Recurring concern

Inadequate suicide-prevention signage at railway stations

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First reported 30 Aug 2018•Latest report 28 Mar 2024

Definition

What this concern includes

Includes failures of signage at railway stations specifically intended to provide suicide-prevention or Samaritan support information, including absent, insufficient, poorly positioned, obscured, outdated or inadequately reviewed signs.

Not included

Excludes general railway warning, live-rail, trespass, wayfinding or emergency-assistance signage unless it is specifically intended to provide suicide-prevention or Samaritan support information.
Excludes generic station communication, public announcements, CCTV or staff-response deficiencies where suicide-prevention signage is not the identified unsafe condition.
Excludes suicide-prevention information outside railway stations unless the assertion explicitly supports the same railway-station signage process.
Excludes failures in the quality of suicide-prevention services or crisis response where the signage control itself is not deficient.

Reports: 2
Individual concerns: 2
Date range: 2018–2024
Stated actions: 3

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Berkshire Healthcare NHS Foundation Trust1

British Transport Police1

First MTR South Western Trains Limited1

West Midlands Trains Limited1

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.

28 Mar2024
Berkshire
Concerns raised1
1. Lack of Samaritan signs at the train station
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Complete a route-wide review of Samaritan signage placement, condition and displayed contact information.
  Stated by SWRStated completed
Respondent positions 3
1. Position
  Existing Samaritan signage was reviewed and assessed as sufficient, so no additional signs are intended at Bracknell station.
  Stated by SWRExisting arrangements considered sufficient
1. Position
  Samaritan signage cannot be increased unilaterally without consultation and consent from the Samaritans.
  Stated by SWRUnable to act
2. Position
  Bracknell was not considered a priority location and had no prevalence of unauthorised access, suicide or suicide attempts.
  Stated by SWRDisputes the concern
AI-generated summary

Daniela Vitalia PANI · 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

Daniela Vitalia PANI died on 29 June 2023 after entering a train station, jumping onto the tracks and being struck by a train. Concerns were raised that potential suicide-risk mitigation measures at the station had not been implemented, and that mental-health staff lacked specific guidance and training for situations where service users declined face-to-face 72-hour reviews.

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 Samaritan signs at the train station
Wider context from the report
“1. A lack of Samaritan signs on the platforms or within the stations. The mitigation proposed was conspicuously placed posters and/or additional signage. ”
Source location
Daniela Vitalia PANI · 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 a route-wide review of Samaritan signage placement, condition and displayed contact information.

Verbatim wording from the response
“3.10 SWR’s senior security manager, Matthew Smith, has also recently undertaken a full review of Samaritan signage across all stations on the SWR route. This was to check correct placement, wear and tear (fading), and the display of the correct information and phone numbers. Bracknell did not require any replacement signs as their signage in place was sufficient. As set out above, this did not include the provision for new signage as this is an agreed process with the Samaritans themselves.”

Source location
Response from South Western Railways
Page 2 · response
Published 4 December 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
Existing Samaritan signage was reviewed and assessed as sufficient, so no additional signs are intended at Bracknell station.

Verbatim wording from the response
“3.5 Since this incident, no additional signs have been placed at Bracknell station and there is currently no intention to place any additional signs at Bracknell station. The signage has been reviewed and has been assessed as appropriate. SWR have set out the background to that conclusion below to assist you in understanding what steps have been taken following this incident.”

Source location
Response from South Western Railways
Page 2 · response
Published 4 December 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
Samaritan signage cannot be increased unilaterally without consultation and consent from the Samaritans.

Verbatim wording from the response
“3.8 SWR work with the Samaritans to place signage where both parties consider it to have the most effective engagement. SWR cannot, however, unilaterally increase the number of signs at a station without consultation and the consent of the Samaritans.”

Source location
Response from South Western Railways
Page 2 · response
Published 4 December 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
Bracknell was not considered a priority location and had no prevalence of unauthorised access, suicide or suicide attempts.

Verbatim wording from the response
“3.7 A risk analysis is undertaken by the Samaritans at every station to determine the level of signage to implement. There are various human and psychological factors which must be measured when considering the number of signs and the placement of signs across the station. This assessment is necessary to balance the provision of information and support to deter suicide and suicide attempts against the unwanted advertisement of the suicide potential of a site. The risk of deliberate unauthorised access to the tracks must also be balanced against the control measures required to mitigate the risks of unintentional/accidental unauthorised access to the tracks.”

Source location
Response from South Western Railways
Page 2 · response
Published 4 December 2024
Open published response
30 Aug2018
Hertfordshire
Concerns raised1
1. Failure to review and update Samaritan signage around the station
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Review station Samaritans signage against current rail industry guidance.
  Stated by WM Trains LimitedStated completed
2. Action
  Remove the outdated Samaritans sign between platforms 2 and 3.
  Stated by WM Trains LimitedStated completed
AI-generated summary

Daniel James O'Mahony · 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 18 December 2017, Daniel James O’Mahony was struck and killed by a train at Hemel Hempstead Railway Station after jumping from the platform onto the track. The concerns identified included inadequate signage, anti-trespass measures, platform markings, gaps between platforms, and the absence of gates to prevent unauthorised access.

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 review and update Samaritan signage around the station
Wider context from the report
“(1) Samaritan Signage has not been reviewed and updated around the station. ”
Source location
Daniel James O'Mahony · 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
Review station Samaritans signage against current rail industry guidance.

Verbatim wording from the response
“Samaritans signage is displayed at stations in line with the Industry Guidance for using Samaritans Communications Materials on the Rail Network as issued by the Rail Industry Suicide Stakeholder Group. A review undertaken in October 2018 concluded that there were 10 signs containing the current Samaritans “Talk to Us” campaign and 116123 number. These signs are displayed at each platform end and 2 are displayed between platforms 2/3 in line with Industry Guidance. The review found that 1 outdated Samaritans sign was displayed on a lighting column between platforms 2/3. This has now been removed.”

Source location
2018-0258-Response-by-West-Midlands-Railway
Page 1 · response
Published 26 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
Remove the outdated Samaritans sign between platforms 2 and 3.

Verbatim wording from the response
“Samaritans signage is displayed at stations in line with the Industry Guidance for using Samaritans Communications Materials on the Rail Network as issued by the Rail Industry Suicide Stakeholder Group. A review undertaken in October 2018 concluded that there were 10 signs containing the current Samaritans “Talk to Us” campaign and 116123 number. These signs are displayed at each platform end and 2 are displayed between platforms 2/3 in line with Industry Guidance. The review found that 1 outdated Samaritans sign was displayed on a lighting column between platforms 2/3. This has now been removed.”

Source location
2018-0258-Response-by-West-Midlands-Railway
Page 1 · response
Published 26 September 2018
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of Samaritan signs at the train station

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised1

Failure to review and update Samaritan signage around the station

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Actions described in response 1

Respondent positions 3

Actions described in response 2