Recurring concern

Ineffective controls preventing access to railway tracks

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First reported 27 May 2015•Latest report 4 Mar 2024

Definition

What this concern includes

Includes failures of controls specifically dedicated to preventing or restricting access to railway tracks, including physical barriers or mitigation measures and responses to identified railway-access risks or recommended remedial actions.

Not included

  • Excludes generic failures in investigation, documentation, training, staffing or governance unless they are directly tied to a dedicated railway-track-access control.
  • Excludes railway hazards unrelated to preventing access to the tracks.
  • Excludes general infrastructure or highway safety deficiencies that do not concern access to railway tracks.
Reports
24

Distinct published reports

Individual concerns
31

A report can raise multiple concerns

Date range
2015–2024

First to latest report issue date

Stated actions
60

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 Rail21
British Transport Police3
Alexandra Park and Palace Charitable Trust1
Arriva Rail North Limited1
Broxtowe Borough Council1
Department for Education1
Derbyshire County Council1
Erewash Borough Council1
Father of the deceased1
First MTR South Western Trains Limited1
London Borough of Hackney1
London North Eastern Railway Limited1
London & South Eastern Railway Limited1
Mother of the deceased1
Nottinghamshire County Council1

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. Inner North London

    AI-generated summary

    Vanessa FORD · 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 23 September 2023, Vanessa Ford consumed a significant amount of alcohol during an acute mental health crisis, accessed the railway network and was struck by a train after dropping onto the tracks. The report raised concerns about frequent public access to the railway in the area, the effectiveness of safety measures on the wall, and street furniture making access easier and potentially undermining safety efforts.

    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 wall mitigation and safety measures to impede railway access

    Wider context from the report

    “(2) Evidence provided from CCTV footage and photographic evidence taken by the British Transport Police demonstrated that the particular piece of wall, which was used to access the railway network on 23 September 2023, was relatively low, despite an approximate drop onto the tracks below being 20 feet. The British Transport Police Post Incident Site Report sets out that the “Road over rail bridge has metal covers and hostile toppings on walls directly over the railway”; ████████ ████████ This raises the concern that the mitigation/safety measures in place on the wall may not have been as effective as one might expect. ”

    Source location

    Vanessa FORD · 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

    Frequent public access to railway tracks in the Hackney Central/Dalston Kingsland vicinity

    Wider context from the report

    “(1) I was provided with evidence that there have been three (non-fatal) incidents in the vicinity of the Hackney Central/Dalston Kingsland areas of the rail network in the 12 months prior to this incident on 23 September 2023 (British Transport Police Post Incident Site Report DOCU Reference: DOCU 2023 1576 refers). ████████ ████████ ████████ The concern here is that there is evidence to suggest that access to the railway tracks by members of the public may be a frequent issue in this vicinity. ”

    Source location

    Vanessa FORD · 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

    Siting of an electrical box facilitating access to the railway wall

    Wider context from the report

    “(3) The CCTV footage and photographic evidence presented to me, demonstrated that Ms Ford’s access to the wall, and thereby the railway network below, ████████ ████████ ████████. In their oral evidence during the inquest, the Officer from the British Transport Police confirmed their view, which I accepted, that this electrical box makes access to the wall much easier than it should be. They also confirmed that this issue is unlikely to be confined solely to the ████████ and that such items of street furniture may pose similar risks across the railway network. ”

    Source location

    Vanessa FORD · 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

    Siting of street furniture facilitating access to the railway network

    Wider context from the report

    “(4) In addition to the ████████ mentioned at (3) above, the evidence revealed numerous items of street furniture on the ████████ ████████, all of which could be used to facilitate easier access to the wall and the railway network. The concern here is that the siting of items of street furniture generally on this bridge poses risks to all manner of members of the public, from those contemplating suicide, to young children, and may undermine safety efforts to impede easy access to the railway network. ”

    Source location

    Vanessa FORD · 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

    Review the Martel Place wall following the report as part of continuous boundary asset management.

    Verbatim wording from the response

    “I note the evidence referred to in your report regarding the nature of the wall at this location, specifically the wall along Martel Place referred to in the Post Incident Site Report. The wall has been reviewed again following receipt of your report as part of Network Rail’s continuous boundary asset management approach.”

    Source location

    Response from Network Rail
    Page 2 · response
    Published 14 March 2024

    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

    Modify the Martel Place access gate to match adjacent fencing and remove the fence gap and climbing foothold.

    Verbatim wording from the response

    “Although the boundary is assessed as compliant to Network Rail standards, we are working with the Local Authority to explore if further measures can be implemented to address the specific concerns identified by this incident. Works have already been scheduled to be undertaken during early May 2024 to the access gate at Martel Place so that it matches the height of the adjacent palisade fencing and the gap underneath the fence and the climbing foothold will be removed. We are working with the Local Authority to consider options to add additional measures to the wall which may include the installation of Vanguard anti-climb rollers, planting Hawthorne or similar and installation of signage to warn people of the risks of the drop to the railway at the other side of the wall. It is anticipated that the selected option will be installed by early May 2024.”

    Source location

    Response from Network Rail
    Page 2 · response
    Published 14 March 2024

    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

    Work with the Local Authority to explore additional wall measures addressing the incident’s specific access risks.

    Verbatim wording from the response

    “Although the boundary is assessed as compliant to Network Rail standards, we are working with the Local Authority to explore if further measures can be implemented to address the specific concerns identified by this incident. Works have already been scheduled to be undertaken during early May 2024 to the access gate at Martel Place so that it matches the height of the adjacent palisade fencing and the gap underneath the fence and the climbing foothold will be removed. We are working with the Local Authority to consider options to add additional measures to the wall which may include the installation of Vanguard anti-climb rollers, planting Hawthorne or similar and installation of signage to warn people of the risks of the drop to the railway at the other side of the wall. It is anticipated that the selected option will be installed by early May 2024.”

    Source location

    Response from Network Rail
    Page 2 · response
    Published 14 March 2024

    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

    Support the Local Authority’s exploration of improvements to street-furniture-related risks at Dalston Lane Road Bridge and Martel Place.

    Verbatim wording from the response

    “Street furniture such as the recycling bins or electrical boxes referred to in your report are managed by the Local Authority. In relation to specific issues on Dalston Lane Road Bridge and Martel Place, Network Rail is liaising with the Local Authority and understand that its Streetscene department is looking to re-locate some of the recycling bins. Though this is outside of Network Rail control we will continue to support the exploration of any improvements that can be made at this location, alongside the physical mitigations being explored as detailed above. We consider that the mitigation works referred to above to add additional measures to the wall will also address the concerns raised in your report regarding the electrical box.”

