Recurring concern

Inadequate physical barriers preventing access to dangerous drops or areas

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First reported 21 Nov 2013•Latest report 6 Mar 2026

Definition

What this concern includes

Includes barrier height, climbability, coverage, replacement and measurement failures where guarding is intended to prevent access to a dangerous drop or area.

Not included

  • Clinical bed or chair fall-prevention controls
  • Vehicle collision barriers
  • Security controls with no physical-injury hazard
Reports
46

Distinct published reports

Individual concerns
57

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
90

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 Rail14
Cornwall Council3
Durham County Council3
National Highways3
Canal & River Trust2
Hammerson PLC2
Isle of Wight Council2
Recipient name withheld2
The National Trust For Places Of Historic Interest Or Natural Beauty2
Alexandra Park and Palace Charitable Trust1
Arriva Rail North Limited1
Bedford Borough Council1
British Transport Police1
Calderdale Borough Council1
Chesterfield Borough 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. Isle of Wight

    AI-generated summary

    Annette Jane Lewis · 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

    Annette Jane Lewis died after throwing herself from a cliff at Tennyson Down while in acute distress and behaving unusually. The concerns identified were the absence of fencing at the cliff edge and the lack of signs directing people in mental distress to support such as the Samaritans.

    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 fencing to protect the public from falling over the cliff edge at Tennyson Down

    Wider context from the report

    “1. I heard evidence from ████████ that there are no fences to protect the public from falling over the edge of the cliff at Tennyson Down, and moreover that there are no signs providing those in some sort of mental distress with the number for the Samaritans. Whilst I acknowledge that putting fences around the edge of the cliff would be a massive undertaking by the landowners, it may prevent a future death if those who are in extremes are reminded that there are people out there who are trained to assist them at that time. 2. Having just concluded a similar inquest involving a woman who threw herself from the top of Culver Cliff where I raised similar concerns with both the National Trust and the Director of Public Health who heads up the Suicide Prevention Group on the Isle of Wight, it seems appropriate that if consideration is being given by these organisations to better signage being implemented at the top of Culver Cliff, at the same time, consideration can also be given to making similar improvements at Tennyson Down. ”

    Source location

    Annette Jane Lewis · 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

    Conduct site visits at Culver and Tennyson Downs with the Isle of Wight Suicide Prevention and Intervention team.

    Verbatim wording from the response

    “2. Engagement with the Suicide Prevention & Intervention, Isle of Wight team. A meeting with ████████ from the group has been scheduled for Friday 3rd April 2020 to conduct site visits to both Culver and Tennyson Downs.”

    Source location

    2020-0004-Response-from-the-Isle-of-Wight-National-Trust-Redacted
    Page 2 · response
    Published 8 February 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

    Conduct a full internal review of suicide-prevention measures after completing the planned stakeholder meetings.

    Verbatim wording from the response

    “6. Conduct a full internal review of our suicide prevention measures. Once all the above meetings are complete, we will conduct a full review of our measures and implement changes where appropriate.”

    Source location

    2020-0004-Response-from-the-Isle-of-Wight-National-Trust-Redacted
    Page 2 · response
    Published 8 February 2020

    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

    Fencing the several miles of coastline is not economically viable or aesthetically appropriate.

    Verbatim wording from the response

    “I can confirm that a number of measures were already in place at Culver Down, including a total of seven Samaritans signs placed within the past few years. A schematic showing the locations of these signs is at Annex A. In addition, ‘dragons teeth’ (wooden bollards to prevent vehicle access) are in place opposite the exits from the car park and there is a ditch to ground vehicles approaching the cliff edge. There is also a barbed wire fence running the”

    Source location

    2020-0004-Response-from-the-Isle-of-Wight-National-Trust-Redacted
    Page 1 · response
    Published 8 February 2020

    Open published response
  2. Nottinghamshire

    AI-generated summary

    Stanislawa Kmiecik · 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

    Stanislawa Kmiecik entered an inaccessible mezzanine area in a Nottingham store and fell approximately 18 feet through an open space to the basement floor, sustaining multiple injuries and dying at the scene. The concerns identified included public and staff access to the area, lack of warning signage and fall protection, uneven flooring, and the risk of objects falling through the openings onto people below.

