Concerns raised 1 Limited warning signage at the walkway gate before the decision point 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.
×
AI-generated summary
Sam Alexander Dudley · 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
Sam Alexander Dudley, aged 29, died after being struck by a train at Hoggs Hill Level Crossing on 24 August 2025 while wearing headphones and entering the crossing when a red light was displayed and a klaxon was sounding. The principal concern was limited signage on the gate before the decision point, particularly as increasing numbers of people wear earphones; clearer pictorial signage warning against earphone use was suggested as potentially helpful.
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. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Limited warning signage at the walkway gate before the decision point
Wider context from the report “Nationally there is signage once individuals pass through the gate, but there is limited signage on the gate itself as people enter the walkway, only a short distance from the “decision point.” Increasingly, more people wear earphones and are therefore less aware of their surroundings. Introducing clear pictorial signage on the gate, before individuals enter the ‘decision point’ area, such as an image of earphones with a line through them, may help alert users at the right moment. Visual cues generally attract initial attention more effectively and support rapid comprehension, while sound cues tend to create a stronger emotional connection. However, using both visual and auditory cues may together provide a more effective form of communication.
” Open source report
5 Aug 2025 Simon Anthony Moore · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 1 Failure to relay signaller-driver welfare information to the attending Driver Manager 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.
×
AI-generated summary
Simon Anthony Moore · 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
Simon Anthony Moore, a train driver, died after stepping in front of a moving train on 4 November 2024, following an incident that he knew could lead to the loss of his train driver licence and further assessment. Evidence at the inquest raised concerns that the attending Driver Manager was unaware of an earlier recorded conversation in which Mr Moore expressed concern about losing his job and sounded distressed, and that there was no means for the signaller to relay this information to the train company Control or Driver Manager.
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. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Failure to relay signaller-driver welfare information to the attending Driver Manager
Wider context from the report “iii. The on-call Driver Manager employed by the Train Company is obliged to attend and in this scenario take the train driver licence from the driver. An initial account of the facts is taken as well as certain medical tests.
iv. The on-call Driver Manager who attended following the incident involving Mr Moore met with him almost 2 hours after the incident. The on-call Driver Manager was unaware of the content of the conversation between Mr Moore and the signaller which occurred 2 hours earlier and soon after the incident. The contents of this conversation would have helped the on-call Driver Manager to assess the driver’s welfare.
v. The Network Rail Signaller has no means through which to relay the details of any discussions with drivers (in this instance Mr Moore) to the train company Control who could then pass this information on to the attending Driver Manager.
” Open source report
Concerns raised 3 Limited visibility of people in the hazardous area from passing trains and station platforms View source Insufficient physical barriers or impediments preventing public access from the platform to the hazardous area View source Failure of safety features to prevent, impede or discourage suicide attempts 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.
×
AI-generated summary
Jody Lee ROBB · 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
Jody Lee ROBB died at 23:03 on 8 April 2025 on the carriageway of Station Approach after taking deliberate steps to end her own life. Concerns included insufficiently restricted access from the station platform and the possibility that her presence was not detected or reported by train crews or station staff, despite 11 trains passing during the preceding hour.
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. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Limited visibility of people in the hazardous area from passing trains and station platforms
Wider context from the report “I read and heard evidence from the investigating CID officer who had reviewed all available
CCTV in relation to the incident. She reported that Jody had arrived on the south bound
platform just over an hour before she jumped. She sat on a bench for a few minutes before
making her way onto ████████. She was on the
████████ for about one hour before she actually did so. A total of 11 trains passed her, north
and southbound, during that hour. No report was made or received of her presence there
by train crews of station staff attending on the station platforms for arrivals and departures.
████████. My concerns are:
1. Access to the ████████ from the platform is not sufficiently barred or impeded to the
public. It is clear by means of signage that the public must not go beyond the end of the
platform. There are what appear to be some sort of wheeled access steps overs on the
platform at and around the fence at its end. But there is nothing to prevent even a
moderately mobile person from going around the fence and ████████. The main
resource preventing access is human by means of station staff intervention, which is
necessarily reliant on their presence at the relevant time;
2. ████████ are not ones designed to prevent, impede or discourage
attempts at suicide
████████████████████████████████████████████████████████████████
3. Eleven trains passed Jody, from north and south, while she was on ████████ during
the hour before she jumped. No reports were made by any train crew of her presence. It
would be exceedingly the available evidence and unfair to infer that train crews and/or
station staff deliberately or negligently ignored her presence there. More likely is that she
was simply not visible. It was dark, being at night in April, and Jody was wearing relatively
dark clothing. However, she seems to have been discernible on CCTV and from the British
Transport Police images I have seen taken from approximately where a driver might have
been placed, it is plausible to suggest that she might have been visible, even laterally, from
the cab of a train either slowing to stop at the station or pulling out from it, even in
deliberately enhanced lighting on the viaduct. Obviously, had a report been made of her
presence, some type of intervention could have been attempted ████████████████████
████████.
” 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 Network Rail; that does not assign responsibility.
PFD Monitor interpretation Insufficient physical barriers or impediments preventing public access from the platform to the hazardous area
Wider context from the report “I read and heard evidence from the investigating CID officer who had reviewed all available
CCTV in relation to the incident. She reported that Jody had arrived on the south bound
platform just over an hour before she jumped. She sat on a bench for a few minutes before
making her way onto ████████. She was on the
████████ for about one hour before she actually did so. A total of 11 trains passed her, north
and southbound, during that hour. No report was made or received of her presence there
by train crews of station staff attending on the station platforms for arrivals and departures.
████████. My concerns are:
1. Access to the ████████ from the platform is not sufficiently barred or impeded to the
public. It is clear by means of signage that the public must not go beyond the end of the
platform. There are what appear to be some sort of wheeled access steps overs on the
platform at and around the fence at its end. But there is nothing to prevent even a
moderately mobile person from going around the fence and ████████. The main
resource preventing access is human by means of station staff intervention, which is
necessarily reliant on their presence at the relevant time;
2. ████████ are not ones designed to prevent, impede or discourage
attempts at suicide
████████████████████████████████████████████████████████████████
3. Eleven trains passed Jody, from north and south, while she was on ████████ during
the hour before she jumped. No reports were made by any train crew of her presence. It
would be exceedingly the available evidence and unfair to infer that train crews and/or
station staff deliberately or negligently ignored her presence there. More likely is that she
was simply not visible. It was dark, being at night in April, and Jody was wearing relatively
dark clothing. However, she seems to have been discernible on CCTV and from the British
Transport Police images I have seen taken from approximately where a driver might have
been placed, it is plausible to suggest that she might have been visible, even laterally, from
the cab of a train either slowing to stop at the station or pulling out from it, even in
deliberately enhanced lighting on the viaduct. Obviously, had a report been made of her
presence, some type of intervention could have been attempted ████████████████████
████████.
” 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 Network Rail; that does not assign responsibility.
PFD Monitor interpretation Failure of safety features to prevent, impede or discourage suicide attempts
Wider context from the report “I read and heard evidence from the investigating CID officer who had reviewed all available
CCTV in relation to the incident. She reported that Jody had arrived on the south bound
platform just over an hour before she jumped. She sat on a bench for a few minutes before
making her way onto ████████. She was on the
████████ for about one hour before she actually did so. A total of 11 trains passed her, north
and southbound, during that hour. No report was made or received of her presence there
by train crews of station staff attending on the station platforms for arrivals and departures.
