Recurring concern

Unreliable railway rules for stopping trains to protect people in danger

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First reported 21 Oct 2013•Latest report 13 Sep 2016

Definition

What this concern includes

Includes deficiencies in railway rule-book provisions and related rule-setting or signalling requirements governing when trains must be stopped to protect people who are unwell, trespassing, or otherwise in danger from a train.

Not included

  • Excludes physical prevention of railway-track access, fencing, barriers and responses to known access risks where the rule-setting or train-stopping authority is not the deficient control.
  • Excludes failures by individual drivers, signallers or controllers to follow otherwise adequate train-stopping rules.
  • Excludes general railway signalling, cautionary driving or emergency-response failures unless they directly concern rules authorising trains to stop to protect a person from train danger.
  • Excludes unrelated railway operating rules that do not govern stopping trains for the protection of people.
Reports
4

Distinct published reports

Individual concerns
4

A report can raise multiple concerns

Date range
2013–2016

First to latest report issue date

Stated actions
0

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.

Rail Safety and Standards Board4
Department of Health and Social Care1
London Ambulance Service NHS Trust1
Metropolitan Police Service1

Concerns and responses across reports

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

  1. North London

    AI-generated summary

    Lauris Kodors · 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

    Lauris Kodors was struck by a train and suffered fatal injuries in the Harrow Tunnel on 11 April 2016; he was discovered on 12 April and confirmed to have died on 13 April 2016. The report raised concern that the RSSB Rule Book allowed trains to be stopped only where a person might damage a train, not where a person might be in danger from a train.

    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 the RSSB Rule Book to allow trains to be stopped when a person may be in danger from a train

    Wider context from the report

    “That the RSSB Rule Book allows trains to be stopped only in circumstances where that person may cause damage to a train, but does not allow for trains to be stopped where the person may be in danger form a train. ”

    Source location

    Lauris Kodors · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. North London

    AI-generated summary

    Michael Anthony Bovell · 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 12 April 2014, Michael Anthony Bovell entered a railway line at Brimsdown Rail Station after reporting a suicide and was struck and run over by a train. The principal concern was that railway rules did not allow the signaller to stop the train when a person was in danger from it, and that the train, although cautioned and slowed, still struck him.

    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 train-stopping rules to provide for stopping trains when a person on the line may be in danger from a train

    Wider context from the report

    “That the RSSB Rule Book allows trains to be stopped only in circumstances where a person who has trespassed onto the line person may cause damage to a train, but does not allow for trains to be stopped where the person may be in danger from a train other than to stop the train to place the train on caution. ”

    Source location

    Michael Anthony Bovell · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. North London

    AI-generated summary

    Lewis Philip Ghessen · 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 25 September 2011, Lewis Philip Ghessen was chased onto railway tracks at Harrow and Wealdstone Railway Station and was struck and killed by a fast train. The concern was that the RSSB Rule Book allowed trains to be stopped only where a person might damage a train, not where a person might be in danger from a train.

    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 the RSSB Rule Book to allow trains to be stopped when a person may be in danger from a train

    Wider context from the report

    “That the RSSB Rule Book allows trains to be stopped only in circumstances where that person may cause damage to a train, but does not allow for trains to be stopped where the person may be in danger form a train. ”

    Source location

    Lewis Philip Ghessen · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  4. North London

    AI-generated summary

    Daniel Maurice McMahon · 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

    Daniel Maurice McMahon suffered severe head injuries after being hit by a train at Willesden Junction Station on 11 January 2012, following reports that he had fallen from a bridge and moved onto the railway track. The report raised concerns about the accuracy and completeness of information recorded by police about the location of a person trespassing on the railway, procedures for stopping trains when an unwell person is on the line, support during mental-health leave, and the use of lung-decompression needles without a valve.

    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 stop trains and set signals to danger when an unwell person is trespassing on the line

    Wider context from the report

    “(3) RSSB:- The Rule book be amended to require that trains stop, (signals are set to danger), when a person who is identified as being unwell or there is reason to believe might be unwell is trespassing on the line. (The current position would be to set the signals to caution). ”

    Source location

    Daniel Maurice McMahon · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026