Coroner calls for solutions from Sadiq Khan after man was run over FOUR instances at Tube station
A coroner has written to London mayor Sir Sadiq Khan with concerns about safety on the Tube after a pensioner was crushed to death by trains.
Brian Mitchell died on the Jubilee Line at London Underground station Stratford in east London on Boxing Day afternoon in 2023.
An inquest heard the 72-year-old was seen on CCTV to get off a train and sit down before standing up, lurching towards the edge of the platform and falling on to the tracks.
East London senior coroner Graeme Irvine said Mr Mitchell moved and tried to climb back on to the deserted platform but five minutes later he was struck by a train – and then was hit by several more.
CCTV images captured his final moments at 2pm as he had sat on a platform bench at the station for 48 minutes before standing up and stumbling on to the line.
Mr Mitchell was struck by a train five minutes later which stopped at the Jubilee line station.
A further three trains went over his dead body before Transport for London staff suspended services.
The coroner said of the first train that struck Mr Mitchell: ‘The impact went unnoticed.
The final moments of Brian Mitchell, 72, were captured on CCTV at Stratford station as he sat on a platform bench before he stumbled on to the tracks and was hit by four trains
‘The train reversed out of the station over Brian. Two further trains entered then left the platform, each moving over Brian twice.
‘A member of staff unsuccessfully tried to prevent a fourth train moving over Brian as it entered platform 13.’
The coroner deemed that in the two years since Mr Mitchell’s death there was ‘no clear evidence to demonstrate that risks of fatal harm have been mitigated’.
The coroner has now sent his Prevention of Future Deaths report to Sir Sadiq Khan and Transport Secretary Heidi Alexander.
They have 56 days to respond, with details of proposed action.
The coroner said Mr Mitchell, from Edinburgh, was drunk at the time of the incident.
He also told how Jubilee Line trains used Automatic Train Operation, which means drivers do not drive them and the acceleration and braking are automated.
Mr Irvine said drivers were expected to keep a close eye on the tracks and brake if they see an object on the line.
A stock image supplied by the Rail Accident Investigation Branch of a Tube train at Stratford station
Yet in this case three separate drivers failed to notice a man on the tracks.
The inquest said the initial collision with Brian should have been avoided by an alert driver braking in time as the train entered the terminus.
Mr Mitchell died from multiple blunt force wounds and his death was recorded as accidental.
The Daily Mail contacted the Mayor of London’s office, Transport for London and the Department for Transport for comment.
Claire Mann, TfL’s Chief Operating Officer said: ‘Our thoughts are with the family and friends of Mr Mitchell, who sadly died at Stratford Tube station.
‘We are committed to learning from this tragic incident and assisted the coroner during the inquest.
‘We will respond to the coroner’s Prevention of Future Deaths report and are taking action to prevent incidents like this from happening again.’
A Rail Accident Investigation Branch report criticised TfL last January over Mr Mitchell’s death.
A coroner has sent a Prevention Of Future Deaths report to Sir Sadiq Khan (pictured in 2022)
The rail safety regulator said there were no other passengers or staff on the platform when Mr Mitchell fell, and the driver of the first train did not see him.
This was ‘possibly’ because the use of an automatic system to control Jubilee line trains reduced their level of attention, the report stated.
Mr Mitchell, who had been living in Hanwell in west London, was found by emergency services to have been fatally injured.
A post-mortem examination found he had a blood alcohol concentration of 272 milligrams of alcohol per 100 millilitres of blood, which is more than three times above the drink-drive limit in England, Wales and Northern Ireland.
The report stated a driver could also have been ‘distracted’ by the presence of another staff member standing on the platform as they arrived.
The RAIB said the ‘consequences of the accident were made more severe’ because the driver of the second train also did not see Mr Mitchell.
After running over the passenger, the third train’s driver left their cab as normal and entered a staff area for a ‘personal needs break’.
Six minutes after stopping the train, they contacted a control room to report they had seen an inflatable doll on the tracks.
Senior east London coroner Graeme Irvine has also shared his concerns following Brian Mitchell’s death with Transport Secretary Heidi Alexander (pictured in December 2025)
A customer service assistant on the platform failed to stop the fourth train despite seeing Mr Mitchell.
The train driver also recognised there was a person on the tracks.
The RAIB recommended that London Underground considers the use of technology that can warn trains if it detects a passenger is in a dangerous position.
It also called on the organisation to assess how drivers may be affected by trains using automatic systems.
In a separate incident, a mother lost her right arm and leg after being hit by two Tube trains on her way home.
PR executive Sarah de Lagarde slipped on a wet, uneven platform at High Barnet station in north London in September 2022, and fell down the gap between the train and the platform.
She broke her nose and two front teeth in the fall, but nobody heard her desperate cries for help.
After being hit by two trains she was rushed to hospital, where her limbs were amputated.
An investigation into Mrs de Lagarde’s accident was carried out by TfL and the Office of Rail and Road Accident Investigation Branch was notified but concluded no further investigation was necessary.
