0:00:02 > 0:00:08Today is relatively unusual. Mostly with train cases, you have a very clear deliberate act.
0:00:08 > 0:00:10West London.
0:00:10 > 0:00:14One of the busiest Coroner's jurisdictions in the country,
0:00:14 > 0:00:16with over 4,000 cases a year.
0:00:16 > 0:00:18He gets almost sucked into the train.
0:00:18 > 0:00:22Today, Coroner Alison Thompson is about to enter court,
0:00:22 > 0:00:28to resolve the mystery of a young man who was hit by a train.
0:00:28 > 0:00:31Hanging around on a platform, plucking up courage,
0:00:31 > 0:00:34is quite consistent. We see that a lot.
0:00:34 > 0:00:38It's the culmination of a nine-month investigation by the Coroner's team.
0:00:38 > 0:00:43It happens so quickly. You can already see the train coming.
0:00:45 > 0:00:49In court, Alison must establish the facts.
0:00:49 > 0:00:51Who was the deceased?
0:00:51 > 0:00:54When, where and how did he die?
0:00:56 > 0:00:58When life's end is unexplained,
0:00:58 > 0:01:01the answer falls to Her Majesty's Coroner.
0:01:03 > 0:01:04Court rise.
0:01:16 > 0:01:18March 2011.
0:01:18 > 0:01:21British Transport Police pass the case of the young Polish man
0:01:21 > 0:01:24to the Coroner's Office.
0:01:25 > 0:01:28Coroner's Officer, Shirley Stewart,
0:01:28 > 0:01:33is trying to retrace the man's final fatal steps with PC Steve Tucker.
0:01:33 > 0:01:36This is the CCTV taken from the station
0:01:36 > 0:01:40and it shows the deceased getting off the train
0:01:40 > 0:01:42and arriving at Hangar Lane Station.
0:01:42 > 0:01:46Have we established where he's been before he gets here?
0:01:46 > 0:01:50Yeah, he'd been drinking after work in the Park Royal area.
0:01:50 > 0:01:52By all accounts, he's not a big drinker.
0:01:52 > 0:01:54He doesn't drink, he's not a boozer.
0:01:54 > 0:01:57What he appears to do, for whatever reason,
0:01:57 > 0:02:01he gets off the train here, one stop too early.
0:02:01 > 0:02:03You'll see him just taking a seat now.
0:02:03 > 0:02:07He gets off that train, and he sits down.
0:02:07 > 0:02:10And he just stays there for 35 minutes.
0:02:10 > 0:02:11His head goes back
0:02:11 > 0:02:14and he basically settles down for a nice little sleep.
0:02:14 > 0:02:17See, it's a classic pose really.
0:02:20 > 0:02:23It's running fast, we see people going about their business.
0:02:23 > 0:02:24People going up to him.
0:02:24 > 0:02:27You see members of the public going up to him.
0:02:27 > 0:02:30What can you do? He's asleep.
0:02:31 > 0:02:35Watch in a minute, and you'll see, he starts to wake up.
0:02:36 > 0:02:40There, you see, he starts to get up, and the trouble he has getting up.
0:02:43 > 0:02:47He's got no balance, and when he does get to his feet,
0:02:47 > 0:02:49he doesn't stay there long.
0:02:52 > 0:02:53Oh dear.
0:02:53 > 0:02:55Straight down onto the platform.
0:02:58 > 0:03:02Seeing that the man is in trouble, two bystanders try to help.
0:03:02 > 0:03:05They've been interviewed by PC Tucker.
0:03:06 > 0:03:10They can tell he smells of drink, he's not with it.
0:03:10 > 0:03:12And then, up to the end there,
0:03:12 > 0:03:15you can quite clearly see in that shot there,
0:03:15 > 0:03:17he's stood right in front of those barriers.
0:03:21 > 0:03:23Those barriers, they're those swing gates that open.
0:03:23 > 0:03:26They say, "don't go beyond this point, high voltage,
0:03:26 > 0:03:28"trespassers will be prosecuted, staff only."
0:03:30 > 0:03:34Ignoring the warnings, the man walks straight through the gates...
0:03:34 > 0:03:37and onto the tracks.
0:03:37 > 0:03:40The two bystanders implore him to come back.
0:03:40 > 0:03:42He doesn't listen.
0:03:42 > 0:03:45It happens so quickly. You can see the train coming.
0:03:56 > 0:03:57There we go.
0:03:57 > 0:04:01Now, we've got no footage of the impact. None at all, there's no cameras covering it.
0:04:04 > 0:04:07But his final moments were seen by the two bystanders,
0:04:07 > 0:04:08who are clearly distraught.
0:04:14 > 0:04:17He's fallen to the floor
0:04:17 > 0:04:20and dragged up against the platform, he impacts the platform.
0:04:27 > 0:04:30The Coroner needs to establish why the young man
0:04:30 > 0:04:34ignored the warnings and walked through the gates.
0:04:34 > 0:04:38She'll need to decide if he meant to take his own life,
0:04:38 > 0:04:41or whether it was a tragic accident.
0:04:41 > 0:04:45Clearly, I accept you could interpret the fact
0:04:45 > 0:04:47that somebody is on railway tracks
0:04:47 > 0:04:52and isn't coming back when encouraged to do so
0:04:52 > 0:04:56by members of the public, as possibly an act of self-harm.
