Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Jakovas Fofonovas · 26 Feb 2016 · Andrew Harris, London Inner (South)
“Recommendations in The BTP Post Fatality Report to create a safer environment at the bridge and restrict public access to the railway had not been effected by the time of the inquest.”
What was promised
Stated action 1 · response to Jakovas Fofonovas (26 Feb 2016) · stated timescale: none stated
“The new footbridge railings are at the current industry standard height of 1250mm.”
Stated action 2 · response to Jakovas Fofonovas (26 Feb 2016) · stated timescale: none stated
“We are in the process of installing acoustic fencing on both sides of the track at a height of 3m. This will also have anti-climb wire extensions fitted as an additional deterrent at certain sections.”
Stated action 3 · response to Jakovas Fofonovas (26 Feb 2016) · stated timescale: none stated
“over At the shoulder of the steps/ramps and the main span there is an anti-climb guard at a greater height than the railings as further mitigation. In addition there is the acoustic fencing and anti-climb wire extensions to prevent anyone accessing the track if they were to climb over”
8 further stated actions are listed on the full chain page.
What recurred
- 4 Aug 2016 · Susan Hamlett · Ian Pears
- 23 Aug 2016 · Stephen Cahill · Ian Pears
- 13 Apr 2017 · Daniel Campbell · Tony Brown · Closely related · confidence 0.90 (high)
- 20 Dec 2017 · Scott Rayner · Edward Solomons · Closely related · confidence 0.90 (high)
- 19 Jun 2018 · Andrew Hanahoe · Ian Pears · Closely related · confidence 0.90 (high)
- 10 Jul 2018 · Bartholomew Coleman · Brendan Allen · Closely related · confidence 0.92 (high)
- 24 Jul 2018 · Taiyah-Grace Peebles · Ian Goldup
- 11 Sept 2018 · Kevin Sherwood · Geoffrey Sullivan · Identical hazard · confidence 0.95 (high)
- 25 Feb 2019 · Steven Key · Robert Chapman · Identical hazard · confidence 0.95 (high)
- 7 Aug 2019 · Carl Klimaytys · Veronica Hamilton-Deeley · Closely related · confidence 0.90 (high)
- 30 Mar 2020 · Jordan Aira · Caroline Topping · Identical hazard · confidence 0.95 (high)
- 18 May 2021 · Callum Evans · Jason Pegg · Identical hazard · confidence 0.90 (high)
- 28 May 2021 · Christine Gould · Nicholas Moss QC · Identical hazard · confidence 0.90 (high)
- 4 Mar 2024 · Vanessa Ford · Ian Potter · Closely related · confidence 0.90 (high)
- 1 Jul 2025 · Jody Robb · Crispin Oliver · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Stephen Cahill · 23 Aug 2016
“Both the gate and | fence provide little deterrence or hindrance to someone wanting to gain | access to the railway”
Later · Steven Key · 25 Feb 2019
“The fencing at the scene of Mr [name redacted] death was a low wooden fence which was easy to climb over.”
What happened next
No evidence found either way · stated action 1
“Vertical Circulation Design Manual NR/GN/CIV/200/05 September 2022 1/96 Document Verification [name redacted] & Architecture, Technical Authority Frank Anatole Principal Architect Buildings & Architecture, Technical Authority [name redacted] & Architecture, Technical Authority Technical Lead Name Department or Role Name Department or Role Dis”
Vertical Circulation · networkrail.co.uk/…/Vertical-Circulation.pdf
“Safety Rail Height Requirement a Code Guide for 2026”
Safety Rail Height Requirement a Code Guide for 2026 – Ultra Modern Rails · ultramodernrails.com/blogs/news/safety-rail-height-requirement
No evidence found does not mean the action did not happen.
No evidence found either way · stated action 2
“Works were completed successfully, with purpose designed anti climb fencing along the full extent of the parapets to prevent unauthorised access”
QTS worked on behalf of Network Rail to deliver anti trespass ... · facebook.com/…/1777132252963031
“WireWorks Anti-Climb fence is a unique perimeter security product that maintains a guarded display of visual screening balancing the need to delay and deter an attack”
WireWorks Anti-Climb | Ameristar · ameristarperimeter.com/…/wireworks-anti-climb
“Discover more about the people who run Network Rail, our commitment to safety and sustainability and how we connect Britain through our infrastructure”
Fencing - Network Rail · networkrail.co.uk/our-work/living-by-the-railway/fencing
No evidence found does not mean the action did not happen.
No evidence found either way · stated action 3
“The Developers Handbook Approval and Authorisation Issue No. Date Comments C-05-OP-32-3001 This procedure will be reviewed at least annually and be revised as required. Printed copies of this document are uncontrolled. For the latest version click here: https://www.networkrail.co.uk/running-the-railway/looking-after-the-railway/asset-protection-and-optimisation/ or contact: Asset Protection Co”
[PDF] The Developers Handbook | Network Rail · networkrail.co.uk/…/Asset-Protection-The-Developers-Handbook.pdf
No evidence found does not mean the action did not happen.
