Recurring concern

Unreliable emergency response arrangements at railway stations

First to latest report 24 Jun 2019 — 23 Jun 2022

Reports that mention this concern: 2
Times this concern has been raised: 4
Stated actions linked to this concern: 2

What this concern includes

Includes dedicated railway-station arrangements for responding to illness or injury and other immediate welfare emergencies, including station-specific response plans, staff procedures, public directions or announcements for obtaining help, emergency communication, coordination with responders and review or assurance of those arrangements.

What is not included

Excludes general railway security, CCTV, track-access, suicide-prevention, passenger-supervision and platform-safety deficiencies unless they directly form part of responding to an illness, injury or immediate welfare emergency at the station.
Excludes generic public-event emergency arrangements where the asserted concern is not the operation of a railway-station emergency response.
Excludes ambulance, fire or police response failures occurring after the station has reliably initiated and coordinated the emergency response.
Excludes generic staff training, communication or documentation deficiencies unless they directly impair the railway-station emergency response arrangement.

Trends

Reports over time

Reports mentioning this concern, over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Addiscombe Road1

British Transport Police1

Department for Transport1

First MTR South Western Trains Limited1

Govia Thameslink Railway Limited1

Mr Davies’ family1

Office of Rail and Road1

Reports and published responses 2 reports

See individual reports that have raised this concern, and the actions taken in response

23 Jun2022
Hampshire, Portsmouth and Southampton
Concerns raised1
1. Lack of public announcements directing people to obtain assistance
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

First MTR South Western Trains Limited
Respondent positions 1
1. First MTR South Western Trains Limited
  Existing automated security and welfare announcements, help points, emergency buttons and Samaritan posters are considered appropriate.
  Existing arrangements considered sufficient
AI-generated summary

Alun John Davies · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Alun John Davies died instantly after jumping from the platform at Portchester railway station into the path of a non-stopping train on 4 May 2021. The evidence described acute anxiety and chronic depression, following recent personal difficulties. Concerns included limited staffing, CCTV coverage and platform visibility at the station, as well as insufficient public security and welfare announcements and information about obtaining assistance.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of public announcements directing people to obtain assistance
Wider context from the report
“(3) The post-incident site report further identified the lack of public security and welfare announcements at the station (and within the station concourse) aimed at providing direction in the event of illness or of assistance being required. There is a lack of information/announcements to other members of the public as to how to obtain assistance if they are concerned by someone else’s condition or actions. It is not clear to what extent this has been further considered or addressed. ”
Source location
Alun John Davies · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Existing automated security and welfare announcements, help points, emergency buttons and Samaritan posters are considered appropriate.

Verbatim wording from the response
“23. The following types of security and welfare announcements are made at Portchester Station:”

Source location
Response from South West Trains
Page 3 · response
Published 22 September 2022
Open published response
24 Jun2019
North London
Concerns raised3
1. Lack of a station-specific plan for responding to illness or injury in station areas
2. Lack of a station-specific plan for responding to illness or injury in station areas
3. Lack of a station-specific plan for responding to illness or injury in station areas
Linked responses

Department for Transport
Govia Thameslink Railway Limited
Office of Rail and Road
Stated actions 2
1. Govia Thameslink Railway Limited
  Produce and issue the “Caring for our Customers” staff aide-mémoire for station managers and staff.
2. Govia Thameslink Railway Limited
  Update Local Incident Response Plans to incorporate the aide-mémoire requirements and PAPI acronym.
Respondent positions 4
1. Department for Transport
  Govia Thameslink Railway is responsible for managing and operating Mill Hill Broadway station as its station facility owner.
  Redirects responsibility
1. Department for Transport
  The Department considers GTR’s measures sufficient to resolve the identified matters of concern.
  No action considered necessary
2. Office of Rail and Road
  Existing safety management systems met minimum legal standards and were considered adequate to manage the relevant station risks.
  Existing arrangements considered sufficient
3. Office of Rail and Road
  The regulator cannot alter compliant duty-holder arrangements or take enforcement action where minimum legal standards are met.
  Outside remit
AI-generated summary

