Network Rail

PFD Addressee
Reports: 39 Earliest: Feb 2014 Latest: 5 Aug 2025
PFD Reports
39 results
Simon Moore
All Responded
2025-0404 5 Aug 2025 Dorset
Suicide
Concerns summary (AI summary) A lack of communication protocol meant critical welfare information from a distressed train driver was not relayed from the signaller to the attending Driver Manager, hindering timely mental health assessment.
Action Planned (AI summary) Network Rail is developing industry guidance on welfare communications and has set up an Industry Working Group on Welfare Communication. The SWR investigation report was considered at the NR SPAD Recommendations and Review Panel.
Jody Robb
All Responded
2025-0330 1 Jul 2025 County Durham and Darlington
Railway related deaths Suicide
Concerns summary (AI summary) Inadequate physical barriers and non-deterrent design allowed track access, compounded by train crews failing to report a person on the tracks despite multiple trains passing, hindering intervention.
Action Planned (AI summary) Network Rail has applied for planning permission to increase the height of the parapet on the viaduct and curve it inwards, installing a safety barrier. The design stage is underway and it is hoped the works can be completed by the end of the financial year, subject to planning permission.
Vanessa Ford
Partially Responded
2024-0125 4 Mar 2024 Inner North London
Railway related deaths
Concerns summary (AI summary) Frequent public access to railway tracks is facilitated by low walls, ineffective safety measures, and street furniture, posing significant risks, including to vulnerable individuals and children.
Action Planned (AI summary) Hackney Council has removed recycling bins near Martel Place and is in discussions with highways and planning to improve identifying and flagging electrical apparatus and street furniture at such locations. Network Rail is working with the Local Authority to explore if further measures can be implemented to address the specific concerns identified by this incident. Works have already been scheduled to be undertaken on during early May to the access gate at Martel Place to increase the height and Vanguard anti-climb rollers may be installed.
Fraser Moore
Historic (No Identified Response)
2023-0497 4 Dec 2023 Inner South London
Railway related deaths
Concerns summary (AI summary) Inadequate CCTV coverage beyond station platforms and failure to immediately transmit footage to Route Control rooms increase the risk of undetected incidents in busy stations.
Tamsin Dolamore
All Responded
2023-0160 12 May 2023 Cornwall and the Isles of Scilly
Other related deaths
Concerns summary (AI summary) High vacancies for detectives handling rape and serious sexual assault cases cause significant delays in securing best evidence, impacting both case quality and volume of work.
Noted (AI summary) Dorset Police are launching Project Synergy to improve their investigative operating model and increase the resilience and wellbeing of investigative teams. They are recruiting a Detective Chief Superintendent to lead the project, which includes forming investigative hubs and introducing investigation support officers. The Ministry of Justice acknowledges the coroner's recommendations and highlights existing and planned government actions related to funding victim support services, improving SARC provisions, and implementing the Victims and Prisoners Bill. Response notes Chief Constable will address concerns about rape investigation caseload. Network Rail has instructed the raising of the parapet at Menacuddle Hill/North Street Bridge to a minimum of 1250mm above adjacent surface level, with an additional course of stonework from an existing minimum height of 990mm. The current timescale for completion of the project is one year from instruction. Cornwall Council acknowledges the complexity of funding for sexual violence recovery services and states that there is no record of Ms. Dolamore having contact with the Council's children's or adult social care services. It describes the Early Help Hub and training offered to professionals.
Hassan Zubair
All Responded
2022-0150 19 May 2022 East London
Railway related deaths
Concerns summary (AI summary) A signals controller failed to advise trains to proceed with caution, indicating a critical lapse in railway safety protocol.
Action Taken (AI summary) Network Rail enhanced the reporting system between Network Rail and MTR for Signallers to contact the station directly, allowing station staff to provide rapid assistance to individuals and workshops have also been undertaken to train relevant staff.
Gregory Barber
All Responded
2021-0429 24 Dec 2021 West Yorkshire (Eastern)
Mental Health related deaths Railway related deaths Suicide
Concerns summary (AI summary) Network Rail failed to implement recommended mitigation measures to curtail access to railway tracks at a specific high-risk location, leaving a vulnerability unaddressed despite police warnings.
Action Planned (AI summary) Network Rail is procuring the installation of 8 metres of 2.4m palisade fencing behind a parapet wall and will close off gaps at either end of the new fence, with work expected to commence the week of March 7, 2022 and be completed within two weeks.
Christine Gould
All Responded
2021-0185 28 May 2021 Cambridgeshire and Peterborough
Child Death Police related deaths Railway related deaths
Concerns summary (AI summary) Investigations into railway suicides by BTP and Network Rail risk missing vital mitigating measures by too readily assuming a single point of access, rather than keeping an open mind about alternative routes.
