Dear Mr Cohen,

Regulation 28 Report to Prevent Future Deaths dated 24 August 2023 with Case Reference concerning the death of Mr Gordon Alexander John Rodger on 2nd March 2023 in the Askam-in Furness area of Cumbria (the “Report”)

I refer to your Report made under Paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

I would like to take this opportunity to express my sincere condolences to the family of Mr Rodger.

I would also like to apologise for the delay in submitting Network Rail Infrastructure Limited’s (“Network Rail”) response, which, unfortunately, resulted from your Report being inadvertently sent to an incorrect e-mail address. Network Rail receives a lot of correspondence and to ensure it is routed to the proper recipient in good time please ensure requests for information from Network Rail are copied to the notices@networkrail.co.uk email address.

Please be assured that Network Rail take all incidents of this nature on the railway incredibly seriously and upon being made aware of your Report we have carefully considered the matters raised in it.

Network Rail has a duty under the Railway Safety (Miscellaneous Provisions) Regulations 1997 to prevent unauthorised access to the railway line so far as is reasonably practicable (Regulation 3 – please see below).

Your Report stated the following two matters of concern:

1) “In the course of the inquest I heard that British Transport Police had recommended to Network Rail that they consider installing "anti-trespass treads and gates to the north end of Platforms on Askam station if operationally possible". By a letter to the Court dated 5th June 2023 Network Rail indicated that they had decided not to take this step. They explained that Askam station is rural, that limited resources dictate which works are prioritised and that there is no history of trespass.”

OFFICIAL

2) “In the course of the inquest the court heard that the line in this location is more accessible that might usually be expected, including by stiles in nearby fences associated with a nearby golf club. In the circumstances I am concerned that the line may be readily accessible to individuals who wish to harm themselves.”

Concern 1

Platform end barriers and anti-trespass treads can provide an effective counter measure to prevent individuals easily accessing the running lines from platforms. Installing physical barriers at the end of a platform can lead to a change in the behaviour of an individual prior to them accessing the infrastructure. That said the face of the platform adjacent to the line will always be exposed to easy access in order to allow passengers to get on and off trains, and access to the infrastructure can also be gained from line crossings if an individual is determined to access the infrastructure.

There is no Network Rail or railway industry standard or requirement to have platform end gates and matting at stations unless a new platform or station is being built.

Network Rail takes its safety obligations seriously and we do take additional measures beyond those required by internal and rail industry Standards where possible, to install additional fencing and anti- trespass matting when budget and resource allows.

British Transport Police made a formal consideration concerning the “installation of anti-trespass treads and gates if operationally possible” to the north end of platforms on Askam station. Network Rail responded to that consideration explaining this consideration would “get added to the route crime and suicide prevention action tracker pending future budget, resource and priorities”. Network Rail informed the Court by letter dated 5th June 2023 that “[a]s this is a rural station with no identified issues of reported trespass, there are no current plans to undertake the suggested work at this location”. These works however remained under review on the route crime and suicide prevention action tracker. Network Rail’s funding is structured into five-year delivery periods. Control Period 6 ended at the end of March 2024 and CP7 started in April 2024. Utilising Control Period 7 (known as CP7) funding Network Rail intends to install platform end gates and anti-trespass matting at locations in Cumbria identified as potentially requiring such installations by post incident site visits, including Askam station.

This is a proactive activity that is in addition to applicable internal and external standards. Askam station had already been identified by Network Rail prior to the Report being received by Network Rail and installation of platform end gates and matting at the north end of Askam station has been included in the CP7 work bank. We are aiming for completion of the whole work bank by 31st March
2026. This timeframe is necessary given internal processes for project delivery which includes a scoping and deliverability review, project estimate, authority paper and panel approval, engineering assurance process in line with applicable Network Rail Standard NR/L2/CIV/003 followed by implementation. We will aim to accelerate this process where reasonably practicable, based on the risk profile of this location, however it should be noted that the installation is part of a wider work bank that will be prioritised by risk profile which includes a mix of locations with varying risk profiles. We envisage a detailed delivery programme will be available by 30th September 2024 and we will aim to provide a further update in due course.