    Source location

    Response from Network Rail
    Page 2 · response
    Published 14 March 2024

    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

    Continue discussions between highways and planning teams to develop a planning-process mechanism for identifying and flagging electrical apparatus and street furniture near railway bridges.

    Verbatim wording from the response

    “9. Discussions have taken place, and will continue, between the highways team and the local planning authority to see whether an effective mechanism could be put in place through the planning process to identify and flag up electrical apparatus and street furniture at locations such as this one.”

    Source location

    Response from Hackney Council
    Page 2 · response
    Published 14 March 2024

    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

    Remove recycling bins near Martel Place that could facilitate access to the railway network.

    Verbatim wording from the response

    “10. In respect of the various recycling bins nearby on Martel Place, the Council has taken steps to remove those bins and this action was completed on 8 May 2024.”

    Source location

    Response from Hackney Council
    Page 2 · response
    Published 14 March 2024

    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

    Network Rail is responsible for further measures addressing concerns about the Martel Place access gate and railway wall.

    Verbatim wording from the response

    “11. The Council has also been in contact with Network Rail to coordinate actions and ensure clear ownership of responsibilities. The Council has received confirmation from Network Rail that further measures to address specific concerns around the access gate at Martel Place and the wall more generally are underway.”

    Source location

    Response from Hackney Council
    Page 2 · response
    Published 14 March 2024

    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 three prior incidents do not indicate that public access to railway tracks is frequent in the Hackney Central and Dalston Kingsland vicinity.

    Verbatim wording from the response

    “I can confirm that the three incidents referred to each occurred at the Hackney Central and Dalston Kingsland railway stations. These are publicly accessible locations and in each instance access was taken from the public station areas directly onto the track. Management of the stations and relevant access mitigations is the responsibility of London Overground as Station Facility Owner. The three incidents referred to therefore do not suggest that access to the railway tracks by members of the public may be a frequent issue in this vicinity. We have no other records of unauthorised access at this location.”

    Source location

    Response from Network Rail
    Page 1 · response
    Published 14 March 2024

    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

    London Overground, as Station Facility Owner, is responsible for managing the stations and relevant access mitigations.

    Verbatim wording from the response

    “I can confirm that the three incidents referred to each occurred at the Hackney Central and Dalston Kingsland railway stations. These are publicly accessible locations and in each instance access was taken from the public station areas directly onto the track. Management of the stations and relevant access mitigations is the responsibility of London Overground as Station Facility Owner. The three incidents referred to therefore do not suggest that access to the railway tracks by members of the public may be a frequent issue in this vicinity. We have no other records of unauthorised access at this location.”

    Source location

    Response from Network Rail
    Page 1 · response
    Published 14 March 2024

    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 Local Authority manages the street furniture and is responsible for decisions concerning its relocation, outside Network Rail’s control.

    Verbatim wording from the response

    “Street furniture such as the recycling bins or electrical boxes referred to in your report are managed by the Local Authority. In relation to specific issues on Dalston Lane Road Bridge and Martel Place, Network Rail is liaising with the Local Authority and understand that its Streetscene department is looking to re-locate some of the recycling bins. Though this is outside of Network Rail control we will continue to support the exploration of any improvements that can be made at this location, alongside the physical mitigations being explored as detailed above. We consider that the mitigation works referred to above to add additional measures to the wall will also address the concerns raised in your report regarding the electrical box.”

    Source location

    Response from Network Rail
    Page 2 · response
    Published 14 March 2024

    Open published response
  2. Cumbria

    AI-generated summary

    Gordon Alexander John RODGER · 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 2 March 2023, a human body was found near the railway line in the Askam-in-Furness area after a train driver reported seeing it. The inquest concluded that Gordon Alexander John RODGER died by suicide, with multiple injuries consistent with being struck by a train; concern was raised that the line may be readily accessible to individuals wishing to harm themselves.

    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

    Readily accessible railway line for individuals wishing to harm themselves

    Wider context from the report

    “In the course of the inquest I heard that British Transport Police had recommended to Network Rail that they consider installing "anti trespass treads and gates to the north end of Platforms on Askam station if operationally possible". By a letter to the Court dated 5th June 2023 Network Rail indicated that they had decided not to take this step. The explained that Askam station is rural, that limited resources dictate which works are prioritised and that there is no history of trespass. In the course of the inquest the court heard that the line in this location is more accessible than might usually be expected, including by stiles in nearby fences associated with a nearby golf club. In the circumstances I am concerned that the line may be readily accessible to individuals who wish to harm themselves. ”

    Source location

    Gordon Alexander John RODGER · 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

    Install platform-end gates and anti-trespass matting at the north end of Askam station through the CP7 work bank.

    Verbatim wording from the response

    “Utilising Control Period 7 (known as CP7) funding Network Rail intends to install platform end gates and anti-trespass matting at locations in Cumbria identified as potentially requiring such installations by post incident site visits, including Askam station.”

    Source location

    Response from Network Rail
    Page 2 · response
    Published 6 September 2023

    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

    Inspect the boundary between Askam station and Heybank footpath crossing, covering both sides of the railway, to verify its integrity.

    Verbatim wording from the response

    “In relation to the concern raised in your Report we instructed the Network Rail Delivery Maintenance Unit for the Askam area to undertake a full boundary inspection to verify the integrity of the boundary from Askam station to Heybank footpath crossing (between the points marked on the map extract below) being a distance of 1,430 yards including the boundary on both sides of the tracks.”

    Source location

    Response from Network Rail
    Page 3 · response
    Published 6 September 2023

    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

    Boundary fencing meets applicable standards, so further action on boundary integrity is not considered necessary in the inspected area.

    Verbatim wording from the response

    “Network Rail can confirm after checking the inspection download and reviewing the photos taken during the additional inspection undertaken in March, that the boundary fencing in the area inspected meets the requirements of the applicable Network Rail Standard and that there are no outstanding items of works. On this basis Network Rail does not believe that the line is readily accessible by means of deficient fencing nor by unauthorised crossing points and does not therefore believe further action is required in relation to boundary integrity in the area inspected (as defined above).”

