Recurring concern

Unreliable sharing of railway concern-for-welfare information with relevant responders

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First reported 1 Dec 2021•Latest report 5 Aug 2025

Definition

What this concern includes

Includes failures of the railway concern-for-welfare information-sharing and reporting process, including obtaining, relaying, recording, escalating or communicating relevant welfare information between signallers, control rooms, railway operators, attending managers and relevant emergency or partner agencies.

Not included

  • Excludes generic communication or information-sharing deficiencies that are not specifically tied to a railway concern-for-welfare report or incident.
  • Excludes failures of the underlying welfare assessment or emergency response where the railway information-sharing process was not deficient.
  • Excludes routine railway operational information that does not concern a person's welfare or an associated safety response.
  • Excludes police, ambulance or other emergency-service information-sharing failures outside the railway concern-for-welfare process.
Reports
4

Distinct published reports

Individual concerns
5

A report can raise multiple concerns

Date range
2021–2025

First to latest report issue date

Stated actions
11

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 Rail2
British Transport Police1
Essex Partnership University NHS Foundation Trust1
Govia Thameslink Railway Limited1
Oxleas NHS Foundation Trust1

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. Dorset

    AI-generated summary

    Simon Anthony Moore · 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

    Simon Anthony Moore, a train driver, died after stepping in front of a moving train on 4 November 2024, following an incident that he knew could lead to the loss of his train driver licence and further assessment. Evidence at the inquest raised concerns that the attending Driver Manager was unaware of an earlier recorded conversation in which Mr Moore expressed concern about losing his job and sounded distressed, and that there was no means for the signaller to relay this information to the train company Control or Driver Manager.

    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 relay signaller-driver welfare information to the attending Driver Manager

    Wider context from the report

    “iii. The on-call Driver Manager employed by the Train Company is obliged to attend and in this scenario take the train driver licence from the driver. An initial account of the facts is taken as well as certain medical tests. iv. The on-call Driver Manager who attended following the incident involving Mr Moore met with him almost 2 hours after the incident. The on-call Driver Manager was unaware of the content of the conversation between Mr Moore and the signaller which occurred 2 hours earlier and soon after the incident. The contents of this conversation would have helped the on-call Driver Manager to assess the driver’s welfare. v. The Network Rail Signaller has no means through which to relay the details of any discussions with drivers (in this instance Mr Moore) to the train company Control who could then pass this information on to the attending Driver Manager. ”

    Source location

    Simon Anthony Moore · 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

    Consider the investigation report and recommendation at the SPAD Recommendations and Review Panel.

    Verbatim wording from the response

    “• The SWR investigation report, including the above recommendation, was considered at the NR SPAD Recommendations and Review Panel.”

    Source location

    Response from Network Rail
    Page 3 · response
    Published 5 August 2025

    Open published response

    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

    Review the end-to-end incident communication process through the industry working group, including welfare concern escalation and communication.

    Verbatim wording from the response

    “Upon receipt of HM Coroner’s Regulation 28 report, and in considering your findings, Network Rail set up an Industry Working Group on Welfare Communication, which includes representatives from Network Rail, Train Operating Companies, and trade unions.”

    Source location

    Response from Network Rail
    Page 4 · response
    Published 5 August 2025

    Open published response

    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

    Develop guidance for signallers communicating with drivers after incidents.

    Verbatim wording from the response

    “As you are aware, SWR’s incident investigation found that, notwithstanding the existing processes in place as described above, opportunities existed to strengthen escalation and communication protocols between signallers, Incident Controllers, TOC Control and Driver Managers. The investigation included a recommendation that Guidance will be created for signallers to support them when communicating with a driver post incident. This Guidance will be developed by the Industry Working Group on Welfare Communications, described further below.”

    Source location

    Response from Network Rail
    Page 3 · response
    Published 5 August 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

    The Network Rail signaller had a means to relay the driver's welfare concerns to train company Control through the incident logging system.

    Verbatim wording from the response

    “The Network Rail Signaller has no means through which to relay the details of any discussions with drivers (in this instance Mr Moore) to the train company Control who could then pass this information on to the attending Driver Manager.”

