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News story: Serious signalling irregularity at Cardiff East Junction

Over the Christmas period in 2016, Network Rail carried out extensive resignalling and track remodelling work in and around Cardiff Central station. This was the final stage of the Cardiff area signalling replacement scheme, a project which has been in progress for several years. This stage involved the closure of the power signal box at Cardiff, with control of the area moving to the South Wales Control Centre (SWCC), and changes to the track layout and signalling on the east side of Cardiff Central station.

Some of the new track layout was brought into use on 29 December. At 08:46 hrs on that morning the driver of train 2T08 from Cardiff Central to Treherbert, which had just left platform 7, noticed that a set of points in the route his train was about to take were not set in the correct position. Train 2T08 was the first up train on the Up Llandaff line after the start of service over the new layout.

The points at which the train stopped were redundant in the new layout and should have been secured in the normal position in readiness for their complete removal at a later date. The project works required eight point ends in two separate locations to be locked and secured in this way. In the event only six of the eight point ends were locked and secured, and the line was re-opened to traffic without the omission having been identified by the project team through the normal checking processes which should take place as part of this type of works. These two point ends were left in a condition in which they were unsecured and not detected by the signalling system, and the points at which train 2T08 stopped, points 817A, were left lying reverse. If the driver had not noticed the position of these points and stopped, the train would have been diverted towards line E (the former down relief line) on which trains can run in either direction. The new signalling system uses axle counters for train detection, and in this situation the system would not have identified that the train was in the wrong place.

A few minutes earlier, at 08:24 hrs, another train, down train 1V02, had travelled over the other points which had been left unsecured at the other end of the same crossover (817B). These points had been left in the normal position, which was correct for trains travelling over them in the down direction.

No-one was injured and no damage was caused by either event, and Network Rail acted quickly to secure both sets of points.

Our investigation will examine:

  • the events leading up to the commissioning of the new track layout in the area of 817 points
  • the methods that Network Rail’s Cardiff area signalling replacement project used for project management and assurance processes
  • the on-site team briefing and works management process.

It will also examine any relevant management issues and consider previous relevant recommendations made by the RAIB.

Our investigation is independent of any investigation by the railway industry or by the industry’s regulator, the Office of Rail and Road.

We will publish our findings, including any recommendations to improve safety, at the conclusion of our investigation. This report will be available on our website.

You can subscribe to automated emails notifying you when we publish our reports.

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It’s welcome news that simplifying fares will be trialled but it is clear that this is just tinkering around the edges – Andy McDonald

Andy McDonald MP, Labour’s Shadow Transport Secretary, commenting on reports that reforms to the rail fare system will be trialled this May, said:

“It’s welcome news that simplifying fares will be trialled but it is clear that this is just tinkering around the edges. 

“Privatised rail has created a fragmented system with a jumble of operators offering a complicated array of fares for passengers to navigate. 

“Passengers don’t want to shop around for tickets, they want to get from A to B for the cheapest price. This is why Labour will bring our railways back into public ownership, creating an integrated national network with simple and affordable fares for all.”

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Tens of thousands of ‘adverse events’ in Scotland’s dementia and geriatric wards

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1 Feb 2017

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Dozens of “adverse events” are recorded every day in the dementia and geriatric wards of Scotland’s hospitals, new figures have shown.

A Freedom of Information request revealed 167,041 such incidents have occurred in the past six years as an under pressure health service attempts to deal with an ageing population.

The Scottish Conservatives said the data illustrates problems many vulnerable patients have encountered, as well as the daily challenges facing staff in elderly inpatient wards.

Incidents range from falls and assaults on staff to self-harm and patients absconding from secure facilities.

In NHS Borders, one staff member was injured while receiving training in dealing with aggressive patients, and in Fife there were reports of bomb threats and suspicious packages, as well as “rooftop protests”.

Much more seriously, bosses at NHS Greater Glasgow and Clyde said adverse events had resulted in the deaths of 49 patients since 2011.

In some cases, staff shortages were posing such a risk that employees formally logged that as an adverse event in itself, while in the Western Isles a lack of staff was blamed directly for allowing a patient to climb out a window and escape from hospital.

Shadow health secretary Donald Cameron warned these problems would become more commonplace as Scotland’s population aged, and cases of dementia increased.

The true figure is likely to be even higher, as some health boards were unable to provide the information, or supplied only the most serious of events.

Last year, it was revealed that maternity units across Scotland had also endured thousands of adverse events, prompting calls for an investigation.

Scottish Conservative shadow health secretary Donald Cameron said:

“Patients in dementia and geriatric wards are among the most vulnerable in our hospitals, and deserve the best possible care.

“And there’s no question that wards dealing with dementia patients are incredibly challenging places to work: many of these incidents illustrate that.

“In such environments many of these adverse incidents will have been unavoidable, and it’s a credit to hardworking NHS staff that they deal with these day, in day out.

“But patients in these wards, and their families, will be extremely worried at the sheer scale of these flashpoints.

“There are a significant number of incidents which were put down to staffing shortages, or a lack of adequate resources and training, and that very much falls at the Scottish Government’s door.

“As our population ages and conditions like dementia become more prevalent, it’s clear something needs to be done to ensure these incidents don’t increase.