OFFICIAL Concern 2

It is the nature of the Cumbrian Coast Line that traverses rugged coastal countryside that there are agricultural and public right of way crossing points. Along this section of this line there are three established and legitimate crossing points:

1. Johnsons No.2 user worked crossing requiring telephone permission for agricultural use consisting of a seven-bar gate at the boundary;

2. Dunnerholne golf course public right of way foot crossing consisting of a stile at the boundary; and

3. Heybank public right of way foot crossing (adjacent to Dunnerholne golf course) consisting of wooden gate at the boundary.

Detailed information around how Network Rail manages level crossing safety can be found at this website: www.networkrail.co.uk/communities/safety-in-the-community/level-crossing-safety

In relation to the concern raised in your Report we instructed the Network Rail Delivery Maintenance Unit for the Askam area to undertake a full boundary inspection to verify the integrity of the boundary from Askam station to Heybank footpath crossing (between the points marked on the map extract below) being a distance of 1,430 yards including the boundary on both sides of the tracks.

Network Rail Standard reference NR/L2/OTK/5100 on the Management of Fencing & Other Boundary Measures, has been created to ensure Network Rail complies with its legal obligations regarding fencing and boundaries, including its obligation under Regulation 3 of the Railway Safety (Miscellaneous Provisions) Regulations 1997 to, so far as is reasonably practicable, where and to the extent necessary for safety, prevent unauthorised access to rail infrastructure.

OFFICIAL Fencing in the Askam station area was last inspected in June 2023 in accordance with Network Rail Standard reference NR/L2/OTK/5100. Under this Standard Network Rail undertakes inspections and remediation works identified as necessary are carried out following such inspections.

The Boundary Inspector’s report provided this month has found that all boundary fencing is in good condition and there is no evidence of trespass, or damage to the boundary fencing. This recent inspection undertaken w/c 11 March 2024 confirms that the fencing is in the same condition as the last inspection undertaken as per the NR/L2/OTK/5100 Standard in June 2023.

These inspections confirm that the majority of fencing along this section of line is a class 3 boundary (see below for boundary classification type details) that is consistent with the predominant adjacent land use in this area that is agricultural/livestock/woodland. There is a small section to both sides having a class 1 boundary (see below for boundary classification type details) where there is industrial use (on the one side) and where there is a road at Askham station level crossing.

The Network Rail Boundary Standard defines the fencing classification types as follows:

Class I fencing - Steel palisade, mesh panel and decorative metal railings, and non- conductive alternatives installed to a minimum height of 1800mm. Brick and mortar walls installed to a minimum height of 2000mm.

Class 2 fencing - Weld mesh, chain link, closeboarded timber and brick and mortar walls installed to a minimum height of 1800mm.

Class 3 fencing - Post and wire fence, livestock fence, post and rail or weld mesh fencing, dry stone or brick/stone and mortar walls installed to a minimum height of 1350mm.

This Standard requires Network Rail to inspect boundary fencing in the required timescales and if any deficiencies are identified to rectify via either repair or renewal in a timely manner.

Network Rail can confirm after checking the inspection download and reviewing the photos taken during the additional inspection undertaken in March, that the boundary fencing in the area inspected meets the requirements of the applicable Network Rail Standard and that there are no outstanding items of works. On this basis Network Rail does not believe that the line is readily accessible by means of deficient fencing nor by unauthorised crossing points and does not therefore believe further action is required in relation to boundary integrity in the area inspected (as defined above).

Network Rail manage the risks of rail suicide and vulnerable presentations in partnership with the wider rail industry and British Transport Police. We also work closely with suicide prevention experts, national agencies such as Public Health England and charities such as the Samaritans, Chasing the Stigma and Shout. Our activities aim to reduce rail suicide and vulnerable presentations. In recent years, the rail industry has made significant strides in understanding rail suicide and vulnerable presentations and in deploying measures to mitigate the risk. We continue to see suicide interventions, with rail employees, the Police and public intervening in more than 2,034 suicide attempts on the railway in 2022/23. Central to our programme is the belief that suicide is not inevitable and we can work collectively to reduce the traumatic loss of life and devastation that suicide causes.

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If there is any further information or clarification that Network Rail can provide in relation to the contents of this letter please let us know soonest.