PFD report

Connor Peter Marron · Prevention of Future Deaths report

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Issued 22 Jun 2022•North London

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
4

Raised in this report

Recipients
3

Named on the report

Responses found
3

Of 3 recipients

Stated actions
10

Described in responses

Recipients and published 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.

Concerns raised4

  1. Lack of lighting beside the stream and railway fence
    Part of recurring concern: Inadequate outdoor safety lighting
  2. Lack of signs identifying the stream, its depth and warnings of danger
    Part of recurring concern: Inadequate controls for drowning risks at open-water locations
  3. Lack of signs assisting with locating a way out from the venue grounds
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.5

  1. Action

    Investigate options to improve the path and bank at location 5, including assessing lighting levels.

    Stated by Thames Water Utilities LimitedStated plannedThe respondent said that this action was planned when they made their response on 22 September 2022.
  2. Action

    Install New River Path warning signage beside the location 1 kissing gate.

    Stated by Thames Water Utilities LimitedStated plannedThe respondent said that this action was planned when they made their response on 22 September 2022.
  3. Action

    Invest in physical measures to prevent unauthorised railway access, including platform-end barriers, mid-platform station fences and lineside fencing.

    Stated by Network Rail Infrastructure LimitedStated completedThe respondent said that this action was complete when they made their response on 22 September 2022.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.7

  1. Position

    APPCT disputes that locating an exit from this open park area is challenging and therefore will not erect exit signs there.

    Stated by Alexandra Park and Palace Charitable TrustDisputes 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

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. ”

Is this part of a recurring concern?

Yes — Inadequate outdoor safety lighting.

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 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. ”

Is this part of a recurring concern?

Yes — Inadequate controls for drowning risks at open-water locations.

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 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. ”

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

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. ”

Is this part of a recurring concern?

Yes — Inadequate physical barriers preventing access to dangerous drops or areas; Ineffective controls preventing access to railway tracks.

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

Investigate options to improve the path and bank at location 5, including assessing lighting levels.

Verbatim wording from the response

“The river path at location 5 is at its narrowest, being close to the river, separated by a narrow steep bank, which shows some damage. There are also tree branches extending over the path close to head height. The path has no lighting but has borrowed lighting from the streetlights on the Chadwell Lane development and the High Street. At location 5 the river is 60cm – 70cm deep with around 20 cm of silt. On the opposite bank a brick pumping house is visible, with significant graffiti and direct access to the river.”

Source location

Response from Thames Water
Page 5 · response
Published 22 September 2022

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 New River Path warning signage beside the location 1 kissing gate.

Verbatim wording from the response

“Location 1 has a kissing gate entrance to the New River path, with palisade fencing on either side in good condition. There is a small notice on the gate concerning right of access and entry at one’s own risk. However, the Thames Water standard hazard warning sign stating, ‘danger deep water, no swimming, no boating, no fishing’, which should be displayed at each access point to the river is not in place in this location. Arrangements have been made for this to be installed so it will mirror the signage at location 6 (see further comments below).”

Source location

Response from Thames Water
Page 4 · response
Published 22 September 2022

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

Invest in physical measures to prevent unauthorised railway access, including platform-end barriers, mid-platform station fences and lineside fencing.

Verbatim wording from the response

“I note that the conclusion of this inquest was an ‘open’ verdict. However, I thought you may be interested in some of the other work we do as we are committed to maintaining a safe railway and to reducing opportunity for members of the public to harm themselves on or near the railway. An example of this is the work being carried out on the Peterborough to Kings Cross line of route, where this section of track is located, which is one of three Focus Areas where Network Rail is working closely with the British Transport Police, Samaritans and Rail Industry partners to prevent suicide. Network Rail has also invested significantly in preventing unauthorised access in this line- of-route through physical mitigations, such as platform end barriers and mid-platform fences at stations and lineside fencing outside.”