0:05:06 > 0:05:10It's the start of a new week at Fulham Coroner's Office.
0:05:13 > 0:05:15Coroner's Office, can I help you?
0:05:15 > 0:05:17John Mitchell, Coroner's Office.
0:05:17 > 0:05:21With a high volume of deaths to deal with from the weekend,
0:05:21 > 0:05:23it's often the busiest time.
0:05:23 > 0:05:25First of all, may I pass on my condolences.
0:05:25 > 0:05:28And don't hesitate to call if you want to know anything.
0:05:28 > 0:05:32Because of the amyl nitrate that was found with him,
0:05:32 > 0:05:34we have to do a postmortem.
0:05:36 > 0:05:38Forensic Pathologist Dr Olaf Biedrzycki
0:05:38 > 0:05:42is performing his third postmortem examination of the day.
0:05:42 > 0:05:46Our next is Michael Downey, 3782011.
0:05:46 > 0:05:51The body is that of a white male,
0:05:51 > 0:05:53medium build with no hypostatise
0:05:53 > 0:05:56and no significant signs of decomposition.
0:05:59 > 0:06:00Now, this poor gentleman
0:06:00 > 0:06:04may have a condition called asbestosis.
0:06:04 > 0:06:10Each year, the West London Coroner investigates some 30 cases of industrially related deaths.
0:06:10 > 0:06:13One of the biggest killers is asbestos.
0:06:13 > 0:06:16As a plasterer in the '60s and '70s,
0:06:16 > 0:06:20Michael may have been exposed to the toxic building material.
0:06:23 > 0:06:26Just opened up the trachea and the right main bronchus,
0:06:26 > 0:06:33and as I'm squeezing, I can see pus within the airways.
0:06:33 > 0:06:36This is what we call bronchial pneumonia.
0:06:36 > 0:06:42And it's a direct consequence of his diseased lungs.
0:06:42 > 0:06:46But Michael's pneumonia does not confirm asbestosis.
0:06:46 > 0:06:49So, Doctor Biedrzycki is cutting small lung samples
0:06:49 > 0:06:52to send for specialist analysis.
0:06:53 > 0:06:56They'll look for fibres invisible to the naked eye.
0:06:58 > 0:07:02We're just going to take five pieces of lung tissue
0:07:02 > 0:07:08to look for the asbestos bodies, and to quantify how many there are.
0:07:08 > 0:07:12Dr Biedrzycki's conclusions are not only important for the Coroner,
0:07:12 > 0:07:18they'll help Michael's family to determine whether his job contributed to his death.
0:07:20 > 0:07:23I think the family are deserving of knowing more about it
0:07:23 > 0:07:26and nationally, we need to know more about it.
0:07:26 > 0:07:30It's on the increase and it's expected to peak around 2020.
0:07:31 > 0:07:34During the 1950s and '60s,
0:07:34 > 0:07:37it was in widespread use as an insulating material,
0:07:37 > 0:07:39an industry where people were not aware
0:07:39 > 0:07:42of the horrible consequences of it.
0:07:44 > 0:07:46With the examination complete,
0:07:46 > 0:07:51deputy mortuary manager Lenny Browse can prepare Michael to be returned to his family.
0:07:54 > 0:07:57Even after 20 years in the job, Lenny still wonders
0:07:57 > 0:08:00about the personalities of the people in his care.
0:08:02 > 0:08:06When someone dies, and is required to have an examination,
0:08:06 > 0:08:09you still get remembered as a human being.
0:08:09 > 0:08:12'Human beings are more than a physical form.
0:08:12 > 0:08:16'Your voice, the way you turn in your sleep.
0:08:16 > 0:08:19'Once was toddling away, short trousers,
0:08:19 > 0:08:22'school cap and blazer.'
0:08:22 > 0:08:26What made them laugh? What were they allergic to?
0:08:26 > 0:08:27Did they like dancing?
0:08:32 > 0:08:38I assumed that when he died, he'd just got, you know, old and tired.
0:08:38 > 0:08:41When I heard his body had gone to the Coroner's Office,
0:08:41 > 0:08:44I was surprised and I thought, what's that about?
0:08:44 > 0:08:48Michael lived in West London with his family.
0:08:48 > 0:08:51He leaves two daughters and three grandchildren,
0:08:51 > 0:08:56daughter Mandy and granddaughter Bonnie have fond memories of him.
0:08:59 > 0:09:03'He used to laugh so much, he used to bring tears to his eyes,
0:09:03 > 0:09:05'and it made everybody else laugh, didn't it?
0:09:05 > 0:09:07'Yeah, he had an infectious laugh.'
0:09:10 > 0:09:15Christmas, obviously Christmas day, I don't know where you was actually.
0:09:15 > 0:09:18That's a quite a nice one of Dad, isn't it?
0:09:19 > 0:09:22'He was a good dad. He was a good dad, I loved him,'
0:09:22 > 0:09:24I was very close to him
0:09:24 > 0:09:28and he was good to Bonnie, used to babysit for Bonnie.
0:09:28 > 0:09:30Shall I tell them about the time we went to the pub?
0:09:30 > 0:09:33I hadn't seen him for a couple of months.
0:09:33 > 0:09:36We walked in the pub to see him,
0:09:36 > 0:09:39and he turned round to my dad.
