3 Dec 2020 WILLIAM STEVEN ISRAEL · Prevention of Future Deaths report North East Kent
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Concerns raised 9 Insufficient and outdated live-rail electrocution warning signage View source Failure to make live-rail death warnings sufficiently prominent View source Lack of public understanding of live-rail electrocution risks View source Unavailability of visible under-platform warning signage View source Inconsistent control of palisade-gate access when the station is unstaffed View source Failure to direct pedestrians from open palisade gates to the underpass View source Risk of intoxicated members of the public using the station as a cut-through View source Insufficient risk assessment of public live-rail electrocution risks when palisade gates are open View source Lack of risk mitigation for public live-rail electrocution hazards at underpasses View source See 6 more concerns
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WILLIAM STEVEN ISRAEL · 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
William Israel, aged 23, died after entering Canterbury East Railway Station while intoxicated, stepping onto the track and landing on the live rail at approximately 03:45 hours. Concerns included insufficient and inadequately prominent electrocution warnings, the absence of signage at the palisade gates, unimplemented recommendations for under-platform warning signs, and insufficient assessment of risks associated with public access to the station when unstaffed.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to London & South Eastern Railway Limited; that does not assign responsibility.
PFD Monitor interpretation Insufficient and outdated live-rail electrocution warning signage
Wider context from the report “(2) There is insufficient signage warning of the risk of electrocution to the public from the live rail and none present at the palisade gates. The evidence at the inquest established that there has been recent national guidance indicating changes to warning signs at railway stations. Signage has not been updated at this station following this death in accordance with that guidance.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to London & South Eastern Railway Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to make live-rail death warnings sufficiently prominent
Wider context from the report “(1) Evidence heard from an experienced South Eastern Railway witness was that a national survey has found that there is a widespread assumption by members of the public that:
a. Power to the rail tracks is switched off at night
b. Power to the rail tracks is only switched on when trains are due
This supports that the risk of electrocution from train tracks is not well understood by the public. The risk of electrocution is from the live rail in such cases and the signage at Canterbury East Station relating to this is at each end of the platform. This signs in this vicinity contain the word ‘Caution’; the font used warning of the risk of death was not highlighted and significantly smaller than the rest of the sign.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to London & South Eastern Railway Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of public understanding of live-rail electrocution risks
Wider context from the report “(1) Evidence heard from an experienced South Eastern Railway witness was that a national survey has found that there is a widespread assumption by members of the public that:
a. Power to the rail tracks is switched off at night
b. Power to the rail tracks is only switched on when trains are due
This supports that the risk of electrocution from train tracks is not well understood by the public. The risk of electrocution is from the live rail in such cases and the signage at Canterbury East Station relating to this is at each end of the platform. This signs in this vicinity contain the word ‘Caution’; the font used warning of the risk of death was not highlighted and significantly smaller than the rest of the sign.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to London & South Eastern Railway Limited; that does not assign responsibility.
PFD Monitor interpretation Unavailability of visible under-platform warning signage
Wider context from the report “(3) The British Transport Police Designing Out of Crime Unit (BTP DOCU) investigated this incident and has made a recommendation to consider the placement of strategic under-platform warning signage that would be visible where a member of the public jumping or stepping down onto the tracks. This recommendation has not been implemented.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to London & South Eastern Railway Limited; that does not assign responsibility.
PFD Monitor interpretation Inconsistent control of palisade-gate access when the station is unstaffed
Wider context from the report “(5) It appears inconsistent that the palisade gates that deter public entering are closed when the station is open and staffed, then open when the station is unstaffed and after trains have stopped running.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to London & South Eastern Railway Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to direct pedestrians from open palisade gates to the underpass
Wider context from the report “(4) The main entrance to the station is open between the hours of 06:00 -22:00 hours Monday to Saturday and 07:00 – 22:00 hours on Sunday during such hours the station is staffed. First and last trains run outside of the staffed hours. There is signage by the main entrance directing the public to an underpass allowing pedestrians to safely cross between Platforms 1 & 2. The station has steel fencing around part of the perimeter that is approximately 2 metres high with spikes at the top and there is a potential alternative egress and ingress comprising palisade gates set withing that fencing. When the station is open and staffed, the palisade gates are locked. When the station is unstaffed the palisade gates are open and there is no signage in that vicinity directing pedestrians to the underpass.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to London & South Eastern Railway Limited; that does not assign responsibility.
PFD Monitor interpretation Risk of intoxicated members of the public using the station as a cut-through
Wider context from the report “(6) Whilst it is not disputed that William had used the underpass with friends to get to a nightclub that night. He had already been drinking prior to this journey, was not local to the area and was alone when he accessed the station through the palisade gates a few hours later. William was intoxicated at the time he attempted to cross the train tracks at Canterbury East Station, however there have been a number of incidents of individuals on the tracks over the last three years and the station is just meters from a nightclub. There is a significant risk that members of the public using the station as a cut through will be intoxicated.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to London & South Eastern Railway Limited; that does not assign responsibility.
