Sam Dudley

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 Coroner's Investigation Officer 
 Sefton, Knowsley and St Helen's Coroner's Office 
 Bootle Town Hall 
 Oriel Road 
 Bootle 
Merseyside, L20 7AD 

Route Director, North West  
Network Rail 
Square One 
4 Travis Street 
Manchester      M1 2NY 

26th March 2026 

Dear Senior Coroner Bhardwaj, 

Inquest touching the death of Sam Alexander Dudley- Response to Regulation 28 Report  

Following the inquest touching the death of Sam Alexander Dudley, this letter sets out Network 
Rail  Infrastructure  Limited’s  (“NRIL”)  response  to  the  Regulation  28  Report  dated  05  February 
2026  (“the  Report”).  NRIL’s  sincere  condolences  remain  with  Mr  Dudley’s  family  and  friends 
following his tragic death. The safety of passengers, railway staff and members of the public who 
use or interact with the railway is at the heart of everything NRIL does, and the issues raised by the 
Coroner have been given careful and considered attention. 

HM Senior Coroner’s Concern and the Inquest Findings 

The Report identifies a concern that there is a risk of future deaths occurring unless action is taken, 
arising from the positioning and nature of signage at footpath level crossings and, in particular, 
the increasing prevalence of distraction associated with the use of earphones or headphones. The 
Report  also  recognises  that,  in  the  circumstances  of  this  case,  it  was  not  considered  that  the 
presence  of  additional  signage  would  have  altered  the  tragic  outcome.  NRIL  has  carefully 
considered the matters raised and welcomes the opportunity to respond. 

The inquest heard evidence, including from independent investigations, which established that the 
Hoggs  Hill  Level  Crossing  was  safe,  compliant  and  operating  as  designed  at  the  time  of  the 
incident.  It  was  demonstrated  that  the  miniature  stop  lights and  audible  warning  system  were 
functioning correctly, and that no causal or contributory failings were identified in the inspection, 
maintenance or management of the crossing. The conclusion reached was that it was more likely 
than not that Mr Dudley proceeded onto the crossing while distracted, having entered the crossing 
while a red light was displayed and the audible warning was sounding. 

Understanding Distraction and the Role of Design 

NRIL recognises that distraction, including from personal audio devices, is an increasing societal 
issue and  one which  requires  careful  and proportionate  consideration.  For  this  reason,  in  2025, 
NRIL commissioned independent behavioural research into accidental human error at passive level 
crossings,  which  includes  crossings  fitted  with  miniature  stop  lights  and  audible  warnings.  This 
research  examined  why  pedestrians  may  fail  to  stop,  look  and  listen,  including  the  role  of 
distraction, habitual use of crossings and misperception of train speed and distance. The research 
concluded that there are no simple or low-cost interventions that can eliminate risk at passive level 
crossings,  and  that  the  most  effective  long-term  measures  are  those  which  reduce  reliance  on 
individual judgement through system-led cues. 

The findings of this research have informed NRIL’s wider approach to level crossing safety and its 
ongoing consideration of signage, warnings and crossing design. In parallel, NRIL has undertaken 
a  review  of  level  crossing  signage  more  generally,  recognising  that  signage  must  be  clear, 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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proportionate and positioned where it will be most effective. This work has identified that excessive 
or poorly positioned signage can reduce effectiveness by contributing to visual clutter, particularly 
for regular users of crossings: this is consistent with findings made by the RAIB as long ago as 2005 
following an incident at Elsenham, when its report determined that “Whilst each individual sign is 
clear in meaning the combination of signage has the potential to be confusing.” [Para. 152]. As a 
result, NRIL is progressing work to review existing signage, remove duplication where appropriate, 
and  ensure  that  remaining  safety-critical  messages  are  positioned  as  close  as  reasonably 
practicable to the point at which users make the decision whether to cross (commonly referred to 
as the “decision point”). 

The aforementioned consideration of level crossing signage, including its positioning, content and 
effectiveness, formed part of NRIL’s ongoing safety and standards work which was already under 
review prior to the inquest. The approach to signage at level crossings is governed by a national 
framework, and in particular The Private Crossings (Signs and Barriers) Regulations 2023 which 
represented  a  complete  re-design  of  signage  at  private  and  public  level  crossings  (not  road 
crossings).  There is no sign within those Regulations asking people to remove headphones. 

As a result, NRIL cannot introduce new or novel signage on a site-by-site basis without appropriate 
consideration.  Signage  is  required  to  comply  with  statutory  requirements  and  established 
standards, and changes to the design or use of signage are developed through an evidence-led 
process involving the rail industry and the Department for Transport, with oversight from the Office 
of Rail and Road. This process is intended to ensure consistency, clarity and effectiveness across 
the national network, and to avoid unintended consequences arising from untested or inconsistent 
interventions. 

The  Report  raises  specific  concern  about  the  limited  signage  positioned  on  pedestrian  gates 
immediately prior to the decision point, and suggests that clear pictorial signage on the gate, such 
as an image of earphones with a line through them, may help alert users at the right moment. 
NRIL has carefully considered whether the introduction of such pictorial signage would be likely to 
reduce  risk.  While  visual  cues  can  attract  attention,  behavioural  evidence  indicates  that  the 
introduction of additional signage does not always result in changes to behaviour and may risk 
adding  to  information  overload  if  not  carefully  designed  and  evaluated.    As  indicated  above, 
signage ‘clutter’ has been shown to result in reduced levels of attention meaning people do not 
read any sign at all.  Accordingly, NRIL’s approach is to try to focus the user on the important safety 
instruction of how to actually cross that specific crossing safely. 

NRIL also notes that, as explained during evidence called at the inquest, the physical design of 
footpath level crossings is intended, so far as is possible, to draw users out of distraction at the 
point of highest risk. At Hoggs Hill, the requirement for users to manually open and pass through 
a  pedestrian  gate  before  reaching  the  tracks  is  a  deliberate  design  feature,  intended  to  slow 
approach speed, create a pause, and focus attention on the warning systems and signage beyond 
the gate. Where practicable, such physical interventions are used to complement visual and audible 
warnings and to reduce reliance on continuous user attention alone. 

Signage Framework, Future Consideration and Risk Management 

Alongside signage and behavioural considerations, NRIL continues to prioritise engineering and 
design-based measures at footpath level crossings where reasonably practicable. This includes the 
installation and  roll-out  of  miniature  stop  lights and  supplementary audible warning  devices at 
appropriate  locations,  improvements  to  crossing  surfaces and  approaches  so  that  crossings  are 
clearly recognisable as hazardous environments, and consideration of physical design features that 
encourage users to slow down and pause before crossing. Decisions in relation to such measures 
are informed by site-specific risk assessments, usage data and professional judgement considering 
both the safety benefits and any unintentional consequences. 

 
 
 
 
 
 
 
 
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In addition, NRIL undertakes education, engagement and awareness activity at both a national 
and local level, working with partner organisations to promote safe behaviour around the railway 
and at level crossings. This forms part of NRIL’s wider strategy to improve understanding of risk 
and to reinforce safety messages beyond the physical infrastructure alone. 

NRIL  continues  to  review  fatality  and  near‑miss  data  across  the  national  network  in  order  to 
identify  trends  and  emerging  risks.  As  set  out  above,  NRIL  recognises  that  distractions  are 
becoming  more  prevalent,  including  from  the  use  of  personal  technology,  and  the  impact  of 
distractions in various forms is an area of active research and consideration. Notwithstanding this, 
distraction  is  monitored  and  tracked  at  a  national  level,  and  learning  from  incidents,  internal 
investigations and external reviews is shared within the organisation and used to inform standards, 
guidance and future risk assessments. 

Conclusion  

Taken together, the evidence heard at the inquest and the steps outlined above demonstrate that 
the safety arrangements at Hoggs Hill were appropriate and that HM Senior Coroner’s concerns 
are  consistent  with  work  already  underway  within  NRIL’s  national  safety  framework.  This  work 
reflects careful consideration of the issues raised and a continued commitment to proportionate, 
evidence-led risk reduction at footpath level crossings. 

Yours sincerely, 

Route Director, North West 
For and on behalf of Network Rail Infrastructure Limited 

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