    Source location

    Response from Network Rail
    Page 4 · response
    Published 6 September 2023

    Open published response
  3. North London

    AI-generated summary

    Connor Peter Marron · 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

    Connor Peter Marron was struck and fatally injured by a train on 2 January 2022 near Hornsey Railway Station after leaving a public house to return to Alexander Palace. Concerns included inadequate lighting and signage near the stream and railway fence, and a fence that was not adequate to prevent access to the railway track.

    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

    Inadequate fencing preventing ingress to the railway track

    Wider context from the report

    “3. The fence separating the venue grounds from the railway track was not adequate to prevent ingress to the railway track. ”

    Source location

    Connor Peter Marron · Prevention of Future Deaths report
    Page 1 · 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

    Repair damage to the Downside access gate and minor fencing defects.

    Verbatim wording from the response

    “In relation to the third matter listed, whilst your report states that the fence separating the venue grounds from the railway track was “….not adequate to prevent ingress to the railway track” and Network Rail’s post-incident inspection of the fencing (on the morning of 2nd January 2022) in the wider area recorded that a small gap in the fencing had been discovered, as well as damage to the Downside access gate, resulting in minor repairs being carried out immediately, we note that the BTP’s Post Incident Site Report (BTP Control Works Reference 15-020122) (“the PISR”) concluded that, having reviewed the possible routes to the incident scene following the incident, “……access onto the railway is inconclusive”.”

    Source location

    Response from Network Rail
    Page 1 · response
    Published 22 September 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

    Replace the chain-link fencing section with palisade fencing through the Route’s work bank.

    Verbatim wording from the response

    “• replacing the relevant section of chain link fencing and continuing with palisade fencing. Whilst, as mentioned previously, the route to the incident scene has been deemed inconclusive, we note that the fencing in closest proximity to the incident scene is, in fact, palisade fencing, rather than chain link fencing (the fencing in this particular area, which separates the venue grounds from the railway track, is currently of a mixed palisade and chain link design). Class I boundary measures, which include palisade fencing, are installed to provide a security measure where the risk of unauthorised access is probable and these boundary measures are designed with anti-tamper and anti-climb components within the installation. The chain link section of fencing is approximately ¼ mile down the track, on the opposite side of the tracks and across approximately 6 miles of track.”

    Source location

    Response from Network Rail
    Page 2 · response
    Published 22 September 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

    Invest in physical measures to prevent unauthorised railway access, including platform-end barriers, mid-platform station fences and lineside fencing.

    Verbatim wording from the response

    “I note that the conclusion of this inquest was an ‘open’ verdict. However, I thought you may be interested in some of the other work we do as we are committed to maintaining a safe railway and to reducing opportunity for members of the public to harm themselves on or near the railway. An example of this is the work being carried out on the Peterborough to Kings Cross line of route, where this section of track is located, which is one of three Focus Areas where Network Rail is working closely with the British Transport Police, Samaritans and Rail Industry partners to prevent suicide. Network Rail has also invested significantly in preventing unauthorised access in this line- of-route through physical mitigations, such as platform end barriers and mid-platform fences at stations and lineside fencing outside.”

    Source location

    Response from Network Rail
    Page 2 · response
    Published 22 September 2022

    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 stream lighting and railway-fence adequacy matters concern assets APPCT does not own or operate and therefore do not require action by APPCT.

    Verbatim wording from the response

    “railway assets owned by Network Rail. To access the railway boundary fence, an individual must first leave the park onto public streets and cross the New River; two locations owned by third parties.”

    Source location

    Response from Alexandra Palace
    Page 2 · response
    Published 22 September 2022

    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

    Lighting on venue grounds is Alexandra Palace’s responsibility, while railway fencing is Network Rail’s responsibility.

    Verbatim wording from the response

    “I will address point number 1, as the other issues appear to relate to the responsibilities of Alexandra Palace and Network Rail respectively. Point 2 relates to lighting on the venue grounds, which is for Alexandra Palace, and fencing separating the venue from the railway track would appear to be the responsibility of Network Rail.”

    Source location

    Response from Thames Water
    Page 2 · response
    Published 22 September 2022

    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 route by which access to the railway occurred is inconclusive, and fencing nearest the incident was palisade rather than chain link.

    Verbatim wording from the response

    “In relation to the third matter listed, whilst your report states that the fence separating the venue grounds from the railway track was “….not adequate to prevent ingress to the railway track” and Network Rail’s post-incident inspection of the fencing (on the morning of 2nd January 2022) in the wider area recorded that a small gap in the fencing had been discovered, as well as damage to the Downside access gate, resulting in minor repairs being carried out immediately, we note that the BTP’s Post Incident Site Report (BTP Control Works Reference 15-020122) (“the PISR”) concluded that, having reviewed the possible routes to the incident scene following the incident, “……access onto the railway is inconclusive”.”

    Source location

    Response from Network Rail
    Page 1 · response
    Published 22 September 2022

    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

    Quarterly inspections and remediation under the boundary fencing standard are considered sufficient for fence-line maintenance.

    Verbatim wording from the response

    “• ensuring that fence line inspections comply with the National Safety Briefing in relation to Boundary Fencing Inspection Standard NR/L2/OTK/5100 Module 01 (1st April 2019) tactile / non-tactile inspections (“the Standard”). Network Rail takes a pro-active approach to asset maintenance and renewal, with inspections complying with the Standard and remediation works carried out following such inspections. Where upgrading of an asset is identified as being required, a fencing proposal is prepared by the Off-Track team and ranked in terms of priority, with those with the highest scores (indicating that they are the highest priority) given precedence. Each route within an area is allocated a fund of monies to be used for maintenance and repair works, with monies focused on delivering the highest priority works identified i.e., those with the highest scores.”

    Source location

    Response from Network Rail
    Page 1 · response
    Published 22 September 2022

    Open published response
  4. West Yorkshire Eastern

    AI-generated summary

    Gregory James Barber · 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

    Gregory James Barber died on 12 April 2021 after sustaining severe head injuries secondary to blunt force impact; a conclusion of suicide was recorded at the inquest. The British Transport Police identified a weakness in fencing that was considered a likely access point to the railway tracks, and the report states that Network Rail had not provided a meaningful response to the recommended mitigation. The concern was that access to the railway tracks remained insufficiently curtailed at the identified location.