PFD Monitor interpretation Insufficient risk assessment of public live-rail electrocution risks when palisade gates are open
Wider context from the report “(8) There appears to be an absence of a sufficient risk assessment of the risks to the public from electrocution from the live rail particularly when the palisade gates are open and, if the palisade gates should remain open, of any potential risk mitigation that might be implemented to ensure safe use of the underpass.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to London & South Eastern Railway Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of risk mitigation for public live-rail electrocution hazards at underpasses
Wider context from the report “(8) There appears to be an absence of a sufficient risk assessment of the risks to the public from electrocution from the live rail particularly when the palisade gates are open and, if the palisade gates should remain open, of any potential risk mitigation that might be implemented to ensure safe use of the underpass .
” Open source report
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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 an additional directional sign by the platform 2 side gate directing users to the station subway.
Verbatim wording from the response “18 Following the Inquest, we have installed an additional directional sign adjacent to the entrance when entering platform 2 from the palisade gate which indicates the presence of the subway. I append a photograph of this sign in situ as Annex B.” Source location 2020-0271-Response-from-Southeastern-Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review Canterbury East risk assessments through routine processes and update them if appropriate.
Verbatim wording from the response “27 We do not agree with the comment regarding risk assessment in paragraph 8. We have set out at paragraph 9 above the details of the four signs which were in place prior to the accident which warned of the danger of the live rail. Following the accident, we installed additional signage at all station entrances to highlight this risk and, as set out in paragraphs 10 and 13 above, we have redesigned this signage to take into account your comments and the findings of the University of Birmingham research (see Annex A). In addition, the risk assessments applicable to Canterbury East will be reviewed as part of our routine review processes following an incident and will be updated if appropriate.” Source location 2020-0271-Response-from-Southeastern-Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Replace three Canterbury East entrance warning signs with the revised design, using “Warning” and greater prominence for electrocution risk.
Verbatim wording from the response “11 Action (a): we will replace the three additional signs at Canterbury East station with a new design based on that shown at Annex A.” Source location 2020-0271-Response-from-Southeastern-Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Engage Chemistry nightclub operators to identify ways to inform and educate clientele about the risks of entering railway tracks.
Verbatim wording from the response “23 Notwithstanding this, in light of the accident we consider that the provision of relevant information to nightclub attendees may reduce the likelihood of other individuals making an attempt to cross over the tracks. This could potentially be achieved by using leaflets, messages on menus or drinks mats, posters in lavatories or use of the industry “You vs. Train” video materials.” Source location 2020-0271-Response-from-Southeastern-Redacted
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The number of intoxicated subway users is not considered significant, and their presence is not considered a significant track-access risk.
Verbatim wording from the response “22 We note the comments in paragraph (6) in relation to previous incidents of individuals on the track although we note that none of these incidents involved a person leaving the Chemistry nightclub. We also note that some members of the public using the subway may be intoxicated but given the large numbers of passengers that use the station each day we would not describe this as a significant number or a “significant risk”.” Source location 2020-0271-Response-from-Southeastern-Redacted
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Further under-platform signage cannot be undertaken because Network Rail refused it over maintenance and structural-defect risks.
Verbatim wording from the response “16 The provision of under-platform signage is a matter for Network Rail as the platform faces concerned are their asset. Southeastern has made representations to Network Rail for such signage to be installed but this has been refused due to concerns that under-platform signs are difficult to maintain, and there is a risk they may obscure developing structural defects in the platform itself. In view of this, Southeastern are unable to take any further action in relation to under-platform signage at Canterbury East or elsewhere.” Source location 2020-0271-Response-from-Southeastern-Redacted
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Under-platform signage is Network Rail’s responsibility because the relevant platform faces are its assets.
Verbatim wording from the response “16 The provision of under-platform signage is a matter for Network Rail as the platform faces concerned are their asset. Southeastern has made representations to Network Rail for such signage to be installed but this has been refused due to concerns that under-platform signs are difficult to maintain, and there is a risk they may obscure developing structural defects in the platform itself. In view of this, Southeastern are unable to take any further action in relation to under-platform signage at Canterbury East or elsewhere.” Source location 2020-0271-Response-from-Southeastern-Redacted
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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 claim that Canterbury East lacked effective live-rail warning signage is disputed because four warning signs were already present before the accident.
Verbatim wording from the response “27 We do not agree with the comment regarding risk assessment in paragraph 8. We have set out at paragraph 9 above the details of the four signs which were in place prior to the accident which warned of the danger of the live rail. Following the accident, we installed additional signage at all station entrances to highlight this risk and, as set out in paragraphs 10 and 13 above, we have redesigned this signage to take into account your comments and the findings of the University of Birmingham research (see Annex A). In addition, the risk assessments applicable to Canterbury East will be reviewed as part of our routine review processes following an incident and will be updated if appropriate.” Source location 2020-0271-Response-from-Southeastern-Redacted
Open published response
Concerns raised 1 Unsafe track access from platforms View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Robert John MULLIS · 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
Robert Mullis, who had Parkinsons, Vascular Dementia and was partially sighted, disembarked a train at Ashford railway station and walked onto the tracks, where he was struck by two trains and died from his injuries. The report raises a concern about track access from railway platforms, with Network Rail and South Eastern addressing this issue nationally.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to London & South Eastern Railway Limited; that does not assign responsibility.
PFD Monitor interpretation Unsafe track access from platforms
Wider context from the report “I make this report with the knowledge that Network Rail and South Eastern are addressing the issue of track access from platforms nationally with Ashford being addressed in Autumn 2017
” Open source report
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Addressed to “South Eastern Railways”, a trading name of London & South Eastern Railway Limited.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations