Railway related deaths

PFD Category
Reports: 103 Areas: 39 Earliest: Nov 2013 Latest: 5 Feb 2026

75% response rate (above 63% average). 43% of classified responses show concrete action taken. Reports fell 30% from 10 (2023) to 7 (2024).

PFD Reports
64 results
Kaja Spiewak
All Responded
2022-0052 1 Dec 2021 West Sussex
Govia Thameslink Railway Ltd and and Ne…
Concerns summary (AI summary) Govia Thameslink Railway lacked mandatory staff training for vulnerable persons, used inappropriate protocols for welfare concerns, and failed to adequately log actions or share critical information with other agencies.
Action Planned (AI summary) Govia Thameslink Railway will use output from Operational Development Days to strengthen guidance to aid better decisions in respect to non-emergency concerns for welfare. This will reinforce the need to contact the BTP to frontline teams via training and staff briefings, supplementing the Samaritans TACTIC booklets. Network Rail and Govia Thameslink Railway have jointly created a new section within their joint incident management standard for dealing with vulnerable people. They have briefed all control room staff with the 'Concern for Welfare' briefing and shared it internally with all route controls nationally.
Croydon Tram Incident
All Responded
2021-0337 South London
Bombardier Transportation UK Ltd Light Rail Safety and Standards Board Transport Focus +9 more
Concerns summary (AI summary) The absence of a centrally funded national tram safety passenger group creates a significant systemic oversight for public safety.
Noted (AI summary) Bombardier Transportation (now Alstom) has completed a door vulnerability assessment, performed design reviews for current and future tram door systems, and engaged with suppliers regarding enhancements. They plan to finalize improvement actions and recommendations for door strengthening for both in-service and new tram fleets by March 2022, and engage with authorities to review UK regulation for light rail doors by April 2022. Transport for London has already procured, developed, and installed a bespoke Physical Prevention of Overspeed System (PPOS) on the London Tram network, reducing the risk of overturning by 76%. They are also investigating the feasibility of strengthening tram doors and will incorporate learnings into future fleet specifications. Tram Operations Ltd is already a member of CIRAS (Confidential Reporting for Safety) for anonymous staff reporting and publicises this to staff. Regarding passenger ejection through doors, they confirm they do not own the trams but welcome discussions with London Trams and would support implementation of strengthening if feasible. Transport Focus clarifies its limited remit and resources to initiate a centrally funded national tram passenger safety group. They state they will engage with operators on passenger safety issues brought to their notice and support any such group initiated by another body. The Department for Transport reports that the Light Rail Safety and Standards Board (LRSSB) has published guidance on driver inattention and speed management, and all tram networks in England now subscribe to the Confidential Incident Reporting & Analysis System (CIRAS). DfT is also consulting on establishing a national tram safety group and supports LRSSB's planned work on automatic braking systems, door strengthening standards, and promoting CIRAS. The Light Rail Safety and Standards Board is engaging with European Standards working groups to inform regulation on tram door security and crashworthiness, and plans to consult with TfL/London Trams to determine remedial actions. LRSSB will then publish a briefing or guidance note for the sector, with timelines to be confirmed. The LRSSB has published new Light Rail Guidance on Driver Inattention (LG3) and Light Rail Standards on Speed Management Systems (LS4), incorporating RAIB recommendations. They have also commissioned a trial of specific technology for driver inattention and speed management, with outcomes expected by January 2022. The Light Rail Safety and Standards Board confirms that all seven UK tramways already subscribe to the Confidential Incident Reporting & Analysis System (CIRAS). LRSSB further plans to produce a tramway-specific guidance note and communication campaign to promote the benefits of such schemes to front-line staff by March 2022.
Eleanor Rose Murphy-Richards
All Responded
2021-0237 11 Jul 2021 Mid Kent and Medway
North East London NHS Foundation Trust
Concerns summary (AI summary) The Child & Adolescent Mental Health Centre lacked protocols for Mental Health Act assessments and failed to create an adequate safety plan with clear responsibilities and contingencies for non-attending patients. Crucially, relevant information about a suicide attempt was not fully shared, and police advice didn't account for absconding history.
Action Planned (AI summary) The Trust is developing an updated electronic risk assessment proforma to prompt a review of the existing safety plan. The Trust will update its training for all staff in relation to the importance of safety plans and contingency planning and has arranged a meeting with the family to share learning and provide further reassurance in respect of improvements made within the service.
Heather Page
All Responded
2021-0213 23 Jun 2021 Nottinghamshire
Broxtowe Borough Council Derbyshire County Council Erewash Borough Council +1 more
Concerns summary (AI summary) Numerous pedestrian crossings require walking on tracks, contributing to a high fatality rate on a specific section, exacerbated by local authority opposition to track rationalisation efforts.
