Brian Mitchell, 72, died on Boxing Day in 2023 after being unable to climb back onto the platform before being struck by a Jubilee line train.
CCTV footage showed that he left a train at 1.36pm and sat on a bench at the platform before standing nearly an hour later towards the edge of the platform.
At 2.50pm a Jubilee line train struck Mr Mitchell and the impact went unnoticed, with the train reversing out of the station over him.
Two further trains then entered and left the platform, moving over him again.
A new coroner report published online on Monday (January 5) has noted that a member of staff tried to stop a fourth train from moving over Mr Mitchell, but this was unsuccessful.
The inquest heard that factors that contributed to his death were that Mr Mitchell was likely drunk but also that since automatic train operators are used on the Jubilee line, thee train operators failed to notice a man on the track to override the automated system.
Graeme Irvine, the coroner for east London, has said that there was “no clear evidence to demonstrate that risks of fatal harm have been mitigated”.
He claimed that two years on since the incident, recommended technological measures to alert staff of a person on the tracks had not been implemented at Stratford.
The report also states there is “no clear data” to demonstrate that train operators were concentrating on looking at the tracks while operating the trains, nor that staff training has improved in communicating during emergencies.
Writing to the Mayor of London and Heidi Alexander, Transport Secretary, Mr Irvine said that action should be taken to prevent future deaths.
He wrote that the death could have been avoidable and: “The track layout would have allowed Brian’s presence to have been noticed by an attentive train operator.
“Additionally, it was asserted that a train operator would have had sufficient time to react and bring the train to a stop many metres before Brian’s location.”
Claire Mann, TfL’s chief operating officer, said: “Our thoughts are with the family and friends of Mr Mitchell, who sadly died at Stratford Tube station.
“We are committed to learning from this tragic incident and assisted the coroner during the inquest.
“We will respond to the coroner’s Prevention of Future Deaths report and are taking action to prevent incidents like this from happening again.”
