Simon Moore

OFFICIAL 

 9th October 2025 

Dear Sir,   

We  write  in  response  to  your Regulation  28 Report  to  Prevent Future  Deaths  dated  5 August 
2025 addressed  to  Network  Rail  Infrastructure  Limited  (“Network  Rail”),  which  was  issued 
following the inquest touching the death of Simon Anthony Moore.  

We are grateful for the opportunity to respond, and the extension to the timeframe for response 
by two weeks.   

As Network Rail  was not designated  Interested Person status at the inquest, nor in attendance 
at the hearing,  it was not able to address HM Coroner on or provide clarification  or context on 
matters relevant to your concern at the time of the hearing. We therefore  take the opportunity 
to  provide  what  we  consider  to  be  important  contextual  information  –  both  in  respect  of 
Network Rail  generally and in relation to a point of clarification  relevant to your concern - before 
summarising  relevant  actions,  some  of  which  industry-wide,  taken  to  date.    I  also  take  the 
opportunity to extend my condolences to the family  and friends of Mr Moore.    

As it is hoped is made  clear  through the  content of this response, Network Rail  has systems in 
place for, and is committed to, effective communication channels in the aftermath of an incident, 
and the prevention of future deaths on the railway, and it is hoped the content helps ameliorate 
the coroner’s concern  outlined in the Regulation  28 report. As reiterated  later  in this response, 
should you require  any further information, Network Rail  will be happy to assist further.   

Introductory  comments   

Network Rail  owns and  manages  Great  Britain’s  rail  infrastructure  including  the track,  signals, 
tunnels, viaducts  and level  crossings, which includes  10,000 miles of route  track, 20,000 miles 
of boundary, 30,000 bridges and viaducts and over 6,000 level  crossings. In addition, there  are 
2,565 stations on the mainline  rail network, nearly all  of which are owned by Network Rail,  and 
Network Rail is responsible for structural safety refurbishment, renewal and upgrading of all the 
stations  it  owns.  Network  Rail  manages  around  30  mainline  and  London  stations,  with  the 
remaining stations operated and managed by train operating companies (TOCs) which lease the 
stations from Network Rail.   

TOCs are  responsible  for passenger safety on trains and at stations that they manage including 
the day-to-day management  of the stations such as risk assessment, and generally  providing a 
safe, reliable  service  to passengers in order  to keep  those passengers and other station visitors 
safe.   

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The  rail  companies  and  organisations  that  make  up  the  railway  industry  work  together  and 
collaborate to operate safely and to apply safety standards set by the Rail Safety Standards Board 
(RSSB) which is the safety standard setting body for the rail network in Great  Britain.  

Network  Rail  has  an  established  health  and  safety  management  system  that  describes  the 
principles,  roles, responsibilities,  systems and processes that are in place by which Network Rail 
manages  the  health,  safety,  welfare  and  security  of  its  employees  and  others  affected  by its 
activities,  and  the  health  and  safety  management  system is  underpinned  by rules,  standards, 
specifications  and procedures, which form an intrinsic  part of the overall  system. Network Rail 
is  structured  with  14  main  Routes  across  the  network.  The  Routes  are  responsible  for 
operations, maintenance and minor renewal, including day-to-day delivery of train performance 
and the relationship  with the  local train  operating companies. The  14 Routes are supported by 
five  Network Rail  regions.  I am  the  Managing  Director  for  the  Southern  Region  which  carries 
over 1 million passengers a day.   

Concern in respect of communication between Signaller and TOC  

We take the opportunity to provide further information and context in respect of the following 
finding in the Regulation 28 report:   

 The  Network  Rail  Signaller  has  no  means  through  which  to  relay  the  details  of  any 
discussions with drivers (in this instance Mr Moore) to the train company Control who could 
then pass this information on to the attending Driver Manager.  

The  Network  Rail  Signaller  does  have  a  means  through  which  to  relay  the  details  of  any 
discussions  with  drivers  (in this  instance  Mr Moore)  to the  train  company Control  who could 
then  pass this information  on to the  attending  Driver  Manager. The  below  explains  what that 
system is, and how it was utilised  in respect  of Mr Moore. Network Rail’s understanding is that 
the system in place  was utilised  by the Network Rail Signaller,  but that joint Control did not pass 
the information to the attending Driver  Manager.   

By  way of  background, Network  Rail  operates  Incident  Control  Centres,  which  are  dedicated 
hubs  for  managing  and  coordinating  the  response  to  incidents  on  the  railway.  They  bring 
together  key  operational  staff  including  signallers  and  Control  managers,  monitoring  the 
network  in  real  time  and  ensuring  the  safe  and  efficient  management  of  train  movements. 
Relevant  to coordinating  information,  liaison  with TOCs and response  to incidents  nationwide, 
there  are  detailed  standards, processes  and  procedures  for  incident  management,  which  are 
not explored  in full for the purposes of this response.    

Incident Control utilise tools such as the Control Centre Incident Log (CCIL). CCIL is Network Rail’s 
incident  management  and logging  tool used to collaboratively  manage any incident  impacting 
upon the operational railway. It allows Control from different  organisations to work together to 
effectively  manage incidents  and enables  Control centres to record  and share information  with 
other  organisations  involved  in  the  incident,  providing  common  and  real  time  incident 
information across the rail industry.   