    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 a meaningful response to an identified railway safety problem and mitigation request

    Wider context from the report

    “The BTP investigation identified a clear problem and recommended a mitigation measure to which there has been no meaningful response, or at all, from Network Rail within the terms of the specific request to so respond within 60 days of the incident. On the evidence that I heard at the inquest, it would appear that the weakness identified by the British Transport Police remains as it was at the time of their investigation and I am concerned that access to the railways tracks is not sufficiently curtailed at the location identified, as recommended. ”

    Source location

    Gregory James Barber · 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

    Insufficient curtailment of access to railway tracks at the identified location

    Wider context from the report

    “The BTP investigation identified a clear problem and recommended a mitigation measure to which there has been no meaningful response, or at all, from Network Rail within the terms of the specific request to so respond within 60 days of the incident. On the evidence that I heard at the inquest, it would appear that the weakness identified by the British Transport Police remains as it was at the time of their investigation and I am concerned that access to the railways tracks is not sufficiently curtailed at the location identified, as recommended. ”

    Source location

    Gregory James Barber · 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

    Procure and install 8 metres of 2.4-metre palisade fencing, including fabricated fencing to close gaps at both ends.

    Verbatim wording from the response

    “Despite these findings, Network Rail is committed to maintaining a safe railway and to reducing opportunity for members of the public to harm themselves on or near the railway. As such, following further engagement with the BTP in December 2021 in relation to this incident, Network Rail remitted works at this location to address the concern raised in the BTP PISR (and since raised in your Regulation 28 report). Specifically, Network Rail is procuring the installation of 8 metres of 2.4m palisade fencing behind the wall (before the land begins to slope downwards), together with specially fabricated palisade fencing closing off the gaps at either end of the new fence. This will further deter potential access over the parapet wall and down to the railway.”

    Source location

    2021-0429-Response-from-Network-Rail_Published
    Page 1 · response
    Published 29 December 2021

    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 parapet wall was not considered a trespass risk because it was difficult to access, vegetation deterred entry, and no hotspot data existed.

    Verbatim wording from the response

    “In addition, on consideration of the PISR, Network Rail did not consider that the parapet wall was a trespass risk for the reasons explained below.”

    Source location

    2021-0429-Response-from-Network-Rail_Published
    Page 1 · response
    Published 29 December 2021

    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 area met current fencing and boundary standards, which were considered sufficient arrangements for the location.

    Verbatim wording from the response

    “4. The area meets Network Rail’s current standards for fencing and boundaries.”

    Source location

    2021-0429-Response-from-Network-Rail_Published
    Page 1 · response
    Published 29 December 2021

    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 parapet wall was not the access point; records identified a Network Rail access gate further along the track.

    Verbatim wording from the response

    “The PISR refers to Mr Barber’s most likely access point as being over the parapet wall at the end of Wyther Lane. However, on the evening of the incident on 12 April 2021, Network Rail representatives attended the area of Kirkstall Lineside near Bridge Road, Leeds along with the BTP to undertake a post-incident site visit. During this visit, the BTP and Network Rail carried out an immediate inspection of the area and our records show that Mr Barber’s access point was agreed to have been at a Network Rail access gate further down the track towards Kirkstall Forge Station. Mr Barber’s personal possessions were found by BTP at this location.”

    Source location

    2021-0429-Response-from-Network-Rail_Published
    Page 1 · response
    Published 29 December 2021

    Open published response
  5. Nottinghamshire

    AI-generated summary

    Heather Frances Page · 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 October 2020, Heather Frances Page stepped in front of a train and died in the resulting collision. The report identified concerns about pedestrian crossings requiring people to walk on the tracks, a high number of fatalities, ease of access to the track, and difficulties reducing or rationalising crossings because of local authority opposition.

    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

    Railway track with multiple easy access points near a popular beauty spot increasing suicide risk

    Wider context from the report

    “Evidence was heard regarding the section of track adjacent to the Attenborough Nature Reserve. I noted the following issues of concern in relation to this section of track:- (1) There are a number of pedestrian crossings along this short stretch of track which involve pedestrians having to walk on the tracks to cross to the other side. (2) There has been a high number of fatalities along this short section of track (seven in as many years). (3) The nature of that section of track is such that it increases the risks of completed suicide due to the ease of access at multiple points and its proximity to a very popular beauty spot. (4) Efforts by Network Rail to reduce / rationalise the number of crossings along that stretch have failed due, in part, to opposition from the relevant local authorities. (5) Support or opposition from local authorities and councils will respectively increase or reduce the prospects of the risks inherent in that stretch of track being reduced. In the absence of support from local authorities and councils, Network Rail will be less likely to make an application to close or rationalise crossings along this section of track, given the known opposition from some persons living near, or using, the crossings. If an application is made, it will be less likely to be granted in the absence of support from the relevant local authorities and councils. ”

    Source location

    Heather Frances Page · 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

    Meet with Public Health Authority officers to discuss Network Rail deaths and near misses.

    Verbatim wording from the response

    “10. Additionally, officers of NCC in its capacity as Local Highway Authority are to meet with officers of NCC in its capacity as Public Health Authority next week to discuss ‘Network Rail Deaths and Near Misses’, which it is understood is specifically in relation to work by the British Transport Police, Network Rail and Public Health colleagues regarding suicides on the railway.”

    Source location

    2021-0213-Response-from-Nottinghamshire-County-Council_Published
    Page 4 · response
    Published 28 June 2021

    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

    Network Rail is responsible for operating, maintaining and improving the safety of the national rail network, including level crossings.

    Verbatim wording from the response

    “B. The operation, maintenance and improvement of a safe national rail network (including level crossings), is the responsibility of Network Rail, with oversight and funding specifically provided to them by the Office of Rail and Road for improving safety at such crossings.”

    Source location

    2021-0213-Response-from-Nottinghamshire-County-Council_Published
    Page 1 · response
    Published 28 June 2021

    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

    Where a person intends suicide, no measures can prevent it, and widespread crossing closures would face overwhelming public resistance.

    Verbatim wording from the response

    “a. as with the highways network, it is inevitably the case that where a person intends to take their own life, there are no measures that can be put in place to prevent it (and widespread closure of all such crossings would meet with overwhelming public resistance due to the level of interference that would represent with people’s enjoyment of such routes); and”

    Source location

    2021-0213-Response-from-Nottinghamshire-County-Council_Published
    Page 4 · response
    Published 28 June 2021

    Open published response
  6. Cambridgeshire and Peterborough

    AI-generated summary

    Christine Elizabeth GOULD (Chris) · 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

    Christine Elizabeth Gould, aged 17, died by suicide on 26 January 2019 after deliberately stepping in front of a passing train near the Cherry Hinton Bypass Level Crossing. The report raised concerns that BTP and Network Rail had too readily assumed a single route of access to the railway and had not sufficiently considered the boundary fence as a credible alternative route, potentially missing opportunities for earlier mitigation.