████████. My concerns are:
1. Access to the ████████ from the platform is not sufficiently barred or impeded to the
public. It is clear by means of signage that the public must not go beyond the end of the
platform. There are what appear to be some sort of wheeled access steps overs on the
platform at and around the fence at its end. But there is nothing to prevent even a
moderately mobile person from going around the fence and ████████. The main
resource preventing access is human by means of station staff intervention, which is
necessarily reliant on their presence at the relevant time;
2. ████████ are not ones designed to prevent, impede or discourage
attempts at suicide
████████████████████████████████████████████████████████████████
3. Eleven trains passed Jody, from north and south, while she was on ████████ during
the hour before she jumped. No reports were made by any train crew of her presence. It
would be exceedingly the available evidence and unfair to infer that train crews and/or
station staff deliberately or negligently ignored her presence there. More likely is that she
was simply not visible. It was dark, being at night in April, and Jody was wearing relatively
dark clothing. However, she seems to have been discernible on CCTV and from the British
Transport Police images I have seen taken from approximately where a driver might have
been placed, it is plausible to suggest that she might have been visible, even laterally, from
the cab of a train either slowing to stop at the station or pulling out from it, even in
deliberately enhanced lighting on the viaduct. Obviously, had a report been made of her
presence, some type of intervention could have been attempted ████████████████████
████████.
” Open source report
4 Mar 2024 Vanessa FORD · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 4 Failure of wall mitigation and safety measures to impede railway access View source Frequent public access to railway tracks in the Hackney Central/Dalston Kingsland vicinity View source Siting of an electrical box facilitating access to the railway wall View source Siting of street furniture facilitating access to the railway network View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
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. The report was sent to Network Rail; that does not assign responsibility.
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 .
” 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 Network Rail; that does not assign responsibility.
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 .
” 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 Network Rail; that does not assign responsibility.
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.
” 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 Network Rail; that does not assign responsibility.
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 .
” 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 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
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
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
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 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
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
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
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
Open published response
4 Dec 2023 Fraser William Moore · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 2 Failure to make station CCTV footage immediately available to Route Control Rooms View source Failure to provide CCTV coverage beyond station concourses and platform ends 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.
×
AI-generated summary
Fraser William Moore · 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 March 2020, Fraser William Moore escaped from custody at London Bridge Station, entered the railway track area, and died after contacting a live rail before power could be severed. The report raised concerns that CCTV coverage ended at the station concourse and that footage was not immediately available to Route Control Rooms, with insufficient coverage beyond the platform ends.
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. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Failure to make station CCTV footage immediately available to Route Control Rooms
Wider context from the report “The CCTV coverage/ footage ends at the end of the station concourse on both the city and country ends. Station footage does not get sent to Route Control. On a risk-based review, the chances of incidents happening in a busy cosmopolitan station must, by footfall and surrounding populations alone, increase the risk of an event. An event that should then be looked at. In order to look at an event, I accept that current CCTV is in place within the station confines but for these stations, I do not consider that I have received sufficient evidence to persuade me that the footages should not be available immediately to the Route Control Rooms or that the coverage should not extend up or down line beyond the end of the platforms.
” 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 Network Rail; that does not assign responsibility.
PFD Monitor interpretation Failure to provide CCTV coverage beyond station concourses and platform ends
Wider context from the report “The CCTV coverage/ footage ends at the end of the station concourse on both the city and country ends. Station footage does not get sent to Route Control. On a risk-based review, the chances of incidents happening in a busy cosmopolitan station must, by footfall and surrounding populations alone, increase the risk of an event. An event that should then be looked at. In order to look at an event, I accept that current CCTV is in place within the station confines but for these stations, I do not consider that I have received sufficient evidence to persuade me that the footages should not be available immediately to the Route Control Rooms or that the coverage should not extend up or down line beyond the end of the platforms .
” Open source report
24 Aug 2023 Gordon Alexander John RODGER · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 1 Readily accessible railway line for individuals wishing to harm themselves 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.
×
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. The report was sent to Network Rail; that does not assign responsibility.
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 .
” Open source report
Concerns raised 6 Delays of over a month in obtaining best evidence through video interview or otherwise View source Lack of formalised, guaranteed funding for long-term therapy and recovery provision View source Failure to extend long-term therapy and recovery provision to domestic abuse and child sexual abuse View source Lack of available DC capacity to progress rape and serious sexual assault complaints View source Failure of the railway bridge parapet to meet statutory obligations View source Delays in long-term therapy and recovery support after sexual violence View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Tamsin Ann Dolamore · 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
Tamsin Ann Dolamore died aged 24 after falling from a railway bridge onto railway lines on 8 January 2018; the inquest recorded an Open Conclusion and the medical cause of death as effects of multiple injuries. The substantive concerns included delays in appointing a Sexual Offence Liaison Officer, delays and gaps in mental-health and support services, and insufficient police resources causing delays in progressing rape and serious sexual assault complaints.
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. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Delays of over a month in obtaining best evidence through video interview or otherwise
Wider context from the report “I was informed by ████████ that as of January this year, there were 600 open cases of rape or serious sexual assault. I was told additionally that there are over 20 vacancies for DCs to progress these complaints. One consequence was that it was taking over a month to achieve best evidence through video interview or otherwise .
████████ agreed that the lack of available DCs meant that both the quality and amount of work that could be done were affected.
” 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 Network Rail; that does not assign responsibility.
PFD Monitor interpretation Lack of formalised, guaranteed funding for long-term therapy and recovery provision
Wider context from the report “There are some steps being taken towards the provision of a more joined-up approach through a pენinsula sexual violence pathfinder [funded by NHSE] which brings together commissioners and services across Devon, Cornwall, Plymouth and Torbay to pilot new approaches to longer- term recovery support for those impacted by sexual violence. Locally, a joined- up service called Safer Futures [a partnership between First Light and Barnardos] has been commissioned by Safer Cornwall which includes Cornwall Council, the Integrated Care Board, NHSE and others.
I am concerned that the provision of long-term therapy and recovery for the survivors of rape and sexual violence, which should be extended to include domestic abuse and child sexual abuse, needs to be formalised and provided with a guaranteed level of funding . You may wish to consider if this should be on a statutory basis. No one should have to wait half a year for help after being assaulted.
” 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 Network Rail; that does not assign responsibility.
PFD Monitor interpretation Failure to extend long-term therapy and recovery provision to domestic abuse and child sexual abuse
Wider context from the report “There are some steps being taken towards the provision of a more joined-up approach through a pენinsula sexual violence pathfinder [funded by NHSE] which brings together commissioners and services across Devon, Cornwall, Plymouth and Torbay to pilot new approaches to longer- term recovery support for those impacted by sexual violence. Locally, a joined- up service called Safer Futures [a partnership between First Light and Barnardos] has been commissioned by Safer Cornwall which includes Cornwall Council, the Integrated Care Board, NHSE and others.
I am concerned that the provision of long-term therapy and recovery for the survivors of rape and sexual violence, which should be extended to include domestic abuse and child sexual abuse , needs to be formalised and provided with a guaranteed level of funding. You may wish to consider if this should be on a statutory basis. No one should have to wait half a year for help after being assaulted.
” 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 Network Rail; that does not assign responsibility.
PFD Monitor interpretation Lack of available DC capacity to progress rape and serious sexual assault complaints
Wider context from the report “I was informed by ████████ that as of January this year, there were 600 open cases of rape or serious sexual assault. I was told additionally that there are over 20 vacancies for DCs to progress these complaints . One consequence was that it was taking over a month to achieve best evidence through video interview or otherwise.
████████ agreed that the lack of available DCs meant that both the quality and amount of work that could be done were affected .
” 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 Network Rail; that does not assign responsibility.
PFD Monitor interpretation Failure of the railway bridge parapet to meet statutory obligations
Wider context from the report “Tamsin fell approximately 21.5’ from Menacuddle Hill/North Street railway bridge in St Austell. During the course of the investigation, enquiries were made relating to the parapet at the bridge. Please find attached:
- Report of ████████ at Strange, Strange & Gardner, Consultant Engineers, dated 30/8/18. You will note his view that the parapet does not meet the obligations of the Railway Clause Consolidation Act 1845 ;
- Email from ████████ dated 14/12/18;
- Email from ████████ dated 24/5/19;
- Email from ████████, Cormac, dated 15/7/19.
” 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 Network Rail; that does not assign responsibility.
PFD Monitor interpretation Delays in long-term therapy and recovery support after sexual violence
Wider context from the report “There are some steps being taken towards the provision of a more joined-up approach through a pენinsula sexual violence pathfinder [funded by NHSE] which brings together commissioners and services across Devon, Cornwall, Plymouth and Torbay to pilot new approaches to longer- term recovery support for those impacted by sexual violence. Locally, a joined- up service called Safer Futures [a partnership between First Light and Barnardos] has been commissioned by Safer Cornwall which includes Cornwall Council, the Integrated Care Board, NHSE and others.
