A coroner has urged the Government to consider fitting automatic brakes to trams after seven people were killed in a crash in Croydon, south London in 2016.

The recommendation was made by south London senior coroner Sarah Ormond-Walshe in a report to prevent future deaths.

She presided over a nine-week inquest at Croydon Town Hall earlier this year which concluded that the victims died as a result of an accident.

Miss Ormond-Walshe wrote: “During the evidence, it became clear that trains have automatic braking systems.

“They are of course different from trams, which are driven by ‘line of sight’.

“However, it seems to me that it would be appropriate for a fresh assessment to be made of whether automatic braking systems would be appropriate for trams.”

She sent the report to the Department for Transport (DfT) and the Light Rail Safety Standards Board.

They must respond by November 16.

Floral tributes left near the scene in Croydon
Floral tributes left near the scene in Croydon in 2016 (Steve Parsons/PA)

Miss Ormond-Walshe made three other recommendations.She said “consideration should be given” for adapting tram doors on current and future models so they are strengthened, as at least one of the seven victims in the Croydon crash died as a result of being ejected through a door.

This was a recommendation by the Rail Accident Investigation Branch but “little seems to have been done”, the coroner noted.

She also called on the DfT to consider setting up a national tram safety passenger group, and for all tram operators to look at introducing schemes enabling staff to anonymously report concerns.

Seven passengers died and 51 were injured when the tram derailed on November 9 2016.

The victims were Dane Chinnery, 19, Philip Seary, 57, Dorota Rynkiewicz, 35, Robert Huxley, 63, and Philip Logan, 52, all from New Addington, and Donald Collett, 62, and Mark Smith, 35, both from Croydon.

During the inquest, the jury heard the tram toppled over and spun off the tracks in darkness and heavy rain near the Sandilands stop after hitting a curve at 73kph (45mph).

The speed limit for that stretch of track was 20kph (12mph).

RAIB chief inspector Simon French told the inquest the driver, Alfred Dorris, may have slipped into a period of “microsleep” on the stretch of track ahead of the curve.

Ben Posford, head of catastrophic injury at Osbornes Law, the law firm representing the relatives of five of those killed, said the coroner’s recommendations are “very welcome” and if properly implemented they will go “some way towards ensuring nobody else will lose their lives in the same horrific way as those who died in the Croydon tram crash”.

Jean Smith, 64, mother of Mr Smith, who died after being ejected through a door, said the coroner adopted “most of the changes that the families campaigned for”.

She went on: “It is outrageous that people travelling in trams could suffer the same terrible death that Mark did as they simply haven’t strengthened the doors.

“While the coroner’s recommendations are welcome, I am still angry and upset that nobody has been held accountable for what happened to my son and everybody else on that tram.

“It hurts more than words can say. It is also wrong and frustrating that we were not able to hear any evidence at the inquest from those responsible. We will now look to the Office of Rail and Road to see if they will prosecute.”

The victims’ families are angry that Miss Ormond-Walshe refused to call evidence during the inquest from witnesses, tram drivers or experts who had reported alleged safety failings.