    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 mezzanine openings

    Wider context from the report

    “(3) Whilst the area is cordoned off from the main shop floor by way of a locked mesh gate and some scaffolding type posts, it remains possible for staff and/or members of the public to access the area. ”

    Source location

    Stanislawa Kmiecik · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Accessible 18-foot drop between the mezzanine and basement shop floor

    Wider context from the report

    “(1) There is a drop of some 18 feet between the mezzanine floor and the basement shop floor below that is accessible via a gate from the shop floor where persons are free to roam ”

    Source location

    Stanislawa Kmiecik · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of fall protection below the mezzanine openings

    Wider context from the report

    “(5) If a member of staff or the public were to access the area, there remains a risk of falling from height as there is no safety netting or other safety structure below either of the two openings in the mezzanine floor. ”

    Source location

    Stanislawa Kmiecik · 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

    Replace the broken gate lock.

    Verbatim wording from the response

    “• the broken lock was replaced on Monday 15 April 2019 ;”

    Source location

    2019-0258-Response-by-URBN-UK-Limited
    Page 1 · response
    Published 6 September 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

    Restrict access beyond the gate to authorised staff and extend the instruction to new staff.

    Verbatim wording from the response

    “• immediately after the incident all moveable items beyond the gate were removed and all members of staff were instructed not to access the area beyond the gate unless authorised to do so. That instruction not to access the area beyond the gate has been repeated and will cover new members of staff ;”

    Source location

    2019-0258-Response-by-URBN-UK-Limited
    Page 1 · response
    Published 6 September 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

    Replace the scaffolding with high railings throughout.

    Verbatim wording from the response

    “• removal of all of the scaffolding and replaced with high railings throughout ;”

    Source location

    2019-0258-Response-by-URBN-UK-Limited
    Page 2 · response
    Published 6 September 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

    Infilling the voids with steel plates.

    Verbatim wording from the response

    “• infilling the voids with steel plates ;”

    Source location

    2019-0258-Response-by-URBN-UK-Limited
    Page 2 · response
    Published 6 September 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 incident was almost certainly caused by deliberate risk-taking, and no member of the public had previously attempted to access the area.

    Verbatim wording from the response

    “We do not wish to pre-judge the evidence that will be heard at the inquest. However, it does seem plain that the cause of the incident was almost certainly a deliberate attempt by the deceased to put herself in a position of danger and potentially take her own life. There can be no other credible explanation for the individual unsecuring the gate or climbing over the gate and then going beyond the scaffolding. No member of the public has ever attempted previously to access the area beyond the gate.”

    Source location

    2019-0258-Response-by-URBN-UK-Limited
    Page 1 · response
    Published 6 September 2019

    Open published response
  3. North Wales (East and Central)

    AI-generated summary

    Kristopher John McDowell · 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 31 May 2016, Kristopher John McDowell fell to his death from the Pontcysyllte aqueduct after an upright rail he was holding became detached while he was on the non-pedestrian side. The concerns identified were that the parapet uprights were spaced widely enough for people to pass through, and that signage did not adequately mitigate this risk. Concerns were also raised that inspection and testing processes were inadequate to ensure the uprights remained properly engaged.

    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

    Excessive spacing between aqueduct parapet uprights

    Wider context from the report

    “(a) The average space between the uprights on the parapet on the aqueduct is 195mm whilst the current industry standard is 110mm as a result of which there exists a risk that a person might be able to pass between them. This is a particular risk for children using the aqueduct but it is also a significant risk for young persons or adults being of sufficient width for them to pass through in circumstances whereby it was their intention to gain access to the non-pedestrian side of the parapet for a purpose which would not be considered the intended use of the structure. In my opinion, the use of signage alone, warning users of the potential risk, does not adequately mitigate the risk of a person passing through the uprights and falling from the aqueduct. (b) Evidence provided by an expert instructed by the Canal and River Trust (CRT) indicated that it was his belief that the upright became detached as a result of a lifting action which dis-engaged the nib on the bottom of the upright from the socket on the outside of the parapet. The evidence provided to the inquest by engineers from CRT advised that their inspection procedures provided for an Annual Inspection which included testing for the extent of embedment by a push/pull/lift test, however in my opinion the subjective elements of this test would permit inconsistencies in the information which it provides. Furthermore, exact measurements of the degree of embedment of uprights would only routinely be established in the course of a Principal Inspection which takes place every twenty years and as a result it is difficult for there to be an accurate/regular assessment of the rates of possible deterioration and hence the true extent of embedment. In my opinion, the testing processes currently adopted (in regard to the matters detailed above) are inadequate to ensure that the uprights are properly engaged at all times. ”

    Source location

    Kristopher John McDowell · 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

    Investigate physical options for reducing gaps between the aqueduct uprights with relevant partners and regulatory bodies.

