Robert English
PFD Report
All Responded
Ref: 2025-0380
All 3 responses received
· Deadline: 19 Sep 2025
Response Status
Responses
3 of 3
56-Day Deadline
19 Sep 2025
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
The provision to protect a trespasser at night are the same as those during the day. The ability to locate a person close to or on the railway lines at night is made more difficult by the absence of suitable lights on the track or the train. In this case Mr English was not seen and run over by the train that has been asked to look for a person on the line .
Responses
Transport for London has already updated its operational rules for track searches and commenced testing a prototype high-lumen lighting rig for train cabs to improve night-time visibility. They have also established a review group to finalise new pursuit and communication policies with police by September 2025, with revised staff training planned by October 2025.
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Dear Sir
Inquest touching the death of Robert Gray English
I write on behalf of Transport for London (TfL) regarding the Senior Coroner’s Regulation 28 Prevention of Future Deaths (PFD) report dated 25 July 2025 following the inquest touching the death of Robert Gray English.
I would like to take this opportunity to repeat, on behalf of TfL, our sincere condolences to the family and friends of Mr English for their tragic loss.
Prevention of Future Deaths (PFD) report
After the inquest, the Senior Coroner sent a PFD report to TfL raising the following matter of concern:
‘The provision to protect a trespasser at night are the same as those during the day. The ability to locate a person close to or on the railway lines at night is made more difficult by the absence of suitable lights on the track or the train. In this case Mr English was not seen and run over by the train that has been asked to look for a person on the line.’
I am grateful to the Senior Coroner for raising these concerns and we set out below TfL’s response.
TfL’s approach to track searches on the Underground network
TfL has well established rules for undertaking track searches when there are reports of persons on or about the track. However, we recognise, through recent events, including the death of Mr English, learning opportunities to further enhance safety on our network by updating our operational rules, associated training and the equipment used during such incidents.
On 12 May 2025, we updated our operational rules related to track searches. Our rules now require our teams to physically search the track environment where there is any doubt about the identity of an object on or around the track environment.
We are also in the process of changing our Rule Book to remove existing references to a train undertaking a track search operating at ‘slow speed’. Under our new operational rules, train operators will be given very specific instructions, requiring them to operate ‘at a speed of no more than 10mph, or the closest speed value available on lines with automatic train operation’. This will better manage the speed at which trains travel through the affected area. The Rules will be formally updated and briefed to our train operators by the end of October
2025.
These two rule changes acting together strengthen our track searching arrangements in contexts where there is either a report of an obstruction or a report of a person on or around the track environment.
You highlighted the need for more suitable lighting for locating a trespasser at night. We are actively assessing options for new equipment to provide additional lighting.
We have started testing a prototype lighting rig which allows a new type of torch to be mounted inside the train operator’s cab. This torch has an adjustable output of up to 100,000 lumen, providing enhanced lighting of track in open-air night- time conditions.
We will continue to test this prototype over the next few months to fully assess its capability, risk assess it for use on the operational railway and identify any improvements required. We will conclude this test by December 2025.
Should this lighting rig be successful, and following appropriate internal assurance, we would roll this out in 2026 across the LU network (for the open-air sections of track).
Effective communications
As part of our investigation into Mr English’s death, we recognise the opportunity to make communication between our operational staff and police more robust. As a result, we have established a review group comprising of representation from TfL Compliance, Policing, Operations and Security, the TfL Rail Control Centre, the Metropolitan Police Service and the British Transport Police. The purpose of this Group is to review the operational procedures for deploying the police on or near to rail tracks. We will finalise a real time pursuit policy, including communications arrangements, between the three control centres by the end of September 2025 with plans to communicate the revised procedures to those affected by the end of October 2025. To support this, the need for additional rail safety training for Metropolitan Police officers will also be reviewed with a conclusion to be reached by the end of October 2025.
Conclusion
I would like to offer again my heartfelt sympathy and condolences to Mr English’s family and friends. We are determined as an organisation to learn lessons from this tragic incident.