Noted (AI summary) Nottinghamshire County Council asserts its duty to protect public highway rights regarding level crossings, clarifies the roles of Network Rail and the public in crossing closures, and states it has been supportive of safety improvements. Derbyshire County Council provides an explanation of their previous involvement in a 2003 proposal to divert Public Footpath No.7, and clarifies that they will work with other agencies to improve safety across the County. Network Rail acknowledged past unsuccessful attempts to change level crossings in the area and expressed willingness to work with local authorities to find potential solutions. Broxtowe Borough Council has scheduled a meeting with Network Rail to seek potential solutions to concerns raised, and will provide further information after the meeting. Erewash Borough Council stated that they previously supported Network Rail's Level Crossing Closures Programme, and would still not oppose the closure of the Barton Road crossing if Network Rail recommends it, though they prefer an accessible footbridge.
Samantha Gould and Christine Gould
All Responded
2021-0184 Cambridgeshire and Peterborough
Cambridgeshire and Peterborough Foundat… Cambridgeshire County Council (CCC) The National Police Chiefs' Council
Concerns summary (AI summary) Police lacked follow-up with clinicians/parents and failed to inform mentally ill child abuse victims about their option to provide evidence later. There was no guidance for police on communicating with such vulnerable minors.
Action Planned (AI summary) The NPCC has implemented an immediate addition to the Authorised Professional Practice (APP) guidance for all UK Police Forces, focusing on police engagement with reluctant victims/witnesses and ongoing support strategies. The NPCC Lead is also communicating this change to Local Safeguarding Children Partnerships. Cambridgeshire County Council has launched the 'Strong Families Strong Communities' strategy (March 2021) and the YOUnited partnership (July 2021) to enhance emotional health and wellbeing services for children and young people, focusing on clear referral pathways and multi-agency support. The Trust is reviewing its AWOL policy (completion by Oct 2021), undertaking a full policy review over six months, reminding doctors of ICD 11 changes, and developing a new joint protocol for overnight assistance for high-need adolescent mental health patients.
Christine Gould
All Responded
2021-0185 28 May 2021 Cambridgeshire and Peterborough
British Transport Police Network Rail
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
Network Rail
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.
Mary Gwanyama
All Responded
2021-0117 21 Apr 2021 Surrey
Surrey and Borders Partnership
Concerns summary (AI summary) A vulnerable patient was prematurely discharged into homelessness from a mental health unit without proper planning, medical review, or adequate risk assessment, failing to follow Care Programme Approach guidelines.
Action Planned (AI summary) The Trust will update its CPA policy and Acute Care Services Operational Protocol to reflect that anyone who is homeless must have a CPA discharge meeting on the inpatient ward prior to discharge. The CMHRS Operational Policy is going to be updated, with specific attention to the ‘transition’ process to another Trust.
James Herbertson
All Responded
2021-0078 West Sussex
Horsham District Council
Concerns summary (AI summary) Inadequate discharge planning from a mental health hospital, including poor communication and unsuitable accommodation, left a vulnerable patient without proper support.
Action Taken (AI summary) Sussex Partnership NHS Trust has updated its Care Programme Approach policy to reduce follow-up time, revised guidance on home leave and discharge planning, and issued updated policies and guidance on MHA Section 17 leave and community care to all staff.
Clive Oxley
All Responded
2020-0301 23 Dec 2020 County Durham and Darlington
LNER and Network Rail
Concerns summary (AI summary) Inadequate barrier construction and fencing on a railway platform allowed a pedestrian to access the track, despite warnings, with previous similar incidents noted.
Action Planned (AI summary) Network Rail altered the southbound platform end at Durham station in December 2019 to deter pedestrian access, including a lockable gate and fence, audible warning system, signage, and anti-trespass flooring. They also fund Samaritans-trained patrollers and BTP officers at Durham. LNER, in collaboration with Network Rail, will arrange a joint site visit to Durham station to ensure fencing meets rail industry standards. LNER has also trained a significant number of staff in suicide risk who are given guidance and training in dealing with vulnerable people.
William Israel
All Responded
2020-0271 3 Dec 2020 North East Kent
London and South Eastern Railway
Concerns summary (AI summary) Public misunderstanding of live rail dangers is exacerbated by inadequate, outdated, and poorly placed warning signage, alongside inconsistent station security measures when unstaffed.
Action Planned (AI summary) Southeastern will replace warning signs at Canterbury East station, engage with a local nightclub to educate patrons about railway safety, review risk assessments for the station, and share findings with the wider railway community. Most actions are planned for completion by March/June 2021. Southeastern replaced warning signs at Canterbury East station with a new design. They also provided Chemistry Night Club with posters and drinks mats highlighting railway safety messages, reviewed risk assessments, and shared learning with the wider industry.
