Dear Senior Coroner Bhardwaj,

Inquest touching the death of Sam Alexander Dudley- Response to Regulation 28 Report

Following the inquest touching the death of Sam Alexander Dudley, this letter sets out Network Rail Infrastructure Limited’s (“NRIL”) response to the Regulation 28 Report dated 05 February 2026 (“the Report”). NRIL’s sincere condolences remain with Mr Dudley’s family and friends following his tragic death. The safety of passengers, railway staff and members of the public who use or interact with the railway is at the heart of everything NRIL does, and the issues raised by the Coroner have been given careful and considered attention.

HM Senior Coroner’s Concern and the Inquest Findings

The Report identifies a concern that there is a risk of future deaths occurring unless action is taken, arising from the positioning and nature of signage at footpath level crossings and, in particular, the increasing prevalence of distraction associated with the use of earphones or headphones. The Report also recognises that, in the circumstances of this case, it was not considered that the presence of additional signage would have altered the tragic outcome. NRIL has carefully considered the matters raised and welcomes the opportunity to respond.

The inquest heard evidence, including from independent investigations, which established that the Hoggs Hill Level Crossing was safe, compliant and operating as designed at the time of the incident. It was demonstrated that the miniature stop lights and audible warning system were functioning correctly, and that no causal or contributory failings were identified in the inspection, maintenance or management of the crossing. The conclusion reached was that it was more likely than not that Mr Dudley proceeded onto the crossing while distracted, having entered the crossing while a red light was displayed and the audible warning was sounding.

Understanding Distraction and the Role of Design

NRIL recognises that distraction, including from personal audio devices, is an increasing societal issue and one which requires careful and proportionate consideration. For this reason, in 2025, NRIL commissioned independent behavioural research into accidental human error at passive level crossings, which includes crossings fitted with miniature stop lights and audible warnings. This research examined why pedestrians may fail to stop, look and listen, including the role of distraction, habitual use of crossings and misperception of train speed and distance. The research concluded that there are no simple or low-cost interventions that can eliminate risk at passive level crossings, and that the most effective long-term measures are those which reduce reliance on individual judgement through system-led cues.

The findings of this research have informed NRIL’s wider approach to level crossing safety and its ongoing consideration of signage, warnings and crossing design. In parallel, NRIL has undertaken a review of level crossing signage more generally, recognising that signage must be clear,

OFFICIAL proportionate and positioned where it will be most effective. This work has identified that excessive or poorly positioned signage can reduce effectiveness by contributing to visual clutter, particularly for regular users of crossings: this is consistent with findings made by the RAIB as long ago as 2005 following an incident at Elsenham, when its report determined that “Whilst each individual sign is clear in meaning the combination of signage has the potential to be confusing.” [Para. 152]. As a result, NRIL is progressing work to review existing signage, remove duplication where appropriate, and ensure that remaining safety-critical messages are positioned as close as reasonably practicable to the point at which users make the decision whether to cross (commonly referred to as the “decision point”).

The aforementioned consideration of level crossing signage, including its positioning, content and effectiveness, formed part of NRIL’s ongoing safety and standards work which was already under review prior to the inquest. The approach to signage at level crossings is governed by a national framework, and in particular The Private Crossings (Signs and Barriers) Regulations 2023 which represented a complete re-design of signage at private and public level crossings (not road crossings). There is no sign within those Regulations asking people to remove headphones.

As a result, NRIL cannot introduce new or novel signage on a site-by-site basis without appropriate consideration. Signage is required to comply with statutory requirements and established standards, and changes to the design or use of signage are developed through an evidence-led process involving the rail industry and the Department for Transport, with oversight from the Office of Rail and Road. This process is intended to ensure consistency, clarity and effectiveness across the national network, and to avoid unintended consequences arising from untested or inconsistent interventions.

The Report raises specific concern about the limited signage positioned on pedestrian gates immediately prior to the decision point, and suggests that clear pictorial signage on the gate, such as an image of earphones with a line through them, may help alert users at the right moment. NRIL has carefully considered whether the introduction of such pictorial signage would be likely to reduce risk. While visual cues can attract attention, behavioural evidence indicates that the introduction of additional signage does not always result in changes to behaviour and may risk adding to information overload if not carefully designed and evaluated. As indicated above, signage ‘clutter’ has been shown to result in reduced levels of attention meaning people do not read any sign at all. Accordingly, NRIL’s approach is to try to focus the user on the important safety instruction of how to actually cross that specific crossing safely.

NRIL also notes that, as explained during evidence called at the inquest, the physical design of footpath level crossings is intended, so far as is possible, to draw users out of distraction at the point of highest risk. At Hoggs Hill, the requirement for users to manually open and pass through a pedestrian gate before reaching the tracks is a deliberate design feature, intended to slow approach speed, create a pause, and focus attention on the warning systems and signage beyond the gate. Where practicable, such physical interventions are used to complement visual and audible warnings and to reduce reliance on continuous user attention alone.

Signage Framework, Future Consideration and Risk Management

Alongside signage and behavioural considerations, NRIL continues to prioritise engineering and design-based measures at footpath level crossings where reasonably practicable. This includes the installation and roll-out of miniature stop lights and supplementary audible warning devices at appropriate locations, improvements to crossing surfaces and approaches so that crossings are clearly recognisable as hazardous environments, and consideration of physical design features that encourage users to slow down and pause before crossing. Decisions in relation to such measures are informed by site-specific risk assessments, usage data and professional judgement considering both the safety benefits and any unintentional consequences.

OFFICIAL In addition, NRIL undertakes education, engagement and awareness activity at both a national and local level, working with partner organisations to promote safe behaviour around the railway and at level crossings. This forms part of NRIL’s wider strategy to improve understanding of risk and to reinforce safety messages beyond the physical infrastructure alone.

NRIL continues to review fatality and near‑miss data across the national network in order to identify trends and emerging risks. As set out above, NRIL recognises that distractions are becoming more prevalent, including from the use of personal technology, and the impact of distractions in various forms is an area of active research and consideration. Notwithstanding this, distraction is monitored and tracked at a national level, and learning from incidents, internal investigations and external reviews is shared within the organisation and used to inform standards, guidance and future risk assessments.

Conclusion

Taken together, the evidence heard at the inquest and the steps outlined above demonstrate that the safety arrangements at Hoggs Hill were appropriate and that HM Senior Coroner’s concerns are consistent with work already underway within NRIL’s national safety framework. This work reflects careful consideration of the issues raised and a continued commitment to proportionate, evidence-led risk reduction at footpath level crossings.