PFD report

Simon Anthony Moore · Prevention of Future Deaths report

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Issued 5 Aug 2025•Dorset

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.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
6

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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

Concerns raised1

  1. Failure to relay signaller-driver welfare information to the attending Driver Manager
    Part of recurring concern: Unreliable sharing of railway concern-for-welfare information with relevant responders
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.3

  1. Action

    Review the end-to-end incident communication process through the industry working group, including welfare concern escalation and communication.

    Stated by Network Rail Infrastructure LimitedStated plannedThe respondent said that this action was planned when they made their response on 5 August 2025.
  2. Action

    Consider the investigation report and recommendation at the SPAD Recommendations and Review Panel.

    Stated by Network Rail Infrastructure LimitedStated completedThe respondent said that this action was complete when they made their response on 5 August 2025.
  3. Action

    Develop guidance for signallers communicating with drivers after incidents.

    Stated by Network Rail Infrastructure LimitedStated plannedThe respondent said that this action was planned when they made their response on 5 August 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    The Network Rail signaller had a means to relay the driver's welfare concerns to train company Control through the incident logging system.

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

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

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. ”

Is this part of a recurring concern?

Yes — Unreliable sharing of railway concern-for-welfare information with relevant responders.

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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 the end-to-end incident communication process through the industry working group, including welfare concern escalation and communication.

Verbatim wording from the response

“Upon receipt of HM Coroner’s Regulation 28 report, and in considering your findings, Network Rail set up an Industry Working Group on Welfare Communication, which includes representatives from Network Rail, Train Operating Companies, and trade unions.”

Source location

Response from Network Rail
Page 4 · response
Published 5 August 2025

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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

Consider the investigation report and recommendation at the SPAD Recommendations and Review Panel.

Verbatim wording from the response

“• The SWR investigation report, including the above recommendation, was considered at the NR SPAD Recommendations and Review Panel.”

Source location

Response from Network Rail
Page 3 · response
Published 5 August 2025

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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

Develop guidance for signallers communicating with drivers after incidents.

Verbatim wording from the response

“As you are aware, SWR’s incident investigation found that, notwithstanding the existing processes in place as described above, opportunities existed to strengthen escalation and communication protocols between signallers, Incident Controllers, TOC Control and Driver Managers. The investigation included a recommendation that Guidance will be created for signallers to support them when communicating with a driver post incident. This Guidance will be developed by the Industry Working Group on Welfare Communications, described further below.”

Source location

Response from Network Rail
Page 3 · response
Published 5 August 2025

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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 Network Rail signaller had a means to relay the driver's welfare concerns to train company Control through the incident logging system.

Verbatim wording from the response

“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.”

Source location

Response from Network Rail
Page 2 · response
Published 5 August 2025

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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.3

  1. 1

    Consider the incident at the Southern OPSRAM industry risk meeting to identify and reduce operational risks.

    Stated by Network Rail Infrastructure LimitedStated completedThe respondent said that this action was complete when they made their response on 5 August 2025.
  2. 2

    Collaborate with and participate in the train operating company’s incident investigation.

    Stated by Network Rail Infrastructure LimitedStated completedThe respondent said that this action was complete when they made their response on 5 August 2025.
  3. 3

    Set up an industry working group on welfare communication with train operators and trade union representatives.

    Stated by Network Rail Infrastructure LimitedStated completedThe respondent said that this action was complete when they made their response on 5 August 2025.

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 the incident at the Southern OPSRAM industry risk meeting to identify and reduce operational risks.

Verbatim wording from the response

“• The incident was considered at Southern OPSRAM.”

Source location

Response from Network Rail
Page 3 · response
Published 5 August 2025

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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

Collaborate with and participate in the train operating company’s incident investigation.

Verbatim wording from the response

“• Network Rail’s Operations Risk Control Coordinator collaborated with and formed part of SWR’s investigation.”

Source location

Response from Network Rail
Page 3 · response
Published 5 August 2025

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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

Set up an industry working group on welfare communication with train operators and trade union representatives.

Verbatim wording from the response

“Upon receipt of HM Coroner’s Regulation 28 report, and in considering your findings, Network Rail set up an Industry Working Group on Welfare Communication, which includes representatives from Network Rail, Train Operating Companies, and trade unions.”

Source location

Response from Network Rail
Page 4 · response
Published 5 August 2025

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

Data last updated 7 September 2026