An inquest jury has found that the 2016 Croydon tram crash was an accident.
The crash resulted in the deaths of seven people: Dane Chinnery, 19; Philip Logan, 52; Philip Seary, 57; Dorota Rynkiewicz, 35; and Robert Huxley, 63; all from New Addington, and Mark Smith, 35; and Donald Collett, 62; from Croydon.
The BBC has reported that the foreman of the jury said: 'The tram driver became disorientated, which caused loss of awareness in his surroundings, probably due to a lack of sleep, as a result of which the driver failed to brake in time and drove his tram towards a tight curve at excessive speed.
'The tram left the rails and overturned on to its right side, as a result of which the deceased [were] ejected from the tram and killed.'
However, controversy hung over the proceedings as the South London senior coroner Sarah Ormond-Walshe invoked the 'Norfolk Rule' and refused to call a number of people who the victims' families wanted to give evidence about alleged safety failings.
The Norfolk Rule relates to duplication of evidence and inquiries. Corner Orman-Walshe stated it was not the job of a coroner to duplicate an investigation unless it was shown to be flawed and she did 'not accept that the [previous] RAIB (Rail Accident Investigation Branch) investigation was 'incomplete, flawed or deficient', adding that 'further evidence is unlikely to be of assistance to the jury'.
Transport for London (TfL) stressed it was the coroner's decision for it not to give evidence and that its trams general manager attended throughout.
Potential witnesses included senior managers of operator Tram Operations Ltd (TOL) - a subsidiary of FirstGroup - and TfL, as well as other experts.
The families of the victims told reporters that 'justice had been suffocated' and reports suggest they intend to call on the attorney general, Michael Ellis, to apply to the High Court to grant a new inquest.
Danielle Wynne, the granddaughter of Philip Logan, told the BBC: 'I'm so upset and angry. It's not an accident. Someone is to blame. We want lessons to be learned so that no other family has to go through this.'
More than 50 people were injured when the tram tipped over and spun off the tracks near Sandilands tram stop in south London, on 9 November 2016. It was travelling more than three times faster than a speed restriction.
The inquest heard that the tram went into a very tight corner at 73km/h (45mph). The speed limit was 20km/h (12mph).
Andy Byford, TfL’s commissioner, said: 'We will never forget the seven people who lost their lives in the Sandilands tragedy - Dane Chinnery, Donald Collett, Robert Huxley, Philip Logan, Dorota Rynkiewicz, Philip Seary and Mark Smith. We know these Inquests have been deeply distressing for their families and friends and all those involved and I want to reiterate my continued support to everyone affected.
'We have supported the Inquests and coroner throughout the process in every way we could and Mark Davis, our London Trams general manager, was in attendance throughout.
'We have worked closely with the RAIB and the Office and Rail and Road and have introduced a number of additional safety measures on the tram network in recent years to ensure nothing like this can ever happen again.'
Safety changes in the wake of a tragedy
As part of the RAIB report into Sandilands tragedy, a number of recommendations were made, which led to TfL introducing additional safety measures including:
- an automatic braking system that brings a moving tram to a controlled stop if exceeding the speed limit at designated locations has been installed on all trams in the fleet
- an in-cab driver protection device has been fitted to all trams to protect against fatigue and distraction
- additional speed restrictions are in force and associated signage has been installed near Sandilands and at three other locations
- a permanent speed reduction has been implemented across the London tram network, meaning the maximum speed trams can travel is now 70kph (previously 80kph)
- the installation of enhanced chevron signs at the four sites with significant bends to provide an additional visual cue for drivers. The number of speed signs has been increased and additional lineside digital signage is providing added speed warnings to drivers
- a new higher specification film that is 75& thicker has been installed to improve the containment provided by tram windows and doors
- a new emergency lighting system has been fitted that operates independently of the tram's battery in the event of an emergency
- new tunnel lighting at Sandilands has been installed and is in operation
- procedures for emergency evacuation from trams have been fully reviewed so that the speed of evacuation is improved
- route risk assessments and risk models have now been reviewed and updated.