PFD report

Hassan Zubair · Prevention of Future Deaths report

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Issued 19 May 2022•East 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.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
2

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.

Report evidence summary

Concerns raised1

  1. Failure of the signals controller to advise trains to proceed with caution
Responses linked to these concerns

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

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

  1. Position

    Existing fencing and other mitigation measures were considered sufficient, so trains on Platform 2 were not stopped or cautioned.

    Stated by Network RailExisting 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

Failure of the signals controller to advise trains to proceed with caution

Wider context from the report

“1. The failure of the signals controller to advise trains travelling through ████████ to proceed with caution. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

Existing fencing and other mitigation measures were considered sufficient, so trains on Platform 2 were not stopped or cautioned.

Verbatim wording from the response

“In terms of the layout of the station and its infrastructure, although Platforms 3 and 2 are back to back, there are a significant number of measures in place to deter members of the public from accessing Platform 2, which services non-stopping trains and is not generally accessible by the general public. Most significantly, a metal fence physically separates Platforms 3 and 2 to deter access by the public to Platform 2. The fencing mitigated the need to caution trains on Platform 2 because it is designed to prevent people from crossing from Platform 3 to Platform 2. Therefore, it was reasonable for the Signaller to caution the trains on Platform 3 only.”

Source location

Response from Network Rail
Page 2 · response
Published 24 May 2022

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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.2

  1. 1

    Enhance the reporting system so signallers can contact station staff directly for rapid assistance.

    Stated by Network RailStated completedThe respondent said that this action was complete when they made their response on 24 May 2022.
  2. 2

    Undertake workshops for relevant staff on responding to welfare concerns.

    Stated by Network RailStated completedThe respondent said that this action was complete when they made their response on 24 May 2022.

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

Enhance the reporting system so signallers can contact station staff directly for rapid assistance.

Verbatim wording from the response

“Following this tragic incident, Network Rail did take action and enhanced the reporting system between Network Rail and MTR for Signallers to contact the station directly. This allows station staff to provide rapid assistance to individuals in these types of situations. Workshops have also been undertaken to relevant staff. Network Rail takes its safety obligations incredibly seriously and we are committed to reducing opportunity for members of the public to come to harm on or near the railway.”

Source location

Response from Network Rail
Page 3 · response
Published 24 May 2022

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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

Undertake workshops for relevant staff on responding to welfare concerns.

Verbatim wording from the response

“Following this tragic incident, Network Rail did take action and enhanced the reporting system between Network Rail and MTR for Signallers to contact the station directly. This allows station staff to provide rapid assistance to individuals in these types of situations. Workshops have also been undertaken to relevant staff. Network Rail takes its safety obligations incredibly seriously and we are committed to reducing opportunity for members of the public to come to harm on or near the railway.”

Source location

Response from Network Rail
Page 3 · response
Published 24 May 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

Official responses located
1/1

Data last updated 7 September 2026