Evidence found · stated action: “In relation to the wooden gate, this gate will be upgraded by the 2° December 2016, as part of a comprehensive upgrade to the fencing at this site.”
“Works were completed successfully, with purpose designed anti climb fencing along the full extent of the parapets to prevent unauthorised access”
QTS worked on behalf of Network Rail to deliver anti trespass ... · facebook.com/…/1777132252963031
“Over 15000 metres of new fencing and gates have been installed at nearly 300 stations across Kent, Sussex and south London as part of a £2.3”
Safety gates installed across South East to reduce trespass ... · networkrailmediacentre.co.uk/…/safety-gates-installed-across-so…
Evidence found · stated action: “e We have commissioned works to enhance the fencing and gates in this area. These works will be delivered by 15”
“Installation of fencing along the railroad right-of-way to deter unauthorized access. ROW) fencing aims to prevent pedestrians from entering the railroad ROW.”
Right-of-way fencing · trespasstoolkit.fra.dot.gov/Elib/Document/133
“We use fences to mark the boundary of our land. They also serve as a deterrent to prevent trespass and vandalism. Part of a structure, buildings - and occasionally natural screens of thorny shrubs - can also act as railway boundaries.”
Fencing - Network Rail · networkrail.co.uk/our-work/living-by-the-railway/fencing
Evidence found · stated action: “Network Rail has reviewed the active fencing proposals for upgrade on both sides of the track in the section where the incident occurred and have included these in our 2018 renewals plan”
“Review of Network Rail's proposed costs October 2018 Contents About this document 4 Context 6 1. Introduction 10 Overall approach 14 Issues and limitations 16 2. Maintenance and renewals costs 17 Overall context 17 Asset management planning 18 Cost planning and estimation 48 Delivery Planning 60 Significant changes since draft determination 82 3. Research and development costs 83 Assessment”
Review of Network Rail's proposed costs · orr.gov.uk/…/pr18-final-determination-review-of-network-rails-p…
“Renewals Planned expenditure £19.3bn There are two key elements of our renewals expenditure: - Core asset renewals - the replacement or life extension of our core assets (e.g. track, structures, drainage) when they have reached the end of their working life, are obsolete, or have degraded to a state where safe operation and reliable performance can no longer be realised.”
Network Rail CP7 Delivery Plan · networkrail.co.uk/…/Network-Rail-CP7-GB-Delivery-Plan.pdf
No evidence found either way · stated action: “in line with this recommendation, an inspection was undertaken by Network Rail's local operations team on 17 May 2017 to establish ownership and condition of the boundary fencing”
Network Rail conducted an inspection of the boundary fencing on 17 May 2017 as part of its standard procedures.
No evidence found does not mean the action did not happen.
Evidence found · stated action: “Network Rail is planning to apply mitigation measures (wire mesh panels with base plated fence posts fixed to the top of the parapet walls) to the parapet walls to further deter access to the track below. An order has now been placed with Network Rail's framework contractors in respect of these works, with an anticipated completion date of the end of September 2018.”
“Works were completed successfully, with purpose designed anti climb fencing along the full extent of the parapets to prevent unauthorised access”
QTS worked on behalf of Network Rail to deliver anti trespass ... · facebook.com/…/1777132252963031
“Our work keeps Britain moving. From maintaining and upgrading thousands of miles of track to delivering major infrastructure projects, we ensure the railway is safe, reliable, and sustainable.”
Fencing - Network Rail · networkrail.co.uk/our-work/living-by-the-railway/fencing
“Railway Fencing Security Solutions Jacksons Fencing has vast experience in enhancing security and reducing noise for trackside applications, railway stations, and storage and maintenance depots.”
Railway Security Fencing | Jacksons Security Fencing · jacksons-security.co.uk/railway-fencing
Evidence found · stated action: “In your report, you state that”
“Over 15000 metres of new fencing and gates have been installed at nearly 300 stations across Kent, Sussex and south London as part of a £2.3”
Safety gates installed across South East to reduce trespass ... · networkrailmediacentre.co.uk/…/safety-gates-installed-across-so…
“Trespass and Suicide Mitigation initiatives (platform end gates, hotspot management, safety films, etc.);”
South East Route Control Period 6 Delivery Plan · networkrail.co.uk/…/Route-Strategic-Plan-South-East.pdf
“The platform boundary combines see-through and opaque fencing to enhance natural visibility and sightlines and minimise blind spots.”
[PDF] Design Manual for Medium to Small Stations - Network Rail · networkrail.co.uk/…/Design-Manual-for-Medium-to-Small-Stations.…