Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0380, written 25 Jul 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Jul 2025 |
|---|---|
| Reference | 2025-0380 |
| Deceased | Robert English |
| Coroner | Andrew Walker |
| Coroner area | London (North) |
| Category | Railway related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Department of Transport 2. Transport for London 3. Rail Safety Board 1 CORONER I am Mr Andrew Walker, senior coroner for the coroner area of Northern London 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On the 24th May 2024 I commenced an investigation into the death of, Robert Grey English, aged 32. The investigation concluded at the end of the inquest on 10th June 2025. The conclusion of the inquest was Consequences of a failure to follow the proper process to recover a person from a stretch of railway. The medical cause of death was 1a Electrocution. 4 CIRCUMSTANCES OF THE DEATH On the 19th May 2024 Robert Gray English was electrocuted when the power supply to the rails was Switched on over a section of track between Hendon Central Station and Burnt Oak Underground, (covering Colindale Station), which he had been travelling down on foot in the dark. A train, that had been held stationary, began to search the track, then ran over Mr English who had passed some 400 to 600 meters from Colindale Station. The train was not adequately equipped to conduct such a search in darkness and this response was inadequate. A little earlier in the evening two police officers had followed Mr English into Colindale railway station having formed the view that he may be unwell and sought to contain him rather than restrain him. Mr English, who may have been confused by the actions of the police, ran to the platform where the police again tried to contain him. Mr English then left the platform and made his way into the night beyond the station. The Local Station Manager asked for the power supply to the track to be turned off. The police officers saw him climb up a part of the fence but was not able to say whether he had climbed over. Members of the public, when the officers passed them, gave in answer to their questions the impression that Mr English had left the trackside and was in the park. This was factually incorrect as neither officer saw 1 Mr English climb over the fence into the park. The officers believed that this might have been the case and made their way to the park where they were told by a member of the public that a person has been seen on the railway side of the fence. Whilst the officers had left to look for Mr English in the park the Local Station Manager was asked to go to the platform and confirm that the police officers were still on the platform by a Service Manager and for confirmation that Mr English had left the track area. The Local Station Manager confirmed that the police had left and that the passenger was nowhere to be seen and that the police did say that he climbed over the fences and has left the tracks. The Service Manager asked the Local Station Manager to contact the controller on his behalf so the power to the track can be switched on. The requirements within the rule book when switching the power supply to the rails were not followed in particular telling all the relevant people that the power supply to the rails is about to be switched on. This would have given the Police and British Transport Police an opportunity to confirm that Mr English had not been found and was likely still on the railway side of the tracks. It is likely that had this step been followed the power supply would not have been switched on and a proper search, which was also possible, is likely to have found Mr English and returned him safely to the station. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – The provision to protect a trespasser at night are the same as those during the day. The ability to locate a person close to or on the railway lines at night is made more difficult by the absence of suitable lights on the track or the train. In this case Mr English was not seen and run over by the train that has been asked to look for a person on the line . 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organization have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Friday 19th September 2025 I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. 2 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons : Met Police British Transport Police Family Legal Representative I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response. 9 DATE: 25th July 2025 3
3 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Minister of State for Rail Great Minster House 33 Horseferry Road London SW1P 4DR Andrew Walker Senior Coroner North London Coroner’s Service Barnet Coroner’s Court 29 Wood Street, London EN5 4BE 23 September 2025 Dear Andrew, Thank you for sending your Report on the Prevention of Future Deaths dated 25 July 2025 relating to the death of Robert Gray English on 19 May 2024, who was electrocuted on a section of track between Hendon Central Station and Burnt Oak Underground. Any death on the transport network is a tragedy. We look to the relevant operators to ensure that they have systems in place to protect staff, travellers and the wider public, in line with their duties under the Health and Safety at Work Act (etc.) 1974 as well as the Railways and Other Guided Transport Systems Regulations 2006 (as amended). These latter regulations provide the regulatory regime for rail safety, including the mainline railway, metros (including London Underground), tramways, light rail and heritage railways. They require operators to comply with relevant safety, operational and technical standards before operators can apply for safety authorisation or safety certification to use vehicles or infrastructure on the railway. Transport for London (TfL) are wholly responsible for the operational safety of the London Underground network, and I understand that they have now responded to you, setting out how they are addressing the findings of your report. I understand that the actions TfL are taking will be implemented rapidly, which reflects the seriousness with which they take their responsibilities. OFFICIAL Yours sincerely, MINISTER OF STATE FOR RAIL OFFICIAL