I am concerned that the provision of long-term therapy and recovery for the survivors of rape and sexual violence , which should be extended to include domestic abuse and child sexual abuse, needs to be formalised and provided with a guaranteed level of funding. You may wish to consider if this should be on a statutory basis. No one should have to wait half a year for help after being assaulted .
” 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 Raise the Menacuddle Hill/North Street Bridge parapet to at least 1250mm above the adjacent surface level.
Verbatim wording from the response “In response to your concern that the height of the parapet at Menacuddle/North Street Bridge was not compliant with legal requirements, Network Rail has extensively reviewed the possible measures that may be taken to rectify this and is committed to raising the height of the parapet to reduce the potential for further incidents.” Source location Response from Network Rail
Open published response
22 Jun 2022 Connor Peter Marron · Prevention of Future Deaths report North London
View report summary
Concerns raised 4 Lack of lighting beside the stream and railway fence View source Lack of signs identifying the stream, its depth and warnings of danger View source Lack of signs assisting with locating a way out from the venue grounds View source Inadequate fencing preventing ingress to the railway track View source See 1 more concern
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.
×
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. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Lack of lighting beside the stream and railway fence
Wider context from the report “1. There was no lighting beside the stream or the railway fence , nor any signs identifying the stream, its depth and any warning of danger.
” 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 Network Rail; that does not assign responsibility.
PFD Monitor interpretation Lack of signs identifying the stream, its depth and warnings of danger
Wider context from the report “1. There was no lighting beside the stream or the railway fence, nor any signs identifying the stream, its depth and any warning of danger.
” 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 Network Rail; that does not assign responsibility.
PFD Monitor interpretation Lack of signs assisting with locating a way out from the venue grounds
Wider context from the report “2. There were no signs in that area to assist with locating a way out from that part of the venue's grounds .
” 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 Network Rail; that does not assign responsibility.
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 .
” Open source report
19 May 2022 Hassan Zubair · Prevention of Future Deaths report East London
View report summary
Concerns raised 1 Failure of the signals controller to advise trains to proceed with caution View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Hassan Zubair · 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
Hassan Zubair was identified on Platform 3 of Goodmayes station after a welfare concern was reported, and was struck and killed instantly by a train at 13:45 on 2 December 2021. The principal concern was the failure of the signals controller to advise trains travelling through the relevant section to proceed with caution.
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. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Failure of the signals controller to advise trains to proceed with caution
Wider context from the report “1. The failure of the signals controller to advise trains travelling through ████████ to proceed with caution .
” 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 Existing fencing and other mitigation measures were considered sufficient, so trains on Platform 2 were not stopped or cautioned.
Verbatim wording from the response “In terms of the layout of the station and its infrastructure, although Platforms 3 and 2 are back to back, there are a significant number of measures in place to deter members of the public from accessing Platform 2, which services non-stopping trains and is not generally accessible by the general public. Most significantly, a metal fence physically separates Platforms 3 and 2 to deter access by the public to Platform 2. The fencing mitigated the need to caution trains on Platform 2 because it is designed to prevent people from crossing from Platform 3 to Platform 2. Therefore, it was reasonable for the Signaller to caution the trains on Platform 3 only.” Source location Response from Network Rail
Open published response
24 Dec 2021 Gregory James Barber · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 2 Failure to provide a meaningful response to an identified railway safety problem and mitigation request View source Insufficient curtailment of access to railway tracks at the identified location View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
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. The report was sent to Network Rail; that does not assign responsibility.
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.
” 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 Network Rail; that does not assign responsibility.
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.
” 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
Open published response
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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 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
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
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
Open published response
1 Dec 2021 Kaja Weronika SPIEWAK · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 4 Failure to provide control-room staff with appropriate information for responding to concern-for-welfare reports View source Failure to appropriately share and report concern-for-welfare information with relevant agencies View source Failure to log all actions taken after concern-for-welfare reports View source Failure to ensure proper training of frontline and control-room staff in dealing with vulnerable or suicidal persons View source See 1 more concern
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.
×
AI-generated summary
Kaja Weronika SPIEWAK · 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 April 2021, Kaja Weronika SPIEWAK was identified as vulnerable while travelling by train and was later declared deceased at 1.07pm after being at Southbourne Station. The report raised concerns about inadequate training, inappropriate control-room guidance, incomplete recording of actions, and failures to share welfare concerns with relevant agencies.
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. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Failure to provide control-room staff with appropriate information for responding to concern-for-welfare reports
Wider context from the report “(2) I heard evidence that Govia Thameslink Railway Ltd staff control room staff relied upon a protocol entitled ‘Person ill on a train’ when a vulnerable person was reported to them . The witness responsible for the Govia Thameslink Railway control room team accepted that this was not an appropriate document to rely upon as it made no mention of vulnerable persons .
I am therefore concerned that the control room staff do not have the appropriate information to assist their colleagues and to arrange an appropriate response when a ‘concern for welfare’ report is made to them .
” 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 Network Rail; that does not assign responsibility.
PFD Monitor interpretation Failure to appropriately share and report concern-for-welfare information with relevant agencies
Wider context from the report “(4) The Govia Thameslink Railway Ltd control room staff did not contact British Transport Police, 999 nor share the information about this ‘concern for welfare’ report with Network Rail despite having a joint control room.
I heard evidence that there was no written protocol covering when Govia Thameslink Railway Ltd staff should share a ‘concern for welfare’ report with Network Rail staff in the shared control room .
I am concerned that there is not appropriate information sharing and reporting to other agencies, including British Transport Police, when a ‘concern for welfare’ is raised .
” 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 Network Rail; that does not assign responsibility.
PFD Monitor interpretation Failure to log all actions taken after concern-for-welfare reports
Wider context from the report “(3) I heard evidence that the Govia Thameslink Railway Ltd control room staff did not log all actions taken after the concern for welfare report .
I am concerned that it is not possible to assess whether all reasonable and appropriate actions were taken by the control room staff and whether individuals or teams have further training needs.
” 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 Network Rail; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure proper training of frontline and control-room staff in dealing with vulnerable or suicidal persons
Wider context from the report “(1) I heard evidence from the Suicide Prevention Manager for Govia Thameslink Railway Ltd that training on dealing with vulnerable persons was not mandatory for frontline staff .
In fact only 583 out of 7,500 staff had attended a course run by the Samaritans entitled Managing Suicidal Contacts , 40% had completed some e-learning and an unknown number had completed an internal course. In addition refresher training on this issue was an aspiration only and had not been rolled out by Govia Thameslink Railway Ltd.
I also heard evidence that the Suicide Prevention Manager for Govia Thameslink Railway Ltd did not have any input into the training for their team based on the joint control room .
I am therefore concerned that those members of staff most likely to have contact with vulnerable or suicidal persons, as well as those responsible for assisting frontline staff, are not all properly trained to deal with the situation in the best possible way .
” Open source report
Concerns raised 1 Failure to consider credible alternative routes of access in post-death railway investigations View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
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. The report was sent to Network Rail; that does not assign responsibility.
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.
” 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
Open published response
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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 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
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
Open published response
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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 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
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
Open published response
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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 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
Open published response
Concerns raised 1 Lack of effective live-rail warning signage at the railway station View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Callum Rhys EVANS · 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
Callum Rhys EVANS, aged 17, died after falling onto the live rail at Hinton Admiral Railway Station while intoxicated with alcohol. The report identified insufficient signage communicating the presence of the live rail and the risk to life, particularly from the station entrance and central part of the platform.
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. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Lack of effective live-rail warning signage at the railway station
Wider context from the report “A friend in the company of the deceased at the railway station indicated a lack of knowledge of the presence of a live electric (third) rail at the railway station and stated that if it had been known that there was a live rail they would not have gone onto the railway tracks.
The deceased and his friends had gone onto the railway tracks by dropping down from the central part of the platform.