0:09:39 > 0:09:42I'd lost quite a lot of weight and he turned round to my dad
0:09:42 > 0:09:44and he went, "Oh Mark, she's got that disease,
0:09:44 > 0:09:47"she's got that anaraxia, she's got that anaraxia."
0:09:47 > 0:09:52I was like, "Granddad, it's called anorexia, and no, I haven't got it."
0:09:52 > 0:09:56He had lots of friends, he used to like going to the pub
0:09:56 > 0:10:00and have his pints of Guinness, which was his favourite tipple.
0:10:00 > 0:10:04- Guinness was his favourite tipple. - And a bit of brandy.
0:10:04 > 0:10:11If the asbestos contributed towards his death, that's very sad,
0:10:11 > 0:10:15because I know he worked very hard, obviously he worked hard for us,
0:10:15 > 0:10:20for his family, and actually he was putting himself at high risk.
0:10:24 > 0:10:27February 2011.
0:10:27 > 0:10:30A devastating earthquake in New Zealand.
0:10:30 > 0:10:33The country's Prime Minister calls it "the darkest day".
0:10:33 > 0:10:36Christchurch, the country's second city,
0:10:36 > 0:10:38is hit by a powerful earthquake.
0:10:38 > 0:10:42'There's obvious concern for British citizens.
0:10:42 > 0:10:45'Can you give us any news? Is it still too early to say?'
0:10:45 > 0:10:48The city is popular with British backpackers
0:10:48 > 0:10:50and home to many ex-pats.
0:10:50 > 0:10:52Yes, it's John, from Fulham.
0:10:52 > 0:10:58Coroner's emailed me to say we may have up to six victims coming back from New Zealand.
0:11:00 > 0:11:03Alison is one of Britain's leading disaster specialists,
0:11:03 > 0:11:05with experience from 9/11,
0:11:05 > 0:11:09the Bali bombing and the Boxing Day Tsunami.
0:11:09 > 0:11:13We need to be able to react very quickly in West London,
0:11:13 > 0:11:15because we have Heathrow in our patch.
0:11:15 > 0:11:18There are commonly repatriations from mass fatalities
0:11:18 > 0:11:24and we have to be ready to respond to anything that we're given.
0:11:24 > 0:11:26We need to know what flight they're on,
0:11:26 > 0:11:28the time they're arriving at the mortuary,
0:11:28 > 0:11:30and be sitting in court and opening the inquest.
0:11:30 > 0:11:34With the tsunami, we would maybe have five or six a day.
0:11:34 > 0:11:39We built out a whole extension, right out here, to the street
0:11:39 > 0:11:43and just had to expand the site to accommodate all the victims.
0:11:44 > 0:11:48It is imperative the victims are correctly identified.
0:11:48 > 0:11:52Therefore the part we play in that here is important.
0:11:52 > 0:11:55We have had coffins come back with the wrong people in them
0:11:55 > 0:11:58and we've put that right, and also if you make one mistake
0:11:58 > 0:12:01in the identification process it throws out the whole thing.
0:12:01 > 0:12:08There's a team gone out with a view to making sure that all of the identification is correct.
0:12:10 > 0:12:14Alison will work closely with the British team in New Zealand.
0:12:14 > 0:12:18Commander Nick Bracken of the Metropolitan Police
0:12:18 > 0:12:20is already on the scene.
0:12:20 > 0:12:25Hello, Richard. Nick Bracken. Are you at the mortuary?
0:12:25 > 0:12:28Cmdr Bracken is leading the British operation.
0:12:28 > 0:12:31He's Alison's eyes and ears on the ground
0:12:31 > 0:12:34and has worked closely with her on previous disasters.
0:12:34 > 0:12:37Bodies have been burnt in this scenario.
0:12:37 > 0:12:41There are the kind of crush and damage injuries
0:12:41 > 0:12:45that present the problems in identification,
0:12:45 > 0:12:47and where mistakes can be made.
0:12:47 > 0:12:53The team is working at a military base several miles out of the city.
0:12:53 > 0:12:58If there are British dead, they'll be identified here.
0:12:58 > 0:13:02I think anyone has real sympathy to anybody who's lost a loved one
0:13:02 > 0:13:06and they will always work as hard as they can to get loved ones recovered.
0:13:06 > 0:13:10It is very, very difficult and that wait must be absolutely agonising for the families.
0:13:10 > 0:13:17And there is every likelihood, given the number of British people that do live and work here
0:13:17 > 0:13:21and of course the high level of British tourists who come to this beautiful city.
0:13:21 > 0:13:26Press reports suggest that up to 10 Britons may be missing.
0:13:26 > 0:13:29One of those is 41-year-old Phil Coppeard,
0:13:29 > 0:13:34whose parents Barbara and Barry live in Suffolk.
0:13:34 > 0:13:38- I think you put the radio on at 6:30. - Put the radio on at 6:30.
0:13:38 > 0:13:41- And heard...- And heard that there'd been an earthquake in Christchurch.
0:13:41 > 0:13:47And obviously then we were immediately trying to contact Philip
0:13:47 > 0:13:50and there was no answer to his phone.
0:13:56 > 0:14:00He was extremely loyal and...
0:14:02 > 0:14:06- ..caring. - Very caring. Fairly strong willed.
