PFD report

Carl Richard KLIMYATYS · Prevention of Future Deaths report

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Issued 7 Aug 2019•Brighton and Hove

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
6

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
14

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 raised6

  1. Lack of up-to-date contact details for Bronze
  2. Lack of safety-critical communication training for emergency call takers
    Part of recurring concern: Unsafe emergency call handling
  3. Failure to verify reported incident locations against available physical information
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.2

  1. Action

    Provide staff with online Track Access and Stations Made Easy resources showing station access, facilities, and track information.

    Stated by Govia Thameslink Railway LimitedStated completedThe respondent said that this action was complete when they made their response on 18 October 2019.
  2. Action

    Include safety-critical communications training in the Customer Ambassador competency standard.

    Stated by Govia Thameslink Railway LimitedStated completedThe respondent said that this action was complete when they made their response on 18 October 2019.

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

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. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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

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. ”

Is this part of a recurring concern?

Yes — Unsafe emergency call handling.

Open source report

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 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. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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 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. ”

Is this part of a recurring concern?

Yes — Unsafe emergency call handling.

Open source report

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 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. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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 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. ”

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

Provide staff with online Track Access and Stations Made Easy resources showing station access, facilities, and track information.

Verbatim wording from the response

“Information resources now include access to a ‘Track Access’ system that can be viewed on line with video and associated track map, and the Stations Made Easy section of National Rail Enquiries, to provide an interactive view of the station and its facilities such as ticket offices etc.”

Source location

2019-0276-Response-by-GTR
Page 6 · response
Published 18 October 2019

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

Include safety-critical communications training in the Customer Ambassador competency standard.

Verbatim wording from the response

“The Resilience Customer Ambassador (RCA) role provides a valuable interface for our customers which can respond directly to their questions about live network operations. Where we anticipate greater demand, agency staff will supplement the normal establishment. Temporary staff are subject to the same training and competency assessment regime as permanent staff. This now includes safety-critical communications training, which is assessed as part of the Customer Ambassador standard, so there is no longer a reliance on a Team Leader to establish a clear understanding about an emerging situation.”

Source location

2019-0276-Response-by-GTR
Page 5 · response
Published 18 October 2019

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.12

  1. 1

    Continue monitoring the effectiveness of trespass-management measures.

    Stated by Govia Thameslink Railway LimitedStated in progressThe respondent said that this action was in progress when they made their response on 18 October 2019.
  2. 2

    Survey all sites for anti-trespass and suicide-prevention measures alongside the general inspection regime.

    Stated by Govia Thameslink Railway LimitedStated in progressThe respondent said that this action was in progress when they made their response on 18 October 2019.
  3. 3

    Use Respect the Edge festive messaging through station posters, social media, and staff briefings to reduce alcohol-related platform risk.

    Stated by Govia Thameslink Railway LimitedStated completedThe respondent said that this action was complete when they made their response on 18 October 2019.
  4. 4

    Continue participating in and sponsoring work to raise public awareness of trespass risks.

    Stated by Govia Thameslink Railway LimitedStated in progressThe respondent said that this action was in progress when they made their response on 18 October 2019.
  5. 5

    Provide enhanced Help Point Assessment training, including system-use tasks, call handling, call-backs, and a knowledge quiz.

    Stated by Govia Thameslink Railway LimitedStated completedThe respondent said that this action was complete when they made their response on 18 October 2019.
  6. 6

    Continue collaborating with industry groups to learn and promote good trespass-management practice.

    Stated by Govia Thameslink Railway LimitedStated in progressThe respondent said that this action was in progress when they made their response on 18 October 2019.
  7. 7

    Maintain barriers, anti-trespass matting, and compliant third-rail and trespass warning signs at stations.

    Stated by Govia Thameslink Railway LimitedStated completedThe respondent said that this action was complete when they made their response on 18 October 2019.
  8. 8

    Run seasonal publicity campaigns warning the public about excessive alcohol consumption and railway travel risks.

    Stated by Network RailStated completedThe respondent said that this action was complete when they made their response on 18 October 2019.
  9. 9

    Operate a life-size indoor train station at Sutton Life Educational Centre as part of youth safety outreach.

    Stated by Network RailStated completedThe respondent said that this action was complete when they made their response on 18 October 2019.
  10. 10

    Attend schools and community events to promote railway safety.

    Stated by Network RailStated completedThe respondent said that this action was complete when they made their response on 18 October 2019.
  11. 11

    Develop educational resources with teachers and pupils addressing railway electrification, level crossings and railway safety.

