ATOC Limited

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First report 12 May 2014•Latest report 12 May 2014

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

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

Reports
1

Naming this recipient

Published responses
100%

Found for named reports

Concerns addressed
1

Across all linked responses

Stated actions
5

Described in responses

Concerns and recipient responses

Statements from ATOC Limited linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Bedfordshire and Luton

    AI-generated summary

    Terence Vincent Anthony FERNANDES · 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

    Terence Vincent Anthony FERNANDES collapsed on a train on 23 January 2013 after drinking alcohol, suffered cardiac arrest associated with airway occlusion, and died in hospital on 25 January 2013. The report raised concern that the train and station personnel who assisted him had no basic first-aid training and may not have recognised that his airway was partially occluded.

    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. The report was sent to ATOC Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of basic first aid training for personnel responding to unwell passengers

    Wider context from the report

    “(1) Terence Fernandes had become seriously unwell during the journey from Blackfriars to St. Albans whilst a passenger on a train. He was taken off the train by the driver, security staff and staff in attendance at the station and yet none of the personnel had even basic first aid training. If someone had had even limited first aid knowledge they may have been able to recognise that Terence’s airway had become partially occluded. ”
    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

    Send members an electronic notification about the death, recovery position, and consideration of changes to station first-aid arrangements.

    Verbatim wording from the response

    “Your Report has led to a further review of how passengers who are taken ill are assisted and sharing of TOC approaches to first aid training and briefing. These detailed discussions took place within the quarterly ATOC Safety Forum in June and at the quarterly Operations Council meeting in July. One of the actions arising from these discussions was for the Council to direct ATOC to write to its members to explicitly alert them to the circumstances of Mr Fernandes’ death and suggest that they consider, as part of each TOC’s continuous obligation to keep its risk assessments under review, whether any changes should be made to the first aid arrangements they have in place at each of their stations. The discussions also reminded members of the importance of the proper recovery position, and casualty management of unconscious persons, which are very infrequent events per location.”

    Source location

    2014-0220-Response
    Page 2 · response
    Published 12 May 2014

    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

    Review passenger illness assistance and share TOC approaches to first-aid training and briefing through the Safety Forum and Operations Council.

    Verbatim wording from the response

    “Your Report has led to a further review of how passengers who are taken ill are assisted and sharing of TOC approaches to first aid training and briefing. These detailed discussions took place within the quarterly ATOC Safety Forum in June and at the quarterly Operations Council meeting in July. One of the actions arising from these discussions was for the Council to direct ATOC to write to its members to explicitly alert them to the circumstances of Mr Fernandes’ death and suggest that they consider, as part of each TOC’s continuous obligation to keep its risk assessments under review, whether any changes should be made to the first aid arrangements they have in place at each of their stations. The discussions also reminded members of the importance of the proper recovery position, and casualty management of unconscious persons, which are very infrequent events per location.”

    Source location

    2014-0220-Response
    Page 2 · response
    Published 12 May 2014

    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

    Individual train operating companies decide and implement proportionate responses to passenger illness risks based on their own risk assessments.

    Verbatim wording from the response

    “As noted in my previous letter, ATOC is answerable to its members – it does not direct them; they direct it. However, groups such as the Council and Forum make it possible to alert members to risks associated with their operations and the safety and welfare of their passengers and staff – including those taken ill – and to influence how they respond through facilitation and cross-member discussions.”

    Source location

    2014-0220-Response
    Page 1 · response
    Published 12 May 2014

    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

    Individual companies’ ongoing review of existing first-aid arrangements is considered a sufficient national response, rather than requiring prescriptive uniform measures.

    Verbatim wording from the response

    “ATOC works with its members and other parties as necessary to identify and provide guidance on matters that are common to the majority of its members. A good example of this is the ATOC Guidance Note ‘Responding to Ill Customer on Trains’, issued in October 2013. Rather than suggest prescriptive arrangements, this includes a recommendation that TOCs should identify suitable stations along each line of route over which they operate at which a passenger who has a life-threatening or other illness can be passed directly into the care of ambulance staff. Clearly the number of such suitable stations is highly dependent on the geography – in some areas there may be considerable distances between stations which are staffed and offer more than the most basic of shelter facilities.”

    Source location

    2014-0220-Response
    Page 2 · response
    Published 12 May 2014

    Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026