    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 consider credible alternative routes of access in post-death railway investigations

    Wider context from the report

    “(1) Following completed suicides on the railway network BTP and Network Rail are both involved in considering further mitigating measures that may be appropriate at the location to guard against further fatalities. (2) In Chris’ case, earlier consideration to the fence boundary being a credible route of access may have led to the fence boundary being improved more quickly after her death. (3) I am concerned that your investigation into, and consideration of, Chris’ death did not keep a sufficiently open mind that she may have climbed the boundary fence to access the railway line. If similar assumptions are made in other investigations, there is a risk of future fatalities: there is a risk that mitigating measures will be missed if BTP and Network Rail too readily assume that one point of access to the railway was used when the evidence permits of credible alternative routes of access. Accordingly, I am concerned that action should be taken in the sphere of guidance in keeping an open mind in post-death investigations but the nature of any appropriate action to be taken is for your organisations to consider. ”

    Source location

    Christine Elizabeth GOULD (Chris) · 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

    Complete the installed 1.8-metre palisade fencing upgrades on the up-side boundary near Cherry Hinton Bypass and the adjacent footpath, Tesco and hospital cemetery.

    Verbatim wording from the response

    “As was explained during the Inquest into Chris’s death, Network Rail is currently carrying out a fencing renewal which will upgrade the fencing between Cherry Hinton and Teversham level crossings to 1.8m palisade fencing (a Class I boundary measure). These works are ongoing and, at the time of drafting this letter, have reached the following stage. We have separately updated the Coroner on these works but include also below for completeness:”

    Source location

    2021-0185-Response-from-Network-Rail_Published
    Page 1 · response
    Published 2 June 2021

    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

    Renew and upgrade the remaining 1.04-kilometre up-side boundary to 1.8-metre palisade fencing between 2m 72ch and Teversham level crossing.

    Verbatim wording from the response

    “As was explained during the Inquest into Chris’s death, Network Rail is currently carrying out a fencing renewal which will upgrade the fencing between Cherry Hinton and Teversham level crossings to 1.8m palisade fencing (a Class I boundary measure). These works are ongoing and, at the time of drafting this letter, have reached the following stage. We have separately updated the Coroner on these works but include also below for completeness:”

    Source location

    2021-0185-Response-from-Network-Rail_Published
    Page 1 · response
    Published 2 June 2021

    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

    Renew the down-side boundary between Cherry Hinton Bypass and Old Fulbourn level crossings with upgraded fencing.

    Verbatim wording from the response

    “3. The down side is also being renewed between the Cherry Hinton Bypass level crossing and the Old Fulbourn level crossing. Works on this side of the railway commenced during the week commencing 28 June 2021, starting from the Cherry Hinton Bypass level crossing (2m 53ch) working back towards 2m 72ch (a distance of 0.38km). This is estimated to be completed by 23 July 2021.”

    Source location

    2021-0185-Response-from-Network-Rail_Published
    Page 2 · response
    Published 2 June 2021

    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

    Require a recorded fence check within 48 hours after a fatality and share this guidance with Anglia Route operations and crime teams.

    Verbatim wording from the response

    “Guidance has been shared within the Anglia Route (to the Operations Team and to the Route Crime Team) to reiterate that, following a fatality, a fence check of the area is to be carried out within 48 hours and a record of this made in the MOM report. This is an additional assurance to ensure Network Rail’s incident response is appropriately recorded, and is in addition to the BTP’s records and the Post Incident Site Report.”

    Source location

    2021-0185-Response-from-Network-Rail_Published
    Page 2 · response
    Published 2 June 2021

    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

    Make national Route Crime teams aware of the need to keep an open mind about track access when the access point is uncertain.

    Verbatim wording from the response

    “In light of this and the concerns raised in your report, Network Rail’s Route Crime teams nationally have been made aware of Chris’s case and the need to keep an open mind about access following a fatality where the point of access to the track is not definitively known. In addition, the reiteration”

    Source location

    2021-0185-Response-from-Network-Rail_Published
    Page 2 · response
    Published 2 June 2021

    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

    Deliver ongoing continuous professional development training on railway fatality scene assessments, rationale documentation, access-point evidence and geolocation tools.

    Verbatim wording from the response

    “The BTP Disruption Team review the Force’s frontline response to non-suspicious fatalities, through their assessments the identify areas of improvement and good practice. The Disruption Team have commenced a programme of regular “bite-sized” continuous professional development training sessions for police officers, one of these specifically targets scene assessments at railway fatality locations. Following the prevention of future deaths report, this training now incorporates renewed focus on attending officers comprehensively documenting their rationale following a scene assessment. The training also seeks to remind staff of how to use static railway infrastructure and modern technology such as the geolocation application What3Words, to provide precise positional locations for key evidential material (i.e. possible access points/recovered property from scenes).”

    Source location

    2021-0185-Response-from-BTP_Published
    Page 2 · response
    Published 2 June 2021

    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

    Apply revised post-incident site-visit procedures requiring incident-log review, pre-deployment liaison, assessment of multiple access points and repeat visits where necessary.

    Verbatim wording from the response

    “BTP has now implemented a procedural change for PISV whereby the DOCO will ensure the full incident log is read prior to a site visit, and liaison will take place prior to deployment with the Fatality Investigator (or SIO if unexplained or a child fatality) assigned to the investigation team when the access point isn’t immediately clear. This is to ensure the location subject to the PISV is the one established to have been used, or potentially include multiple points if entirely unknown. If at any point following completion of a PISV report, a location(s) other than that visited and referenced in the report is established to have been the point of entry, a second site visit to the correct location will be made and a new report is issued.”

    Source location

    2021-0185-Response-from-BTP_Published
    Page 2 · response
    Published 2 June 2021

    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 British Transport Police has jurisdiction over post-incident investigations, and Network Rail relies on its investigation and conclusions after immediate actions.

    Verbatim wording from the response

    “Network Rail works closely with the BTP when fatalities sadly occur on the railway. In the immediate aftermath of an emergency incident, following report from a Train Driver to Network Rail Control, the duty Network Rail Mobile Operations Manager (MOM) attends site and liaises with the BTP. The BTP has jurisdiction in relation to such investigations. Initial investigations are undertaken during the emergency response to secure the area, which includes identifying any areas of the infrastructure that may require repair, including potential access points. Any immediate issues identified (such as damaged boundary fencing or potential access points as a result of branches or sagging etc) are escalated by the MOM within Network Rail fault control systems.”