“We need to see a proper plan to make sure our staff and hospitals are equipped for all the future challenges they face.”


Below is a list of the adverse events recorded by health boards for the past six years:

Ayrshire and Arran – 15,043
Borders – 10,252
Dumfries and Galloway – 6399
Fife – 19,308
Forth Valley – 13,629
Greater Glasgow and Clyde – 270
Grampian – 16,426
Highland – 7073
Lanarkshire – 33,092
Lothian – 44,890
Orkney – n/a
Shetland – n/a
Tayside – no response
Western Isles – 659

Total – 167,041

Below is a list of the national figures broken down by year:

2011 – 28,239
2012 – 28,659
2013 – 28,317
2014 – 29,847
2015 – 28,906
2016 – 23,118*

Total – 167,041

*Some health boards only supplied information for part of 2016, which may explain the lower number.

All details were obtained by the Scottish Conservatives through Freedom of Information. For a copy of individual responses, contact the Scottish Conservative press office.

Last year, it was revealed that thousands of adverse events had occurred in maternity units across the country:
http://www.bbc.co.uk/news/uk-scotland-scotland-politics-38055060

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“Reform is an essential part of the future” says Vaughan Gething

Speaking ahead of the conference, Vaughan Gething said:

“2016 was a tumultuous year for our country. A year of unprecedented political upheaval and uncertainty that will impact on society and public service delivery for many years to come.

“But despite that uncertainty and despite record demand, our NHS delivered better health care for people across Wales. Welsh Ambulance performance is now the best in the UK, cancer survival rates continue to improve faster in Wales than any other part of the UK and overall waiting times are down 20% on last year. 

“Whatever services people use – hospitals, GPs, social care, mental health services – they expect good quality care in a timely manner. Above all else, delivering on that is our prime concern.

“Our staff have worked extremely hard this winter and we have seen diagnostic and planned care waiting times reduce dramatically over the past year.  I want to thank them for their dedication and commitment to the values of the NHS and to providing high-quality care.  

“I’m proud of our achievements, but I want us to be more ambitious for 2017. I want us to continue to reduce planned care and diagnostic waits. I want us to build a health service that meets and delivers on the needs of our patients and that is sustainable, in spite of the challenges.

“Reform is an essential part of the future.  If we do not reform then we will not deliver the change and improvement that is needed.  

“This is our mission. It won’t be easy but it will be worth it. 

“It’s time good performance was recognised. I want to encourage the boards and trusts that are operating well, that are delivering for local people, and incentivise excellence in our health service. We will be exploring how we can best make that happen.”

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Press release: Charity payment after water company permit breach

The Environment Agency has accepted an Enforcement Undertaking which will see Northumbrian Water pay £375,000 to charities in the North East after it breached environmental permitting regulations.

The offer also includes actions for Northumbrian Water to improve its operations and infrastructure.

It follows a sewage pollution incident involving West Wylam pumping station, investigated by the Environment Agency on 18 February 2015.

A blockage upstream of the pumping station resulted in raw sewage overflowing into Park Burn, a tributary of the River Tyne, breaching its permit.

Investigations showed significant water quality impact at Park Burn, with sewage odour and litter visible, and ammonia and suspended solid levels above accepted levels. Surveys indicated there had been no significant impact on the invertebrate population in the burn, and there was no impact on the Tyne, due to the river size and flow of the river.

Northumbrian Water carried out an immediate clean-up of the polluted area after it was reported to them.

Wide range of measures

The Environment Agency is making better use of the wide range of measures that are available to bring sites back into compliance as quickly as possible. Along with prosecutions, it uses enforcement notices, stop notices and civil sanctions to either improve performance or stop sites from operating.

The Environment Agency’s use of civil sanctions is in line with recent legislation extending their availability for more offences.

Civil sanctions such as these can be a proportionate and cost-effective way for businesses to make amends for less serious environmental offences. The company must offer to restore or remediate the harm caused by the incident, and demonstrate they will change their behaviour and ensure future compliance with legislation.

Proportionate response

Fiona Morris, Environment Manager with the Environment Agency in the North East, said:

We will always take forward prosecutions in the most serious cases and while we did initially consider prosecution, the company submitted an EU which we subsequently accepted.

We felt it to be a more proportionate response that would benefit the environment – achieving more than if the company had been convicted and fined.

We work hard to protect people and the environment, and a clear regulatory framework with agreed standards and targets has helped to drive major environmental improvements over the last few decades.

We’re continuing to improve our approach to ensure that we remain a fair and proportionate regulator.

The actions offered in the accepted EU, require Northumbrian Water to:

  • Make donations to Tyne Rivers Trust (£134,500), Northumberland Rivers Trust (£59,500), Wear Rivers Trust (£48,500), Tees Rivers Trust (£58,500).
  • Make a donation of £74,000 to Groundwork towards the Land of Oak and Iron Project.
  • Make improvements to site operations and infrastructure, including updated sewerage records, an updated process for asset planning and management and refurbishment of West Wylam pumping station, as well as an accelerated programme of planned upgrades to sewer infrastructure in the area.
  • Further inspections and surveys of the impacted area.
  • Pay Environment Agency costs.

Failure to comply with an EU may result in the offender being prosecuted for the original offence.

See the full list of the most recent enforcement undertakings

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