The railway station has an absence of signage stating the presence and risk to life of a live rail on the railway tracks which can be seen by those entering the railway station or whilst on the central part of the platform. The only sign referring to the live rail is at the far sloped end of the platform, some distance from the station entrance and central part of the platform, which states “Do not touch live rail”.
There is signage stating “No trespassing” but nothing effectively communicating the presence of a live rail or the risk to life from that live rail.
” 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 Trial under-platform warning signage at ten Wessex locations, including Hinton Admiral.
Verbatim wording from the response “That said we do understand that awareness of our risks needs to be continually refreshed and needs to be a combination of hard mitigations, key messages and signage so we are now planning to trial under platform warning signage. This will be at 10 locations across the Wessex region with Hinton Admiral being one of the trial locations, and will feature warning signs underneath the platform which will be visible to passengers standing on the opposite platform.” Source location 2021-0159-Response-from-Network-Rail_Published
Open published response
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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 South Western Railway is responsible for signs at Hinton Admiral and for applying the relevant standards under its franchise agreement.
Verbatim wording from the response “The railway industry involves many companies who collaborate to operate safely. Network Rail owns and operates the rail infrastructure i.e. the track, signalling, bridges, level crossings etc. Other companies operate the trains and most stations. The Rail Safety and Standards Board (RSSB) coordinates standards that apply across the industry.” Source location 2021-0159-Response-from-Network-Rail_Published
Open published response
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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 Network Rail considers compliant platform-end signs and consistent industry-standard signage sufficient, so additional wording about risk to life is not required.
Verbatim wording from the response “Signage on the railway is set out in the industry standards. These state that we have a “do not trespass” sign at all locations. We also have signs at the ends of the platform, which were in place at Hinton Admiral, to prohibit unauthorised access and warn of the dangers, including of electrocution. The signs displayed at the station warn of the danger of electrocution and comply with the Railway Group Standard GI/RT 7033. To avoid confusion at different locations, there is safety benefit in consistent and clear signs that meet British Standard ISO 3864 – 1.2011: ‘Graphical symbols’ and the Health and Safety (Safety Signs and Signals) Regulations 1996. Network Rail’s own company standard NR/L2/ELP/21131 applies the industry and national standards and follows appropriate risk assessments. The signs provided by Network Rail at Hinton Admiral remain compliant with those standards.” Source location 2021-0159-Response-from-Network-Rail_Published
Open published response
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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 Existing signs at Hinton Admiral warn of electrocution, contrary to the concern that the station lacked signage warning of live-rail risks.
Verbatim wording from the response “You have stated that “the railway station has an absence of signage stating the presence, and risk to life, of a live rail on the railway tracks which can be seen by those entering the railway station or whilst on the central part of the platform”.” Source location 2021-0159-Response-from-Network-Rail_Published
Open published response
Concerns raised 2 Inadequate construction of the barrier preventing pedestrian access to the track View source Incomplete and gapped wire fencing along the viaduct parapet wall View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
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. The report was sent to Network Rail; that does not assign responsibility.
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 .
” 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 Network Rail; that does not assign responsibility.
PFD Monitor interpretation Incomplete and gapped wire fencing along the viaduct parapet wall
Wider context from the report “2) The impression from officers from the British Transport Police and Durham CID who gave evidence is that the wire fence that extends the height of the viaduct parapet wall runs along only a short length of the wall , and that there are in any event gaps between the sections of that fence , the deceased gaining access to the parapet wall through one such gap.
” 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 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
Open published response
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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 Liaise with stakeholders and planning authorities to consider installing wire-mesh fencing along the viaduct parapet.
Verbatim wording from the response “Significant parapet fencing has previously been trialled at this location. However, the viaduct has Grade II listed status, which introduces constraints in this respect. Our mandatory fencing standard was therefore applied. Following receipt of your report we are liaising with relevant stakeholders and appropriate planning authorities to consider whether additional measures can be taken over and above what is required in the fencing standard. Specifically, we are considering whether a wire mesh fence can be installed along the parapet to restrict individuals from climbing over the existing structure. This is something that we have done at other Grade II listed structures. In the meantime, the fencing at the viaduct is compliant with and will continue to be maintained as required by our mandatory fencing standard.” Source location 2020-0301-Response-from-Network-Rail-Redacted
Open published response
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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 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
Open published response
30 Mar 2020 JORDAN MICHAEL AIRA · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 4 Lack of physical boundaries preventing public access to railway tracks View source Failure of warning signs to warn of the risk of immediate death from touching the live rail View source Lack of a national curriculum requirement to teach pupils about the risk posed by the live rail View source Emergency telephone located adjacent to railway track View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
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. The report was sent to Network Rail; that does not assign responsibility.
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 .
” 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 Network Rail; that does not assign responsibility.
PFD Monitor interpretation Failure of warning signs to warn of the risk of immediate death from touching the live rail
Wider context from the report “3. The warning signs in place which are standard in the rail industry do not in terms warn of the risk of immediate death if you touch the live rail .
” 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 Network Rail; that does not assign responsibility.
PFD Monitor interpretation Lack of a national curriculum requirement to teach pupils about the risk posed by the live rail
Wider context from the report “4. There is no requirement in the national curriculum to teach pupils about the risk posed by the live rail .
” 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 Network Rail; that does not assign responsibility.
PFD Monitor interpretation Emergency telephone located adjacent to railway track
Wider context from the report “2. The emergency telephone which may be used by members of the public is located adjacent to the railway track .
” 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 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
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 compliant warning signs at Ashford station warning against track access, trespass and electrocution from the live rail.
Verbatim wording from the response “The signs displayed at the station clearly warn of the danger of electrocution and comply with the Railway Group Standard GI/RT 7033. To avoid confusion at different locations, there is safety benefit in consistent and clear signs that meet British Standard ISO 3864 – 1.2011: ‘Graphical symbols’ and the Health and Safety (Safety Signs and Signals) Regulations 1996.” Source location 2020-0082-Response-from-Network-Rail_Redacted
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 warning signs comply with applicable standards and clearly warn of electrocution, so adding wording about immediate death is unnecessary and potentially harmful.
Verbatim wording from the response “The signs displayed at the station clearly warn of the danger of electrocution and comply with the Railway Group Standard GI/RT 7033. To avoid confusion at different locations, there is safety benefit in consistent and clear signs that meet British Standard ISO 3864 – 1.2011: ‘Graphical symbols’ and the Health and Safety (Safety Signs and Signals) Regulations 1996.” Source location 2020-0082-Response-from-Network-Rail_Redacted
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 Determining whether live-rail risks must be taught in the national curriculum falls outside the respondent’s authority.
Verbatim wording from the response “4. There is no requirement in the national curriculum to teach pupils about the risk posed by the live rail.” Source location 2020-0082-Response-from-Network-Rail_Redacted
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 station help points and restricted operational telephones are considered sufficient, so relocating the railway telephones is unnecessary.
Verbatim wording from the response “At Ashford there is a “help point” telephone on the station for passengers to speak directly with SWR customer support staff. But the emergency telephone quoted is not for public use. The two railway telephones attached to the signal post are for operational contact with the signaller and electrical control. They are located by the track beyond the platform sign prohibiting public access. That they are in a prohibited area demonstrates they are not intended for public use.” Source location 2020-0082-Response-from-Network-Rail_Redacted
Open published response
25 Sep 2019 Benjamin Michael HADDON-CAVE and Patrick Thomas BOLSTER · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 7 Failure of track-engineer challenge of missed fence inspections View source Failure to determine whether fencing inspection failures are national View source Failure of the dual-submission inspection recording system View source Inadequacy of internal investigation into fencing inspection system failures View source Failure of internal audit to identify missed inspections and absent challenge View source Failure to inspect relevant fence sections from an accessible alternative viewpoint View source Accessible worn fence gap creating an easy route to trackside danger View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
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. The report was sent to Network Rail; that does not assign responsibility.
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.
” 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 Network Rail; that does not assign responsibility.
PFD Monitor interpretation Failure to determine whether fencing inspection failures are national
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.