I hope this response is helpful and welcome. Please contact me if I can be of any further assistance.
Inquest touching the death of Robert Gray English
I write on behalf of Transport for London (TfL) regarding the Senior Coroner’s Regulation 28 Prevention of Future Deaths (PFD) report dated 25 July 2025 following the inquest touching the death of Robert Gray English.
I would like to take this opportunity to repeat, on behalf of TfL, our sincere condolences to the family and friends of Mr English for their tragic loss.
Prevention of Future Deaths (PFD) report
After the inquest, the Senior Coroner sent a PFD report to TfL raising the following matter of concern:
‘The provision to protect a trespasser at night are the same as those during the day. The ability to locate a person close to or on the railway lines at night is made more difficult by the absence of suitable lights on the track or the train. In this case Mr English was not seen and run over by the train that has been asked to look for a person on the line.’
I am grateful to the Senior Coroner for raising these concerns and we set out below TfL’s response.
TfL’s approach to track searches on the Underground network
TfL has well established rules for undertaking track searches when there are reports of persons on or about the track. However, we recognise, through recent events, including the death of Mr English, learning opportunities to further enhance safety on our network by updating our operational rules, associated training and the equipment used during such incidents.
On 12 May 2025, we updated our operational rules related to track searches. Our rules now require our teams to physically search the track environment where there is any doubt about the identity of an object on or around the track environment.
We are also in the process of changing our Rule Book to remove existing references to a train undertaking a track search operating at ‘slow speed’. Under our new operational rules, train operators will be given very specific instructions, requiring them to operate ‘at a speed of no more than 10mph, or the closest speed value available on lines with automatic train operation’. This will better manage the speed at which trains travel through the affected area. The Rules will be formally updated and briefed to our train operators by the end of October
2025.
These two rule changes acting together strengthen our track searching arrangements in contexts where there is either a report of an obstruction or a report of a person on or around the track environment.
You highlighted the need for more suitable lighting for locating a trespasser at night. We are actively assessing options for new equipment to provide additional lighting.
We have started testing a prototype lighting rig which allows a new type of torch to be mounted inside the train operator’s cab. This torch has an adjustable output of up to 100,000 lumen, providing enhanced lighting of track in open-air night- time conditions.
We will continue to test this prototype over the next few months to fully assess its capability, risk assess it for use on the operational railway and identify any improvements required. We will conclude this test by December 2025.
Should this lighting rig be successful, and following appropriate internal assurance, we would roll this out in 2026 across the LU network (for the open-air sections of track).
Effective communications
As part of our investigation into Mr English’s death, we recognise the opportunity to make communication between our operational staff and police more robust. As a result, we have established a review group comprising of representation from TfL Compliance, Policing, Operations and Security, the TfL Rail Control Centre, the Metropolitan Police Service and the British Transport Police. The purpose of this Group is to review the operational procedures for deploying the police on or near to rail tracks. We will finalise a real time pursuit policy, including communications arrangements, between the three control centres by the end of September 2025 with plans to communicate the revised procedures to those affected by the end of October 2025. To support this, the need for additional rail safety training for Metropolitan Police officers will also be reviewed with a conclusion to be reached by the end of October 2025.
Conclusion
I would like to offer again my heartfelt sympathy and condolences to Mr English’s family and friends. We are determined as an organisation to learn lessons from this tragic incident.
I hope this response is helpful and welcome. Please contact me if I can be of any further assistance.
The Department for Transport stated that Transport for London (TfL) is wholly responsible for the operational safety of the London Underground network and has responded separately to the coroner's concerns.
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Dear Andrew,
Thank you for sending your Report on the Prevention of Future Deaths dated 25 July 2025 relating to the death of Robert Gray English on 19 May 2024, who was electrocuted on a section of track between Hendon Central Station and Burnt Oak Underground.