    Source location

    2021-0185-Response-from-Network-Rail_Published
    Page 2 · response
    Published 2 June 2021

    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

    Network Rail is responsible for deciding whether appropriate and proportionate action is needed to implement BTP’s proposed access-point improvements.

    Verbatim wording from the response

    “Through the changes that have been implemented to the structure of non-suspicious fatalities, the ongoing training of frontline staff around scene assessment and the preparing, production and submission of PISV reports, BTP has implemented robust procedures which significantly reduce the risk of mitigating measures being missed by the BTP during post-incident site visits. There is a structured process for the PISV reports to be passed on to Network Rail, whose responsibility it is to decide on any appropriate and proportionate action around the proposed improvement considerations highlighted by BTP.”

    Source location

    2021-0185-Response-from-BTP_Published
    Page 2 · response
    Published 2 June 2021

    Open published response
  7. County Durham and Darlington

    AI-generated summary

    Clive OXLEY · 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

    Clive OXLEY entered the track at Durham railway station, climbed the viaduct parapet, and jumped onto North Road below. Concerns included whether the pedestrian barrier adequately prevented access to the track and whether gaps and limited coverage in the wire fence enabled access to the parapet; two similar incidents were also noted.

    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

    Inadequate construction of the barrier preventing pedestrian access to the track

    Wider context from the report

    “1) It is accepted that the barrier to pedestrian traffic between the southbound platform and the viaduct makes it clear that pedestrians should not access the viaduct from the platform (as does the automatic voice alert which is activated as the barrier is passed). However, I am concerned that the barrier itself is not of a construction adequate to prevent a determined pedestrian such as the deceased from accessing the track at that particular point. ”

    Source location

    Clive OXLEY · Prevention of Future Deaths report
    Page 1 · 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

    Provide platform-end gates and fencing at higher-risk locations to restrict unauthorised access to the railway.

    Verbatim wording from the response

    “In order to make suicide and trespass as difficult as possible, platform end gates and fencing is provided, and prioritised at locations deemed higher risk to prevent access to the line wherever possible. With specific regards to Durham, this is supported by signage promoting services offered by the Samaritans and the warning system that is in place at the Station. In addition, LNER have trained a significant number of staff in suicide risk who are given guidance and training in dealing with vulnerable people when they are seen on the rail network.”

    Source location

    2020-0301-Response-from-LNER-Redacted
    Page 1 · response
    Published 8 January 2021

    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

    Contact Network Rail to seek a joint site visit assuring that the fencing meets rail-industry standards.

    Verbatim wording from the response

    “LNER have made contact with Network Rail with a view to arranging a joint site visit in order to seek assurance that the fencing meets the requirements of the rail industry standards.”

    Source location

    2020-0301-Response-from-LNER-Redacted
    Page 1 · response
    Published 8 January 2021

    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

    Complete southbound platform-end alterations, including a lockable gate, robust obscuring fence, audible warning, signage and anti-trespass flooring.

    Verbatim wording from the response

    “As part of that exercise, in December 2019, we undertook significant alteration to the end of the southbound platform to deter pedestrian access and to obscure the view of the viaduct from the platform. This was done by removing the sloped nose of the platform and installing a lockable gate and robust fence at the platform end. The fence itself is 1.8 metres high with a coarse infill to limit any view of the viaduct from the platform. The platform end also has an audible warning system, signage making clear that pedestrians are prohibited from passing the end of the platform and Samaritans signage. Anti-trespass flooring was also installed either side of the fencing the full width of the platform to further discourage pedestrians from passing the fence.”

    Source location

    2020-0301-Response-from-Network-Rail-Redacted
    Page 1 · response
    Published 8 January 2021

    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

    Network Rail is generally responsible for platform end and boundary fencing beyond LNER’s day-to-day station management.

    Verbatim wording from the response

    “LNER work collaboratively with Network Rail to reduce the number of trespass and fatality incidents along the LNER line of route, though in practical terms, LNER operate Durham Station under a long-term lease and are generally responsible for the day to day management of the Station. Platform end fencing and general boundary fencing in place to prevent unauthorised access to the track and other infrastructure is generally the responsibility of Network Rail.”

    Source location

    2020-0301-Response-from-LNER-Redacted
    Page 1 · response
    Published 8 January 2021

    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

    A full-width southbound platform fence cannot be installed because mandatory gauging standards prohibit it.

    Verbatim wording from the response

    “Decisions in relation to the location and design of these measures took into account Network Rail’s relevant mandatory standards. Standards prohibit fencing to be constructed the full width of the platform due to gauging requirements (i.e. the need to consider the potential for a train to come into contact with the fence when passing the platform). The fence has been placed as far along the platform as standards allow. Consideration was also given to a derogation from standards but it was recognised that a determined individual could in any event access the track by climbing down from the platform edge.”

    Source location

    2020-0301-Response-from-Network-Rail-Redacted
    Page 1 · response
    Published 8 January 2021

    Open published response
  8. Surrey

    AI-generated summary

    JORDAN MICHAEL AIRA · 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

    Jordan Michael Aira was electrocuted after walking onto the railway lines at Ashford Station in the early hours of 23 March 2019. The concerns included inadequate physical barriers, the location of the emergency telephone, warning signs that did not explicitly warn of immediate death from touching the live rail, and no national curriculum requirement to teach pupils about the risk posed by live rails.

    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 physical boundaries preventing public access to railway tracks

    Wider context from the report

    “1. There were no physical boundaries at the end of the platform preventing members of the public accessing the railway tracks. ”

    Source location

    JORDAN MICHAEL AIRA · 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

    Deploy Rail Safety Accredited Security Officers to patrol for trespass and antisocial behaviour and target hotspot locations with partner agencies.

    Verbatim wording from the response

    “Locally to SWR, we have Rail Safety Accredited Security Officers (Rail Community Officers) whose core activities include the following:”

    Source location

    2020-0082-Response-from-South-Western-Railway_Redacted
    Page 2 · response
    Published 16 April 2020

    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

    Add extra platform markings and barriers at Ashford station to further deter trespass.

    Verbatim wording from the response

    “Ashford was not therefore a priority station for additional barriers. However, as was explained at the Inquest, work to improve that station is planned and will now include extra platform markings and barriers to further deter trespass.”