Source location

Response from Network Rail
Page 2 · response
Published 22 September 2022

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

Repair damage to the Downside access gate and minor fencing defects.

Verbatim wording from the response

“In relation to the third matter listed, whilst your report states that the fence separating the venue grounds from the railway track was “….not adequate to prevent ingress to the railway track” and Network Rail’s post-incident inspection of the fencing (on the morning of 2nd January 2022) in the wider area recorded that a small gap in the fencing had been discovered, as well as damage to the Downside access gate, resulting in minor repairs being carried out immediately, we note that the BTP’s Post Incident Site Report (BTP Control Works Reference 15-020122) (“the PISR”) concluded that, having reviewed the possible routes to the incident scene following the incident, “……access onto the railway is inconclusive”.”

Source location

Response from Network Rail
Page 1 · response
Published 22 September 2022

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

Replace the chain-link fencing section with palisade fencing through the Route’s work bank.

Verbatim wording from the response

“• replacing the relevant section of chain link fencing and continuing with palisade fencing. Whilst, as mentioned previously, the route to the incident scene has been deemed inconclusive, we note that the fencing in closest proximity to the incident scene is, in fact, palisade fencing, rather than chain link fencing (the fencing in this particular area, which separates the venue grounds from the railway track, is currently of a mixed palisade and chain link design). Class I boundary measures, which include palisade fencing, are installed to provide a security measure where the risk of unauthorised access is probable and these boundary measures are designed with anti-tamper and anti-climb components within the installation. The chain link section of fencing is approximately ¼ mile down the track, on the opposite side of the tracks and across approximately 6 miles of track.”

Source location

Response from Network Rail
Page 2 · response
Published 22 September 2022

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

APPCT disputes that locating an exit from this open park area is challenging and therefore will not erect exit signs there.

Verbatim wording from the response

“With particular reference to Matter of Concern 2, we do not share your concern that it is challenging for a park user to locate an exit from this area of the park. This is an open area of the park and with multiple options through which to exit the park and choose a number of adjoining roads. We are also very conscious of the precedent that such a decision could create for all park operators across the UK.”

Source location

Response from Alexandra Palace
Page 2 · response
Published 22 September 2022

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 stream lighting and railway-fence adequacy matters concern assets APPCT does not own or operate and therefore do not require action by APPCT.

Verbatim wording from the response

“railway assets owned by Network Rail. To access the railway boundary fence, an individual must first leave the park onto public streets and cross the New River; two locations owned by third parties.”

Source location

Response from Alexandra Palace
Page 2 · response
Published 22 September 2022

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

Lighting on venue grounds is Alexandra Palace’s responsibility, while railway fencing is Network Rail’s responsibility.

Verbatim wording from the response

“I will address point number 1, as the other issues appear to relate to the responsibilities of Alexandra Palace and Network Rail respectively. Point 2 relates to lighting on the venue grounds, which is for Alexandra Palace, and fencing separating the venue from the railway track would appear to be the responsibility of Network Rail.”

Source location

Response from Thames Water
Page 2 · response
Published 22 September 2022

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

Lighting along Network Rail’s fence line will not be provided because Network Rail policy does not require it.

Verbatim wording from the response

“Addressing the matters set out in your report in turn, in relation to the first two matters listed we note that it states that there was “….no lighting beside the stream or the railway fence, nor any signs identifying the stream, its depth and any warning of danger” and “….no signs in that area to assist with locating a way out from that part of the venue’s grounds”. The stream and venue referenced are not located on Network Rail land and therefore the provision of lighting and/or signage in those locations is a matter for the relevant landowners, whom Network Rail understands are Thames Water and Alexandra Palace. With regard to lighting beside the railway fence, it is not Network Rail policy to provide lighting along its fence line and, accordingly, lighting is not in place along this particular section of fencing.”

Source location

Response from Network Rail
Page 1 · response
Published 22 September 2022

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

Quarterly inspections and remediation under the boundary fencing standard are considered sufficient for fence-line maintenance.

