A senior coroner has concluded that the death of a pensioner who was struck by four separate London Underground trains at Stratford station could and should have been avoided. Brian Mitchell, 72, died in December 2023 after falling onto the tracks at the east London station.
A Tragic Sequence of Events
Graeme Irvine, the senior coroner for east London, detailed the incident in a Prevention of Future Deaths report published on Monday, 5 January 2026. CCTV footage showed that Mr Mitchell, who was likely intoxicated, stepped off a train and sat on a platform bench. He then stood up and "lurched towards the edge of the platform" before falling onto the tracks.
The report states that Mr Mitchell moved and attempted to climb back onto the deserted platform. However, an incoming Jubilee line train entered Platform 13 and struck him. The driver of this train did not notice the impact, and the train subsequently reversed out of the station, passing over Mr Mitchell a second time.
Shockingly, two further trains then entered and left the terminus platform, each moving over him twice. A member of staff tried unsuccessfully to stop a fourth train from entering the platform as the tragedy unfolded.
Serious Questions Over Automated Systems
Coroner Irvine raised significant concerns about the Automatic Train Operation (ATO) system used on the Jubilee line. This system automates both acceleration and braking, meaning train operators are not manually driving.
"The track layout would have allowed Brian’s presence to have been noticed by an attentive train operator," Mr Irvine stated. He emphasised that operators must pay close attention to the track ahead and be prepared to override the ATO if they see an obstruction. The court heard that the driver of the first train may have mistaken Mr Mitchell for a 'blow-up doll'.
The coroner identified a specific risk at terminus platforms like Stratford's Platform 13, where a lowered level of attention from operators might occur.
Lack of Action and Clear Data
In his report, addressed directly to Transport for London (TfL), Mr Irvine listed several critical failures. He noted that despite investigations by the British Transport Police, the Rail Accident Investigation Branch, and TfL over the two years since the death, there is no clear evidence that risks have been mitigated.
Key concerns included:
- Recommended technology to detect people on tracks has not been implemented at Stratford.
- No clear data shows that training for drivers using ATO has improved their concentration on the track ahead.
- There is no clear data demonstrating improved emergency communication by station staff.
"In my opinion there is a risk that future deaths could occur unless action is taken," the coroner concluded.
Claire Mann, TfL’s Chief Operating Officer, responded: “Our thoughts are with the family and friends of Mr Mitchell. We are committed to learning from this tragic incident... We will respond to the coroner’s report and are taking action to prevent incidents like this from happening again.”
