Brian was hit by four trains.  

Of the four train operators, the jury said that three of those whose trains hit Brian did not see him on the tracks, including the operator of the third train who mistook Brian’s body for an “inflatable doll”. The jury noted that none of the three operators applied an emergency brake.  

The operator of a fourth train did see Brian’s body, but because they were in shock, they also did not use the emergency brake, the jury concluded. 

The jury also added that as the fourth train arrived, a member of staff on the platform was unable to give a signal to prevent Brian being hit.  

Senior Coroner for East London, Graeme Irvine, said that following the inquest he intends to make a regulation 28 PFD report to Transport for London.  

He will issue the report within the next 10 days but indicated that he was making the report as he felt there was a risk of future death on Platform 13 at Stratford Station as “not a huge amount has changed” since Brian’s death two years ago.  

Brian died after he is believed to have stumbled and fallen onto the tracks of the Jubilee line at the east London station. The jury heard that Brian was struck seven times, by four tube trains. Stratford is the eastern terminus of the Jubilee Line. 

The cause of death was confirmed as multiple injuries caused by blunt force trauma. 

The jury accepted the contents of a Rail Accident Investigation Bureau (RAIB) report which stated that Brian fell onto the track and was unable to reach a place of safety, no intervention prevented the first train from arriving in the platform and the train operator did not see Brian on the track ahead. The report described some possible contributing factors of the incident included automation on the Underground system, and distraction by other staff members on the platform. 

“Automatic train operation” or “ATO mode”, helps to minimise the gaps between trains as the system automatically controls the train’s speed and stopping at a platform. However, ATO can lead to a train operator losing concentration due to what is known as “cognitive underload” from the limited tasks they are required to perform and the low mental demand of the job. This causes alertness to drop. 

A full copy of the RAIB report and its findings is available here. 

The inquest, which opened on Monday 15 December, concluded on Wednesday 17 December 2025 and the jury has now been discharged. 

Brian was originally from Edinburgh, but lived in Hanwell, west London at the time of his death, and had been visiting friends at Christmas. 

During the inquest, the coroner and jury heard also heard from Det Sgt Gerry Griffin at British Transport Police who confirmed the circumstances of Brian’s death. 

The RAIB report states that Brian had been seated on a platform bench after alighting a Jubilee line train at Stratford station at around 2pm, Boxing Day 2023. Roughly 45 minutes later, he stumbled forwards while standing up and fell onto the tracks. 

RAIB found that Brian tried unsuccessfully to get off the tracks for about a minute before laying on the tracks for a further four minutes before being struck by the first arriving train. He was then struck six more times by trains coming in and out of the platform and was fatally injured. 

The RAIB report found that, in a reconstruction, Brian would have been visible to a train driver as far away as 112 metres, and that trains required only 40 metres to stop.  

No other passengers or staff were present when Brian fell, and no intervention was made before the first train arrived. The RAIB report found that the operator of the first train may have had their attention reduced due to “the use of automatic train operation”. 

The report also found the driver of the second train had not seen Brian and that while the driver of the third train reported what they thought was a blow-up doll on the tracks, they did not recognise it as a person on the tracks. 

The inquest heard from the RAIB report that the fourth train driver and a customer service assistant on the platform then realised there was a person on the track. However, the train was not stopped before it drew into the station. 

The inquest also heard evidence from the Head of Safety, Health and Environment at Transport for London, Marian Kelly, about lessons learnt following this incident. Following this evidence coroner said he intended to make a PFD report to Transport for London as he was not clear that there was evidence to demonstrate a material change in the situation. 

Brian’s family are represented by Thomas Jervis a partner and solicitor Philippa Wheeler of law firm, Leigh Day. 

Leigh Day partner Thomas Jervis who represents Brian’s family said: 

“The facts of this case are truly harrowing.  It has been really difficult for Brian’s family to hear that Brian was hit by a tube train not only once, but seven times. They have found it almost unbelievable that this was able to happen.    

“People who use the TfL network assume the right processes are in place to ensure safety. The coroner has been clear – he has ongoing concerns that further lives could be at risk, and he will be issuing a prevention of future deaths report.  

"Brian's family would like to thank the coroner and the jury for their thorough investigation. 

"While this legal case will not bring Brian back, his family sincerely hope that meaningful change will be introduced to prevent lapses in concentration caused by train operator underload and to significantly improve safety at terminus stations so that this cannot happen again.” 

James Macdonald of 7 Bedford Row is instructed as counsel.