Action Taken (AI summary) Network Rail is upgrading the fencing between Cherry Hinton and Teversham level crossings to 1.8m palisade fencing and has completed a significant portion of the upgrade. They are also reviewing their post-incident fence check process. The British Transport Police has created a single Fatality Investigation Team, trained frontline staff, and implemented procedures for Post Incident Site Visit (PISV) reports. They are working with Network Rail to establish regular meetings to discuss PISV reports and improvement considerations.
Callum Evans
All Responded
2021-0159 18 May 2021 Hampshire, Portsmouth and Southampton
Alcohol, drug and medication related deaths Railway related deaths
Concerns summary (AI summary) A lack of visible and prominent signage regarding the live electrified third rail at the railway station meant individuals were unaware of its presence and life-threatening danger.
Action Taken (AI summary) Network Rail has installed additional safety measures at stations, including Hinton Admiral, such as platform end gates, yellow hatching warning lines and anti-trespass matting and conducts campaigns to warn of the dangers and target people at risk and high-risk areas.
Jordan Aira
Partially Responded
2020-0082 30 Mar 2020 Surrey
Child Death Railway related deaths
Concerns summary (AI summary) Absence of physical barriers at platform ends, location of emergency phones near tracks, inadequate warning signs about live rail dangers, and lack of related education in the national curriculum create significant railway safety risks.
Noted (AI summary) SWR outlines existing signage at Ashford station and describes its participation in national campaigns and initiatives to raise awareness of railway safety and reduce trespassing. They do not consider further action is required, but will continue to engage with the wider rail group. Network Rail describes existing measures to prevent access to the railway tracks, including physical barriers and signage, as well as ongoing educational programs and safety campaigns. They have reduced overall trespass incidents by 24% and youth trespass by 32% in two years.
Patrick Bolster
All Responded
2019-0314 25 Sep 2019 London Inner (North)
Railway related deaths
Concerns summary (AI summary) A broken fence was not inspected for over two years due to dense vegetation blocking the view, inspectors failed to view the fence from the public side, and system failures led to the track engineer and internal auditors not seeing evidence of the failure to inspect the fence.
Action Planned (AI summary) Network Rail is issuing a National Safety Bulletin to Off Track teams, completing a special topic audit on compliance with the new boundary inspection standard, and reviewing national data. These actions are tracked via the Network Rail CMO-Compliance Tracked Action system.
Ben Haddon-Cave
All Responded
2019-0314-wp26824 25 Sep 2019 London Inner (North)
Railway related deaths
Concerns summary (AI summary) Railway fence inspection failures, exacerbated by dense vegetation and inadequate viewing practices, alongside systemic flaws in dual inspection reporting, led to a lack of oversight and repair.
Action Planned (AI summary) • A National Safety Bulletin will be issued to all Off Track teams, which are the Network Rail maintenance teams that carry out boundary inspections. • The National Safety Bulletin will reference the key learning from this tragic event, specifically stating that where a team is unable to view a boundary fence from trackside due to vegetation, they must view the fence from the other (public) side. • The National Safety Bulletin will also state that if the fence cannot be viewed from either side, the team must record this and escalate it to their supervisor.
Carl Klimaytys
All Responded
2019-0276 7 Aug 2019 Brighton and Hove
Railway related deaths
Concerns summary (AI summary) The fact that a member of the public discovered the body on the railway platform raises concerns about monitoring and detection systems.
Noted (AI summary) Network Rail clarifies that Govia Thameslink Railway (GTR) is responsible for signage at Preston Park station under the terms of their lease and that Network Rail supports safety awareness programmes, including the 'You vs Train' film, and runs seasonal publicity campaigns warning about the risks of excessive alcohol intake on the railway. GTR has enhanced training for Help Point Assessment, including functional tasks and a competency management system. Information resources now include access to a 'Track Access' system and the Stations Made Easy section of National Rail Enquiries.
Colin Cameron
All Responded
2019-0218 26 Jun 2019 Gloucestershire
Railway related deaths
Concerns summary (AI summary) Signallers lacked instructions for extracting information from users, and authorities had not sufficiently considered closing the railway crossing.
Noted (AI summary) Network Rail states that instructions *are* provided to signallers, and closing the crossing would require agreement from the authorised user, for which compensation has been offered. They have also contacted the public rights of way officer at Gloucestershire County Council to consider the feasibility of extinguishing or diverting the bridleway.
Steven Key
All Responded
2019-0102 25 Feb 2019 Cumbria
Railway related deaths Suicide
Concerns summary (AI summary) Inadequate low fencing at the railway line allowed easy access, posing a significant risk of death or injury from high-speed trains to both adults and children, despite a clear duty to prevent access.
Action Taken (AI summary) Network Rail has installed additional meshing and netting at the location. They will investigate whether affixing a mesh to the galvanised iron tubular hand rail safety rail at the top of the bridge could make this area more secure.