Verbatim wording from the response

“• ensuring that fence line inspections comply with the National Safety Briefing in relation to Boundary Fencing Inspection Standard NR/L2/OTK/5100 Module 01 (1st April 2019) tactile / non-tactile inspections (“the Standard”). Network Rail takes a pro-active approach to asset maintenance and renewal, with inspections complying with the Standard and remediation works carried out following such inspections. Where upgrading of an asset is identified as being required, a fencing proposal is prepared by the Off-Track team and ranked in terms of priority, with those with the highest scores (indicating that they are the highest priority) given precedence. Each route within an area is allocated a fund of monies to be used for maintenance and repair works, with monies focused on delivering the highest priority works identified i.e., those with the highest scores.”

Source location

Response from Network Rail
Page 1 · response
Published 22 September 2022

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

Lighting and signage at the stream and venue are matters for the relevant landowners, not Network Rail.

Verbatim wording from the response

“Addressing the matters set out in your report in turn, in relation to the first two matters listed we note that it states that there was “….no lighting beside the stream or the railway fence, nor any signs identifying the stream, its depth and any warning of danger” and “….no signs in that area to assist with locating a way out from that part of the venue’s grounds”. The stream and venue referenced are not located on Network Rail land and therefore the provision of lighting and/or signage in those locations is a matter for the relevant landowners, whom Network Rail understands are Thames Water and Alexandra Palace. With regard to lighting beside the railway fence, it is not Network Rail policy to provide lighting along its fence line and, accordingly, lighting is not in place along this particular section of fencing.”

Source location

Response from Network Rail
Page 1 · response
Published 22 September 2022

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 route by which access to the railway occurred is inconclusive, and fencing nearest the incident was palisade rather than chain link.

Verbatim wording from the response

“In relation to the third matter listed, whilst your report states that the fence separating the venue grounds from the railway track was “….not adequate to prevent ingress to the railway track” and Network Rail’s post-incident inspection of the fencing (on the morning of 2nd January 2022) in the wider area recorded that a small gap in the fencing had been discovered, as well as damage to the Downside access gate, resulting in minor repairs being carried out immediately, we note that the BTP’s Post Incident Site Report (BTP Control Works Reference 15-020122) (“the PISR”) concluded that, having reviewed the possible routes to the incident scene following the incident, “……access onto the railway is inconclusive”.”

Source location

Response from Network Rail
Page 1 · response
Published 22 September 2022

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.5

  1. 1

    Remove overhanging branches beside the New River Path at location 5.

    Stated by Thames Water Utilities LimitedStated plannedThe respondent said that this action was planned when they made their response on 22 September 2022.
  2. 2

    Share response findings with New River Inspection Teams for incorporation into routine river inspections.

    Stated by Thames Water Utilities LimitedStated plannedThe respondent said that this action was planned when they made their response on 22 September 2022.
  3. 3

    Enter the proposed actions into the Risk Management System and monitor them through completion with Health and Safety Team and Board Committee oversight.

    Stated by Thames Water Utilities LimitedStated plannedThe respondent said that this action was planned when they made their response on 22 September 2022.
  4. 4

    Share the location 7 access-control and signage assessment with the Chadwell Lane development property owner.

    Stated by Thames Water Utilities LimitedStated plannedThe respondent said that this action was planned when they made their response on 22 September 2022.
  5. 5

    Work with British Transport Police, Samaritans and rail industry partners on suicide-prevention measures for the Peterborough to Kings Cross route.

    Stated by Network Rail Infrastructure LimitedStated in progressThe respondent said that this action was in progress when they made their response on 22 September 2022.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    Borrowed and surrounding light makes the path distinguishable and presents low risk across most of the area.

    Stated by Thames Water Utilities LimitedExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
  2. 2

    Existing fencing balances accessibility and safety; additional protection covers pipe crossings, channels and steep-sided banks.

