Recurring concern

Unreliable supervision of members of the public on station premises

Pin Get email alerts Request correction

First reported 24 Jun 2016•Latest report 1 Jul 2025

Definition

What this concern includes

Includes failures of station-based supervision and oversight of members of the public, including monitoring public reception areas and platforms, identifying prolonged or concerning presence, and maintaining appropriate supervision when stations are staffed or open while unmanned.

Not included

  • Excludes supervision of people in police custody, prisoners, patients, care-home residents or other groups where the station-premises public-supervision concern is not involved.
  • Excludes railway track-access prevention, signage, announcements, emergency communication and rescue-equipment deficiencies unless the report also identifies failure to supervise or identify members of the public on station premises.
  • Excludes generic station staffing or training deficiencies unless they directly undermine supervision or identification of members of the public on station premises.
  • Excludes routine passenger monitoring or security surveillance where no unsafe failure to identify a vulnerable, distressed or potentially at-risk person is asserted.
Reports
6

Distinct published reports

Individual concerns
7

A report can raise multiple concerns

Date range
2016–2025

First to latest report issue date

Stated actions
1

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Network Rail3
Arriva Rail North Limited1
British Transport Police1
Essex Partnership University NHS Foundation Trust1
Metropolitan Police Service1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. County Durham and Darlington

    AI-generated summary

    Jody Lee ROBB · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Jody Lee ROBB died at 23:03 on 8 April 2025 on the carriageway of Station Approach after taking deliberate steps to end her own life. Concerns included insufficiently restricted access from the station platform and the possibility that her presence was not detected or reported by train crews or station staff, despite 11 trains passing during the preceding hour.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Limited visibility of people in the hazardous area from passing trains and station platforms

    Wider context from the report

    “I read and heard evidence from the investigating CID officer who had reviewed all available CCTV in relation to the incident. She reported that Jody had arrived on the south bound platform just over an hour before she jumped. She sat on a bench for a few minutes before making her way onto ████████. She was on the ████████ for about one hour before she actually did so. A total of 11 trains passed her, north and southbound, during that hour. No report was made or received of her presence there by train crews of station staff attending on the station platforms for arrivals and departures. ████████. My concerns are: 1. Access to the ████████ from the platform is not sufficiently barred or impeded to the public. It is clear by means of signage that the public must not go beyond the end of the platform. There are what appear to be some sort of wheeled access steps overs on the platform at and around the fence at its end. But there is nothing to prevent even a moderately mobile person from going around the fence and ████████. The main resource preventing access is human by means of station staff intervention, which is necessarily reliant on their presence at the relevant time; 2. ████████ are not ones designed to prevent, impede or discourage attempts at suicide ████████████████████████████████████████████████████████████████ 3. Eleven trains passed Jody, from north and south, while she was on ████████ during the hour before she jumped. No reports were made by any train crew of her presence. It would be exceedingly the available evidence and unfair to infer that train crews and/or station staff deliberately or negligently ignored her presence there. More likely is that she was simply not visible. It was dark, being at night in April, and Jody was wearing relatively dark clothing. However, she seems to have been discernible on CCTV and from the British Transport Police images I have seen taken from approximately where a driver might have been placed, it is plausible to suggest that she might have been visible, even laterally, from the cab of a train either slowing to stop at the station or pulling out from it, even in deliberately enhanced lighting on the viaduct. Obviously, had a report been made of her presence, some type of intervention could have been attempted ████████████████████ ████████. ”

    Source location

    Jody Lee ROBB · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Maintain a yellow cross-hatched exclusion and visibility area near the platform end.

    Verbatim wording from the response

    “Near the end of the platform, there is also a yellow cross-hatched box. The main intention is to deter individuals from going within the box, as well as making anyone within the box more visible.”

    Source location

    2025-0330 Response from Network Rail
    Page 2 · response
    Published 14 July 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Permanent viaduct lighting is not considered appropriate because it may impair drivers’ vision and increase trespassing.

    Verbatim wording from the response

    “In respect of the lighting on the viaduct, I can confirm that temporary lighting is only used where works to the railway are taking place; however, it is not usual to permanently light the railway. There are various safety reasons for this, including lighting potentially inhibiting driver’s vision and ability to see signals.”

    Source location

    2025-0330 Response from Network Rail
    Page 2 · response
    Published 14 July 2025

    Open published response

  2. Essex

    AI-generated summary

    Amanda Hitch · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Amanda Hitch died on 12 February 2022 after deliberately jumping in front of a train intending to die. She was receiving community mental health treatment. Concerns included important clinical information not being visible to the care team, structured risk-management tools not being specifically considered, and railway-station attendances not being reliably passed to her care coordinator under a multi-agency support plan.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Unavailability of resources to identify and provide information about all unstaffed railway station attendances

    Wider context from the report

    “(3) There was also evidence about the measures that the British Transport Police had taken, seeking to provide additional support by setting up multi- agency support plan, which provided a system for alerting a number of people including the deceased’s care co-ordinator, when she attended at railway stations. In fact, for various reasons, although there are several known attendances at railway stations, none were passed on to the care co- Ordinator. The evidence at the inquest was that British Transport Police does not have the resources always to provide information about attendance at unstaffed stations (although in fact, one such attendance had been known about but was not passed on). The plan as presented does not make it entirely clear what the limitations in relation to information from attendances at unstaffed stations may be, and should it remain the position that BTP lacks the resources to identify all such attendances at railway stations by persons at specific risk of suicide on the railway, there is a risk that those expecting to receive information under such a plan may not realise that the plan will often not assist where its subject is attending unmanned stations. ”