    Stated by Network RailStated completedThe respondent said that this action was complete when they made their response on 18 October 2019.
  12. 12

    Support safety-awareness programmes, including the You vs Train film about third-rail dangers.

    Stated by Network RailStated completedThe respondent said that this action was complete when they made their response on 18 October 2019.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.3

  1. 1

    Cross-hatching is rejected as an additional platform-edge control because evidence indicates platform markings provide weak safety benefits and other markings should be avoided.

    Stated by Govia Thameslink Railway LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
  2. 2

    Existing compliant warning signs, barriers, anti-trespass matting, tactile paving and yellow lines are considered sufficient at Preston Park Station.

    Stated by Govia Thameslink Railway LimitedExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
  3. 3

    GTR, as station lessee and Station Facility Owner, is responsible for station signage and does not require Network Rail’s permission for signage works.

    Stated by Network RailRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 monitoring the effectiveness of trespass-management measures.

Verbatim wording from the response

“GTR continues to work with groups such as the industry Trespass Risk Group to learn and promote good practice, monitor the effectiveness of current trespass management and be involved and sponsor work in this area to raise public awareness. This broader approach is combined with the local notifications at specific locations to reduce the likelihood of trespass.”

Source location

2019-0276-Response-by-GTR
Page 3 · response
Published 18 October 2019

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

Survey all sites for anti-trespass and suicide-prevention measures alongside the general inspection regime.

Verbatim wording from the response

“In recent years there has been significant investment in anti-trespass measures at stations. This includes barriers and anti-trespass matting at platform ends, in addition to the trespass warning and danger of live rail signs. These signs are compliant with Railway Group Standard GI/RT7033 in both design and positioning (CB01 – Electrical Hazard: Warnings to the Public; CA03 – Danger – No Unauthorised Access). To supplement our planned general inspection regime, GTR are currently surveying all its sites to access anti-trespass and suicide measures,”

Source location

2019-0276-Response-by-GTR
Page 3 · response
Published 18 October 2019

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

Use Respect the Edge festive messaging through station posters, social media, and staff briefings to reduce alcohol-related platform risk.

Verbatim wording from the response

“We recognise the significant risks associated with heavy drinking in how it potentially impairs judgement and the increased risk of death on the railway for those affected. In preparation for this year’s festive season, GTR made use of the Respect the Edge campaign messaging to keep people and staff safe.”

Source location

2019-0276-Response-by-GTR
Page 4 · response
Published 18 October 2019

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

Continue participating in and sponsoring work to raise public awareness of trespass risks.

Verbatim wording from the response

“GTR continues to work with groups such as the industry Trespass Risk Group to learn and promote good practice, monitor the effectiveness of current trespass management and be involved and sponsor work in this area to raise public awareness. This broader approach is combined with the local notifications at specific locations to reduce the likelihood of trespass.”

Source location

2019-0276-Response-by-GTR
Page 3 · response
Published 18 October 2019

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 enhanced Help Point Assessment training, including system-use tasks, call handling, call-backs, and a knowledge quiz.

Verbatim wording from the response

“The new training for Help Point Assessment includes functional tasks such as launching and logging into the system, answering calls and making calls back to the help point. This enhanced competency development cycle includes a ‘Quiz’ which tests personal knowledge and was established in February 2019 as an action from the learnings from this tragic incident.”

Source location

2019-0276-Response-by-GTR
Page 6 · response
Published 18 October 2019

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

Continue collaborating with industry groups to learn and promote good trespass-management practice.

Verbatim wording from the response

“GTR continues to work with groups such as the industry Trespass Risk Group to learn and promote good practice, monitor the effectiveness of current trespass management and be involved and sponsor work in this area to raise public awareness. This broader approach is combined with the local notifications at specific locations to reduce the likelihood of trespass.”

Source location

2019-0276-Response-by-GTR
Page 3 · response
Published 18 October 2019

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

Maintain barriers, anti-trespass matting, and compliant third-rail and trespass warning signs at stations.

Verbatim wording from the response

“In recent years there has been significant investment in anti-trespass measures at stations. This includes barriers and anti-trespass matting at platform ends, in addition to the trespass warning and danger of live rail signs. These signs are compliant with Railway Group Standard GI/RT7033 in both design and positioning (CB01 – Electrical Hazard: Warnings to the Public; CA03 – Danger – No Unauthorised Access). To supplement our planned general inspection regime, GTR are currently surveying all its sites to access anti-trespass and suicide measures,”

Source location

2019-0276-Response-by-GTR
Page 3 · response
Published 18 October 2019

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

Run seasonal publicity campaigns warning the public about excessive alcohol consumption and railway travel risks.