” 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 Network Rail; that does not assign responsibility.
PFD Monitor interpretation Failure of the dual-submission inspection recording system
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.
” 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 Network Rail; that does not assign responsibility.
PFD Monitor interpretation Inadequacy of internal investigation into fencing inspection system failures
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.
” 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 Network Rail; that does not assign responsibility.
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.
” 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 Network Rail; that does not assign responsibility.
PFD Monitor interpretation Failure to inspect relevant fence sections from an accessible alternative viewpoint
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.
” 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 Network Rail; that does not assign responsibility.
PFD Monitor interpretation Accessible worn fence gap creating an easy route to trackside danger
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.
” 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 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
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 Re-brief Tottenham inspectors on conducting non-tactile inspections, including vegetation clearance and access from alternative sides or vantage points.
Verbatim wording from the response “1.1.5 Tottenham Delivery Unit improvements” Source location 2019-0314-Response-by-Network-Rail
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 Train delivery-unit personnel to use the electronic inspection system and associated MyWork forms through additional support training.
Verbatim wording from the response “2.1.2 Additional Support Training” Source location 2019-0314-Response-by-Network-Rail
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
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
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 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
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 Issue a National Safety Bulletin instructing boundary inspectors to use alternative methods when tactile inspection is unavailable.
Verbatim wording from the response “1.1.1 National Safety Bulletin” Source location 2019-0314-Response-by-Network-Rail
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
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
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 Brief Anglia Track Maintenance Engineers to use and maintain electronic inspection records instead of paper records.
Verbatim wording from the response “3.1.2 On a local level, the failure has been addressed by taking the following steps:” Source location 2019-0314-Response-by-Network-Rail
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 boundary inspection standard to specify work required to enable future tactile inspections.
Verbatim wording from the response “1.1.4 Future enhancement to the Boundary Fencing Inspection Standard” Source location 2019-0314-Response-by-Network-Rail
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
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 nationally whether boundary inspections continue to use dual paper and electronic recording systems.
Verbatim wording from the response “3.1 Network Rail Response-Q3:” Source location 2019-0314-Response-by-Network-Rail
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 Update the mandatory boundary inspection competency module to specify how inspectors must proceed when trackside tactile inspection is impossible.
Verbatim wording from the response “1.1.2 Competency Training Module” Source location 2019-0314-Response-by-Network-Rail
Open published response
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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 Issue a National Special Inspection Notice requiring electronic form use, correct sign-off and risk assessment of repeat non-tactile locations.
Verbatim wording from the response “2.1.3 National Special Inspection Notice” Source location 2019-0314-Response-by-Network-Rail
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 standard then in force permitted either paper or electronic inspection records, disputing that the dual-recording system was inherently flawed.
Verbatim wording from the response “2.1.1 The ‘Boundary Measures Network Rail Standard’ (NR/L2/TRK/5100) in force at the time of the 2017 and 2018 inspections and in force at the time of Benjamin Michael Haddon-Cave and Patrick Thomas Bolster’s tragic deaths, made it permissible to use either paper or electronic forms. Network Rail was aware of the flaws in this Standard prior to the inquest and had revised the national Standard to (NR/L2/OTK/5100) which came into force in April 2019. This Standard specifies that only electronic records are to be used from the 31st August 2019. In terms of the system we now require a single electronic system to be used.” Source location 2019-0314-Response-by-Network-Rail
Open published response
7 Aug 2019 Carl Richard KLIMYATYS · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 6 Lack of up-to-date contact details for Bronze View source Lack of safety-critical communication training for emergency call takers View source Failure to verify reported incident locations against available physical information View source Failure to escalate emergency calls from initial call takers to team leaders View source Failure to enter the correct train headcode View source Failure to contact train drivers when the train describer system is unavailable View source See 3 more concerns
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.
×
AI-generated summary
Carl Richard KLIMYATYS · 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
Carl Richard KLIMYATYS’s body was found at Preston Park Station, where incorrect information about its location was communicated within the Regional Operating Centre. This contributed to an approaching train not being stopped and striking and carrying the body away. The report raises concerns about safety-critical communication training, the handling and verification of emergency information, the use of resources, and outdated contact details in the operating centre.
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. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Lack of up-to-date contact details for Bronze
Wider context from the report “Three Bridges Regional Operating Centre (ROC)
A member of the public arriving at Preston Park Station saw Carl’s body at Platform 2.
He used the help phone pressing the emergency button to inform of this.
The call was answered promptly by the initial call taker called a Resilience Customer Ambassador (RCA). This person had not been given the safety critical communication training. He had only been employed recently as an agency person to provide cover in the RCA over the Christmas period.
The Inquest heard that when an emergency call comes in to the ROC there is a red flashing light and a buzzer to announce that this is an emergency call.
The Inquest heard that the RCA should have picked up the telephone and handed it to his team leader who was shadowing him and sitting opposite him doing his own work.
At 0602 the member of the public pressed the emergency button at the help phone.
In fact the RCA answered the member of public’s call, took details from him which were correct as to the location of Carl’s body, said goodbye and terminated the call which lasted eleven seconds.
The Inquest heard that almost immediately he passed information that the body was not on Track 2 but on Track 1.
The Inquest heard that the Team Leader tried to phone the member of public back on the help phone but could not get an answer.
It was not until 0609 hrs that the Team Leaders was able to speak to the member of public and ask for confirmation of the location of Carl’s body. This time the member of public appears to be saying that the body was straddling Tracks 1 and 2 (in fact he was straddling Tracks 3 and 2).
The Team Leader should have known from the information available to him in the ROC that for Carl’s body to be straddling Tracks 2 and 1 was a physical impossibility since they are separated by a large island Platform.
His call to the member of public lasted nineteen seconds.
As a result of this incorrect and impossible information it was believed that Carl’s body would not be disrupted by the train 9T90 approaching from Brighton and due to arrive in Preston Park Station on Line 2 at 0611.
The plan was to prevent the train stopping at the station for reasons which were explained at the Inquest, but because of the inputting of the wrong headcode and the fact that the train describer system was down the driver of 9T90 was not contacted, came into Preston Park Station arriving on the track where Carl’s body was lying, decapitating and then disrupting it, stopping at the station for approximately two minutes before leaving carrying Carl’s body with it.
The other matter which caused concern from the point of view of what was going on in the ROC was that they apparently did not have up to date contact details for Bronze.
Having set out these facts the purpose of this Regulation 28 Report is to refer to the failings in the ROC and to request that actions are taken regarding appropriate training and use of resources for those who work in that operating centre.
” 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 Network Rail; that does not assign responsibility.
PFD Monitor interpretation Lack of safety-critical communication training for emergency call takers
Wider context from the report “Three Bridges Regional Operating Centre (ROC)
A member of the public arriving at Preston Park Station saw Carl’s body at Platform 2.
He used the help phone pressing the emergency button to inform of this.
The call was answered promptly by the initial call taker called a Resilience Customer Ambassador (RCA). This person had not been given the safety critical communication training. He had only been employed recently as an agency person to provide cover in the RCA over the Christmas period.
The Inquest heard that when an emergency call comes in to the ROC there is a red flashing light and a buzzer to announce that this is an emergency call.
The Inquest heard that the RCA should have picked up the telephone and handed it to his team leader who was shadowing him and sitting opposite him doing his own work.
At 0602 the member of the public pressed the emergency button at the help phone.
In fact the RCA answered the member of public’s call, took details from him which were correct as to the location of Carl’s body, said goodbye and terminated the call which lasted eleven seconds.
The Inquest heard that almost immediately he passed information that the body was not on Track 2 but on Track 1.
The Inquest heard that the Team Leader tried to phone the member of public back on the help phone but could not get an answer.
It was not until 0609 hrs that the Team Leaders was able to speak to the member of public and ask for confirmation of the location of Carl’s body. This time the member of public appears to be saying that the body was straddling Tracks 1 and 2 (in fact he was straddling Tracks 3 and 2).
The Team Leader should have known from the information available to him in the ROC that for Carl’s body to be straddling Tracks 2 and 1 was a physical impossibility since they are separated by a large island Platform.