Any death on the transport network is a tragedy. We look to the relevant operators to ensure that they have systems in place to protect staff, travellers and the wider public, in line with their duties under the Health and Safety at Work Act (etc.) 1974 as well as the Railways and Other Guided Transport Systems Regulations 2006 (as amended). These latter regulations provide the regulatory regime for rail safety, including the mainline railway, metros (including London Underground), tramways, light rail and heritage railways. They require operators to comply with relevant safety, operational and technical standards before operators can apply for safety authorisation or safety certification to use vehicles or infrastructure on the railway.
Transport for London (TfL) are wholly responsible for the operational safety of the London Underground network, and I understand that they have now responded to you, setting out how they are addressing the findings of your report. I understand that the actions TfL are taking will be implemented rapidly, which reflects the seriousness with which they take their responsibilities.
OFFICIAL
Thank you for sending your Report on the Prevention of Future Deaths dated 25 July 2025 relating to the death of Robert Gray English on 19 May 2024, who was electrocuted on a section of track between Hendon Central Station and Burnt Oak Underground.
Any death on the transport network is a tragedy. We look to the relevant operators to ensure that they have systems in place to protect staff, travellers and the wider public, in line with their duties under the Health and Safety at Work Act (etc.) 1974 as well as the Railways and Other Guided Transport Systems Regulations 2006 (as amended). These latter regulations provide the regulatory regime for rail safety, including the mainline railway, metros (including London Underground), tramways, light rail and heritage railways. They require operators to comply with relevant safety, operational and technical standards before operators can apply for safety authorisation or safety certification to use vehicles or infrastructure on the railway.
Transport for London (TfL) are wholly responsible for the operational safety of the London Underground network, and I understand that they have now responded to you, setting out how they are addressing the findings of your report. I understand that the actions TfL are taking will be implemented rapidly, which reflects the seriousness with which they take their responsibilities.
OFFICIAL
The Railway Safety and Standards Board (RSSB) stated that its standards do not apply to the London Underground network, as it is a metro system and not part of the mainline railway. Therefore, RSSB is not proposing to take any action regarding the concerns.
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94/248/Response to Regulation 28 - 3 ~ 4147-7373-0655 v.1.docx
IN THE BARNET CORONER’S COURT INQUEST TOUCHING THE DEATH OF ROBERT ENGLISH _____________________________________________________________________________ RSSB RESPONSE TO REGULATION 28: REPORT TO PREVENT FUTURE DEATHS _____________________________________________________________________________ The Rail Safety and Standards Board (“RSSB”) is an independent body for the mainline railway, established to manage industry standards across organisation and technical boundaries, which includes annual rail industry level safety performance reporting. RSSB produces standards on behalf of the mainline railway of Great Britain. The standards directorate within RSSB manages the delivery of these standards and supports collective rail industry decisions related to changes to standards. The mainline railway of Great Britain is defined in the Railways and Other Guided Transport (Safety) Systems Regulations (2006) (as amended). London Underground-owned infrastructure, including the Northern Line, is not part of the mainline railway (it is a metro system) and so RSSB standards do not apply to London Underground. The operating context of the mainline railway can be different to London Underground. The current regulation for mainline train headlamps is the Locomotives and Passenger National Technical Specification Notice, enforced by the Railways (Interoperability) Regulations 2011 (as amended). The mainline rules for train drivers responding to reports of trespassers require a driver to proceed ‘at caution’. This requires drivers to be able to stop within the distance that they can see to be clear. As the rule is the same irrespective of lighting conditions, this means in practice, drivers are likely to travel at a lower speed when proceeding at caution in darkness than in daylight. In darkness the above regulations mean that the headlamps are designed to illuminate the track when proceeding at caution. As trains principally drive to signals rather than on sight on national mainline infrastructure to which access is normally restricted (by fencing, for example), it is not reasonably practicable to provide continuous lineside illumination. From safety reporting data for the mainline railway since 2015, there are no recorded instances of a trespasser being struck by a train when the train driver was instructed to run at caution. For the reasons set out above, RSSB are not proposing to take any action. Dated: 3 September 2025