Signallers  play a vital, safety-critical,  role in  ensuring the  safe and efficient  movement of trains 
across  the  railway,  including  in  incident  management  by  communicating  with  drivers  and 
implementing emergency procedures. As part of their role, having undergone extensive training, 
information  to  Incident  Control  Centres  (or  Route  Control)  for  wider 
they  relay  critical 
management  and  investigation.  As  part  of  this,  signallers  are  expected  to  promptly  and 
accurately record tactical operational detail of an incident, such as the location, time and specific 

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irregularities.  Though  signallers  are  not  a  welfare-related  specific  role,  this  would include  the 
communication of any concern or distress presented  by a train driver.    

In  this  instance,  the  Signaller  in  question  included  in  the  information  provided  to  Control  in 
respect  of  the  SPAD  incident  the  presentation  of  the  driver  having  been  in  distress.  The 
Investigating  Officer,  namely  the  On-call  Local  Operations  Manager,  subsequently  reviewed 
those  communications  and  confirmed  that  the  driver  sounded  shaken  during  the  call.  Such 
reports were recorded on the CCIL, which is enclosed with this response, with relevant extracts 
highlighted  for ease  of reference,  and  names redacted.  Whilst  SWR  Control has  access  to the 
CCIL and opportunity to relay information to its On-Call Driver  Managers, or other personnel  as 
needed, it appears on this occasion that these entries  were not communicated as effectively  as 
they could be.    

Actions  

Whilst it is hoped that the above information provides helpful context and clarification in respect 
of your concern,  Network Rail  remains  committed  to the  prevention of future deaths  and set 
out below is information on the various workstreams following the  Incident which fall  relevant 
to the Regulation 28 report.  

Investigation, recommendation and consideration  of next steps   

As part of Network Rail’s  commitment  to preventing incidents  on the railway, it  has in  place  a 
range of tools and processes to learn  from incidents,  manage outcomes and recommendations 
of  investigations  and  drive  continuous  improvement.  It  collaborates  closely  with  industry 
partners, regulators and trade unions to ensure a joined-up approach to learning.   

Examples  are set out below of relevant  investigations/reviews in the aftermath of this incident. 
All  of these  occurred  before  the  inquest into  Mr Moore’s death  and before  the  Prevention of 
Future Deaths Report was issued:  

•  The incident was considered at Southern OPSRAM.    

OPSRAM  is  an  industry  wide  meeting  to  work  jointly  with  colleagues  and  operating 
companies  to identify  and reduce  risks, put measures  in place  to prevent incidents,  and 
share good practice  to support the safe and effective  management  of operations.  

•  Network  Rail’s Operations Risk Control Coordinator collaborated with and formed part 

of SWR’s investigation.   

As you are  aware, SWR’s  incident  investigation found  that, notwithstanding the  existing 
processes in place  as described  above, opportunities existed  to strengthen escalation and 
communication protocols between signallers, Incident Controllers, TOC Control and Driver 
Managers.  The  investigation  included  a  recommendation  that  Guidance  will  be  created 
for  signallers  to  support  them  when  communicating  with  a  driver  post  incident.  This 
Guidance  will  be developed  by the Industry Working Group on Welfare  Communications, 
described  further below.   

•  The SWR investigation report, including the above recommendation, was considered at 

the NR SPAD Recommendations and Review  Panel. n 

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The  SPAD  Recommendations  and  Review  Panel  is  set  up  to  review  investigations  into 
SPADS, check that the causes and contributing factors have been fully understood, ensure 
that recommendations  are  clear  and practical,  and agree  how actions  will  be  tracked  to 
closure so that lessons are learned, and similar  events can be prevented in the future.   

Industry working group   

Upon receipt  of HM Coroner’s Regulation  28 report, and in considering  your findings, Network 
Rail  set  up  an  Industry  Working  Group  on  Welfare  Communication,  which  includes 
representatives  from Network Rail, Train Operating Companies, and trade unions.  

The working group’s remit is to review the end-to-end process for incident communication, with 
a  view  to  ensuring  that  welfare  concerns  are  communicated  effectively  at  all  stages  of  the 
process.   

A workshop for the working group is scheduled  for early  October.  

Should you be assisted by receiving  a further updates on the output of this group, we would be 
happy to keep  you informed.   

Concluding comments   
We  thank HM  Coroner  for  the  time  taken  to consider  this  response,  and it  is  hoped  that  the 
clarification  and further information  ameliorate  your concerns.   

Network  Rail  remains  committed  to  ensuring  that  welfare  concerns  are  communicated 
effectively,  and to the prevention of future deaths on the railway. Should Network Rail  be  able 
to assist further in anyway, it would be happy to do so.  

Yours sincerely   

Managing Director, Southern Region  

Network Rail  Infrastructure Limited  Registered Office:  Network Rail, Waterloo General  Office,   
London, SE1 8SW Registered  in England and Wales No. 2904587  www.networkrail.co.uk  

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