IN THE BARNET CORONER’S COURT INQUEST TOUCHING THE DEATH OF ROBERT ENGLISH _____________________________________________________________________________ RSSB RESPONSE TO REGULATION 28: REPORT TO PREVENT FUTURE DEATHS _____________________________________________________________________________ The Rail Safety and Standards Board (“RSSB”) is an independent body for the mainline railway, established to manage industry standards across organisation and technical boundaries, which includes annual rail industry level safety performance reporting. RSSB produces standards on behalf of the mainline railway of Great Britain. The standards directorate within RSSB manages the delivery of these standards and supports collective rail industry decisions related to changes to standards. The mainline railway of Great Britain is defined in the Railways and Other Guided Transport (Safety) Systems Regulations (2006) (as amended). London Underground-owned infrastructure, including the Northern Line, is not part of the mainline railway (it is a metro system) and so RSSB standards do not apply to London Underground. The operating context of the mainline railway can be different to London Underground. The current regulation for mainline train headlamps is the Locomotives and Passenger National Technical Specification Notice, enforced by the Railways (Interoperability) Regulations 2011 (as amended). The mainline rules for train drivers responding to reports of trespassers require a driver to proceed ‘at caution’. This requires drivers to be able to stop within the distance that they can see to be clear. As the rule is the same irrespective of lighting conditions, this means in practice, drivers are likely to travel at a lower speed when proceeding at caution in darkness than in daylight. In darkness the above regulations mean that the headlamps are designed to illuminate the track when proceeding at caution. As trains principally drive to signals rather than on sight on national mainline infrastructure to which access is normally restricted (by fencing, for example), it is not reasonably practicable to provide continuous lineside illumination. From safety reporting data for the mainline railway since 2015, there are no recorded instances of a trespasser being struck by a train when the train driver was instructed to run at caution. For the reasons set out above, RSSB are not proposing to take any action. Dated: 3 September 2025 94/248/Response to Regulation 28 - 3 ~ 4147-7373-0655 v.1.docx
16 September 2025
HM Senior Coroner Andrew Walker
North London Coroner’s Service
Barnet Coroner’s Court
29 Wood Street
London
EN5 4BE
Chief Operating Officer
Transport for London
Palestra
1 97 Blackfriars Road
London
SE1 8NJ
Dear Sir
Inquest touching the death of Robert Gray English
I write on behalf of Transport for London (TfL) regarding the Senior Coroner’s
Regulation 28 Prevention of Future Deaths (PFD) report dated 25 July 2025
following the inquest touching the death of Robert Gray English.
I would like to take this opportunity to repeat, on behalf of TfL, our sincere
condolences to the family and friends of Mr English for their tragic loss.
Prevention of Future Deaths (PFD) report
After the inquest, the Senior Coroner sent a PFD report to TfL raising the
following matter of concern:
‘The provision to protect a trespasser at night are the same as those during the
day. The ability to locate a person close to or on the railway lines at night is made
more difficult by the absence of suitable lights on the track or the train. In this
case Mr English was not seen and run over by the train that has been asked to
look for a person on the line.’
I am grateful to the Senior Coroner for raising these concerns and we set out
below TfL’s response.
TfL’s approach to track searches on the Underground network
TfL has well established rules for undertaking track searches when there are
reports of persons on or about the track. However, we recognise, through recent
events, including the death of Mr English, learning opportunities to further
enhance safety on our network by updating our operational rules, associated
training and the equipment used during such incidents.
On 12 May 2025, we updated our operational rules related to track searches. Our
rules now require our teams to physically search the track environment where
there is any doubt about the identity of an object on or around the track
environment.
We are also in the process of changing our Rule Book to remove existing
references to a train undertaking a track search operating at ‘slow speed’. Under
our new operational rules, train operators will be given very specific instructions,
requiring them to operate ‘at a speed of no more than 10mph, or the closest
speed value available on lines with automatic train operation’. This will better
manage the speed at which trains travel through the affected area. The Rules will
be formally updated and briefed to our train operators by the end of October
2025.
These two rule changes acting together strengthen our track searching
arrangements in contexts where there is either a report of an obstruction or a
report of a person on or around the track environment.
You highlighted the need for more suitable lighting for locating a trespasser at
night. We are actively assessing options for new equipment to provide additional
lighting.
We have started testing a prototype lighting rig which allows a new type of torch
to be mounted inside the train operator’s cab. This torch has an adjustable output
of up to 100,000 lumen, providing enhanced lighting of track in open-air night-
time conditions.
We will continue to test this prototype over the next few months to fully assess its
capability, risk assess it for use on the operational railway and identify any
improvements required. We will conclude this test by December 2025.
Should this lighting rig be successful, and following appropriate internal
assurance, we would roll this out in 2026 across the LU network (for the open-air
sections of track).
Effective communications
As part of our investigation into Mr English’s death, we recognise the opportunity
to make communication between our operational staff and police more robust. As
a result, we have established a review group comprising of representation from
TfL Compliance, Policing, Operations and Security, the TfL Rail Control Centre,
the Metropolitan Police Service and the British Transport Police. The purpose of
this Group is to review the operational procedures for deploying the police on or
near to rail tracks. We will finalise a real time pursuit policy, including
communications arrangements, between the three control centres by the end of
September 2025 with plans to communicate the revised procedures to those
affected by the end of October 2025. To support this, the need for additional rail
safety training for Metropolitan Police officers will also be reviewed with a
conclusion to be reached by the end of October 2025.
Conclusion
I would like to offer again my heartfelt sympathy and condolences to Mr English’s
family and friends. We are determined as an organisation to learn lessons from
this tragic incident.
I hope this response is helpful and welcome. Please contact me if I can be of any
further assistance.
Yours sincerely,
Chief Operating Officer
cc:
, TfL Commissioner
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