Priscilla Tropp · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

On 27 November 2018, Priscilla Tropp fell down steps at Mill Hill Broadway Station and was taken to hospital, where she died from injuries sustained in the fall. The principal concern was the absence of a station flow chart or plan for managing people who become ill or injured, including steps to mitigate potential injury to them and others using the station.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of a station-specific plan for responding to illness or injury in station areas
Wider context from the report
“That there is no flow chart or plan for this station, taking into account its design and available public spaces, to cover the situations where a person is taken ill on the station, or in any of the area that are involved in moving around the station , that sets out a sensible series of steps that need to be taken by staff to mitigate any potential injury to the person who may themselves have been injured or to any one else using the station. ”
Source location
Priscilla Tropp · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of a station-specific plan for responding to illness or injury in station areas
Wider context from the report
“That there is no flow chart or plan for this station, taking into account its design and available public spaces, to cover the situations where a person is taken ill on the station, or in any of the area that are involved in moving around the station, that sets out a sensible series of steps that need to be taken by staff to mitigate any potential injury to the person who may themselves have been injured or to any one else using the station. ”
Source location
Priscilla Tropp · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of a station-specific plan for responding to illness or injury in station areas
Wider context from the report
“That there is no flow chart or plan for this station, taking into account its design and available public spaces, to cover the situations where a person is taken ill on the station, or in any of the area that are involved in moving around the station , that sets out a sensible series of steps that need to be taken by staff to mitigate any potential injury to the person who may themselves have been injured or to any one else using the station. ”
Source location
Priscilla Tropp · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Produce and issue the “Caring for our Customers” staff aide-mémoire for station managers and staff.

Verbatim wording from the response
“Since the inquest, we have developed some guidance for managers and staff when dealing with ill or injured persons on stations. This guidance is designed as a straightforward aide-mémoire to supplement the existing training and will complement our recent training programme for dealing with people ill or in trains. Operating stations of varied design with different risk factors, means each location is subject to its own risk assessment, with its own mitigations and access to certain equipment. These differences are identified to staff on their local induction.”

Source location
2019-0213-Response-by-Thameslink
Page 1 · response
Published 25 August 2019
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Update Local Incident Response Plans to incorporate the aide-mémoire requirements and PAPI acronym.

Verbatim wording from the response
“• Local Incident Response Plans (LIRP) to be updated to include the requirements of the Staff Aide-Mémoire “Caring for our Customers” and the PAPI acronym to provide a consistent approach to incident management – Planned completion of revised and updated LIRPs by 31st August 2019.”

Source location
2019-0213-Response-by-Thameslink
Page 1 · response
Published 25 August 2019
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Govia Thameslink Railway is responsible for managing and operating Mill Hill Broadway station as its station facility owner.

Verbatim wording from the response
“Govia Thameslink Railway (GTR), as a franchisee of the Department for Transport, is the train operating company that is responsible, as station facility owner, for managing and operating Mill Hill Broadway station.”

Source location
2019-0213-Response-by-Department-for-Transport
Page 1 · response
Published 25 August 2019
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The Department considers GTR’s measures sufficient to resolve the identified matters of concern.

Verbatim wording from the response
“Jerome Pacatte, Head of Customer Service at Thameslink / Great Northern (a part of GTR) wrote to you on 2 August 2019, to set out the measures that GTR is undertaking in response to your stated ‘Matters of Concern’. These measures are:”

Source location
2019-0213-Response-by-Department-for-Transport
Page 2 · response
Published 25 August 2019
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Existing safety management systems met minimum legal standards and were considered adequate to manage the relevant station risks.

Verbatim wording from the response
“Whilst acknowledging and respecting the Coroner’s view on aspects of the safety management arrangements at the station, the ORR’s assessment is that if the safety management systems in place were not causative of or contributory to Mrs Tropp’s death and were in compliance with the minimum standards required by health and safety legislation then the ORR has no authority to alter those arrangements. It is the assessment of the Inspector that investigated this incident that the safety management systems that are in place do meet the minimum standards.”

Source location
2019-0213-Response-by-ORR
Page 2 · response
Published 25 August 2019
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The regulator cannot alter compliant duty-holder arrangements or take enforcement action where minimum legal standards are met.

Verbatim wording from the response
“Whilst acknowledging and respecting the Coroner’s view on aspects of the safety management arrangements at the station, the ORR’s assessment is that if the safety management systems in place were not causative of or contributory to Mrs Tropp’s death and were in compliance with the minimum standards required by health and safety legislation then the ORR has no authority to alter those arrangements. It is the assessment of the Inspector that investigated this incident that the safety management systems that are in place do meet the minimum standards.”

Source location
2019-0213-Response-by-ORR
Page 2 · response
Published 25 August 2019
Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Data last updated 7 September 2026

What this concern includes

Trends

Reports mentioning this concern, over time

Concerns raised1

Lack of public announcements directing people to obtain assistance

Linked response

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised3

Lack of a station-specific plan for responding to illness or injury in station areas

Lack of a station-specific plan for responding to illness or injury in station areas

Lack of a station-specific plan for responding to illness or injury in station areas

Linked responses

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4

Respondent positions 1

Stated actions 2

Respondent positions 4