His call to the member of public lasted nineteen seconds.
As a result of this incorrect and impossible information it was believed that Carl’s body would not be disrupted by the train 9T90 approaching from Brighton and due to arrive in Preston Park Station on Line 2 at 0611.
The plan was to prevent the train stopping at the station for reasons which were explained at the Inquest, but because of the inputting of the wrong headcode and the fact that the train describer system was down the driver of 9T90 was not contacted, came into Preston Park Station arriving on the track where Carl’s body was lying, decapitating and then disrupting it, stopping at the station for approximately two minutes before leaving carrying Carl’s body with it.
The other matter which caused concern from the point of view of what was going on in the ROC was that they apparently did not have up to date contact details for Bronze.
Having set out these facts the purpose of this Regulation 28 Report is to refer to the failings in the ROC and to request that actions are taken regarding appropriate training and use of resources for those who work in that operating centre.
” 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 Network Rail; that does not assign responsibility.
PFD Monitor interpretation Failure to verify reported incident locations against available physical information
Wider context from the report “Three Bridges Regional Operating Centre (ROC)
A member of the public arriving at Preston Park Station saw Carl’s body at Platform 2.
He used the help phone pressing the emergency button to inform of this.
The call was answered promptly by the initial call taker called a Resilience Customer Ambassador (RCA). This person had not been given the safety critical communication training. He had only been employed recently as an agency person to provide cover in the RCA over the Christmas period.
The Inquest heard that when an emergency call comes in to the ROC there is a red flashing light and a buzzer to announce that this is an emergency call.
The Inquest heard that the RCA should have picked up the telephone and handed it to his team leader who was shadowing him and sitting opposite him doing his own work.
At 0602 the member of the public pressed the emergency button at the help phone.
In fact the RCA answered the member of public’s call, took details from him which were correct as to the location of Carl’s body, said goodbye and terminated the call which lasted eleven seconds.
The Inquest heard that almost immediately he passed information that the body was not on Track 2 but on Track 1.
The Inquest heard that the Team Leader tried to phone the member of public back on the help phone but could not get an answer.
It was not until 0609 hrs that the Team Leaders was able to speak to the member of public and ask for confirmation of the location of Carl’s body. This time the member of public appears to be saying that the body was straddling Tracks 1 and 2 (in fact he was straddling Tracks 3 and 2).
The Team Leader should have known from the information available to him in the ROC that for Carl’s body to be straddling Tracks 2 and 1 was a physical impossibility since they are separated by a large island Platform.
His call to the member of public lasted nineteen seconds.
As a result of this incorrect and impossible information it was believed that Carl’s body would not be disrupted by the train 9T90 approaching from Brighton and due to arrive in Preston Park Station on Line 2 at 0611.
The plan was to prevent the train stopping at the station for reasons which were explained at the Inquest, but because of the inputting of the wrong headcode and the fact that the train describer system was down the driver of 9T90 was not contacted, came into Preston Park Station arriving on the track where Carl’s body was lying, decapitating and then disrupting it, stopping at the station for approximately two minutes before leaving carrying Carl’s body with it.
The other matter which caused concern from the point of view of what was going on in the ROC was that they apparently did not have up to date contact details for Bronze.
Having set out these facts the purpose of this Regulation 28 Report is to refer to the failings in the ROC and to request that actions are taken regarding appropriate training and use of resources for those who work in that operating centre.
” 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 Network Rail; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate emergency calls from initial call takers to team leaders
Wider context from the report “Three Bridges Regional Operating Centre (ROC)
A member of the public arriving at Preston Park Station saw Carl’s body at Platform 2.
He used the help phone pressing the emergency button to inform of this.
The call was answered promptly by the initial call taker called a Resilience Customer Ambassador (RCA). This person had not been given the safety critical communication training. He had only been employed recently as an agency person to provide cover in the RCA over the Christmas period.
The Inquest heard that when an emergency call comes in to the ROC there is a red flashing light and a buzzer to announce that this is an emergency call.
The Inquest heard that the RCA should have picked up the telephone and handed it to his team leader who was shadowing him and sitting opposite him doing his own work.
At 0602 the member of the public pressed the emergency button at the help phone.
In fact the RCA answered the member of public’s call, took details from him which were correct as to the location of Carl’s body, said goodbye and terminated the call which lasted eleven seconds.
The Inquest heard that almost immediately he passed information that the body was not on Track 2 but on Track 1.
The Inquest heard that the Team Leader tried to phone the member of public back on the help phone but could not get an answer.
It was not until 0609 hrs that the Team Leaders was able to speak to the member of public and ask for confirmation of the location of Carl’s body. This time the member of public appears to be saying that the body was straddling Tracks 1 and 2 (in fact he was straddling Tracks 3 and 2).
The Team Leader should have known from the information available to him in the ROC that for Carl’s body to be straddling Tracks 2 and 1 was a physical impossibility since they are separated by a large island Platform.
His call to the member of public lasted nineteen seconds.
As a result of this incorrect and impossible information it was believed that Carl’s body would not be disrupted by the train 9T90 approaching from Brighton and due to arrive in Preston Park Station on Line 2 at 0611.
The plan was to prevent the train stopping at the station for reasons which were explained at the Inquest, but because of the inputting of the wrong headcode and the fact that the train describer system was down the driver of 9T90 was not contacted, came into Preston Park Station arriving on the track where Carl’s body was lying, decapitating and then disrupting it, stopping at the station for approximately two minutes before leaving carrying Carl’s body with it.
The other matter which caused concern from the point of view of what was going on in the ROC was that they apparently did not have up to date contact details for Bronze.
Having set out these facts the purpose of this Regulation 28 Report is to refer to the failings in the ROC and to request that actions are taken regarding appropriate training and use of resources for those who work in that operating centre.
” 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 Network Rail; that does not assign responsibility.
PFD Monitor interpretation Failure to enter the correct train headcode
Wider context from the report “Three Bridges Regional Operating Centre (ROC)
A member of the public arriving at Preston Park Station saw Carl’s body at Platform 2.
He used the help phone pressing the emergency button to inform of this.
The call was answered promptly by the initial call taker called a Resilience Customer Ambassador (RCA). This person had not been given the safety critical communication training. He had only been employed recently as an agency person to provide cover in the RCA over the Christmas period.
The Inquest heard that when an emergency call comes in to the ROC there is a red flashing light and a buzzer to announce that this is an emergency call.
The Inquest heard that the RCA should have picked up the telephone and handed it to his team leader who was shadowing him and sitting opposite him doing his own work.
At 0602 the member of the public pressed the emergency button at the help phone.
In fact the RCA answered the member of public’s call, took details from him which were correct as to the location of Carl’s body, said goodbye and terminated the call which lasted eleven seconds.
The Inquest heard that almost immediately he passed information that the body was not on Track 2 but on Track 1.
The Inquest heard that the Team Leader tried to phone the member of public back on the help phone but could not get an answer.
It was not until 0609 hrs that the Team Leaders was able to speak to the member of public and ask for confirmation of the location of Carl’s body. This time the member of public appears to be saying that the body was straddling Tracks 1 and 2 (in fact he was straddling Tracks 3 and 2).
The Team Leader should have known from the information available to him in the ROC that for Carl’s body to be straddling Tracks 2 and 1 was a physical impossibility since they are separated by a large island Platform.
His call to the member of public lasted nineteen seconds.
As a result of this incorrect and impossible information it was believed that Carl’s body would not be disrupted by the train 9T90 approaching from Brighton and due to arrive in Preston Park Station on Line 2 at 0611.
The plan was to prevent the train stopping at the station for reasons which were explained at the Inquest, but because of the inputting of the wrong headcode and the fact that the train describer system was down the driver of 9T90 was not contacted, came into Preston Park Station arriving on the track where Carl’s body was lying, decapitating and then disrupting it, stopping at the station for approximately two minutes before leaving carrying Carl’s body with it.
The other matter which caused concern from the point of view of what was going on in the ROC was that they apparently did not have up to date contact details for Bronze.
