To repair the first two breakages, Cooke managed to find spare three-link or screw couplings; but at Droitwich he was only able to patch up the side chains, which were not designed to hold the full weight of a train.
The second train had reached Brettell Lane about eleven or twelve minutes behind the first, and therefore was clear to proceed to Round Oak.
The line ran in a series of curves, limiting forward visibility, the night was dark, there were no lights in the coaches, excursion trains did not have to have a red light on the rearmost vehicle,[2] and smoke was blowing across the line from neighbouring factories; consequently the crew of the second train did not see the runaway coaches until they were about 300 yards away.
The best insurance against failure of couplings was the selection of intelligent men of known character and steadiness for the execution of responsible duties.
It cannot for a moment be supposed that a man habitually trustworthy should on this occasion only have so far forgotten himself as to invite the passengers into his van, to smoke and drink with them, to employ them at his brake handle, and four times to fracture the couplings in one day by his carelessness; and if the company or their officers were not aware of his character previously, then it can only be said that they ought to have been aware of it, and that they ought to have used an amount of circumspection that would have prevented them from appointing a careless man, as he proves clearly to have been, to such important duties For a train of 28 carriages, two brake vans were inadequate, more than 28 carriages were needed to hold a thousand pleasure-seeking excursionists without over-crowding, and to maintain good order in a thousand pleasure-seeking excursionists more was needed than two guards (who had their normal duties to perform).
Tyler also noted two points which, whilst having no bearing on the accident, were, he felt, indicative of 'a want of proper discipline in the administration of the company'
In his summing up, the coroner directed the jury as follows Almost all the scientific witnesses agreed in thinking that if Cook, the guard, had applied his brake in a proper manner when the carriages separated at the Round Oak Station, he would have stopped the train and have prevented the collision, and thus have avoided the death of the unfortunate deceased.
If the guard mismanaged his brake, not from want of any intention or opportunity, but because he became frightened, it might show that the man was unfit for his situation, but it could not make him guilty of manslaughter.
"His lordship, having observed ... that there was evidence to show that the guard was doing his best to stop the train by applying the brake, went on to remark that" when a man had a duty to perform, if he performed it negligently, and death ensued in consequence, he was liable for the consequences; but a man was not guilty of manslaughter merely because he did not do that which a stronger or more clever or cool-headed person would have done under similar circumstances.
[e] Reporting this, the Worcestershire Chronicle noted "This result entirely fulfils our prognostications as to the failure of this unfounded and unjustifiable prosecution.