William Israel

Ms S M Hayes 
Assistant Coroner North East Kent 
North East Kent Coroners 
Cantium House County Hall 
Sandling Road 
Maidstone 
Kent 
ME14 1XD 

30th September 

Dear Ms Hayes 

Regulation 28 Report: William Steven Israel 

1 

I wrote to you on 6 January in response to your Regulation 28 report regarding the tragic death of 

William Steven Israel at Canterbury East railway station on 15 March 2020. 

2 

In that letter I committed Southeastern to taking to following actions: 

(a)

Replacing  the  three  warning  signs  provided  at  the  main  entrance  and  palisade  gates  at

platforms 1 and 2 at Canterbury East station with a new design.

(b)

Engaging with the operators of the Chemistry nightclub to seek ways to inform and educate

their clientele in relation to the risks associated with people going on to railway tracks.

(c)

Reviewing the risk assessments applicable to Canterbury East as part of our routine review

processes and updating them as appropriate.

(d)

Sharing the findings of the Inquest, the Regulation 28 report and details of our actions with

the wider railway community via the industry Passenger Operators’ Safety Group (POSG)

and Passengers on Trains and Stations Risk Group (PTSRG).

3 

 I now write to update you on progress with the implementation of those actions. 

a) Warning signs at station entrances

4 

We have replaced the three warning signs at the various entrances to the station with a new design 

as promised and photographs of these signs are attached as Annex A. 

 
 5 

In addition to this we have also engaged with the wider rail industry with a view to establishing a 

project to review and replace existing station warning signs with more informative alternatives that 

highlight the “Danger of Death” message. 

b)  Chemistry Night Club 

6 

We  have  engaged  with  the  operators  of  the  Chemistry  Night  Club  and  developed  a  constructive 

working  relationship  with  them.  As  part  of  this  we  have  agreed  to  provide  the  night  club,  free  of 

charge,  with  a  supply  of  A4  posters  and  several  thousand  drinks  mats  which  highlight  three  key 

railway safety messages in a “fun facts” format intended to engage and inform.  These are drawn 

from our Travel Smart Travel Safe campaign and highlight: 

(a) 

The fact that the conductor rail is never switched off 

(b) 

The extended stopping distance for trains (equivalent to 20 Premier League football pitches 

or 2 km) 

(c) 

The weight of trains (equivalent to 80 elephants or 400 tonnes) 

c)  Review of Risk Assessments 

7 

We have completed our review of the risk assessments at Canterbury East station and have updated 

them in the light of this accident and physical changes to the station, including the recent completion 

of an “Access for All” footbridge with lifts. 

d)  Sharing findings 

8 

We have shared all our learning from this tragic accident with the wider industry via the POSG and 

PTSRG and this has prompted both discussions and actions, including work on signage reference 

in paragraph 5 above. 

Yours sincerely 

Managing Director  
Southeastern 

 
 
 
 
 
 
 Annex A – New warning signs at station entrances

Ms S M Hayes 
Assistant Coroner North East Kent 
North East Kent Coroners  
Cantium House County Hall  
Sandling Road  
Maidstone  
Kent ME14 1XD 

6th January 2021 

Dear Ms Hayes 

Regulation 28 Report: William Steven Israel (ref: 

) 

1 

I write in response to your Regulation 28 report dated 3 December 2020 regarding the death 

of William Steven Israel on railway tracks at Canterbury East railway station on 15 March 

2020. 

2 

I would like to begin by expressing my condolences to Mr Israel’s family and my sorrow for 

their loss. I can assure you and them that we will learn lessons from this tragedy to prevent 

recurrence of similar events.  

3 

I, my colleagues at Southeastern and indeed the whole railway community are very aware 

of the risks associated with unauthorised access to railway tracks – particularly where it is 

electrified  using  the  DC  conductor  rail  system  –  and  we  take  this  issue  very  seriously. 

Regrettably, it is a matter of record that the vast majority of deaths on Britain’s railways arise 

from unauthorised access onto the tracks. For that reason, we implement a wide range of 

strategies and initiatives with the aim of reducing and preventing unauthorised access. 

4 

The strategies and initiatives Southeastern take range from physical deterrents and barriers 

to community engagement (to educate and raise awareness). For example, Southeastern 

(sometimes  in  conjunction  with  British  Transport  Police  and/or  Network  Rail)  take  part  in 

regular school visits, media campaigns such as “Respect the Edge”, “Next Day Regrets” and 

“You vs Train” as well as installing enhanced fencing (where appropriate) and gating platform 

ends. We also take part in localised activities around level crossings and other “hot spots” 

for trespass and have recently worked with Network Rail to develop a “Life Centre” for youth 

 education  at Margate  station,  which  includes  a  full-size  mock-up  of  a  platform  with  track, 

conductor rail and train. 

5 

In addition to our initiatives to reduce and prevent unauthorised access to railway tracks, we 

fund  a  number  of  Welfare  Officers  dedicated  to  identifying  and  engaging  with  vulnerable 

persons  at  stations,  and  significant  numbers  of  our  station  staff  have  been  trained  by 

Samaritans to be aware of people who may be vulnerable and, where appropriate, how to 

intervene and support them. 

