The death of a police sergeant who was hit by a train while trying to help a vulnerable man on a railway line was “wholly preventable”, a coroner has ruled.
Sergeant Graham Saville, 46, who worked for Nottinghamshire Police, was on the line in Balderton, near Newark, Nottinghamshire, on August 24 2023 when he was struck by a train travelling at up to 125mph.
Nottingham Coroner’s Court heard that officers attending the incident with Sgt Saville repeatedly told a police dispatcher that the distressed man, referred to in court as Patient C, was near the railway line on the evening of August 24 2023.
Coroner Laurinda Bower has ruled that his death was “probably more than minimally” contributed to by a delay in the force’s control room contacting Network Rail to tell them there were people on the line.
Ms Bower said “there were multiple missed opportunities” by his employer which meant that Sgt Saville “died what was a wholly preventable death”.
She said the call came “too late for any evasive action” to be taken by Network Rail, and had a warning been issued by the rail company to its drivers that there could be people on the track, Sgt Saville may not have been killed.
The warning would have meant the train would have been driven at a “crawling” speed and would have likely been ready to stop had the driver seen people by the tracks.
It would also have meant Sgt Saville would have been more likely to see the train approaching and move out of the way.
She also criticised a lack of “structure” in the police force’s control room and training for control room and frontline staff, including when and how dispatchers should contact Network Rail.
The inquest heard that when a dispatcher finally called Network Rail five minutes after police officers at the scene alerted the control room that the vulnerable man was near a railway line, they dialled the public emergency helpline instead of the York Rail Operations Centre and they were placed on hold for minutes.
While nationally-approved railway safety guidance was also issued to the force and disseminated to some officers and staff, no records were kept of who received it, who considered it, or whether it had been understood.
Ms Bower said it was “reasonably foreseeable” that officers would have to attend incidents on or near the railway line, but that risk assessments were deficient when compared to risk assessments for working near water or roads and failed to identify the “obvious risk of death facing officers when entering a live railway line”.
She said Sgt Saville may not have died had the force implemented a “safe, co-ordinated”, system of risk assessment and training for officers and staff attending incidents on or near to the railway line.
There was also no “policy or procedure” about whether an order to stay off the tracks should be given by a senior officer in the control room.
The coroner said the evidence she had heard fell short of the requirements needed for her to conclude that Sgt Saville’s death was unlawful, and instead made a narrative conclusion.
Ms Bower said: “Graham’s death from injuries sustained in a collision with a high-speed passenger trial while in the execution of his duties as a police officer, was probably more than minimally contributed to by his employer’s failure to have in place a safe system of risk assessment, training and guidance dissemination on the risks associated with incidents on and near to the railway line.
“There were multiple missed opportunities for his employer to have detected these shortcomings and to have remedied the same prior to his death.
“The failures to do so meant that Graham died what was a wholly preventable death.”
She said she was satisfied that there was not a need for a prevention of future deaths report to be made because Nottinghamshire Police had made a raft of improvements to their procedures and training since Sgt Saville’s death.
She added: “The difference between how Nottinghamshire Police managed the obvious risk of death associated with entry to the live railway network pre-August 2023 and post Graham’s death could not be starker. It is night and day in comparison.”
In a statement, Sgt Saville’s family said the inquest process, which they had waited almost two years for, was “robust” but had revealed “shocking and disturbing information” about Nottinghamshire Police as an organisation.
They said: “Put simply, we have learned that they failed in their duty of care to protect their employees.
“The inquest has identified deficiencies in so many areas, which, had they been in place and followed, could have prevented this tragedy occurring.”
They added: “What this inquest has shown us is that Graham, and his colleagues on the ground responding to the incident, were focused on protecting and serving, which is what being a police officer is about.”
Nottinghamshire Police Federation said it was ready to work with the force to make sure all issues raised were dealt with.
It said: “We stand ready as a critical friend to work with the force and rectify the issues identified, ensuring that officers are adequately trained and that systems of work are put in place to protect them when they do so.”
Following Sgt Saville’s death, additional training has been provided to police officers and control room staff about the dangers of entering railway lines, Nottinghamshire Police said.
Chief Superintendent Claire Rukas, force lead for corporate services, said: “We have just received the coroner’s findings and will reflect on all the points she has raised. We will take all the necessary steps to keep the public and our officers safe.
“We know the full impact Graham’s death has caused across the whole organisation and our thoughts continue to be with his family and friends.”
