19 December 2022

Before HM Assistant Coroner Dr Julian Morris  
Southwark Coroner’s Court  
Heard 5 -14 December 2022

A critical inquest has concluded into the death of a young man, who died on a live rail at London Bridge train station on 25 March 2020, after being unjustifiably handcuffed and wrongfully arrested by British Transport Police (BTP) officers.  

Fraser Moore, 25, had been in mental health crisis on a train and was being supported by two off duty Met officers who had expected he would be taken to hospital. Instead he was arrested by BTP, ran off and died. The inquest concluded the actions and inactions of BTP contributed to his death. 

Fraser was a Canadian man travelling to London to pursue his entrepreneurial endeavours in the music production industry. He had been in London less than 24 hours at the time of his death. Fraser’s family describe him as a creative spirit with an adventurous nature, and a contagious laugh. He was a much-loved brother, son, nephew and friend.  

In the early hours of 25 March 2020 at 5.17am, days after the country went into lockdown, Fraser boarded a train. He was loud and animated and had no top on, despite the cold weather, but was wearing three pairs of trousers.  

Fraser came to the attention of two off duty Metropolitan police sergeants who were travelling on the same train. One of them spent over 20 minutes talking to him, expecting help from the BTP once the train came into London Bridge. He was acting and speaking bizarrely, and this was recorded by one of the officers.  

One of the police sergeants gave evidence to the inquest. She said that, given his behaviour, she was expecting Fraser to be taken to hospital by BTP officers, under mental health detention powers (section 136 of the Mental Health Act). 

The jury heard that Fraser had agreed to go to hospital and was fully compliant with the officers. However, when a BTP sergeant boarded at London Bridge he instead handcuffed Fraser immediately, without asking either of the off duty officers a single question. 

Another BTP officer, a police constable, then decided to arrest Fraser. This was again without seeking any information at all from either off-duty officers, both of whom were present. 

The BTP officer relied on what was recorded on an inaccurate and incomplete information, from the BTP control works log. These incorrectly stated that an offence of indecent exposure had occurred. This had come from a Met police 999 call operator.  

The BTP officer did not record the necessity of the arrest at the time. Seeing Fraser’s agitation, the off duty Met police officer asked the BTP officers to give her some space as they had a good rapport. As the BTP officers left the train, Fraser was able to run off with his hands still cuffed to the front. 

Despite being responsible for his detention, the BTP officers had failed to cover of one of the carriage exits. Fraser was chased by a BTP officer down the platform. He then jumped onto the live tracks, fell onto the ground where he was electrocuted. He was pronounced dead by medics at 6.16.am.  

Due to the unclear communication from the BTP officers, it took around 15 minutes for Network Rail to turn off the power on the tracks. However, the jury heard medical evidence that he would have died very quickly. 

The inquest jury concluded that Fraser’s death was caused by electrocution and contact with a live rail. The jury also highlighted the following issues which contributed to Fraser’s death: 

• Inappropriate handcuffing, unnecessary arrest, inadequate supervision of his arrest, and failing to prevent his escape. 
• The ‘National Decision Making Model’ [a framework which police use to make decisions] which stipulates an officer must first gather enough information before making any decision, including handcuffing and arrests, not being followed. This was despite the presence of Met officers who were able to provide this information. 
• Inadequate supervision of Fraser, as BTP officers left the carriage and lost visual contact.  

The jury noted that no aggression was displayed by Fraser prior to being handcuffed, as is clear from the CCTV. They also highlighted that BTP do not provide specific training on assuming a covering position at doors of rail carriages to prevent escape.  

The coroner is considering making reports to prevent future deaths on a number of issues, including to Network Rail on the control room access to the CCTV, as well as the coverage of the cameras at London Bridge. He is also considering evidence around the Met police 999 call operator recording inaccurate and misleading information.  

Fraser’s sister, Kirstyn De Vries, said: “My brother, Fraser was arrested and handcuffed for a crime he never committed. He died terribly and suddenly due to electrocution, whilst being pursued by a BTP police officer.  

Fraser was a hopeful person, with strong ambition. Coming to London in March 2020, there was much opportunity on the horizon to fuel his adventurous and entrepreneurial nature. However, this ambition and hope was all too sadly brought to an abrupt end, and me and the family still feel a deep loss.   

In my opinion Fraser’s vulnerability and mental health were not considered by the BTP police officers on the morning of the 25th. He was willing to be taken to hospital, but instead he was unlawfully handcuffed and arrested. 

Following the handcuffing and during the pursuit by the BTP officer, I believe that my brother was unable to steady his balance on the uneven trackside surface, due to the front-stack handcuffing, ultimately leading to his fall.  

The Met officers had offered to bring him to a hospital, get him care. The BTP officers instead ‘spooked’ him. Officers are trained to keep hold of people that are arrested or detained, and the officers failed to do this.   

In his innocence, and mental vulnerability it troubles me that the police were not more cautious, understanding and careful. Fraser was my little brother, but also a son, a friend, a creative spirit whose life ended abruptly at the age of 25.   

I am deeply upset by the actions of the police officers on the day of Fraser’s death, and only hope that both the Met and BTP endeavour to take necessary next steps to prevent future deaths of this kind.” 

Selen Cavcav, Senior Caseworker at INQUEST, said: "What happened to Fraser is another shocking example of police culture centred around unnecessary and inappropriate use of force towards people with mental ill health.  

The contrast between the Met and Transport police officers’ actions in this case demonstrate just how unnecessary and harmful this is. 

The jury findings in this case spell out all the failures that contributed to Fraser's preventable death. His family deserves nothing less than absolute assurance that proper changes have now been put in place, and that the officers involved in the incident will be held to account." 

Jade Brown of Taylor Rose MW, who represents the family, said: “The inquest has been extremely difficult for Fraser’s family, especially his mum who lives in Canada. Fraser was clearly unwell when he encountered officers on 25 March 2020, yet instead of the officers exercising their powers under the Mental Health Act and treating him with care, he was arrested and handcuffed for a crime he did not commit.  

The handcuffing appeared to be a trigger for Fraser who unfortunately went on the tracks whilst being pursued by an officer and was electrocuted. Officers are trained to deal with vulnerable individuals, yet we repeatedly see those that are vulnerable being failed leading to death. It is the family’s hope that following the hearing and the jury’s findings that police officers, who cited the National Decision Model in evidence, actually apply it in future”  

ENDS  

NOTES TO EDITORS  

For further information, please contact Lucy McKay on [email protected] or 020 7263 1111.  

The family is represented by INQUEST Lawyers Group members Jade Brown of Taylor Rose MW solicitors and Maya Sikand KC of Doughty Street Chambers. 

Other interested persons represented at the inquest are British Transport Police, the Metropolitan Police Service and Network Rail.  

Journalists should refer to the Samaritans guidance for reporting on inquests.