    Verbatim wording from the response

    “The Trust has also given further careful thought to this issue raised in your report. It also bears in mind, and has high regard to, the perception by the public of the safety of its structures. Our ambitions and those of our partners for the World Heritage Site are to see it protected and celebrated, drawing increasing numbers of visitors. The significant heritage status of the Aqueduct, including the parapet, means that the Trust must seek explicit consent from the Welsh Government through CADW (the Welsh Government's historic environment service) before carrying out any works to the structure with any permanent changes to the appearance of the Aqueduct likely to be of particular concern. As visitor safety – and perception of safety - remains our paramount concern, we have decided to explore with CADW and our other partners how the”

    Source location

    2019-0083-Response-by-Canal-River-Trust
    Page 2 · response
    Published 9 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

    Conduct an informal public consultation on suitable options for reducing the gaps between the uprights.

    Verbatim wording from the response

    “• We have started an investigation of the physical options available to address gaps between the uprights, working with relevant partners and regulatory bodies. We aim to have this completed by the end of September 2019. If we conclude there is more than one physical option that is suitable (taking into account the physical integrity of the Aqueduct) to reduce the width of the gaps then we will proceed to the consultation process referred to immediately below this bullet point;”

    Source location

    2019-0083-Response-by-Canal-River-Trust
    Page 3 · response
    Published 9 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

    Develop and submit a final design for reducing the gaps between the uprights for statutory approval after consultation.

    Verbatim wording from the response

    “• For example, at Marple Aqueduct which was referred to at the Inquest, we undertook an informal public consultation relating to the options which guided the final design and, we believe, eased the consenting process. We will expect to do the same here and need to allow sufficient time for this; our outline plan is for this consultation to be conducted later in 2019 and completed by early 2020;”

    Source location

    2019-0083-Response-by-Canal-River-Trust
    Page 3 · response
    Published 9 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

    Existing signage, volunteer ranger and information controls adequately address risks associated with normal aqueduct use.

    Verbatim wording from the response

    “Given the Aqueduct’s extraordinary heritage significance, the Trust has deliberately sought to manage the risk of anyone passing between the gaps by non-invasive controls to minimise any impact on the original aqueduct design. As stated in evidence to the Inquest, the Trust uses warning signage to advise visitors prior to them accessing the structure, and through the use of volunteer rangers at peak times and by appropriate information found on the Trust’s website. The signage is installed in prominent locations on the approach to the parapet and on “repeater” posts installed in the towpath. The Trust has identified the risk of unsupervised young children in relation to the gaps, and specifically addresses this in the warning signage. During the course of your investigation, these signs were enhanced by the Trust to advise dog owners that dogs should be kept on a lead.”

    Source location

    2019-0083-Response-by-Canal-River-Trust
    Page 2 · response
    Published 9 June 2019

    Open published response
  4. 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
  5. West Yorkshire (Western)

    AI-generated summary

    Jordan Ryan Sheils · 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 Ryan Sheils went missing from his father’s home on the evening of 3 April 2017 after sending worrying text messages, and his body was found beneath the North Bridge on 4 April 2017. The report concerned measures to deter similar incidents at the bridge, including anti-climbing mesh and prominently displayed CCTV cameras, and noted that their introduction should be expedited.

    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

    Delay in implementing anti-climbing mesh at the location

    Wider context from the report

    “During the inquest I heard very helpful evidence from ████████, Highway Asset Manager, who told me that the council are currently in the process of considering of obtaining planning permission for anti-climbing mesh at the location, although it is not thought it will be implemented until early next year. • To review the existing measures for deterring such tragedies with a view to expediting their introduction particularly with regard to prominently displayed CCTV cameras overlooking the bridge. ”

    Source location

    Jordan Ryan Sheils · 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

    Finalize drawings for the preferred anti-climb mesh and steeple coping option.

    Verbatim wording from the response

    “3.2 A report was submitted to Calderdale Council’s Cabinet on 30th July 2018 outlining the installation of anti-climb mesh affixed to horizontal rails to cover the cut outs in the parapet and a steeple coping to cover the castellated top of the existing parapet providing a 1.45m unclimbable parapet (which would comply with current Design Manual for Roads and Bridges standards). A similar methodology was implemented on Hebble Viaduct which carries the A58 over North Bridge as a suicide prevention measure in 2010.”