Having set out these facts the purpose of this Regulation 28 Report is to refer to the failings in the ROC and to request that actions are taken regarding appropriate training and use of resources for those who work in that operating centre.
” 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 Network Rail; that does not assign responsibility.
PFD Monitor interpretation Failure to contact train drivers when the train describer system is unavailable
Wider context from the report “Three Bridges Regional Operating Centre (ROC)
A member of the public arriving at Preston Park Station saw Carl’s body at Platform 2.
He used the help phone pressing the emergency button to inform of this.
The call was answered promptly by the initial call taker called a Resilience Customer Ambassador (RCA). This person had not been given the safety critical communication training. He had only been employed recently as an agency person to provide cover in the RCA over the Christmas period.
The Inquest heard that when an emergency call comes in to the ROC there is a red flashing light and a buzzer to announce that this is an emergency call.
The Inquest heard that the RCA should have picked up the telephone and handed it to his team leader who was shadowing him and sitting opposite him doing his own work.
At 0602 the member of the public pressed the emergency button at the help phone.
In fact the RCA answered the member of public’s call, took details from him which were correct as to the location of Carl’s body, said goodbye and terminated the call which lasted eleven seconds.
The Inquest heard that almost immediately he passed information that the body was not on Track 2 but on Track 1.
The Inquest heard that the Team Leader tried to phone the member of public back on the help phone but could not get an answer.
It was not until 0609 hrs that the Team Leaders was able to speak to the member of public and ask for confirmation of the location of Carl’s body. This time the member of public appears to be saying that the body was straddling Tracks 1 and 2 (in fact he was straddling Tracks 3 and 2).
The Team Leader should have known from the information available to him in the ROC that for Carl’s body to be straddling Tracks 2 and 1 was a physical impossibility since they are separated by a large island Platform.
His call to the member of public lasted nineteen seconds.
As a result of this incorrect and impossible information it was believed that Carl’s body would not be disrupted by the train 9T90 approaching from Brighton and due to arrive in Preston Park Station on Line 2 at 0611.
The plan was to prevent the train stopping at the station for reasons which were explained at the Inquest, but because of the inputting of the wrong headcode and the fact that the train describer system was down the driver of 9T90 was not contacted , came into Preston Park Station arriving on the track where Carl’s body was lying, decapitating and then disrupting it, stopping at the station for approximately two minutes before leaving carrying Carl’s body with it.
The other matter which caused concern from the point of view of what was going on in the ROC was that they apparently did not have up to date contact details for Bronze.
Having set out these facts the purpose of this Regulation 28 Report is to refer to the failings in the ROC and to request that actions are taken regarding appropriate training and use of resources for those who work in that operating centre.
” Open source report
26 Jun 2019 Colin Duncan Whistler Cameron · Prevention of Future Deaths report Gloucestershire
View report summary
Concerns raised 2 Failure to provide signallers with instructions on extracting information from users View source Failure to give sufficient consideration to whether the crossing can be closed View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Colin Duncan Whistler Cameron · 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
Colin Duncan Whistler Cameron, aged 60, was killed when a high-speed train struck his vehicle at the Frampton Mansell user-worked crossing on 7 February 2017. Concerns related to the absence of instructions for signallers on how to obtain information from crossing users and whether the crossing should be closed.
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. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Failure to provide signallers with instructions on extracting information from users
Wider context from the report “1. Whether sufficient consideration has been given to address the absence of any instructions to signallers on how to extract information from the user ,
” 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 Network Rail; that does not assign responsibility.
PFD Monitor interpretation Failure to give sufficient consideration to whether the crossing can be closed
Wider context from the report “2. Whether the relevant authorities and persons authorised to use this crossing have given sufficient consideration to whether this crossing can be closed .
” 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 Close 1,203 level crossings since 2009.
Verbatim wording from the response “With regard to the second concern raised, level crossings represent the highest risk on the railway and Network Rail always seeks to close crossings wherever possible. Since 2009 Network Rail has closed 1203 level crossings.” Source location Colin-Cameron-Response
Open published response
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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 Ask Gloucestershire County Council’s public rights of way officer to consider diverting or extinguishing the bridleway crossing the railway.
Verbatim wording from the response “Network Rail has written to the public rights of way officer at Gloucestershire County Council to consider the feasibility of extinguishing or diverting the bridleway where it crosses the railway. However, there are significant difficulties associated with extinguishing or diverting public rights of way, and any proposal to do so can be subject to a public inquiry. Network Rail can present evidence to support closure at such an inquiry, but the outcome is not one that Network Rail can control.” Source location Colin-Cameron-Response
Open published response
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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 Ask the authorised user to consider releasing vehicular crossing rights and offer to discuss reasonable compensation.
Verbatim wording from the response “After making renewed enquiries since the inquest, we believe there to be one authorised user of the vehicular level crossing at Frampton. This individual is under no legal obligation to release their rights and Network Rail cannot compel them to do so. Demands for compensation for the release of these rights must be proportionate and give due consideration to the use of public money.” Source location Colin-Cameron-Response
Open published response
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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 Pursue diversion of the bridleway, in association with the Council officer and with public support, using all reasonable efforts.
Verbatim wording from the response “Notwithstanding these difficulties, Network Rail will do all it reasonably can to remove the vehicular rights at the crossing and, in association with the Council public rights of way officer and with public support, will do all it reasonably can to divert the bridleway so the crossing can be completely closed.” Source location Colin-Cameron-Response
Open published response
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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 Pursue removal of vehicular rights at the crossing using all reasonable efforts.
Verbatim wording from the response “Notwithstanding these difficulties, Network Rail will do all it reasonably can to remove the vehicular rights at the crossing and, in association with the Council public rights of way officer and with public support, will do all it reasonably can to divert the bridleway so the crossing can be completely closed.” Source location Colin-Cameron-Response
Open published response
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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 Network Rail cannot control the outcome of a public inquiry concerning extinguishing or diverting the bridleway.
Verbatim wording from the response “Network Rail has written to the public rights of way officer at Gloucestershire County Council to consider the feasibility of extinguishing or diverting the bridleway where it crosses the railway. However, there are significant difficulties associated with extinguishing or diverting public rights of way, and any proposal to do so can be subject to a public inquiry. Network Rail can present evidence to support closure at such an inquiry, but the outcome is not one that Network Rail can control.” Source location Colin-Cameron-Response
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 cannot compel an authorised user to release rights needed to close the vehicular crossing.
Verbatim wording from the response “Network Rail does not have unilateral powers to close level crossings as many have public or private rights. Closure of a user-worked crossing such as Frampton requires the consent of the authorised users. Efforts to close Frampton crossing in the past have been unsuccessful.” Source location Colin-Cameron-Response
Open published response
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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 Existing rules, local training and prompt cards provide signallers with instructions to obtain information from level-crossing users.
Verbatim wording from the response “This first concern refers to there being an absence of any instructions to signallers on how to extract information from a level crossing user. However, the evidence presented at the Inquest highlighted that instructions are provided to signallers. The Inquest heard evidence that the signaller is required to follow the railway industry Rule Book GE/RT 8000, Module T9 ‘Level crossings – signallers’ regulations’, issue 3 dated 05/12/2015.” Source location Colin-Cameron-Response
Open published response
25 Feb 2019 Steven John Key · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 1 Failure to prevent access to the railway line through adequately secure fencing View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
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. The report was sent to Network Rail; that does not assign responsibility.
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.
” 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 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
Open published response
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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 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
Open published response
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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 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
Open published response
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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 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
Open published response
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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 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
Open published response
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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 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
Open published response
15 Nov 2018 Richard John Hill · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 3 Possibility of repeat incidents at or near the crossing View source Failure to display a Network Rail contact telephone at the crossing View source Absence of telephones at the crossing View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Richard John Hill · 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
Richard John Hill died on 17 August 2018 when he was struck by a London North Eastern train near the Cromwell Lane level crossing, also known as the Norwell Lane level crossing, near Newark, Nottinghamshire. The concerns identified were that the crossing had no telephones, no displayed contact telephone for Network Rail, and a possibility of a repeat incident at or near the location in the future.