    Source location

    Response from Network Rail
    Page 2 · response
    Published 5 August 2025

    Open published response
  2. West London

    AI-generated summary

    Denise Jane PORTER · 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

    Denise Jane PORTER died after jumping onto the tracks at Turnham Green Underground Station in front of an oncoming train on 19 February 2023. A prior similar incident had been referred to Oxleas NHS Trust, but the Trust relied on a partial summary and did not make further inquiries into the available police information. The report raised concern that this resulted in missed opportunities to recognise the level of risk and make an appropriate referral or care 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

    Failure to make relevant inquiries when British Transport Police reporting is ambiguous or incomplete

    Wider context from the report

    “The inquest heard the Trust did not interrogate the Safeguarding and Vulnerability Report, prepared by British Transport Police. The Trust Staff relied on the summary of the incident, both at the triage stage and subsequently during the psychiatric reviews. The Trust staff did not contact British Transport Police again to establish any information about the incident (for example the CCTV was not viewed nor a summary of the footage requested, nor were any meetings convened or discussions held between the Trust and British Transport Police). The Trust conducted a review of the care and treatment provided to Mrs Porter. Their Report stated: "Had the referral from BTP to OACMHT included a full account of the circumstances of the incident on 25 January 2023, the OACMHT would have had a fuller understanding of the level of intent exhibited on that occasion, and subsequently risks would have been determined as high, and a more robust plan of care implemented to mitigate against these risks, that would have been immediately shared with her family". It was established at Inquest that had the full details of the incident on 25th January 2023 been understood - ie that Denise intended to take her life and this was only prevented by the slowing and halting of the train - that the psychiatrist would have referred her either to the Intensive Home Treatment Team (with consent) or for a Mental Health Act assessment (if no consent had been forthcoming). The Trust's Report stated: "There were no identified service delivery issues that impacted on the services' ability to offer care and treatment". However, in oral evidence, the Trust's witness agreed this was inaccurate, following reflection upon the missed opportunities of investigating the events of 25th January 2023. The Trust was unable to provide the Inquest with information to satisfy my concern that the Trust has robust systems in place to avoid the risk that staff may rely upon short summaries from British Transport Police, rather than scrutinising all the information contained within a referral and making relevant inquiries if the reporting is ambiguous or incomplete. In this case, the Trust was clearly of the view that the detail was significant but was overly reliant upon partial information which resulted in missed opportunities for appropriate referral. ”

    Source location

    Denise Jane PORTER · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  3. 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
  4. West Sussex

    AI-generated summary

    Kaja Weronika SPIEWAK · 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

    On 7 April 2021, Kaja Weronika SPIEWAK was identified as vulnerable while travelling by train and was later declared deceased at 1.07pm after being at Southbourne Station. The report raised concerns about inadequate training, inappropriate control-room guidance, incomplete recording of actions, and failures to share welfare concerns with relevant agencies.

    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 provide control-room staff with appropriate information for responding to concern-for-welfare reports

    Wider context from the report

    “(2) I heard evidence that Govia Thameslink Railway Ltd staff control room staff relied upon a protocol entitled ‘Person ill on a train’ when a vulnerable person was reported to them. The witness responsible for the Govia Thameslink Railway control room team accepted that this was not an appropriate document to rely upon as it made no mention of vulnerable persons. I am therefore concerned that the control room staff do not have the appropriate information to assist their colleagues and to arrange an appropriate response when a ‘concern for welfare’ report is made to them. ”

    Source location

    Kaja Weronika SPIEWAK · Prevention of Future Deaths report
    Page 2 · 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 appropriately share and report concern-for-welfare information with relevant agencies

    Wider context from the report

    “(4) The Govia Thameslink Railway Ltd control room staff did not contact British Transport Police, 999 nor share the information about this ‘concern for welfare’ report with Network Rail despite having a joint control room. I heard evidence that there was no written protocol covering when Govia Thameslink Railway Ltd staff should share a ‘concern for welfare’ report with Network Rail staff in the shared control room. I am concerned that there is not appropriate information sharing and reporting to other agencies, including British Transport Police, when a ‘concern for welfare’ is raised. ”

    Source location

    Kaja Weronika SPIEWAK · Prevention of Future Deaths report
    Page 3 · 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

    Create and implement a joint incident-management procedure distinguishing concern-for-welfare reports from person-ill-on-train incidents.

    Verbatim wording from the response

    “NR and GTR have worked jointly to prepare a new section within our joint NR/GTR incident management standard. As a result, there is now a clear joined-up procedure between NR and GTR for dealing with vulnerable people or where there is a concern for someone’s welfare (termed ‘concern for welfare’ reports). This standard now specifically distinguishes between the ‘person ill on train’ procedure relating primarily to physical illness and a ‘concern for welfare’ procedure which can include situations where we have a concern for a person’s mental health, such as a person being distressed, vulnerable or in crisis.”

    Source location

    2022-0052-Response-from-Network-Rail_Published
    Page 1 · response
    Published 21 February 2022

    Open published response

    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

    Brief every Network Rail and Govia Thameslink Railway control-room staff member on recognising, handling and sharing concern-for-welfare reports.