    Source location

    Amanda Hitch · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Bedfordshire and Luton

    AI-generated summary

    Ryan John James WILLIAMS · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Ryan John James WILLIAMS returned to Sandy Railway Station in the early hours of 27 April 2018 and was run over by a train about an hour later. Concerns were raised that the unmanned station had no staff supervision, including no means of supervising potentially intoxicated members of the public if stations remained open while unmanned.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to supervise members of the public on station premises

    Wider context from the report

    “1. It is of concern that a member of the public was able to be on the station premises for an hour without any supervision from a member of staff. 2. It is not uncommon for members of the public to be vulnerable due to intoxication. It is a concern that if stations do have to be kept open, but unmanned, that there is no means of supervising the use of the station by the public. ”

    Source location

    Ryan John James WILLIAMS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Cheshire

    AI-generated summary

    Thomas Coyne · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Thomas Coyne consumed alcohol at a stag party, inadvertently entered Earlestown Railway station, accessed the railway lines and was struck by a passing train on 21 May 2016. Concerns were raised that station CCTV did not cover all platform areas and that there was no physical barrier at the end of platform three, allowing access to the tracks.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of station CCTV to cover all platform areas

    Wider context from the report

    “1. The CCTV installed at the station and which can be monitored by the staff on duty, does not actually cover all the platform areas, and thus the member of staff could not see Mr Coyne (who was the only passenger on the station at the time) as he mistakenly wandered on to the tracks. ”

    Source location

    Thomas Coyne · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The station is not considered high risk under the criteria used to prioritise CCTV coverage extensions.

    Verbatim wording from the response

    “The CCTV system does not extend to the entirety of every platform area on all 500 stations. As the system is developed it has been necessary to prioritise extensions and this has been done by reference to the risk profile of each station, by reference to a diverse range of factors, including the incidence of suicide, vandalism, theft and antisocial behaviour. Earlestown is not considered a high risk station on this evaluation.”

    Source location

    2017-0207-Arriva-Rail-North-Limited
    Page 1 · response
    Published 28 July 2017

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    CCTV coverage expansion must proceed incrementally across the entire network rather than being delivered immediately at every station.

    Verbatim wording from the response

    “As CCTV technology evolves, it is hoped to expend the coverage area and quality of the images produced, but this must inevitably be an incremental programme across the entire network.”

    Source location

    2017-0207-Arriva-Rail-North-Limited
    Page 1 · response
    Published 28 July 2017

    Open published response

  5. Inner North London

    AI-generated summary

    Susan Sian JONES · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Susan Sian Jones suffered a cardiorespiratory arrest at Hornsey Police station while waiting to make a statement about an allegation of historical sexual assault. At inquest, the jury concluded that her death resulted from methadone and alcohol intoxication together with inadequate police policies, procedures and training. The report identified a lack of specific protocol or training for monitoring members of the public in police stations who are not in police custody.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of protocol and training for monitoring members of the public in police stations who are not in police custody

    Wider context from the report

    “I heard evidence at inquest that there is no specific protocol or training regarding the monitoring of members of the public in police stations who are not in police custody. This was acknowledged by the Metropolitan Police Service to be a gap. In seeking to plug this gap by way of policy development, it may be helpful for you to consider the following. • Snoring is not always a reassuring sign and may indicate a partial airway obstruction. A partial airway obstruction can be life threatening. • In considering whether snoring is sign for concern, the fact of intoxication by alcohol or drugs or both – even if the individual is capable – is highly relevant. In addition, officers should bear in mind that members of the public sometimes lie about alcohol or drug taking, even when there seems no obvious reason to lie. • Any relevant information gleaned by officers, for example that an individual is a methadone user, should be passed on to colleagues with responsibility (and preferably recorded in some way or other). • The only way of determining whether snoring is benign is by rousing, most particularly by waking the individual and determining whether they are able to sit up and hold a conversation. • The rousing itself may have a therapeutic purpose even over and above its value as a tool of assessment. And an unresponsive individual must be treated as a medical emergency. • All police officers and staff should know the location of the nearest defibrillator. If they are attending a police station for the first time, they should make themselves aware of its location. In terms of feedback regarding officer training generally and for the officer who led this resuscitation attempt, I should also point out that after Ms Jones’s cardiorespiratory arrest, the cardiopulmonary resuscitation given was later noted by a paramedic to be extremely effective. ”

    Source location

    Susan Sian JONES · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Inner South London

    AI-generated summary

    Richard Hinchliffe · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Richard Hinchliffe died on 2 October 2015 after accessing railway tracks between Blackfriars and London Bridge stations and suffering fatal electrocution. Concerns were raised about how securely the barrier to the railway lines was maintained and whether the presence of a person apparently asleep on the platform would have been identified as a safety or security concern.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to identify prolonged presence on a station platform

    Wider context from the report

    “(2) Mr Hinchliffe was seemingly asleep on the platform for approximately one hour before gaining access onto the line. The evidence was that Blackfriars station is staffed 24 hours. It is not clear whether his presence would have been noted and flagged as a possible security/safety concern. ”

    Source location

    Richard Hinchliffe · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to flag concerning presence on a station platform

    Wider context from the report

    “(2) Mr Hinchliffe was seemingly asleep on the platform for approximately one hour before gaining access onto the line. The evidence was that Blackfriars station is staffed 24 hours. It is not clear whether his presence would have been noted and flagged as a possible security/safety concern. ”

    Source location

    Richard Hinchliffe · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
Back to top

Data last updated 7 September 2026