Following an inquest into his death, she concluded: “In my opinion, there is a risk that future deaths could occur unless action is taken.”
The coroner added that “increasingly, more people wear earphones and are therefore less aware of their surroundings”.
She said visual signs on the approach to level crossings should be improved to prevent further accidents.
“Visual cues generally attract initial attention more effectively and support rapid comprehension, while sound cues tend to create a stronger emotional connection,” she said.
Network Rail, as the operator, is obliged to respond to her report by 31 March with details and a timetable of plans for action.