6 

At Canterbury East Station, there were already a range of measures to prevent unauthorised 

access prior to Mr Israel’s death, including: (i) red anti-trespass signage at the booking hall 

entrance and at the side gate providing access and egress to platform 2 from Station Road; 

and (ii) barriers, anti-trespass matting, trespass warning and danger of live rail signage at 

the  platform  ends.  Following  Mr  Israel’s  death,  we  considered  whether  there  were  any 

additional measures which could be put in place at Canterbury East Station. As a result, we 

have already installed new signage at each of the three station entrances (the main entrance 

and the palisade gates on platforms 1 and 2) to emphasise the danger of crossing the tracks. 

Photographs  of  these  signs  were  provided  to  the  Inquest  as  exhibits  CC  15,  16  and  17 

appended to our witness statement.  

7 

Turning to the specifics of the report, I shall respond to the detailed points which you raised 

in section 5. 

Response to Paragraph (1)  

8 

It is correct that – except for when engineering work takes place – the live DC conductor rails 

are energised at all times. It is also the case that surveys show that many members of the 

public are not aware of this fact and assume either that the power is routinely turned off at 

night or that it is only switched on when a train is approaching. Existing industry educational 

and campaign material – for both conductor rail and overhead line electrification systems – 

addresses this point directly and emphasises that the power is always on.  

9 

We wish to clarify the signage which was present prior to the accident, and the signage that 

has been installed post-accident. Prior to this accident there were four signs at Canterbury 

East station which warned of the danger of the live DC conductor rails. These were the four 

platform end signs, photographs of which were provided to the Inquest as exhibits CC 3, 4, 

5 and 6. These signs carry the wording “Danger. Do not touch the live rail” and the word 

“Danger” is the largest on the sign.  

10 

After the accident, we took the initiative to design and install a further three signs at or close 

to the palisade side entrance gates to platforms 1 and 2 and at the main station entrance. 

Photographs  of  this  signage  were  provided  to  the  Inquest  as  exhibits  CC  15,  16  and  17. 

These signs carry the wording “Caution – Do not cross the tracks – Danger of Death – High 

voltage power rails live at all times”. The intention of these new signs was to highlight more 

 
 prominently  the risks of the live  DC conductor rails. We  believe that it  is  these additional 

signs to which you refer in paragraph (1). We note your concerns regarding the use of the 

word “Caution” and the size of the text relating to the risk of death and have addressed these 

through a revised design (see Annex A). 

11 

Action (a): we will replace the three additional signs at Canterbury East station with a new 

design based on that shown at Annex A. 

Response to Paragraph (2) 

12 

We wish to correct the statement in your paragraph (2) that there is no signage present at 

the palisade gates. As explained at paragraph 10 above, we installed three additional signs 

at or close to the palisade gates as well as at the main station entrance following the accident 

(see our witness statement at paragraph 19.3).  

13 

We note that you refer to “national guidance” on the changes to warning signs at railway 

stations.  We  apologise  if  our  evidence  was  unclear  on  this  point.  The  Effective  Signage 

Project (led by the University of Birmingham’s Centre for Railway Research and Education) 

is an academic study not national guidance.  The study was commissioned by Network Rail’s 

Trespass Improvement Group and led to a recent report1. The aim of the study and report is 

to assist Network Rail in the design of future signage to deter unauthorised access to the 

railway.  

14 

Southeastern provided input into this research via Network Rail, and a copy of the report 

was provided to us on 16 November 2020. Section 4.1.1.1 of this report states that “Signal 

words ‘Danger’ and ‘Warning’ are more likely to attract attention than ‘Caution’ or ‘Notice’ 

and have stronger connotations of risk.”  

15 

We are considering the findings of the research report and how the recommendations could 

improve our signage. This includes the redesign of the station entrance signs described at 

paragraph 10 above. 

Response to Paragraph (3) 

16 

The provision of under-platform signage is a matter for Network Rail as the platform faces 

concerned are their asset. Southeastern has made representations to Network Rail for such 

signage to be installed but this has been refused due to concerns that under-platform signs 

are difficult to maintain, and there is a risk they may obscure developing structural defects 

in the platform itself. In view of this, Southeastern are unable to take any further action in 

relation to under-platform signage at Canterbury East or elsewhere. 

1 “Effective signage to prevent trespass” - 
Birmingham, 7 September 2020 

., University of 

 
 
 
 Response to Paragraph (4) 

17 

Before the accident, directional signage to the station subway was provided in the form of a 

double-sided sign affixed perpendicular to the wall of the station building adjacent to the top 

of the subway stairs.  

18 

Following  the  Inquest,  we  have  installed  an  additional  directional  sign  adjacent  to  the 

entrance when entering platform 2 from the palisade gate which indicates the presence of 

the subway. I append a photograph of this sign in situ as Annex B. 

19 

Action (b) completed: A new directional sign has been installed adjacent to the side gate to 

platform 2. 