    Verbatim wording from the response

    “NR has worked with GTR to brief every member of control room staff, including those employed by both NR and GTR, with the ‘Concern for Welfare’ briefing, either in person or on MS teams. The briefings addressed the sequence of events that led to Kaja’s tragic death and highlighted the key learning and crucially the importance of all agencies including NR, GTR and notably the British Transport Police (BTP) sharing information relating to ‘Concern for Welfare’. A copy of this briefing is attached.”

    Source location

    2022-0052-Response-from-Network-Rail_Published
    Page 1 · response
    Published 21 February 2022

    Open published response

    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

    Disseminate the concern-for-welfare briefing through face-to-face and virtual briefings to all national route controls.

    Verbatim wording from the response

    “NR has shared this ‘Concern for Welfare’ briefing internally, through face-to-face and virtual briefings with all route controls nationally, including NR route controls and other joint NR/Train Operating Company route controls similar to that in Three Bridges.”

    Source location

    2022-0052-Response-from-Network-Rail_Published
    Page 1 · response
    Published 21 February 2022

    Open published response

    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

    Hold Operations Development Days on responding consistently to vulnerable people and welfare concerns.

    Verbatim wording from the response

    “The range of possible responses to a non-emergency concern for welfare is, as you have witnessed, less well defined. Between the 9th February and 16th March, the Sussex Control centre will be holding a series of Operations Development Days, covering dealing with vulnerable people / cause for concern, which GTR staff will take part in to raise consistency in response to these situations. Learning from these development days will be incorporated, under subject of concern for welfare reports, into the Joint Incident Management Framework, in a new section covering Safety Incidents & Emergencies. This will reinforce the requirement of all staff in the Control Room to report every incident involving vulnerable people (or other emergency such as damage to infrastructure, trespass etc.) to Network Rail Controllers.”

    Source location

    2022-0052-Response-from-Govia-Thameslink-Railway-Ltd_Published
    Page 3 · response
    Published 21 February 2022

    Open published response

    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

    Incorporate learning from the Operations Development Days into a new welfare-reporting section of the Joint Incident Management Framework.

    Verbatim wording from the response

    “The range of possible responses to a non-emergency concern for welfare is, as you have witnessed, less well defined. Between the 9th February and 16th March, the Sussex Control centre will be holding a series of Operations Development Days, covering dealing with vulnerable people / cause for concern, which GTR staff will take part in to raise consistency in response to these situations. Learning from these development days will be incorporated, under subject of concern for welfare reports, into the Joint Incident Management Framework, in a new section covering Safety Incidents & Emergencies. This will reinforce the requirement of all staff in the Control Room to report every incident involving vulnerable people (or other emergency such as damage to infrastructure, trespass etc.) to Network Rail Controllers.”

    Source location

    2022-0052-Response-from-Govia-Thameslink-Railway-Ltd_Published
    Page 3 · response
    Published 21 February 2022

    Open published response

    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

    Develop a training course for handling vulnerable people’s calls through telephones and station help points.

    Verbatim wording from the response

    “On occasion the control room might take a call, via a station call point, from a member of the public or the vulnerable person themselves. GTR’s suicide Prevention Manager is working with the Samaritans to develop a training course specific to dealing with vulnerable people over the phone and help points. Learning will be underpinned with a practical assessment for GTR control room staff, which is done annually, on how they would deal with a help point call from a suicidal person.”

    Source location

    2022-0052-Response-from-Govia-Thameslink-Railway-Ltd_Published
    Page 4 · response
    Published 21 February 2022

    Open published response

    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

    Assess control-room staff annually through a practical exercise on responding to help-point calls from suicidal people.

    Verbatim wording from the response

    “On occasion the control room might take a call, via a station call point, from a member of the public or the vulnerable person themselves. GTR’s suicide Prevention Manager is working with the Samaritans to develop a training course specific to dealing with vulnerable people over the phone and help points. Learning will be underpinned with a practical assessment for GTR control room staff, which is done annually, on how they would deal with a help point call from a suicidal person.”

    Source location

    2022-0052-Response-from-Govia-Thameslink-Railway-Ltd_Published
    Page 4 · response
    Published 21 February 2022

    Open published response

    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

    Strengthen guidance on non-emergency welfare concerns through training and staff briefings, reinforcing contact with British Transport Police.

    Verbatim wording from the response

    “threshold. I agree that this ambiguity needs to be eradicated. The output from the Operational Deployment Days will be used to strengthen guidance to aid better decisions in respect to non-emergency concerns for welfare.”

    Source location

    2022-0052-Response-from-Govia-Thameslink-Railway-Ltd_Published
    Page 5 · response
    Published 21 February 2022

    Open published response
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Data last updated 7 September 2026