    Source location

    2020-0082-Response-from-Network-Rail_Redacted
    Page 3 · response
    Published 16 April 2020

    Open published response
  9. Inner North London

    AI-generated summary

    Benjamin Michael HADDON-CAVE and Patrick Thomas BOLSTER · 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

    Benjamin Michael HADDON-CAVE and Patrick Thomas BOLSTER climbed onto a freight train near Hackney Wick Station in the small hours of 21 March 2019 and were electrocuted. The report identifies concerns about an unrepaired gap in the track perimeter fence, failures to inspect and report it, inadequate internal investigation, and uncertainty about whether there was a national fencing-inspection system failure.

    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 track-engineer challenge of missed fence inspections

    Wider context from the report

    “Paddy and Ben died on 21 March 2019. The last time the broken fence was checked was 27 October 2016. In the intervening two and a half years, reasonable endeavours had not been made to inspect (and repair) the fence. 1. The fence was marked down for annual inspections because there was no history of problems in that area. However, the inspectors conducting the inspections on 27 October 2017 and 27 October 2018 (a different inspector on each occasion) did not consider the relevant part of the fence because dense vegetation blocked their view from trackside. Neither inspector attempted to view the fence from the other (public) side, which they could easily have done. This represents a failure of the two individuals and/or a failure of their training and/or both. There are only four inspectors at Tottenham, so two inspectors represents half the inspections workforce. 2. Both inspectors inputted their inspection onto a computer system, but neither submitted a paper form as they were mean to do. This represents a failure of the two individuals and/or a failure of their training and/or both. In any event, such a system of dual submission was inherently flawed. 3. As a consequence of no paper forms being submitted, the track engineer did not see the evidence of the failure to inspect the fence, and so was not in a position to challenge this. This represents a system failure. 4. As a consequence of no paper forms being submitted, the internal auditors did not see the evidence of the failure to inspect the fence or the evidence of the failure to challenge, and so were not in a position to highlight this. This represents a system failure. 5. Network Rail identified the gap in the fence within a week of the deaths but, despite what was described as a full internal investigation, the system failures were only discovered after the inquest had resumed on 30 August 2019. Their original investigation was inadequate. Network Rail had been operating for the previous five and a half months on the basis that this was a localised problem. Even after an adjournment to facilitate further investigations, a senior Network Rail representative gave evidence to that effect on 13 September 2019. Yet the reality is that Network Rail does not know if it has a national system failure of fencing inspection. Paddy and Ben were adults who had responsibility for their own actions, but the fence gap was accessible to children and appeared to be worn. And I heard no evidence that the two had planned to go up onto trackside. A determined effort can be difficult to thwart, but an impulsive action (with judgement and motor skills impaired through alcohol) might well be avoided if the route to danger is not so very easily taken. ”

    Source location

    Benjamin Michael HADDON-CAVE and Patrick Thomas BOLSTER · 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 of internal audit to identify missed inspections and absent challenge

    Wider context from the report

    “Paddy and Ben died on 21 March 2019. The last time the broken fence was checked was 27 October 2016. In the intervening two and a half years, reasonable endeavours had not been made to inspect (and repair) the fence. 1. The fence was marked down for annual inspections because there was no history of problems in that area. However, the inspectors conducting the inspections on 27 October 2017 and 27 October 2018 (a different inspector on each occasion) did not consider the relevant part of the fence because dense vegetation blocked their view from trackside. Neither inspector attempted to view the fence from the other (public) side, which they could easily have done. This represents a failure of the two individuals and/or a failure of their training and/or both. There are only four inspectors at Tottenham, so two inspectors represents half the inspections workforce. 2. Both inspectors inputted their inspection onto a computer system, but neither submitted a paper form as they were mean to do. This represents a failure of the two individuals and/or a failure of their training and/or both. In any event, such a system of dual submission was inherently flawed. 3. As a consequence of no paper forms being submitted, the track engineer did not see the evidence of the failure to inspect the fence, and so was not in a position to challenge this. This represents a system failure. 4. As a consequence of no paper forms being submitted, the internal auditors did not see the evidence of the failure to inspect the fence or the evidence of the failure to challenge, and so were not in a position to highlight this. This represents a system failure. 5. Network Rail identified the gap in the fence within a week of the deaths but, despite what was described as a full internal investigation, the system failures were only discovered after the inquest had resumed on 30 August 2019. Their original investigation was inadequate. Network Rail had been operating for the previous five and a half months on the basis that this was a localised problem. Even after an adjournment to facilitate further investigations, a senior Network Rail representative gave evidence to that effect on 13 September 2019. Yet the reality is that Network Rail does not know if it has a national system failure of fencing inspection. Paddy and Ben were adults who had responsibility for their own actions, but the fence gap was accessible to children and appeared to be worn. And I heard no evidence that the two had planned to go up onto trackside. A determined effort can be difficult to thwart, but an impulsive action (with judgement and motor skills impaired through alcohol) might well be avoided if the route to danger is not so very easily taken. ”

    Source location

    Benjamin Michael HADDON-CAVE and Patrick Thomas BOLSTER · 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

    Implement the revised Boundary Fencing Inspection Standard requiring electronic inspection records, non-tactile inspection documentation and supervisory approval.

    Verbatim wording from the response

    “1.1.3 New Boundary Fencing Inspection Standard”

    Source location

    2019-0314-Response-by-Network-Rail
    Page 2 · response
    Published 5 November 2019

    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

    Conduct onsite reviews of route inspectors’ non-tactile inspection reports and processes.

    Verbatim wording from the response

    “As a further measure, the Route Lineside Senior Asset Engineer within the Route where Tottenham Delivery Unit are located is undertaking a set of onsite reviews with all Route inspectors using recently created non-tactile inspection reports. This is to review the reports and the process followed prior to submission of the reports. All inspectors in the Route will have been reviewed by 31st December 2019. We can confirm the inspectors involved with the fencing inspections linked to the tragic deaths have already been reviewed by the Route Lineside Senior Asset Engineer.”

    Source location

    2019-0314-Response-by-Network-Rail
    Page 3 · response
    Published 5 November 2019

    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

    Provide engineers with a report flagging consecutive non-tactile inspections and inspection forms not completed within 180 days.

    Verbatim wording from the response

    “• The Engineers will be receiving a new report showing what is in the system for processing and the report will flag two consecutive non-tactile inspections, plus any forms not processed to completion within 180 days. This will allow the Engineers to check that suitable challenges have occurred for those locations or actions to close are in progress.”