Response to Paragraph (5)  

20 

The purpose of the palisade gates is to permit access and egress to and from the station 

during the hours that the booking hall is closed and the station is unstaffed, and not to act 

as  a  deterrent  to  such  access.  They  are  not  required  to  be  open  during  the  day  as  it  is 

possible to enter the station via the booking hall and, as there are Automatic Ticket Gates 

provided to protect revenue, they are closed whilst the booking hall is open and the ticket 

gates in operation.  

21 

The booking hall is closed at 20:00 each evening and it is at this point that the palisade gates 

on platforms 1 and 2 are opened. They are closed again when the booking hall opens in the 

morning at 06:00 (Monday – Saturday) or 07:00 (Sunday). There are several reasons why 

the palisade gates need to be opened during these hours including passengers needing to 

access  and  egress  the  station  for  train  services  scheduled  after  20:00  and  before 

06:00/07:00.  

Response to Paragraph (6)  

22 

We note the comments in paragraph (6) in relation to previous incidents of individuals on the 

track although we note that none of these incidents involved a person leaving the Chemistry 

nightclub.    We  also  note  that  some  members  of  the  public  using  the  subway  may  be 

intoxicated  but  given  the  large  numbers  of  passengers  that  use  the  station  each  day  we 

would not describe this as a significant number or a “significant risk”.  

23 

Notwithstanding  this,  in  light  of  the  accident  we  consider  that  the  provision  of  relevant 

information to nightclub attendees may reduce the likelihood of other individuals making an 

attempt  to  cross  over  the  tracks.  This  could  potentially  be  achieved  by  using  leaflets, 

messages on menus  or drinks mats, posters in lavatories  or use of the industry  “You vs. 

Train” video materials.  

24 

Action  (c):  we  will  engage  with  the  operators  of  the  Chemistry  nightclub  with  a  view  to 

highlighting the dangers of the rail tracks to their clientele.  

 
 Response to Paragraph (7)  

25 

We note the contents of the BTP DOCU report, and the comments provided by our staff.  

26 

We do not propose to alter staff shift patterns or station opening hours. We believe that there 

are more effective methods of preventing unauthorised track access which we have set out 

in this letter together with the detail provided in our witness statement (see paragraphs 23 – 

26). 

Response to Paragraph (8) 

27 

We do not agree with the comment regarding risk assessment in paragraph 8. We have set 

out at paragraph 9 above the details of the four signs which were in place prior to the accident 

which warned of the danger of the live rail. Following the accident, we installed additional 

signage at all station entrances to highlight this risk and, as set out in paragraphs 10 and 13 

above, we have redesigned this signage to take into account your comments and the findings 

of the University of Birmingham research (see Annex A). In addition, the risk assessments 

applicable  to  Canterbury  East  will  be  reviewed  as  part  of  our  routine  review  processes 

following an incident and will be updated if appropriate. 

28 

Action (d): we will review the risk assessments applicable to Canterbury East as part of our 

routine review processes and will update if appropriate.  

Response to Paragraph (9) 

29 

Action (e): we will share details of this Inquest and Regulation 28 report with the wider railway 

community via the industry Passenger Operators’ Safety Group and Passengers on Trains 

and Stations Risk Group. We provided an initial briefing to the Passenger Operators’ Safety 

Group on 9 December. 

Summary  

30 

In summary, the actions that we propose to take in light of this report are as follows: 

(a) 

We will replace the three warning signs provided at the main entrance and palisade 

gates at platforms 1 and 2 at Canterbury East station with a new design as shown 

at  Annex  A.  These  signs  reflect  the  concerns  raised  in  you  report  and  take  into 

consideration the University of Birmingham’s findings and include replacing the word 

“Caution”  with  the  word  “Warning”  and  giving  greater  prominence  to  the  risk  of 

electrocution. 

(b) 

We have already provided signage at the side entrance to Platform 2 at Canterbury 

East station which directs users to the subway at the middle of the platforms. 

 
 (c) 

We will engage with the operators of the Chemistry nightclub to seek ways to inform 

and educate their clientele in relation to the risks associated with people going on to 

railway tracks. 

(d) 

 We will review the risk assessments applicable to Canterbury East as part of our 

routine review processes and will update if appropriate. 

(e) 

We will share the findings of the Inquest, the Regulation 28 report and details of our 

actions  with  the  wider  railway  community  via  the  industry  Passenger  Operators’ 

Safety Group and Passengers on Trains and Stations Risk Group. 

31 

Our current intention is to complete actions (a), (d) and (e) by 31 March 2021, action (b) is 

already complete, and to complete action (c) by 30 June 2021. These timescales may need 

to be altered dependent upon the impact of the Covid-19 lockdown/Tier restrictions. We do 

not intend to progress any other actions at this stage for the reasons indicated above. 

Yours Sincerely 

Managing Director  
Southeastern 

 
 
 
 
 
 
 Annex A – Initial design for new warning signs to be placed at all entrances to Canterbury East 
station (final design may be in landscape format). 

 Annex B - Photograph of new sign at the side entrance to platform 2