Verbatim wording from the response

“We note from the Record of Inquiry that the presence of alcohol is listed under the medical causes of death. The inherent dangers of the railway are of course exacerbated by excessive alcohol intake. Anything you, as one of Her Majesty’s Senior Coroners, could do to draw attention to the significant risks associated with heavy drinking and impaired judgements and the significant risk of death on the railway – whether being struck by a train or by electrocution – would be very much appreciated. Network Rail regularly runs seasonal publicity campaigns warning the public of the risks of excessive alcohol intake and travelling on the railway.”

Source location

2019-0276-Response-by-Network-Rail
Page 2 · response
Published 18 October 2019

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

Operate a life-size indoor train station at Sutton Life Educational Centre as part of youth safety outreach.

Verbatim wording from the response

“A key part of our work in the community is education and we regularly attend schools and community events to promote safety on the railway. Educational resources have also been developed with teachers and pupils about electrification on the railway, level crossings and railway safety. A life-size indoor train station has even been built at Sutton Life Educational Centre to bring home safety messages to young people and is a part of our safety outreach programme for young people.”

Source location

2019-0276-Response-by-Network-Rail
Page 2 · response
Published 18 October 2019

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

Attend schools and community events to promote railway safety.

Verbatim wording from the response

“A key part of our work in the community is education and we regularly attend schools and community events to promote safety on the railway. Educational resources have also been developed with teachers and pupils about electrification on the railway, level crossings and railway safety. A life-size indoor train station has even been built at Sutton Life Educational Centre to bring home safety messages to young people and is a part of our safety outreach programme for young people.”

Source location

2019-0276-Response-by-Network-Rail
Page 2 · response
Published 18 October 2019

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

Develop educational resources with teachers and pupils addressing railway electrification, level crossings and railway safety.

Verbatim wording from the response

“A key part of our work in the community is education and we regularly attend schools and community events to promote safety on the railway. Educational resources have also been developed with teachers and pupils about electrification on the railway, level crossings and railway safety. A life-size indoor train station has even been built at Sutton Life Educational Centre to bring home safety messages to young people and is a part of our safety outreach programme for young people.”

Source location

2019-0276-Response-by-Network-Rail
Page 2 · response
Published 18 October 2019

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

Support safety-awareness programmes, including the You vs Train film about third-rail dangers.

Verbatim wording from the response

“We care about making sure passengers and members of the public understand how to stay safe and we support a number of safety awareness programmes, including the You vs Train film about the dangers of the third rail.”

Source location

2019-0276-Response-by-Network-Rail
Page 2 · response
Published 18 October 2019

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

Cross-hatching is rejected as an additional platform-edge control because evidence indicates platform markings provide weak safety benefits and other markings should be avoided.

Verbatim wording from the response

“Consideration for the use of cross-hatching to demark the platform edge is a recommendation made regularly by the Designing Out Crime Unit and is based on a theoretical basis that it could influence people in suicide crisis so not cross the psychological barrier. However, there is no evidence to support this either influences the behaviours of those in crisis or travelling passengers generally.”

Source location

2019-0276-Response-by-GTR
Page 5 · response
Published 18 October 2019

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 compliant warning signs, barriers, anti-trespass matting, tactile paving and yellow lines are considered sufficient at Preston Park Station.

Verbatim wording from the response

“In recent years there has been significant investment in anti-trespass measures at stations. This includes barriers and anti-trespass matting at platform ends, in addition to the trespass warning and danger of live rail signs. These signs are compliant with Railway Group Standard GI/RT7033 in both design and positioning (CB01 – Electrical Hazard: Warnings to the Public; CA03 – Danger – No Unauthorised Access). To supplement our planned general inspection regime, GTR are currently surveying all its sites to access anti-trespass and suicide measures,”

Source location

2019-0276-Response-by-GTR
Page 3 · response
Published 18 October 2019

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

GTR, as station lessee and Station Facility Owner, is responsible for station signage and does not require Network Rail’s permission for signage works.

Verbatim wording from the response

“You identify that these concerns are matters for consideration by the train operator, namely, Govia Thameslink Railway Ltd (GTR) and a copy of your report is sent to Network Rail in its capacity as landlords for GTR who may need to seek Network Rail’s permission to carry out works at the station.”

Source location

2019-0276-Response-by-Network-Rail
Page 1 · response
Published 18 October 2019

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