Richard Hill
All Responded
15 Nov 2018 Nottinghamshire
Railway related deaths
Concerns summary (AI summary) The railway crossing lacked essential telephones and Network Rail contact information, posing a risk of repeat incidents due to inadequate emergency communication at the site.
1 response from Richard Hill
Ryan Williams
Historic (No Identified Response)
2018-0341 6 Nov 2018 Bedfordshire & Luton
Railway related deaths
Concerns summary (AI summary) Unsupervised, unmanned stations pose a risk, as vulnerable individuals can remain on premises for extended periods without any oversight or means of intervention.
Kevin Sherwood
All Responded
2018-0289 11 Sep 2018 Hertfordshire
Railway related deaths Suicide
Concerns summary (AI summary) Insufficient railway boundary fencing, consisting only of post and wire, in an area frequented by walkers, creates a risk of trespass onto the train line.
Action Planned (AI summary) Network Rail has increased the frequency of fence inspections to three-monthly and scheduled renewal of the fencing in the Inckneild Hitchin area for 2019/2020. Platform End Anti-trespass measures have been added to Hitchin Station.
Darren Urquhart
Historic (No Identified Response)
2018-0291 10 Sep 2018 Hertfordshire
Railway related deaths
Concerns summary (AI summary) Inadequate railway anti-trespass measures, including poor trespass mat placement, missing platform gates, and insufficient fencing, create a risk of future deaths from track access.
Taiyah-Grace Peebles
All Responded
2018-0239 24 Jul 2018 North East Kent
Railway related deaths
Concerns summary (AI summary) Many railway platforms lack barriers to prevent accidental contact with live rails, which pose a significant electrocution risk compared to safer overhead power systems used elsewhere.
Action Taken (AI summary) Platform-end gates have been installed at 30 locations in Kent and Sussex. £800,000 of work is due to be completed by April 2019 to improve fencing at higher risk areas.
Bartholomew Coleman
All Responded
2018-0250 10 Jul 2018 Dorset
Railway related deaths
Concerns summary (AI summary) The railway line is easily accessible from a bridge with a low wall, showing signs of frequent public use and alcohol consumption, without adequate warning of danger.
Action Planned (AI summary) Network Rail is planning to apply mitigation measures (wire mesh panels with base plated fence posts fixed to the top of the parapet walls) to further deter access to the track below, with an anticipated completion date of the end of September 2018. They will also erect a warning sign of the dangers presented.
Andrew Hanahoe
All Responded
2018-0184 19 Jun 2018 Bedfordshire & Luton
Suicide
Concerns summary (AI summary) A railway foot crossing lacked adequate safety measures, including proper fencing, warning lights, or trespass deterrence, despite high-speed trains, posing a significant risk.
Action Taken (AI summary) Network Rail has trained over 20,000 railway staff to intervene with people who may be at risk of suicide, funded and implemented a team of eight patrollers in the Thameslink area to conduct suicide prevention patrols, and engaged with the local authority to discuss community-based suicide prevention measures. They also highlight existing fencing and risk assessment protocols.
Scott Rayner
All Responded
2017-0345 20 Dec 2017 Hertfordshire
Railway related deaths
Concerns summary (AI summary) Inadequate fencing adjacent to the railway track, specifically behind a scrap metal dealer, presented a significant risk of trespass onto a high-speed line for both adults and children.
Action Taken (AI summary) Following a post-incident report, Network Rail inspected boundary fencing around St Albans Road and Bedford Street, and completed enhancement work on 22 February 2018, including installing additional palisade fencing in the area.
Sarah Athersmith
Partially Responded
2017-0350 30 Nov 2017 Black Country
Child Death Railway related deaths
Concerns summary (AI summary) An unprotected level crossing lacked warning systems, causing confusion when multiple trains passed, and double-height freight carriages obscured views, increasing pedestrian danger.
Noted (AI summary) Network Rail confirms that the crossing was closed to members of the public on 26 September 2017 via temporary order granted by Walsall Local Authority and remains closed today. In 2016 enhancements were made including extending the crossing deck, installing low level solar lighting studs, and de-vegetation works. Walsall MBC are undertaking an urgent review of Network Rail's revised closure application and continue to provide assistance and guidance to Network Rail in the closure application process. As Walsall MBC is not the landowner, it has no authority to convert the crossing into a controlled crossing.
Harminder Dhillon
All Responded
2017-0266 6 Nov 2017 Bedfordshire and Luton
Railway related deaths
Concerns summary (AI summary) The level crossing lacked CCTV monitoring and was prone to misuse due to insufficient half-barriers. The coroner suggested full-length barriers to prevent future incidents.
Action Planned (AI summary) Network Rail is developing additional enhancements targeting accidental and deliberate misuse at Automatic Half Barrier Crossings (AHBCs). The Marston level crossing is scheduled to be replaced by a vehicular road bridge in 2019.