    Stated by Thames Water Utilities LimitedExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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

Remove overhanging branches beside the New River Path at location 5.

Verbatim wording from the response

“The river path at location 5 is at its narrowest, being close to the river, separated by a narrow steep bank, which shows some damage. There are also tree branches extending over the path close to head height. The path has no lighting but has borrowed lighting from the streetlights on the Chadwell Lane development and the High Street. At location 5 the river is 60cm – 70cm deep with around 20 cm of silt. On the opposite bank a brick pumping house is visible, with significant graffiti and direct access to the river.”

Source location

Response from Thames Water
Page 5 · response
Published 22 September 2022

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

Share response findings with New River Inspection Teams for incorporation into routine river inspections.

Verbatim wording from the response

“The ongoing operation of the New River is inspected twice weekly by the River Inspection Teams. Currently these inspections focus on operational matters relating to water supply but do touch on some safety and security matters. A review of these inspection requirements will aid in spreading learnings from this incident more broadly with respect to how we manage the New River.”

Source location

Response from Thames Water
Page 7 · response
Published 22 September 2022

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

Enter the proposed actions into the Risk Management System and monitor them through completion with Health and Safety Team and Board Committee oversight.

Verbatim wording from the response

“5. Share the findings from this response with the New River Inspection Teams so that they can be incorporated, as appropriate, into the routine inspections of the New River by the end of September 2022. Any further improvements identified will be managed through Thames Water’s existing Asset Risk Management process on an ongoing basis.”

Source location

Response from Thames Water
Page 7 · response
Published 22 September 2022

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

Share the location 7 access-control and signage assessment with the Chadwell Lane development property owner.

Verbatim wording from the response

“Location 7 is the entry point to the development on New River Avenue and Chadwell Lane and is private property. There are Danger Deep Water signs in place along the length of the development pathway along the bank of the New River.”

Source location

Response from Thames Water
Page 6 · response
Published 22 September 2022

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 British Transport Police, Samaritans and rail industry partners on suicide-prevention measures for the Peterborough to Kings Cross route.

Verbatim wording from the response

“I note that the conclusion of this inquest was an ‘open’ verdict. However, I thought you may be interested in some of the other work we do as we are committed to maintaining a safe railway and to reducing opportunity for members of the public to harm themselves on or near the railway. An example of this is the work being carried out on the Peterborough to Kings Cross line of route, where this section of track is located, which is one of three Focus Areas where Network Rail is working closely with the British Transport Police, Samaritans and Rail Industry partners to prevent suicide. Network Rail has also invested significantly in preventing unauthorised access in this line- of-route through physical mitigations, such as platform end barriers and mid-platform fences at stations and lineside fencing outside.”

Source location

Response from Network Rail
Page 2 · response
Published 22 September 2022

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

Borrowed and surrounding light makes the path distinguishable and presents low risk across most of the area.

Verbatim wording from the response

“There appears to be adequate lighting on the Chadwell Lane development. The absence of lighting on Thames Water property would make visibility at night on the New River Path low, but not completely dark due to the borrowed light from the opposite bank and surrounding urban area. The river itself reflects light and would be distinguishable from the path even in overcast weather at night. This coupled with the general distance of the path from the river, presents a low risk for a majority of the area concerned. Where the path narrows at location 5 and there are overhanging trees, where we will undertake a further review and make any necessary changes.”

Source location

Response from Thames Water
Page 6 · response
Published 22 September 2022

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 fencing balances accessibility and safety; additional protection covers pipe crossings, channels and steep-sided banks.

Verbatim wording from the response

“is consistent with fencing scheme to balance accessibility and safety/security. Hence only areas where there is easy egress out of the river are unfenced. Pipe crossings, channels and steep sided banks are also protected.”

Source location

Response from Thames Water
Page 7 · response
Published 22 September 2022

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