Xuanze Piao
All Responded
2020-0230 11 Nov 2020 Coventry
Coventry University
Concerns summary (AI summary) The university failed to hold a face-to-face meeting or contact the guardian/parents of an under-18 overseas student before sending a critical email indicating course removal risk, revealing a lack of clear communication policy.
Action Planned (AI summary) Coventry University is undertaking a full review of its policy and procedures relating to students who are under the age of 18, expected to be complete by January 31, 2021. They have also put in place an additional process for responding when international students under 18 fail to engage with their course, including a face-to-face meeting with a welfare advisor.
Luiz Anjos
All Responded
2020-0259 13 Jul 2020 Essex
Highways Agency Essex County Council
Concerns summary (AI summary) Easy access over the footbridge parapet and sides at the location remains a significant safety concern, despite other identified issues having been remedied.
Action Planned (AI summary) Essex Highways has identified three potential options to improve safety at the St Dominic Road Footbridge and prefers installing full-height corrugated steel parapets. A full structural assessment is estimated to be completed by the end of January 2021, with design and refurbishment works to follow, subject to Network Rail approval.
Patrick Bolster
All Responded
2019-0314 25 Sep 2019 London Inner (North)
Network Rail
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)
Network Rail
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
Govia Thameslink Railways Network Rail
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
Network Rail
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.
Georgia Nelson
All Responded
2019-0140 29 Apr 2019 London Inner (West)
Central and North West London NHS Trust Royal Borough of Kensington and Chelsea
Concerns summary (AI summary) There is a lack of suitable housing specifically for young patients with severe and enduring mental health issues.
Action Planned (AI summary) RBKC and partner agencies are working together to identify ongoing needs and service developments arising from the closure of rehabilitation inpatient beds at Horton, including a potential local 'wrap around community rehab offer' with support and rehabilitation services in supported accommodation within 18 months. CNWL acknowledges the concerns raised and states that as discharge planning starts at admission, they will follow new NICE guidance on considering rehabilitation as appropriate. They offer a range of person-centred interventions and have a well-developed vocational service, offering Employment Support using the Individual Placement and Support Model, a User Employment Programme and a strong programme of Peer Support.
Alfonso Sinclair
All Responded
2019-0141 29 Apr 2019 London Inner (West)
Transport for London
Concerns summary (AI summary) A distressed individual's overtly odd and illegal behaviour at a tube station went unnoticed and unchallenged by staff, despite CCTV, due to a lack of system to alert odd behaviour or alarms at platform end barriers.
Action Planned (AI summary) London Underground will review its training for front-line station staff on spotting unusual suicidal behaviour to include customer behaviours at the gateline and ticket hall, with changes implemented by late 2019. Initial trials of new remote accessibility systems for CCTV and other systems are expected by the end of 2020.
Danyon Chesters
All Responded
2019-0079 26 Feb 2019 Manchester (South)
Department of Health and Social Care
Concerns summary (AI summary) Significant delays in accessing NHS mental health services led to fragmented private care, lack of information sharing between professionals, and private therapists not reviewing medication, impacting the deceased's treatment.
Noted (AI summary) The Department acknowledges the concerns raised and explains the NHS's role in commissioning services and targets for psychological therapies. They reference guidance for therapists on managing client confidentiality and risk, emphasizing the importance of acting within their expertise and seeking advice when necessary. They highlight government initiatives for suicide prevention.
Steven Key
All Responded
2019-0102 25 Feb 2019 Cumbria
Network Rail
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.
Christopher McGuffie
All Responded
2018-0386 10 Dec 2018 County Durham and Darlington
Northern Rail Limited
Concerns summary (AI summary) Railway stations lack immediate and effective alert systems for detecting and reporting persons on the line.
Action Planned (AI summary) Arriva Rail North is developing a campaign using various media, providing bespoke training for customer service controllers and are looking to bring forward the planned installation of CCTV at Chester le Street station.
Richard Hill
All Responded
15 Nov 2018 Nottinghamshire
Network Rail
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
Kevin Sherwood
All Responded
2018-0289 11 Sep 2018 Hertfordshire
Network Rail
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.
Daniel O’Mahony
All Responded
2018-0258 30 Aug 2018 Hertfordshire
London North Western Railways
Concerns summary (AI summary) Inadequate railway anti-trespass measures, including missing gates, gaps in fencing, and unreviewed signage, increase access to railway lines and the risk of future deaths.
Action Planned (AI summary) West Midlands Railway (operated by West Midlands Trains) removed an outdated Samaritans sign and will install new signs at the Hemel Hempstead Railway Station. Network Rail have submitted a remit to install fencing and a swing gate, and to fill gaps between platforms 2 and 3 with sliding gates.