Coroner warns Transport Secretary and London Mayor automatic tube trains could cause more deaths

Brian Mitchell, 72 died at Stratford tube station on Boxing Day 2023 and Senior Coroner for East London, Mr Graeme Irvine has now confirmed the Jubilee line’s automatic train operation system likely contributed to his death.

Last month, a jury concluded Brian, who was originally from Edinburgh had fallen onto the tracks while intoxicated and, unable to reach a place of safety was struck by four trains on seven separate occasions.

The jury said three train operators did not see Brian on the tracks, with one mistaking him for an “inflatable doll” and none applied an emergency break.  Evidence was heard that the fourth train operator did see Brian on the track but did not apply the emergency brake before hitting him because they “froze”.

A 2025 report by the Rail Accident Investigation Branch found the operator of the first train may have had their attention reduced due to the use of automatic train operation.

A newly issued prevention of future deaths (PFD) report explains Jubilee Line trains operate in Automatic Train Operation (ATO) mode at various points where they are not driven by their operators. Highlighting concerns about this system, the coroner said there is no technology to detect when someone is on the tracks.

He stated that the expectation of train operators is that they pay close attention to the train and the tracks before them and override the ATO system and apply brakes if they observe an object on the tracks.

The PFD report also warns there is a lack of data on whether automatic train operation training given to staff has improved safety.

It states there is “no clear evidence” the risk of future harm at Stratford station has been addressed in the two years since Brian’s death.

Transport Secretary, Heidi Alexander, Mayor of London, Sadiq Khan and Transport for London commissioner, Andrew Lord have been sent the report and urged to act.

The coroner listed his concerns, and said if they are not addressed there is a risk more people die:

1. In the two years since Brian’s death investigations have been conducted by British Transport Police, The Rail Accident Investigation Branch and Transport for London and there is no clear evidence to demonstrate risks of fatal harm have been mitigated.
2. Recommended technological measures to detect and alert staff to people on the tracks have not been implemented at Stratford station.
3. No clear data is available to demonstrate training to ensure train operators concentrate and look at the tracks whilst operating trains automatically has resulted in positive improvement in performance.
4. No clear data is available to demonstrate station staff training has improved emergency communication.

Individuals or organisations issued with a PFD report are under a statutory duty to respond.

Brian Mitchell’s family are represented by Leigh Day partner Thomas Jervis and solicitor Philippa Wheeler.

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

“Brian’s family hopes the Senior Coroner’s report serves as a serious wake-up call for TfL to make meaningful changes. This is the latest in a long line of serious incidents on the network – incidents which investigations have found should never have happened. We will also be writing to the London Assembly to inform them of Brian’s case. His family looks forward to receiving responses that acknowledge the severity of the concerns raised in this report.”

James Macdonald of 7 Bedford Row is instructed as counsel.