    Source location

    2018-0319-Response-by-Calderdale-Council
    Page 1 · response
    Published 24 February 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

    Obtain Cabinet approval for planning and listed-building applications and make funding available for the preferred option.

    Verbatim wording from the response

    “The following resolutions were passed:”

    Source location

    2018-0319-Response-by-Calderdale-Council
    Page 1 · response
    Published 24 February 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

    Submit and progress planning and listed-building consent applications for the anti-climb mesh and steeple coping works.

    Verbatim wording from the response

    “• That an application for listed building consent and an application for planning permission for the preferred option described at paragraph 5.3 (anti climb mesh and steeple coping) is submitted to the Local Planning Authority;”

    Source location

    2018-0319-Response-by-Calderdale-Council
    Page 1 · response
    Published 24 February 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

    Prepare the contract and tender process for the North Bridge anti-climb works.

    Verbatim wording from the response

    “3.3 A Planning and Listed Building Consent application was submitted on the 5th October 2018, upon approval the works will be tendered and is currently pending approval.”

    Source location

    2018-0319-Response-by-Calderdale-Council
    Page 1 · response
    Published 24 February 2019

    Open published response
  6. Hertfordshire

    AI-generated summary

    Darren Robert URQUHART · 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 13 November 2017, Darren Urquhart was struck by a train after jumping from platform 1 at Hitchin Railway Station and was confirmed dead at the scene. The substantive concerns related to the position of a trespass mat, the lack of gates at the south ends of platforms 1 and 2, and inadequacies in fencing and the placement of a trespass deterrence mat.

    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

    Inadequacy of fencing

    Wider context from the report

    “(1) The position of the trespass mat referred to in the report of T.Ramskill at recommendation 2 of his site report. (2) The lack of gates at the south end of platforms 1 and 2. (3) The inadequacy of the fencing shown in Image 6 of T.Ramskill’s report and the position of the trespass deterrence mat low down on the ramp. ”

    Source location

    Darren Robert URQUHART · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  7. North East Kent

    AI-generated summary

    Taiyah-Grace Sharon Peebles · 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

    Taiyah-Grace Sharon Peebles, who was intoxicated, dismounted from a train in the wrong direction at Herne Bay Station, stumbled down an un-barriered platform slope and made contact with a live rail, resulting in her death. The principal concerns were the absence of an end-of-platform barrier and the accessibility of a ground-level live rail, with similar barriers absent on other platforms in the area.

    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 public access to live rails at ground level

    Wider context from the report

    “The absence of an end of platform barrier and the existence of a live rail at ground level that might be accessible to members of the public may in my opinion create a risk that future deaths will occur unless action is taken. The Assistant Coroner understands that a barrier has since been constructed at Herne Bay Station to help prevent deaths in similar circumstances but that other platforms in the area have no such barrier. His further understanding is that in other parts of the country trains are powered by electric current supplied by way of overhead cables rather than live rails at ground level thereby making contact with the power supply less likely ”

    Source location

    Taiyah-Grace Sharon Peebles · 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

    Continue developing reasonably practicable safety solutions for the ground-level conductor rail system.

    Verbatim wording from the response

    “The ground level conductor rail system on the South East route was installed in the 1950s and, although Network Rail has no future plans to install new conductor rail systems, it is not reasonably practicable to convert the system to an overhead contact line due to the complexity and cost to the railway industry. Whilst the ground level conductor rail cannot be replaced, Network Rail is committed to continue to develop reasonably practical solutions to improve the safety of the system wherever possible.”

    Source location

    2018-0239-Response-by-Natwork-Rail
    Page 2 · response
    Published 23 September 2018

    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

    Install platform-end gates and anti-trespass measures at more than 50 South East route stations, with works already completed at 30 locations.

    Verbatim wording from the response

    “With regards to platform-end fencing, historically the fencing has not been installed as standard practice. The risks involved in intentional and unintentional accessing of the rail network were controlled via warning notices at the platform-end. The platform-end fencing and anti-trespass panels that have been installed at Herne Bay are part of a wider program of mitigations that are being applied to locations across the South East route to address the risks associated with members of the public either intentionally or unintentionally accessing the rail network. There are currently two programmes of activity which will see platform-end gates installed at over 50 stations on the South East route. We have already completed works on 30 locations over the Kent and Sussex areas. We expect the majority of works to be completed by the end of 2018 with some being finished in early 2019.”

    Source location

    2018-0239-Response-by-Natwork-Rail
    Page 2 · response
    Published 23 September 2018

    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

    Improve fencing at higher-risk locations through a programme including £800,000 of work due for completion by April 2019.

    Verbatim wording from the response

    “There are also programmes to improve our fencing at areas we consider to be at higher risk of intentional or unintentional public access and this includes £800,000 of work which is due to be completed by April 2019.”

    Source location

    2018-0239-Response-by-Natwork-Rail
    Page 2 · response
    Published 23 September 2018

    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

    Converting or replacing the ground-level conductor rail is not reasonably practicable because of the railway system’s complexity and cost.

    Verbatim wording from the response

    “The ground level conductor rail system on the South East route was installed in the 1950s and, although Network Rail has no future plans to install new conductor rail systems, it is not reasonably practicable to convert the system to an overhead contact line due to the complexity and cost to the railway industry. Whilst the ground level conductor rail cannot be replaced, Network Rail is committed to continue to develop reasonably practical solutions to improve the safety of the system wherever possible.”

    Source location

    2018-0239-Response-by-Natwork-Rail
    Page 2 · response
    Published 23 September 2018

    Open published response
  8. Bedfordshire and Luton

    AI-generated summary

    Andrew Thomas HANAHOE · 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

    Andrew Thomas HANAHOE died after walking onto Lindsells Foot Crossing at Biggleswade Railway Station as a train approached on 29 December 2017. Concerns were raised about the crossing’s safety, including its exposure to high-speed trains, inadequate fencing and the absence of measures such as repeater lights or trespass deterrence; the report states that the risk of a future death remained.

    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 trespass deterrence and fencing around the foot crossing

    Wider context from the report

    ““(1) The Post Incident Site Report states: “Ideally this foot crossing should be closed. It crosses railway line that have trains regularly passing over it at speeds up to 125 mph. “Biggleswade, like many towns, is growing in size and any future development in this area will bring housing closer to the crossing. “Would the crossing be installed today? “If the crossing is a recognised “foot path” then an enclosed foot bridge, to prevent items being thrown at or dropped on trains, should be installed, together with suitable fencing on both sides of the line adjacent to it, to prevent simple access to the tracks. “Currently there is just “post and wire” fencing immediately next to the adjacent railway structure... “If the crossing is to be retained, then “repeater lights” should be installed on either side of the crossing, so that users on the crossing can be made aware that a train is approaching”. “Additionally trespass deterrence “Pyramid matting” that has been approved for use by Network Rail ... or similar should be installed on either side of the crossing, to deter simple access to the railway. Additional fencing is also needed between the existing line side fencing and the trespass deterrence to prevent access to the embankment.” I understand that no decision has been made since this Report was made in January 2018, yet the risk of a future death remains. ”

    Source location

    Andrew Thomas HANAHOE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Anti-trespass matting is not considered appropriate because there is no evidence of shortcuts or trespass at the crossing.

    Verbatim wording from the response

    “The PISR also suggests that anti-trespass matting should be installed on either side of the crossing. Trespass deterrent measures of this nature are considered and installed if, for example, there is evidence of people using the level crossing to trespass on the railway. There is no evidence of users taking shortcuts or other such behaviour at Lindsells Level Crossing. As a result, it is not considered that this type of deterrent is appropriate at this crossing.”

    Source location

    2018-0184-Response-by-Network-Rail
    Page 2 · response
    Published 8 July 2018

    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

    Further boundary mitigation is not required because fencing is in good condition, fit for purpose, compliant, and unrelated to the incident’s access route.

    Verbatim wording from the response

    “The fencing in the area of Lindsells Level Crossing is a mixture of Class 1 (1.8m high, which includes palisade fencing) and Class 3 (1.4m high), which includes post and wire boundary measures. The latest inspection recorded all fencing in the area of Lindsells Level Crossing to be in good condition, fit for purpose and compliant with the current fencing standard. We understand that there is no suggestion in this incident that access was taken to the railway as a result of failure of the boundary measures, therefore it is not considered that further boundary mitigation is required at this time.”