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. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Possibility of repeat incidents at or near the crossing
Wider context from the report “1. That the British Transport Police post incident site report, by Paul Hardy, a copy of which has been sent to you, states the following:
1.1 There are no telephones at the crossing.
1.2 No contact telephone for Network Rail is displayed at the crossing.
1.3 There is a possibility of a repeat incident at or near to this location in the future and that Network Rail staff should be made aware of this.
” 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 Network Rail; that does not assign responsibility.
PFD Monitor interpretation Failure to display a Network Rail contact telephone at the crossing
Wider context from the report “1. That the British Transport Police post incident site report, by Paul Hardy, a copy of which has been sent to you, states the following:
1.1 There are no telephones at the crossing.
1.2 No contact telephone for Network Rail is displayed at the crossing.
1.3 There is a possibility of a repeat incident at or near to this location in the future and that Network Rail staff should be made aware of this.
” 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 Network Rail; that does not assign responsibility.
PFD Monitor interpretation Absence of telephones at the crossing
Wider context from the report “1. That the British Transport Police post incident site report, by Paul Hardy, a copy of which has been sent to you, states the following:
1.1 There are no telephones at the crossing.
1.2 No contact telephone for Network Rail is displayed at the crossing.
1.3 There is a possibility of a repeat incident at or near to this location in the future and that Network Rail staff should be made aware of this.
” 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 Establish a joint suicide and trespass prevention operation with local stakeholders, focusing on locations including Cromwell Lane level crossing.
Verbatim wording from the response “Moreover, Network Rail has funded an Embedded BTP Inspector to coordinate our activity across the rail industry and bring in BTP data. We have funded overtime patrols deployed on a priority basis and have established a joint operation to prevent suicide and trespass, working with local stakeholders to focus on areas including Cromwell Lane level crossing.” Source location Richard-Hill-Response
Open published response
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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 Deploy funded overtime patrols on a priority basis to address suicide and trespass risks.
Verbatim wording from the response “Moreover, Network Rail has funded an Embedded BTP Inspector to coordinate our activity across the rail industry and bring in BTP data. We have funded overtime patrols deployed on a priority basis and have established a joint operation to prevent suicide and trespass, working with local stakeholders to focus on areas including Cromwell Lane level crossing.” Source location Richard-Hill-Response
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 Implement risk-prioritised patrol teams covering Cromwell Lane level crossing and other at-risk locations.
Verbatim wording from the response “In October of 2018 Network Rail implemented a team of patrollers who cover this level crossing and other at-risk locations in the area. They patrol on a risked based priority all locations which are identified by the rail industry’s suicide and trespass workstreams.” Source location Richard-Hill-Response
Open published response
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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 A telephone is not required because CCTV monitoring, emergency services and Network Rail’s emergency number provide sufficient reporting arrangements.
Verbatim wording from the response “There is no requirement for a telephone Cromwell Lane level crossing because it is a CCTV monitored crossing. Should a member of the public be concerned about an emergency situation, this should be reported by calling 999. Network Rail also maintains a 24 hour emergency number (03457 11 41 41) for the reporting of safety incidents on or near the railway, details of which are widely publicised. The emergency services closely liaise with Network Rail to pass information to signallers where required.” Source location Richard-Hill-Response
Open published response
6 Nov 2018 Ryan John James WILLIAMS · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 1 Failure to supervise members of the public on station premises 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.
×
AI-generated summary
Ryan John James WILLIAMS · 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
Ryan John James WILLIAMS returned to Sandy Railway Station in the early hours of 27 April 2018 and was run over by a train about an hour later. Concerns were raised that the unmanned station had no staff supervision, including no means of supervising potentially intoxicated members of the public if stations remained open while unmanned.
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. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Failure to supervise members of the public on station premises
Wider context from the report “1. It is of concern that a member of the public was able to be on the station premises for an hour without any supervision from a member of staff .
2. It is not uncommon for members of the public to be vulnerable due to intoxication. It is a concern that if stations do have to be kept open, but unmanned, that there is no means of supervising the use of the station by the public .
” Open source report
11 Sep 2018 Kevin Phillip SHERWOOD · Prevention of Future Deaths report Hertfordshire
View report summary
Concerns raised 1 Insufficient railway boundary fencing in areas used by dog walkers and others View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kevin Phillip SHERWOOD · 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 20 February 2018, Kevin Phillip Sherwood was struck and killed by a passenger train while standing on the railway line near Hitchin Station. The report raised concern that the railway boundary in the area had only post and wire fencing, and that nearby areas were used by dog walkers and others.
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. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Insufficient railway boundary fencing in areas used by dog walkers and others
Wider context from the report “(1) Only post and wire fencing at the railway boundary in this area. The areas on both sides off the Ickneild Way, particularly to the west of the railway, are used by dog walkers and others.
” 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 Reassess the Icknield Way boundary risk using the fencing standard after the incident.
Verbatim wording from the response “At the time of the incident the boundary measure in the Icknield Way, Hitchin area had been assessed as 3 (Likelihood) x 3 (Consequence) + 0 (Condition) = 9 and, as such, deemed medium risk. The class 3 (1.4m high) boundary measure on both sides of the track was installed twelve years ago. The inspection prior to the incident on 15th February 2018 recorded the fence as ‘good condition’ and regarded as compliant to the Fencing Standard.” Source location 2018-0289-Response-by-Network-Rail
Open published response
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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 Carry out three-monthly inspections of the Icknield Way fencing to manage its increased risk rating.
Verbatim wording from the response “As a result of this incident, the site was re-assessed (in line with the Fencing Standard) and the likelihood score increased from 3 to 4 as there was now “recorded evidence of trespass or vandalism within the last twelve months”. The consequence score was also increased from 3 to 4 as a result of the increase in numbers of trains through this section of railway. The revised score, therefore, became 4 (Likelihood) x 4 (Consequence) + 0 (Condition) = 16.” Source location 2018-0289-Response-by-Network-Rail
Open published response
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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 Renew the Icknield Way fencing with a scheduled replacement in 2019/2020.
Verbatim wording from the response “The mitigation for the increased risk score is a requirement to increase the frequency of inspection from annual to three monthly. The standard also requires that, at the point where the current fence becomes life expired, it will be replaced by a class 1 (1.8m high) fence. A fence line may be renewed prior to life expiry in some circumstances due to operational requirements or route enhancement projects (subject to funding).” Source location 2018-0289-Response-by-Network-Rail
Open published response
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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 Existing compliant fencing, three-monthly inspections and scheduled renewal are considered sufficient pending replacement.
Verbatim wording from the response “The mitigation for the increased risk score is a requirement to increase the frequency of inspection from annual to three monthly. The standard also requires that, at the point where the current fence becomes life expired, it will be replaced by a class 1 (1.8m high) fence. A fence line may be renewed prior to life expiry in some circumstances due to operational requirements or route enhancement projects (subject to funding).” Source location 2018-0289-Response-by-Network-Rail
Open published response
10 Sep 2018 Darren Robert URQUHART · Prevention of Future Deaths report Hertfordshire
View report summary
Concerns raised 3 Inadequate positioning of the trespass deterrence mat View source Inadequacy of fencing View source Lack of gates at the south end of platforms 1 and 2 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.
×
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. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Inadequate positioning of the trespass deterrence mat
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 .
” 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 Network Rail; that does not assign responsibility.
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.
” 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 Network Rail; that does not assign responsibility.
PFD Monitor interpretation Lack of gates at the south end of platforms 1 and 2
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.
” Open source report
24 Jul 2018 Taiyah-Grace Sharon Peebles · Prevention of Future Deaths report North East Kent
View report summary
Concerns raised 2 Lack of end-of-platform barriers on platforms View source Failure to prevent public access to live rails at ground level View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
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. The report was sent to Network Rail; that does not assign responsibility.
PFD Monitor interpretation Lack of end-of-platform barriers on platforms
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
” 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 Network Rail; that does not assign responsibility.
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
” 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 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
Open published response
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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 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
Open published response
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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 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
Open published response
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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 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
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations