PFD report

Sam Alexander Dudley · Prevention of Future Deaths report

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Issued 5 Feb 2026•Sefton, St Helens and Knowsley

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
1

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
7

Described in responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Report evidence summary

Concerns raised1

  1. Limited warning signage at the walkway gate before the decision point
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

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

  1. Action

    Review existing level-crossing signage, remove duplication where appropriate, and position remaining safety-critical messages near crossing decision points.

    Stated by Network Rail Infrastructure LimitedStated in progressThe respondent said that this action was in progress when they made their response on 10 February 2026.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Existing safety arrangements and work within the national framework are considered an appropriate response to the Coroner’s concerns.

    Stated by Network Rail Infrastructure LimitedExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Review existing level-crossing signage, remove duplication where appropriate, and position remaining safety-critical messages near crossing decision points.

Verbatim wording from the response

“The findings of this research have informed NRIL’s wider approach to level crossing safety and its ongoing consideration of signage, warnings and crossing design. In parallel, NRIL has undertaken a review of level crossing signage more generally, recognising that signage must be clear,”

Source location

Response from Network Rail
Page 1 · response
Published 10 February 2026

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 safety arrangements and work within the national framework are considered an appropriate response to the Coroner’s concerns.

Verbatim wording from the response

“Taken together, the evidence heard at the inquest and the steps outlined above demonstrate that the safety arrangements at Hoggs Hill were appropriate and that HM Senior Coroner’s concerns are consistent with work already underway within NRIL’s national safety framework. This work reflects careful consideration of the issues raised and a continued commitment to proportionate, evidence-led risk reduction at footpath level crossings.”

Source location

Response from Network Rail
Page 3 · response
Published 10 February 2026

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

New site-specific signage cannot be introduced without statutory compliance and evidence-led consideration through established industry and regulatory processes.

Verbatim wording from the response

“The aforementioned consideration of level crossing signage, including its positioning, content and effectiveness, formed part of NRIL’s ongoing safety and standards work which was already under review prior to the inquest. The approach to signage at level crossings is governed by a national framework, and in particular The Private Crossings (Signs and Barriers) Regulations 2023 which represented a complete re-design of signage at private and public level crossings (not road crossings). There is no sign within those Regulations asking people to remove headphones.”

Source location

Response from Network Rail
Page 2 · response
Published 10 February 2026

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.6

  1. 1

    Consider physical design features that encourage users to slow down and pause before crossing.

    Stated by Network Rail Infrastructure LimitedStated in progressThe respondent said that this action was in progress when they made their response on 10 February 2026.
  2. 2

    Commission independent behavioural research into distraction and accidental human error at passive level crossings.

    Stated by Network Rail Infrastructure LimitedStated completedThe respondent said that this action was complete when they made their response on 10 February 2026.
  3. 3

    Install and roll out miniature stop lights and supplementary audible warning devices at appropriate footpath level crossings.

    Stated by Network Rail Infrastructure LimitedStated in progressThe respondent said that this action was in progress when they made their response on 10 February 2026.
  4. 4

    Undertake national and local education, engagement and awareness activity promoting safe behaviour around railways and level crossings.

    Stated by Network Rail Infrastructure LimitedStated in progressThe respondent said that this action was in progress when they made their response on 10 February 2026.
  5. 5

    Review national fatality and near-miss data, track distraction-related risks, and share incident learning to inform standards, guidance and future risk assessments.

    Stated by Network Rail Infrastructure LimitedStated in progressThe respondent said that this action was in progress when they made their response on 10 February 2026.
  6. 6

    Improve footpath level-crossing surfaces and approaches so crossings are clearly recognisable as hazardous environments.

    Stated by Network Rail Infrastructure LimitedStated in progressThe respondent said that this action was in progress when they made their response on 10 February 2026.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    The crossing was safe, compliant and operating as designed, with no inspection, maintenance or management failures contributing to the death.

    Stated by Network Rail Infrastructure LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Consider physical design features that encourage users to slow down and pause before crossing.

Verbatim wording from the response

“Alongside signage and behavioural considerations, NRIL continues to prioritise engineering and design-based measures at footpath level crossings where reasonably practicable. This includes the installation and roll-out of miniature stop lights and supplementary audible warning devices at appropriate locations, improvements to crossing surfaces and approaches so that crossings are clearly recognisable as hazardous environments, and consideration of physical design features that encourage users to slow down and pause before crossing. Decisions in relation to such measures are informed by site-specific risk assessments, usage data and professional judgement considering both the safety benefits and any unintended consequences.”

Source location

Response from Network Rail
Page 2 · response
Published 10 February 2026

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 independent behavioural research into distraction and accidental human error at passive level crossings.

Verbatim wording from the response

“NRIL recognises that distraction, including from personal audio devices, is an increasing societal issue and one which requires careful and proportionate consideration. For this reason, in 2025, NRIL commissioned independent behavioural research into accidental human error at passive level crossings, which includes crossings fitted with miniature stop lights and audible warnings. This research examined why pedestrians may fail to stop, look and listen, including the role of distraction, habitual use of crossings and misperception of train speed and distance. The research concluded that there are no simple or low-cost interventions that can eliminate risk at passive level crossings, and that the most effective long-term measures are those which reduce reliance on individual judgement through system-led cues.”

Source location

Response from Network Rail
Page 1 · response
Published 10 February 2026

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Install and roll out miniature stop lights and supplementary audible warning devices at appropriate footpath level crossings.

Verbatim wording from the response

“Alongside signage and behavioural considerations, NRIL continues to prioritise engineering and design-based measures at footpath level crossings where reasonably practicable. This includes the installation and roll-out of miniature stop lights and supplementary audible warning devices at appropriate locations, improvements to crossing surfaces and approaches so that crossings are clearly recognisable as hazardous environments, and consideration of physical design features that encourage users to slow down and pause before crossing. Decisions in relation to such measures are informed by site-specific risk assessments, usage data and professional judgement considering both the safety benefits and any unintended consequences.”

Source location

Response from Network Rail
Page 2 · response
Published 10 February 2026

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

Undertake national and local education, engagement and awareness activity promoting safe behaviour around railways and level crossings.

Verbatim wording from the response

“In addition, NRIL undertakes education, engagement and awareness activity at both a national and local level, working with partner organisations to promote safe behaviour around the railway and at level crossings. This forms part of NRIL’s wider strategy to improve understanding of risk and to reinforce safety messages beyond the physical infrastructure alone.”

Source location

Response from Network Rail
Page 3 · response
Published 10 February 2026

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 national fatality and near-miss data, track distraction-related risks, and share incident learning to inform standards, guidance and future risk assessments.

Verbatim wording from the response

“NRIL continues to review fatality and near-miss data across the national network in order to identify trends and emerging risks. As set out above, NRIL recognises that distractions are becoming more prevalent, including from the use of personal technology, and the impact of distractions in various forms is an area of active research and consideration. Notwithstanding this, distraction is monitored and tracked at a national level, and learning from incidents, internal investigations and external reviews is shared within the organisation and used to inform standards, guidance and future risk assessments.”

Source location

Response from Network Rail
Page 3 · response
Published 10 February 2026

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Improve footpath level-crossing surfaces and approaches so crossings are clearly recognisable as hazardous environments.

Verbatim wording from the response

“Alongside signage and behavioural considerations, NRIL continues to prioritise engineering and design-based measures at footpath level crossings where reasonably practicable. This includes the installation and roll-out of miniature stop lights and supplementary audible warning devices at appropriate locations, improvements to crossing surfaces and approaches so that crossings are clearly recognisable as hazardous environments, and consideration of physical design features that encourage users to slow down and pause before crossing. Decisions in relation to such measures are informed by site-specific risk assessments, usage data and professional judgement considering both the safety benefits and any unintended consequences.”

Source location

Response from Network Rail
Page 2 · response
Published 10 February 2026

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 crossing was safe, compliant and operating as designed, with no inspection, maintenance or management failures contributing to the death.

Verbatim wording from the response

“The inquest heard evidence, including from independent investigations, which established that the Hoggs Hill Level Crossing was safe, compliant and operating as designed at the time of the incident. It was demonstrated that the miniature stop lights and audible warning system were functioning correctly, and that no causal or contributory failings were identified in the inspection, maintenance or management of the crossing. The conclusion reached was that it was more likely than not that Mr Dudley proceeded onto the crossing while distracted, having entered the crossing while a red light was displayed and the audible warning was sounding.”

Source location

Response from Network Rail
Page 1 · response
Published 10 February 2026

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Official responses located
1/2

Data last updated 7 September 2026