17 Jul 2019 ANNABEL NEWPORT · Prevention of Future Deaths report London Inner (South)
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Concerns raised 5 Lack of consistent provision of defibrillators on trains and at stations View source Failure of the Pass-Com alarm to remain available after activation without guard reset View source Uncertainty about first aid training of drivers and control staff View source Insufficiently clear passenger information about Pass-Com reuse and use of the next carriage alarm View source Lack of first aid training for train guards responsible for identifying life-threatening conditions View source See 2 more concerns
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ANNABEL NEWPORT · Prevention of Future Deaths report
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Report summary
Annabel Newport collapsed shortly after boarding a train on 21 March 2018 and received CPR from passengers, but there was no defibrillator on board. She was taken to hospital after the train reached Waterloo and died two days later from brain damage suffered during cardiac arrest. The principal concerns were the lack of defibrillators, insufficient first-aid awareness among railway staff, and limitations in the operation of the emergency alarm system.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Heart Foundation; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent provision of defibrillators on trains and at stations
Wider context from the report “(i) The lack of consistent provision of defibrillators on trains and at stations
1. Although out of hospital cardiac arrest carries a generally poor prognosis, for some patients defibrillation can be lifesaving:
• The inquest received evidence that London Ambulance Service data suggests that around 32.9% of those with a shockable heart rhythm who receive defibrillation survive. Those figures are based on patients who received defibrillation from the emergency services. It is a reasonable inference that the survival rate will be higher if those who received defibrillation from a member of the public before the arrival of the emergency services are included in the data.
• The European Resuscitation Council Guidelines for Resuscitation (2010) suggest that in some cases CPR can double the chances of survival from out of hospital cardiac arrest. Early defibrillation is one of the four key stages of the “Chain of Survival” alongside early recognition of the problem, calling 999 and CPR.¹
2. The inquest received evidence that Eurostar International provides defibrillators on its trains and Virgin Trains has them on at least its ‘Pendolino’ trains.
3. There is a concern that South Western Railway does not provide defibrillators on any of its trains or at any of its stations, other than 12 chosen stations in the area it serves, across Kent, Sussex and in London. Other Train Operating Companies may adopt similar policies in this respect.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Heart Foundation; that does not assign responsibility.
PFD Monitor interpretation Failure of the Pass-Com alarm to remain available after activation without guard reset
Wider context from the report “(iii) The operation of the Pass-Com emergency alarm system
7. The Pass-Com is the emergency passenger alarm system found in the South Western Railway train carriages. It is understood that this may feature on other Train Operating Companies’ trains. Due to the operation of the alarm if it is activated by the passenger, once the call is terminated by the driver the alarm cannot be used again until the guard has re-set it .
8. In this case, the guard could not be located and so the alarm could not be used . Accordingly, a passenger took it upon himself to walk through the train to alert the driver to Ms Newport’s condition and lost potentially valuable time in order to do so. This may have contributed to the delay in her receiving ambulance treatment. The passenger did not appear to have realised that he could use a Pass-Com in another carriage. This may have been due to the stressful situation he found himself in, which is quite likely to occur if someone has used the Pass-Com due to a medical emergency.
9. There is a concern that it is not sufficiently apparent to passengers that once the Pass-Com has been used once, it cannot be used again without being re-set by the guard, and that in those circumstances they should immediately go to the next carriage to use the one there.
” Open source report × 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 British Heart Foundation; that does not assign responsibility.
PFD Monitor interpretation Uncertainty about first aid training of drivers and control staff
Wider context from the report “(ii) First aid awareness among the South Western Railway train guards and other staff
4. South Western Railway train guards are not first aid trained, although under its “Caring for Customers – What to do when a person is taken ill on a train” Protocol, it is the guard who is primarily responsible for identifying whether an unwell passenger’s condition is “life-threatening”.
5. It is also not clear whether South Western Railway drivers and control staff are first aid trained . In this case, the driver knew that Ms Newport had collapsed and was unconscious. There was communication about her between him and the control staff. The control staff decided that the train would proceed to Waterloo, leading to a delay in Ms Newport in her receiving ambulance treatment. This was on the basis that it was not understood that her condition was life-threatening.
6. There is a concern that a lack of first aid training of the driver and/or the control staff may have led to a failure to recognise that being unconscious is a potentially life-threatening condition .
” Open source report × 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 British Heart Foundation; that does not assign responsibility.
