Coroner Issues Stark Warning to TfL and Mayor Khan Over Tube Safety After Fatal Incident

Coroner Highlights Unmitigated Risks on Jubilee Line

A coroner has issued a critical warning to Sir Sadiq Khan, the Mayor of London, and Transport for London (TfL), urging them to implement urgent safety measures to prevent future fatalities on the London Underground network. The warning comes in a Prevention of Future Deaths (PFD) report, following the accidental death of Brian Mitchell, a 72-year-old man who was struck by multiple trains on the Jubilee Line at Stratford station on Boxing Day, December 26, 2023.

Graeme Irvine, the Senior Coroner for East London, stated in his report, issued on Monday, January 5, 2026, that 'there is a risk that future deaths could occur unless action is taken.' The inquest jury had previously ruled Mr. Mitchell's death as accidental.

Details of the Tragic Incident

The inquest heard harrowing details of the incident, revealing that Mr. Mitchell, who was 'heavily intoxicated by alcohol,' fell onto the tracks at Stratford station's Platform 13 after 'lurching towards the edge' of the platform. He remained on the tracks for over five minutes before being struck by the first of four trains. In total, he was hit on seven occasions.

A significant concern raised was that the initial collision was 'likely avoidable.' Furthermore, one train operator reportedly mistook Mr. Mitchell's body for an 'inflatable doll,' and emergency brakes were not applied by any of the first three incoming train operators. A staff member attempted to prevent a fourth train from moving over him, but was unsuccessful.

Coroner's Unaddressed Safety Concerns

The PFD report, addressed to Mayor Khan, TfL, and Transport Secretary Heidi Alexander, highlighted several critical safety deficiencies that remain unaddressed two years after the incident:

• 'No clear evidence to demonstrate that risks of fatal harm have been mitigated.'
• 'Recommended technological measures to detect and alert staff to the presence of persons on the tracks have not been implemented at Stratford station.'
• A lack of clear data to show that Tube drivers are actively looking for risks when trains operate in Automatic Train Operation (ATO) mode, where acceleration and braking are automated.
• No clear data to demonstrate improved staff training for communicating effectively during emergencies.

The coroner emphasized that the track layout 'would have allowed Brian's presence to have been noticed by an attentive .'

TfL's Response

In response to the coroner's findings, Claire Mann, TfL's Chief Operating Officer, stated, 'Our thoughts are with the family and friends of Mr Mitchell, who sadly died at Stratford Tube station.' She added that TfL is 'committed to learning from this tragic incident and assisted the coroner during the inquest.' TfL has pledged to 'respond to the coroner's Prevention of Future Deaths report and are taking action to prevent incidents like this from happening again.'