0:14:06 > 0:14:09Very strong willed!
0:14:09 > 0:14:12As they say in this part of the country,
0:14:12 > 0:14:14he was a good little old boy.
0:14:14 > 0:14:16THEY CHUCKLE
0:14:16 > 0:14:21After a career in the City, Phil and his wife Suzanne,
0:14:21 > 0:14:26who was from New Zealand, decided to settle in Christchurch.
0:14:26 > 0:14:31They actually married in England four years ago,
0:14:31 > 0:14:36but we flew out immediately and had a church blessing in Christchurch.
0:14:36 > 0:14:42And they had bought a house in New Zealand anyway, and they decided
0:14:42 > 0:14:48about two years ago that they would change their lifestyle completely.
0:14:48 > 0:14:54They weren't materialistic. The money... They weren't after all that,
0:14:54 > 0:14:59they just wanted a simpler, easier lifestyle.
0:15:01 > 0:15:06Phil and his wife had been living in Christchurch for just six months.
0:15:06 > 0:15:09He had recently started a degree course.
0:15:09 > 0:15:14On the day of the earthquake, he left home to catch a bus to university,
0:15:14 > 0:15:16but was not seen after that.
0:15:16 > 0:15:20His wife Suzanne was interviewed by local radio.
0:15:20 > 0:15:22When did you last see Phil?
0:15:22 > 0:15:29He left home some time between 12:15 and 12:30.
0:15:29 > 0:15:35He was still, you know, working out bus timetables and how long it would take to get to university,
0:15:35 > 0:15:38so he wanted to make sure that he was on time.
0:15:38 > 0:15:41The bus that took Phil to university was a number 702.
0:15:41 > 0:15:44A bus of that number was crushed by a building
0:15:44 > 0:15:48that collapsed in the earthquake.
0:15:48 > 0:15:53My husband is not the usual university student age, he's 41.
0:15:53 > 0:16:02The phone for a long time after the quake was ringing and ringing and then going to voicemail.
0:16:02 > 0:16:07I'm just struggling to get information, and we just really want Phil to come back.
0:16:12 > 0:16:16He'd phoned us about an hour or two before he got on the bus,
0:16:16 > 0:16:20he was going off for his second day at university,
0:16:20 > 0:16:24told us all about what had happened on the first day.
0:16:24 > 0:16:30We didn't know if he was still on the bus under the rubble,
0:16:30 > 0:16:33we didn't know if he was alive or not at that time,
0:16:33 > 0:16:40and didn't know if he was badly injured in a hospital somewhere, so...
0:16:41 > 0:16:43With hundreds still missing,
0:16:43 > 0:16:47this city is bracing itself for even further loss.
0:16:52 > 0:16:56On the other side of the world in London, the Coroner's team
0:16:56 > 0:16:59are still waiting for news of British victims.
0:17:02 > 0:17:05Progress is being made in the case of the young Polish man
0:17:05 > 0:17:07hit by an underground train.
0:17:11 > 0:17:15In Uxbridge, forensic pathologist Dr Ashley Fegan-Earl
0:17:15 > 0:17:18has completed his postmortem report.
0:17:18 > 0:17:24The cause of death is unlike the majority of railway fatalities.
0:17:24 > 0:17:28It is a bit of a more unusual one.
0:17:28 > 0:17:33As I understand it, it's managed to pinion him between the tracks,
0:17:33 > 0:17:37as it were, and the...something called the shoe of the train.
0:17:37 > 0:17:42What it's actually done as a consequence is pinioned his chest,
0:17:42 > 0:17:48preventing any of the normal movements of breathing, resulting in this traumatic asphyxia.
0:17:48 > 0:17:53We can see that from the petechial haemorrhages that are present in his eyes.
0:17:53 > 0:17:59The postmortem has revealed that the man's liver was undamaged,
0:17:59 > 0:18:03corroborating accounts that he was not a regular drinker.
0:18:03 > 0:18:07There's certainly no changes in his liver that would suggest that.
0:18:07 > 0:18:11The exact effects of drink on any one individual are obviously going to
0:18:11 > 0:18:14depend on how used to drinking they are.
0:18:14 > 0:18:19Toxicology results from St George's, University of London,
0:18:19 > 0:18:22reveal that the man had alcohol concentrations
0:18:22 > 0:18:25five times higher than the legal drink-drive limit.
0:18:25 > 0:18:30They have been passed to Coroner's Officer Shirley Stewart.
0:18:30 > 0:18:34The alcohol has been absorbed into the bloodstream so the concentration
0:18:34 > 0:18:38in the urine is higher than in the blood, which indicates to us
0:18:38 > 0:18:42that this is someone who's been drinking over a several-hour period.
0:18:42 > 0:18:45I do know that he was self-employed here in the UK
0:18:45 > 0:18:49working as a carpenter, and that he was a very reliable worker.
0:18:49 > 0:18:53And he'd been at work the day before he died.
0:18:53 > 0:18:57And whilst he was at work he was saying that he felt quite unwell
0:18:57 > 0:19:01and wasn't sure whether or not he was going to go in the next day.
0:19:01 > 0:19:05Life in Poland prior to coming to the UK, we have very little,
0:19:05 > 0:19:11other than the fact that he was a happily married man, with a two-year old son.
0:19:11 > 0:19:15There was no evidence at postmortem that he was suffering any natural disease or illness
0:19:15 > 0:19:21that has either caused or contributed to his death, so it's really very tragic.
0:19:22 > 0:19:24The Coroner has yet to decide
0:19:24 > 0:19:27if the young man's death was accidental or deliberate.
0:19:27 > 0:19:31But, for mortuary technicians like Cassie,
0:19:31 > 0:19:33the latter is all too familiar.
0:19:33 > 0:19:40We went through a patch here of a lot of Polish...young Polish gentlemen hanging themselves,
0:19:40 > 0:19:45I presume...coming over to start a new life, and earn money,
0:19:45 > 0:19:51and it obviously didn't work out for a lot of them and we went through a stage of having a huge number.
0:19:51 > 0:19:56Probably...why would there be more men?
0:19:56 > 0:19:59I guess there's more financial pressure on men -
0:19:59 > 0:20:04you know, to run a family, to run a home.
0:20:04 > 0:20:06Not that I'm being sexist,
0:20:06 > 0:20:10but I would say there's probably more pressure on a gentleman.
0:20:10 > 0:20:16I just find it very sad. I find it sad for the family.
0:20:18 > 0:20:22There are now over half a million Polish people living in the UK
0:20:22 > 0:20:25and West London is a major hub for the community.
0:20:26 > 0:20:31When deaths occur, they're dealt with by Monika Panasiuk of the Polish Embassy...
0:20:31 > 0:20:34Monika.
0:20:34 > 0:20:39..who liaises between the Coroner's Office and bereaved families.
0:20:40 > 0:20:44Sometimes people, they have never heard even such a word, coroner,
0:20:44 > 0:20:47because in Polish there is no such a word, coroner.
0:20:47 > 0:20:51They're asking, "Coroner, Coroner? What is it, who is it?"
0:20:51 > 0:20:55Also I can tell you one thing, that in Poland there is a tradition
0:20:55 > 0:21:01that the...person who died is buried very quickly.
0:21:01 > 0:21:04Even after one, two days after death.
0:21:04 > 0:21:07Hello?
0:21:07 > 0:21:10Shirley. Shirley's on the line.
0:21:10 > 0:21:13Hello, Monika, it's Shirley from the Coroner's Office.
0:21:13 > 0:21:17Shirley is preparing for the court inquest into the young man's death.
0:21:17 > 0:21:23His wife lives in Poland and has been asked if she wants to attend.
0:21:23 > 0:21:29- And she told us that she's not going to be come.- 'So she's not going to be attending. OK.'- No.
0:21:29 > 0:21:34'There's probably also the matter of money, and the matter of organising the family life,
0:21:34 > 0:21:37'so that's why she's not coming.'
0:21:37 > 0:21:41However, her friend, or their friend, is going to attend.
0:21:41 > 0:21:44The Coroner often likes to have somebody that can actually
0:21:44 > 0:21:47tell us who that person was in life,
0:21:47 > 0:21:50and what their dreams and aspirations were.
0:21:50 > 0:21:54And, you know, just what their life expectations
0:21:54 > 0:21:56and who they were as a person,
0:21:56 > 0:22:00and I also think it's always very nice to have that on record as well.
0:22:00 > 0:22:03The reasons people are taking their own life,
0:22:03 > 0:22:06it's probably the expectation.
0:22:06 > 0:22:10Or different reality, if they met here.
0:22:10 > 0:22:13Also they feel lonely.
0:22:13 > 0:22:17They have troubles and they have no-one to talk about this.
0:22:17 > 0:22:22Because someone appeared to be a satisfied, reliable person
0:22:22 > 0:22:26who seems to have settled in the UK, it may be that at inquest
0:22:26 > 0:22:31somebody will turn round to say, "Well, actually, that's not the case."
0:22:31 > 0:22:36Probably it was suicide. Well, we'll see what the Coroner says.
0:22:36 > 0:22:38So we will see.
0:22:45 > 0:22:50Dr Olaf Biedrzycki is at the pathology lab at Queen Mary, University of London.
0:22:53 > 0:22:59He's here to continue the investigation into how former plasterer Michael Downey died.
0:23:01 > 0:23:05Michael's lung tissue has been prepared for detailed forensic examination.
0:23:08 > 0:23:12Dr Biedrzycki takes each section of the sample
0:23:12 > 0:23:14to count the number of asbestos fibres.
0:23:14 > 0:23:17They are quite hard to find,
0:23:17 > 0:23:19and to fulfil a diagnosis of asbestosis,
0:23:19 > 0:23:25we need to find at least two asbestos bodies per centimetre squared of the tissue.
0:23:29 > 0:23:32The problem we have is that we haven't got enough asbestos bodies
0:23:32 > 0:23:35to substantiate the diagnosis.
0:23:37 > 0:23:41After weeks of extensive testing, there's insufficient evidence
0:23:41 > 0:23:45to determine whether Michael's exposure to asbestos caused his death.
0:23:47 > 0:23:51Six months after he died, Michael's case is at its conclusion.
0:23:53 > 0:23:56There is a danger that if we didn't get involved,
0:23:56 > 0:24:01these deaths would be lost under the title of chronic respiratory disease,
0:24:01 > 0:24:05chronic lung disease, whatever, but we are able to bring them
0:24:05 > 0:24:09out of that general category into a category of their own,
0:24:09 > 0:24:14labelled as industrial disease, and therefore we're able to predict
0:24:14 > 0:24:16that we're going to hit a peak in 2020
0:24:16 > 0:24:21and we need to be preparing for treating those patients over the next 10 years
0:24:21 > 0:24:24and giving them the best quality of life that we can.
0:24:31 > 0:24:35For my Granddad, who in baptism was given the pledge of eternal life,
0:24:35 > 0:24:38that he now may be admitted to the company of the saints.
0:24:40 > 0:24:45This is a copy of a letter that was sent to my Auntie Maureen.
0:24:46 > 0:24:50"I'm very sorry to hear about Mick. He was larger than life and very funny.
0:24:50 > 0:24:54"He was fun to drink with, God love him.
0:24:54 > 0:24:58"There are so many people who act like we live in an artificial world.
0:24:58 > 0:25:02"When I think back as a kid, I remember...
0:25:05 > 0:25:09"I remember the local characters that made the difference.
0:25:12 > 0:25:17"To me they were the colours, the bright colours to a dull, boring canvas.
0:25:17 > 0:25:19"Michael was a bright colour."
0:25:19 > 0:25:23And that's from America. From my dad's first cousin.
0:25:33 > 0:25:39Two Britons are known to have died in the earthquake that struck the city of Christchurch in New Zealand.
0:25:39 > 0:25:42In total, 102 people are known to have died,
0:25:42 > 0:25:45although more than 200 are still missing,
0:25:45 > 0:25:49but hopes of finding more survivors are already fading.
0:25:49 > 0:25:52Nearly two weeks after the earthquake,
0:25:52 > 0:25:57missing Briton Phil Coppeard has still not been identified.
0:25:57 > 0:26:03The grim task being undertaken at a military base is painstaking forensic work.
0:26:03 > 0:26:07It's an agonising wait for anxious families.
0:26:10 > 0:26:14Until the identification process was followed through
0:26:14 > 0:26:17right to the end, we couldn't say a word to anybody.
0:26:17 > 0:26:21We couldn't say Phil was dead because we didn't know for certain.
0:26:21 > 0:26:25And that was the most horrible time.
0:26:27 > 0:26:29For the postmortem examinations,
0:26:29 > 0:26:32a temporary mortuary has been organised in an army hangar.
0:26:32 > 0:26:38Complete bodies and unidentified remains are stored in refrigerated containers.
0:26:40 > 0:26:43Because of the nature of the disaster,
0:26:43 > 0:26:46much of the identification work falls to forensic experts.
0:26:46 > 0:26:50Dr Chris Briggs is an Australian forensic anthropologist.
0:26:50 > 0:26:55It's very important to measure the diameters of certain bones
0:26:55 > 0:26:58and that will provide information in relation to the age,
0:26:58 > 0:27:02the sex and the ethnicity of the people who've died here.
0:27:02 > 0:27:07Many of the victims were very badly burnt.
0:27:07 > 0:27:12And it's very easy for those remains to become mixed up with adjacent remains
0:27:12 > 0:27:17and also with building material, so at times it's very difficult
0:27:17 > 0:27:21to distinguish human from non-human from building material.
0:27:23 > 0:27:29Most mass fatality incidents, of the four questions we answer - "Who, when, where, how?" -
0:27:29 > 0:27:31"who" is the most important.
0:27:33 > 0:27:39The other part of the identification process is obtaining antemortem information.
0:27:39 > 0:27:41Toothbrushes, hairbrushes,
0:27:41 > 0:27:48anything that might contain DNA or fingerprints from the missing person, is obtained from their home.
0:27:48 > 0:27:52People will always be critical of the length of time it takes to do
0:27:52 > 0:27:55the identification work, and I think we have to stress from an early stage
0:27:55 > 0:28:02that it really has to take time, it can't be rushed, it's really important that we get it right.
0:28:02 > 0:28:07Personal items such as keys and watches are taken from the remains.
0:28:07 > 0:28:10Medical and dental records are trawled through,
0:28:10 > 0:28:15all with the aim of providing a match with the postmortem evidence.
0:28:15 > 0:28:19They took DNA from the house, and then
0:28:19 > 0:28:23they asked for dental records, but he'd got absolutely perfect teeth.
0:28:23 > 0:28:29He'd never had - although he hadn't been very meticulous about cleaning his teeth -
0:28:29 > 0:28:32he had had no fillings as a child,
0:28:32 > 0:28:37no treatment at all, but he had no outstanding identification marks.
0:28:37 > 0:28:40He had no tattoos or anything.
0:28:40 > 0:28:45It was extremely frustrating, but there was nothing we could do.
0:28:47 > 0:28:53As so many nationalities are involved, the coroner's process for identifying British victims
0:28:53 > 0:28:56is now going to have to take place in New Zealand.
0:28:59 > 0:29:03In a corner of the army building, a small room transformed into a temporary Coroner's Court
0:29:03 > 0:29:07houses the most important part of the process.
0:29:10 > 0:29:18Coroner Sue Johnson presides over the hearings in which postmortem and antemortem information are matched.
0:29:18 > 0:29:21Do you swear that the evidence you are about to give
0:29:21 > 0:29:26- will be the truth, the whole truth and nothing but the truth? - Yes, I do.- Thank you.
0:29:26 > 0:29:31The evidence I have received consists of fingerprint comparison,
0:29:31 > 0:29:36property comparison and some circumstantial evidence.
0:29:36 > 0:29:40What happens in here, if that evidence is sufficient to establish
0:29:40 > 0:29:45the identity of that body, then we can then say,
0:29:45 > 0:29:49"This body that's only had a number has now got a name."
0:29:49 > 0:29:53And that's a very...poignant moment.
0:29:59 > 0:30:05In this way, the earthquake victim given the number DVI 15720
0:30:05 > 0:30:07was proved to be Phil Coppeard.
0:30:09 > 0:30:13When they asked about identification and we said he'd had one ear pierced
0:30:13 > 0:30:17and we couldn't remember... you can see it in that photo.
0:30:17 > 0:30:20It was his left ear. THEY CHUCKLE
0:30:21 > 0:30:23Two weeks after the earthquake,
0:30:23 > 0:30:28Barbara and Barry were given confirmation of Phil's death by his wife Suzanne.
0:30:28 > 0:30:30Mm.
0:30:31 > 0:30:36She had promised that she would phone us. I made her promise that she would phone us.
0:30:36 > 0:30:38And so...she phoned us
0:30:38 > 0:30:44and told us that it was confirmed that Phil was dead.
0:30:44 > 0:30:48The fallen building that crushed the bus Phil was on
0:30:48 > 0:30:52had been badly damaged after a smaller earthquake the previous year.
0:30:52 > 0:30:56The traffic passing the building was not restricted that morning.
0:30:56 > 0:31:00At the Coroner's inquest in New Zealand
0:31:00 > 0:31:04it was revealed that he died of multiple injuries.
0:31:04 > 0:31:06I was just glad to know that he was...
0:31:06 > 0:31:10if you like, in a perverse sort of way, that he was safe.
0:31:10 > 0:31:13You know, that he was...
0:31:13 > 0:31:19I presume, you would have known that they treated people, I'm sure, with dignity
0:31:19 > 0:31:23and that...he was...safe.
0:31:25 > 0:31:28Not safe and alive, but safe.
0:31:35 > 0:31:38Phil's family decided that he should rest in New Zealand,
0:31:38 > 0:31:41the country he had wanted to make his home.
0:31:42 > 0:31:45He was one of 20 British citizens
0:31:45 > 0:31:49who died as a result of the Christchurch earthquake.
0:31:49 > 0:31:52None were repatriated to the UK.
0:31:52 > 0:31:57We have to remain involved where we've got British nationals killed overseas.
0:31:57 > 0:32:02I don't think we could have predicted any of the incidents that we've dealt with
0:32:02 > 0:32:07but they always have to be adapted to the particular circumstances
0:32:07 > 0:32:12of the disaster you're dealing with, and no two of them are ever the same.
0:32:12 > 0:32:15It's a safeguard. It's a safeguard that hopefully exists
0:32:15 > 0:32:18whether you die here or overseas.
0:32:18 > 0:32:23And then it's an entitlement for the family to know exactly what happened,
0:32:23 > 0:32:27and I hope that that is reassuring to them,
0:32:27 > 0:32:30that we're able to do that for them.
0:32:37 > 0:32:43The date of the court hearing into the death of the young Polish man has now been set.
0:32:43 > 0:32:49PC Steve Tucker from the British Transport Police has been called as a witness.
0:32:50 > 0:32:54Five months after he handed the case to the Coroner's Office,
0:32:54 > 0:32:56he's revisiting the scene of the incident.
0:32:59 > 0:33:04This is the...end of the platform.
0:33:04 > 0:33:05Leads to the tracks beyond.
0:33:05 > 0:33:08This is where it happened.
0:33:08 > 0:33:12Two types of signs here, signs that tell you it's dangerous and signs that tell you it's illegal.
0:33:12 > 0:33:18We have no idea why he would go through these gates and down there.
0:33:18 > 0:33:20'This is Hangar Lane.
0:33:20 > 0:33:23'Please mind the gap between the train and the platform.'
0:33:23 > 0:33:27And the loss is...is terrible.
0:33:27 > 0:33:30His wife's a widow, his child's not got a father,
0:33:30 > 0:33:34and...all in the blink of an eye.
0:33:36 > 0:33:42It's September 2011, nine months after the young man's death.
0:33:42 > 0:33:46Today, the court inquest will finally establish
0:33:46 > 0:33:50whether it was a deliberate act or a terrible accident.
0:33:50 > 0:33:54I think there's always that edge before you go into court.
0:33:54 > 0:33:59I've got the Polish Embassy to liaise with the family, because obviously I don't speak Polish.
0:33:59 > 0:34:01No. You barely speak English!
0:34:03 > 0:34:05Here you're doing all the hard work.
0:34:05 > 0:34:09You're taking the witness through their evidence, you need to have read it.
0:34:10 > 0:34:14The young man's family will not be attending from Poland.
0:34:14 > 0:34:18But the two key witnesses, who saw how he died, are here.
0:34:20 > 0:34:24You've got to assess how long a witness is going to take, it's got to look slick.
0:34:24 > 0:34:27You finish one witness, you're on to the next.
0:34:27 > 0:34:29This is the court room itself.
