PFD report

Steven John Key · Prevention of Future Deaths report

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Issued 25 Feb 2019•Cumbria

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
3

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 prevent access to the railway line through adequately secure fencing
    Part of recurring concern: Failure to prevent public access to closed or restricted hazardous sitesPart of recurring concern: Inadequate physical barriers preventing access to dangerous drops or areasPart of recurring concern: Ineffective controls preventing access to railway tracks
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

    Install additional meshing and netting at the location to deter climbing.

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

    Investigate whether attaching mesh to the bridge’s tubular handrail or safety rail would improve security.

    Stated by Network RailStated plannedThe respondent said that this action was planned when they made their response on 11 June 2019.
  3. Action

    Review trespass risk around the area and identify the bridge wing wall and track-level safety rail for further mitigation.

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

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    The line speed at this location is 110mph, not 125mph, although trains still travel at high speed.

    Stated by Network RailDisputes 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 prevent access to the railway line through adequately secure fencing

Wider context from the report

“(1) You have a duty under the Railway Safety (Miscellaneous Provisions) Regulations 1997 to prevent access to the railway line so far as is reasonably practicable. (2) The fencing at the scene of Mr Key’s death was a low wooden fence which was easy to climb over. (3) The British Transport Police (BTP) report into the death, reference CRUO 2018 1711 & BTP 404-14091, of which you received a copy, recommended replacing the fence and gate with a heightened palisade gate and fence. I agree with that recommendation. (4) Trains regularly travel on this section of the track at speeds of 125 mph. (5) Children and adults would, like Mr Key, be able to climb the wooden fence and be at risk of injury or death on the track from passing trains. (6) It would be reasonably practicable for you to fence the track at this point in the way suggested in the BTP Report. ”

Is this part of a recurring concern?

Yes — Failure to prevent public access to closed or restricted hazardous sites; Inadequate physical barriers preventing access to dangerous drops or areas; Ineffective controls preventing access to railway tracks.

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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

Install additional meshing and netting at the location to deter climbing.

Verbatim wording from the response

“Network Rail takes its safety obligations seriously and has taken additional measures beyond those required by its standards, to install additional meshing and netting at this location to act as an increased deterrent to climbing. This is explained in the responses to your matters of concern.”

Source location

2019-0102-Response-by-Network-Rail
Page 1 · response
Published 11 June 2019

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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

Investigate whether attaching mesh to the bridge’s tubular handrail or safety rail would improve security.

Verbatim wording from the response

“Unfortunately, the risk of trespass cannot be entirely eliminated even with the best of fencing, but I consider that in this particular area the current boundary measures in place meet the reasonably practicable test. That said, Network Rail is constantly striving to improve safety on our network and that is why we create and adhere to standards such as NR/L2/TRK/5100. In the light of Mr Key’s death, we have reviewed the risk of potential trespass in this area in general and have identified the bridge wing wall and the galvanised iron tubular hand rail / safety rail at track level as an area where we could further mitigate any risk of trespass. To this end, the Route Structures Senior Asset Engineer has been”

Source location

2019-0102-Response-by-Network-Rail
Page 3 · response
Published 11 June 2019

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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 trespass risk around the area and identify the bridge wing wall and track-level safety rail for further mitigation.

Verbatim wording from the response

“Unfortunately, the risk of trespass cannot be entirely eliminated even with the best of fencing, but I consider that in this particular area the current boundary measures in place meet the reasonably practicable test. That said, Network Rail is constantly striving to improve safety on our network and that is why we create and adhere to standards such as NR/L2/TRK/5100. In the light of Mr Key’s death, we have reviewed the risk of potential trespass in this area in general and have identified the bridge wing wall and the galvanised iron tubular hand rail / safety rail at track level as an area where we could further mitigate any risk of trespass. To this end, the Route Structures Senior Asset Engineer has been”

Source location

2019-0102-Response-by-Network-Rail
Page 3 · response
Published 11 June 2019

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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 line speed at this location is 110mph, not 125mph, although trains still travel at high speed.

Verbatim wording from the response

“While our records indicate that the line speed at this location is 110mph, I nevertheless accept that trains do travel at high speed along this section of the track.”

Source location

2019-0102-Response-by-Network-Rail
Page 3 · response
Published 11 June 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

Current boundary measures meet the reasonably practicable obligation, and no further assessment is triggered because there is no prior evidence of trespass.

Verbatim wording from the response

“As this area has no prior evidence of trespass, a Class III boundary measure would be appropriate as per the Standard, and in effectively having a Class III equivalent barrier in place I consider that Network Rail has met its obligation to prevent unauthorised access to the railway in so far as reasonably practicable.”

Source location

2019-0102-Response-by-Network-Rail
Page 3 · response
Published 11 June 2019

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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

Replacing all fencing with palisade is not reasonably practicable given the scale of the railway network and local risk assessment requirements.

Verbatim wording from the response

“While I understand the British Transport Police’s recommendation to replace the fence and gate with a heightened palisade gate and fence, Network Rail is responsible for looking after some 20,000 miles of track and 30,000 bridges and it is not reasonably practicable to fence all of it with palisade. Our risk assessment process takes account of all local factors in determining the most appropriate boundary measure to implement, bearing in mind what is reasonably practicable.”

Source location

2019-0102-Response-by-Network-Rail
Page 3 · response
Published 11 June 2019

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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