IN THE BARNET CORONER’S COURT INQUEST TOUCHING THE DEATH OF ROBERT ENGLISH _____________________________________________________________________________ RSSB RESPONSE TO REGULATION 28: REPORT TO PREVENT FUTURE DEATHS _____________________________________________________________________________ The Rail Safety and Standards Board (“RSSB”) is an independent body for the mainline railway, established to manage industry standards across organisation and technical boundaries, which includes annual rail industry level safety performance reporting. RSSB produces standards on behalf of the mainline railway of Great Britain. The standards directorate within RSSB manages the delivery of these standards and supports collective rail industry decisions related to changes to standards. The mainline railway of Great Britain is defined in the Railways and Other Guided Transport (Safety) Systems Regulations (2006) (as amended). London Underground-owned infrastructure, including the Northern Line, is not part of the mainline railway (it is a metro system) and so RSSB standards do not apply to London Underground. The operating context of the mainline railway can be different to London Underground. The current regulation for mainline train headlamps is the Locomotives and Passenger National Technical Specification Notice, enforced by the Railways (Interoperability) Regulations 2011 (as amended). The mainline rules for train drivers responding to reports of trespassers require a driver to proceed ‘at caution’. This requires drivers to be able to stop within the distance that they can see to be clear. As the rule is the same irrespective of lighting conditions, this means in practice, drivers are likely to travel at a lower speed when proceeding at caution in darkness than in daylight. In darkness the above regulations mean that the headlamps are designed to illuminate the track when proceeding at caution. As trains principally drive to signals rather than on sight on national mainline infrastructure to which access is normally restricted (by fencing, for example), it is not reasonably practicable to provide continuous lineside illumination. From safety reporting data for the mainline railway since 2015, there are no recorded instances of a trespasser being struck by a train when the train driver was instructed to run at caution. For the reasons set out above, RSSB are not proposing to take any action. Dated: 3 September 2025
Report Sections
Investigation and Inquest
On the 24th May 2024 I commenced an investigation into the death of, Robert Grey English, aged 32. The investigation concluded at the end of the inquest on 10th June 2025. The conclusion of the inquest was Consequences of a failure to follow the proper process to recover a person from a stretch of railway. The medical cause of death was 1a Electrocution.
Circumstances of the Death
On the 19th May 2024 Robert Gray English was electrocuted when the power supply to the rails was Switched on over a section of track between Hendon Central Station and Burnt Oak Underground, (covering Colindale Station), which he had been travelling down on foot in the dark. A train, that had been held stationary, began to search the track, then ran over Mr English who had passed some 400 to 600 meters from Colindale Station. The train was not adequately equipped to conduct such a search in darkness and this response was inadequate. A little earlier in the evening two police officers had followed Mr English into Colindale railway station having formed the view that he may be unwell and sought to contain him rather than restrain him. Mr English, who may have been confused by the actions of the police, ran to the platform where the police again tried to contain him. Mr English then left the platform and made his way into the night beyond the station. The Local Station Manager asked for the power supply to the track to be turned off. The police officers saw him climb up a part of the fence but was not able to say whether he had climbed over. Members of the public, when the officers passed them, gave in answer to their questions the impression that Mr English had left the trackside and was in the park. This was factually incorrect as neither officer saw Mr English climb over the fence into the park. The officers believed that this might have been the case and made their way to the park where they were told by a member of the public that a person has been seen on the railway side of the fence. Whilst the officers had left to look for Mr English in the park the Local Station Manager was asked to go to the platform and confirm that the police officers were still on the platform by a Service Manager and for confirmation that Mr English had left the track area. The Local Station Manager confirmed that the police had left and that the passenger was nowhere to be seen and that the police did say that he climbed over the fences and has left the tracks. The Service Manager asked the Local Station Manager to contact the controller on his behalf so the power to the track can be switched on. The requirements within the rule book when switching the power supply to the rails were not followed in particular telling all the relevant people that the power supply to the rails is about to be switched on. This would have given the Police and British Transport Police an opportunity to confirm that Mr English had not been found and was likely still on the railway side of the tracks. It is likely that had this step been followed the power supply would not have been switched on and a proper search, which was also possible, is likely to have found Mr English and returned him safely to the station.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.