0:34:29 > 0:34:33Now, the Coroner comes through the door at the side there.
0:34:33 > 0:34:35Do they need a break, is somebody looking tired?
0:34:35 > 0:34:40And I need to establish if you're going to swear on the Bible or if you'd prefer to affirm?
0:34:40 > 0:34:45I get a fair amount of adrenaline going, maybe that helps you do the job properly.
0:34:47 > 0:34:49Court rise.
0:34:50 > 0:34:54The inquest this afternoon concerns the death of Mr Marcin...
0:34:54 > 0:35:00Under English law, cameras are banned from filming in open court.
0:35:00 > 0:35:04What follows is taken from the court's own transcripts.
0:35:04 > 0:35:08And the purpose of the hearing is to determine and record how this young man died.
0:35:10 > 0:35:12Though the images are representative,
0:35:12 > 0:35:14the words are real.
0:35:15 > 0:35:20Now, I'm going to hear from two eyewitnesses, Mr Cristou and Mr Humphries, who I assume are here.
0:35:20 > 0:35:24I swear by Almighty God that the evidence I shall give...
0:35:24 > 0:35:28- I, David Humphries, do solemnly... - And nothing but the truth.
0:35:28 > 0:35:32As Pete and I were standing talking, waiting for the train to arrive,
0:35:32 > 0:35:36we heard some sort of impact noise behind us.
0:35:36 > 0:35:40It was certainly loud enough to catch our attention from a few yards away.
0:35:43 > 0:35:47Pete and I went over to him and asked him if he was OK.
0:35:47 > 0:35:50He wasn't aggressive towards us in any way
0:35:50 > 0:35:53but he wasn't interested very much in our help.
0:35:53 > 0:35:57We tried to give him his phone and bag back but he didn't take any notice of that.
0:35:57 > 0:36:00He didn't have any interest in getting those back from us.
0:36:00 > 0:36:03- He didn't seem interested in getting his possessions back?- No.
0:36:06 > 0:36:09We saw him walking down towards the very end of the platform,
0:36:09 > 0:36:11through the barrier.
0:36:11 > 0:36:15We were calling to him to come back, and don't be stupid.
0:36:17 > 0:36:20Pete and I went through the gate and followed him down.
0:36:20 > 0:36:22- So you followed him as well? - Yeah, yeah.
0:36:22 > 0:36:24He kind of turned around to us,
0:36:24 > 0:36:28the force of the train kind of span him round.
0:36:28 > 0:36:31Some part of the train seemed to catch his clothing, dragged him,
0:36:31 > 0:36:36I don't know, for about five yards or so, released him, then another part grabbed him again.
0:36:36 > 0:36:38It was pretty horrible.
0:36:38 > 0:36:41Obviously at that moment the panic set in,
0:36:41 > 0:36:43and I felt a bit sick as well
0:36:43 > 0:36:47and I seem to remember one person distastefully taking pictures.
0:36:49 > 0:36:55I don't know if he was drunk or he was just having a bit of a wander, I've no idea why.
0:36:55 > 0:36:58Perhaps if he was drunk, he may have thought
0:36:58 > 0:37:04that we weren't trying to help him, that conversely, we were trying to cause him harm.
0:37:04 > 0:37:07That's kind of what I thought might have happened.
0:37:09 > 0:37:12Essentially that concludes all the evidence.
0:37:12 > 0:37:16Obviously I do need to consider at least the possibility of suicide,
0:37:16 > 0:37:23but remind myself that I have to be satisfied to a very high standard of proof indeed.
0:37:23 > 0:37:28I mean, there was simply insufficient evidence to support any finding of suicide.
0:37:28 > 0:37:32This is in all probability a sad accident.
0:37:32 > 0:37:35Our formal verdict will be one of accidental death.
0:37:35 > 0:37:40Just... Yeah, just a guy being in the wrong place at the wrong time.
0:37:40 > 0:37:43I think he was unwell, very intoxicated
0:37:43 > 0:37:45and just disorientated and confused.
0:37:45 > 0:37:46Thanks, Steve.
0:37:47 > 0:37:53Sad that he wasn't accustomed to it, and what a shock for the family.
0:37:53 > 0:37:56You'd like to think it would put their minds at rest in terms of
0:37:56 > 0:38:00any suggestion that it may not have been an accident.
0:38:01 > 0:38:05Some people say, so what is the point of a Coroner's inquest?
0:38:05 > 0:38:08It says that in the fast-moving world we live in
0:38:08 > 0:38:12that we can still find the time, even now, to sit down in a room,
0:38:12 > 0:38:17every single time someone dies in circumstances other than natural causes, to talk about it.
0:38:17 > 0:38:21And it puts an importance on it, for the family, because it says,
0:38:21 > 0:38:25this death was important, because this person's life was important.
0:38:29 > 0:38:32Another day of...
0:38:32 > 0:38:35of sadness. SHE LAUGHS
0:38:37 > 0:38:41Alison, if you hadn't have been a Coroner, what would you be doing?
0:38:41 > 0:38:44I would have wanted to be an actress and a dancer.
0:38:44 > 0:38:48That was my basic ambition when I was a youngster. It hasn't changed...
0:39:06 > 0:39:08..I've just never done it.
0:39:13 > 0:39:15Subtitles by Red Bee Media Ltd