    Source location

    2019-0314-Response-by-Network-Rail
    Page 5 · response
    Published 5 November 2019

    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

    Apply the revised audit protocol to check electronic inspection records against the new boundary inspection standard.

    Verbatim wording from the response

    “4.1.1 Internal auditing”

    Source location

    2019-0314-Response-by-Network-Rail
    Page 5 · response
    Published 5 November 2019

    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

    Amend the audit protocol by adding guidance to review example F3212 forms from inspectors.

    Verbatim wording from the response

    “The previous Standard in force allowed the use of either paper or electronic systems. The lesson from these tragic deaths will be shared with our national audit teams so they can share the lesson. The audit protocol has been changed, since the audit referenced above, to reflect the new Standard and all auditors will be checking to the new Standard including checking of the electronic records.”

    Source location

    2019-0314-Response-by-Network-Rail
    Page 5 · response
    Published 5 November 2019

    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

    Complete the national review of sampled Off Track sections to assess compliance with the boundary inspection requirements.

    Verbatim wording from the response

    “5.1 Network Rail Response Q5:”

    Source location

    2019-0314-Response-by-Network-Rail
    Page 5 · response
    Published 5 November 2019

    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

    Commission a national special-topic audit of compliance with the revised boundary inspection standard for non-tactile forms.

    Verbatim wording from the response

    “new boundary inspection Standard re non-tactile forms will be undertaken by the Network Rail National Audit Team within the next 3 months to identify whether we have a national failure and to what extent.”

    Source location

    2019-0314-Response-by-Network-Rail
    Page 6 · response
    Published 5 November 2019

    Open published response
  10. Cumbria

    AI-generated summary

    Steven John Key · 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

    Steven John Key died at the scene after lying on a railway track in front of an oncoming train near Oxenholme Station on 14 September 2018. The principal concern was that a low wooden fence was easy to climb, allowing access to the track, where trains travelled at up to 125 mph; replacing it with a heightened palisade gate and fence was identified as reasonably practicable.

    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 prevent access to the railway line through adequately secure fencing

    Wider context from the report

    “(1) You have a duty under the Railway Safety (Miscellaneous Provisions) Regulations 1997 to prevent access to the railway line so far as is reasonably practicable. (2) The fencing at the scene of Mr Key’s death was a low wooden fence which was easy to climb over. (3) The British Transport Police (BTP) report into the death, reference CRUO 2018 1711 & BTP 404-14091, of which you received a copy, recommended replacing the fence and gate with a heightened palisade gate and fence. I agree with that recommendation. (4) Trains regularly travel on this section of the track at speeds of 125 mph. (5) Children and adults would, like Mr Key, be able to climb the wooden fence and be at risk of injury or death on the track from passing trains. (6) It would be reasonably practicable for you to fence the track at this point in the way suggested in the BTP Report. ”

    Source location

    Steven John Key · Prevention of Future Deaths report
    Page 1 · 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

    Install additional meshing and netting at the location to deter climbing.

    Verbatim wording from the response

    “Network Rail takes its safety obligations seriously and has taken additional measures beyond those required by its standards, to install additional meshing and netting at this location to act as an increased deterrent to climbing. This is explained in the responses to your matters of concern.”

    Source location

    2019-0102-Response-by-Network-Rail
    Page 1 · response
    Published 11 June 2019

    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 trespass risk around the area and identify the bridge wing wall and track-level safety rail for further mitigation.

    Verbatim wording from the response

    “Unfortunately, the risk of trespass cannot be entirely eliminated even with the best of fencing, but I consider that in this particular area the current boundary measures in place meet the reasonably practicable test. That said, Network Rail is constantly striving to improve safety on our network and that is why we create and adhere to standards such as NR/L2/TRK/5100. In the light of Mr Key’s death, we have reviewed the risk of potential trespass in this area in general and have identified the bridge wing wall and the galvanised iron tubular hand rail / safety rail at track level as an area where we could further mitigate any risk of trespass. To this end, the Route Structures Senior Asset Engineer has been”

    Source location

    2019-0102-Response-by-Network-Rail
    Page 3 · response
    Published 11 June 2019

    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

    Investigate whether attaching mesh to the bridge’s tubular handrail or safety rail would improve security.

    Verbatim wording from the response

    “Unfortunately, the risk of trespass cannot be entirely eliminated even with the best of fencing, but I consider that in this particular area the current boundary measures in place meet the reasonably practicable test. That said, Network Rail is constantly striving to improve safety on our network and that is why we create and adhere to standards such as NR/L2/TRK/5100. In the light of Mr Key’s death, we have reviewed the risk of potential trespass in this area in general and have identified the bridge wing wall and the galvanised iron tubular hand rail / safety rail at track level as an area where we could further mitigate any risk of trespass. To this end, the Route Structures Senior Asset Engineer has been”

    Source location

    2019-0102-Response-by-Network-Rail
    Page 3 · response
    Published 11 June 2019

    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 line speed at this location is 110mph, not 125mph, although trains still travel at high speed.

    Verbatim wording from the response

    “While our records indicate that the line speed at this location is 110mph, I nevertheless accept that trains do travel at high speed along this section of the track.”

    Source location

    2019-0102-Response-by-Network-Rail
    Page 3 · response
    Published 11 June 2019

    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

    Current boundary measures meet the reasonably practicable obligation, and no further assessment is triggered because there is no prior evidence of trespass.

    Verbatim wording from the response

    “As this area has no prior evidence of trespass, a Class III boundary measure would be appropriate as per the Standard, and in effectively having a Class III equivalent barrier in place I consider that Network Rail has met its obligation to prevent unauthorised access to the railway in so far as reasonably practicable.”

    Source location

    2019-0102-Response-by-Network-Rail
    Page 3 · response
    Published 11 June 2019

    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

    Replacing all fencing with palisade is not reasonably practicable given the scale of the railway network and local risk assessment requirements.

    Verbatim wording from the response

    “While I understand the British Transport Police’s recommendation to replace the fence and gate with a heightened palisade gate and fence, Network Rail is responsible for looking after some 20,000 miles of track and 30,000 bridges and it is not reasonably practicable to fence all of it with palisade. Our risk assessment process takes account of all local factors in determining the most appropriate boundary measure to implement, bearing in mind what is reasonably practicable.”

    Source location

    2019-0102-Response-by-Network-Rail
    Page 3 · response
    Published 11 June 2019

    Open published response
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Data last updated 7 September 2026