    Source location

    2018-0184-Response-by-Network-Rail
    Page 3 · response
    Published 8 July 2018

    Open published response
  9. Cornwall and Isles of Scilly

    AI-generated summary

    Hans-Peter Schmidt · 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

    Hans-Peter Schmidt died on 17 June 2017 at Lands End, Cornwall, from multiple injuries following an unwitnessed fall from a cliff while cycling along the cliff edge. The report raised concerns about the maintenance and absence of permanent barriers at identified cliff hot spots, inadequate warning signs and pictograms, and the lack of staff training uptake offered by the RNLI.

    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 maintenance of temporary rope barriers at cliff hot spot sites

    Wider context from the report

    “(1) The apparent lack of maintenance of the temporary rope barriers located at two hot spot sites identified by RNLI and police witnesses, namely 1) that immediately below Greeb farm where a path from the farm meets the cliff face at a right angle and forms a junction with other paths above the sheer cliff face, this being the sight of two fatal accidents in 2017, namely those of Mr Jachec and Herr Schmidt. 2) that known as the arch viewing area, being the furthest southern location of the Lands End resort on the border with National Trust property. (2) Regarding the lack of permanent barriers as recommended by the RNLI at the two hot spot sites discussed above. ”

    Source location

    Hans-Peter Schmidt · Prevention of Future Deaths report
    Page 3 · 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

    Lack of permanent barriers at cliff hot spot sites

    Wider context from the report

    “(1) The apparent lack of maintenance of the temporary rope barriers located at two hot spot sites identified by RNLI and police witnesses, namely 1) that immediately below Greeb farm where a path from the farm meets the cliff face at a right angle and forms a junction with other paths above the sheer cliff face, this being the sight of two fatal accidents in 2017, namely those of Mr Jachec and Herr Schmidt. 2) that known as the arch viewing area, being the furthest southern location of the Lands End resort on the border with National Trust property. (2) Regarding the lack of permanent barriers as recommended by the RNLI at the two hot spot sites discussed above. ”

    Source location

    Hans-Peter Schmidt · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
  10. Hertfordshire

    AI-generated summary

    Scott RAYNER · 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 16 April 2017, Scott Rayner trespassed onto the railway track near Watford Junction Station and was struck and killed by a train. The investigation identified inadequate fencing beside the track, particularly near a scrap metal dealer, creating a risk of adults and children trespassing onto a line where the speed limit was 100mph.

    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 beside the railway track

    Wider context from the report

    “British Transport Police investigating revealed that fencing beside the railway track was inadequate especially at the rear of a scrap metal dealer located off St Albans Road and Bedford Street, leading to a risk that adults and children may trespass on the line where the speed limit is 100mph. ”

    Source location

    Scott RAYNER · 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

    Implement a mandatory fencing standard requiring risk-assessed boundary management measures for Network Rail-controlled infrastructure.

    Verbatim wording from the response

    “In accordance with its legal obligations, Network Rail implements a mandatory fencing standard “Management of Fencing and Other Boundary Measures” which applies to the boundary of Network Rail controlled infrastructure (the Fencing Standard).”

    Source location

    2017-0345-Response-by-Network-Rail
    Page 1 · response
    Published 5 February 2018

    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 enhancement work at identified Watford-area access locations, including installing additional palisade fencing around St Albans Road and Bedford Street.

    Verbatim wording from the response

    “Although no faults were identified in the boundary fencing around St Albans Road and Bedford Street, the local operations team planned a further multi stakeholder inspection of the wider Watford area in order to investigate trespass incidents where specific locations of access were unknown. This took place on the 30 May 2017 in conjunction with the British Transport Police. A number of lineside locations in the Watford area were inspected and identified for additional enhancement work to prevent access to the railway. Work to implement this enhancement work was completed on 22 February 2018, which included installing additional palisade fencing in the St Albans Road and Bedford Street area.”

    Source location

    2017-0345-Response-by-Network-Rail
    Page 2 · response
    Published 5 February 2018

    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 boundary fencing was compliant and inspections identified no faults requiring repair in the St Albans Road and Bedford Street area.

    Verbatim wording from the response

    “The last annual inspection of the St Albans Road and Bedford Street area, including the area to the rear of the H&D Motors, prior to April 2017 was undertaken on 26 June 2016. This inspection identified that there was no repair work required in the area and the boundary fencing was compliant with the Fencing Standard.”

    Source location

    2017-0345-Response-by-Network-Rail
    Page 2 · response
    Published 5 February 2018

    Open published response
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Data last updated 7 September 2026