PFD Monitor interpretation Insufficiently clear passenger information about Pass-Com reuse and use of the next carriage alarm
Wider context from the report “(iii) The operation of the Pass-Com emergency alarm system
7. The Pass-Com is the emergency passenger alarm system found in the South Western Railway train carriages. It is understood that this may feature on other Train Operating Companies’ trains. Due to the operation of the alarm if it is activated by the passenger, once the call is terminated by the driver the alarm cannot be used again until the guard has re-set it.
8. In this case, the guard could not be located and so the alarm could not be used. Accordingly, a passenger took it upon himself to walk through the train to alert the driver to Ms Newport’s condition and lost potentially valuable time in order to do so. This may have contributed to the delay in her receiving ambulance treatment. The passenger did not appear to have realised that he could use a Pass-Com in another carriage. This may have been due to the stressful situation he found himself in, which is quite likely to occur if someone has used the Pass-Com due to a medical emergency.
9. There is a concern that it is not sufficiently apparent to passengers that once the Pass-Com has been used once, it cannot be used again without being re-set by the guard , and that in those circumstances they should immediately go to the next carriage to use the one there .
” Open source report × 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 British Heart Foundation; that does not assign responsibility.
PFD Monitor interpretation Lack of first aid training for train guards responsible for identifying life-threatening conditions
Wider context from the report “(ii) First aid awareness among the South Western Railway train guards and other staff
4. South Western Railway train guards are not first aid trained , although under its “Caring for Customers – What to do when a person is taken ill on a train” Protocol, it is the guard who is primarily responsible for identifying whether an unwell passenger’s condition is “life-threatening” .
5. It is also not clear whether South Western Railway drivers and control staff are first aid trained. In this case, the driver knew that Ms Newport had collapsed and was unconscious. There was communication about her between him and the control staff. The control staff decided that the train would proceed to Waterloo, leading to a delay in Ms Newport in her receiving ambulance treatment. This was on the basis that it was not understood that her condition was life-threatening.
6. There is a concern that a lack of first aid training of the driver and/or the control staff may have led to a failure to recognise that being unconscious is a potentially life-threatening condition.
” Open source report
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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 Support workplaces to purchase and place defibrillators.
Verbatim wording from the response “We also support workplaces to purchase defibrillators – for example we have recently supported a national construction company to purchase over 300 defibrillators that will be placed within the new housing estates they are developing.” Source location 2019-0240-Response-by-British-Heart-Foundation
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Encourage train stations and rail network providers to place defibrillators in stations and on trains.
Verbatim wording from the response “While there is no legislative onus on train stations and rail network providers to place defibrillators within train stations and on trains, we do encourage those relevant organisations to do so and can support them as I outlined above.” Source location 2019-0240-Response-by-British-Heart-Foundation
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train stations and rail network providers have no legislative obligation to place defibrillators in stations or on trains.
Verbatim wording from the response “While there is no legislative onus on train stations and rail network providers to place defibrillators within train stations and on trains, we do encourage those relevant organisations to do so and can support them as I outlined above.” Source location 2019-0240-Response-by-British-Heart-Foundation
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25 Oct 2016 Jane Louise Reason · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 3 Insufficient public education in the use of public access defibrillators View source Inadequate placement of public access defibrillators View source Insufficient availability of public access defibrillators in colleges and schools View source
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AI-generated summary
Jane Louise Reason · 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
Jane Louise Reason, a lecturer, collapsed at work on 28 April 2016 and was later declared deceased in hospital; the medical cause of death was recorded as hypertensive heart disease. The inquest highlighted the importance of early defibrillation and CPR and raised concern about the availability and public education surrounding public access defibrillators, particularly in colleges and schools.
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 British Heart Foundation; that does not assign responsibility.
PFD Monitor interpretation Insufficient public education in the use of public access defibrillators
Wider context from the report “1. Evidence at the inquest confirmed that the greatest chance of survival following an arrhythmic out of cardiac arrest is with early defibrillation and CPR. I heard evidence that there was a need for more public access defibrillators particularly in colleges and school. Further consideration needs to be given to the placement of public access defibrillators and education of the public in their use .
” Open source report × 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 British Heart Foundation; that does not assign responsibility.
PFD Monitor interpretation Inadequate placement of public access defibrillators
Wider context from the report “1. Evidence at the inquest confirmed that the greatest chance of survival following an arrhythmic out of cardiac arrest is with early defibrillation and CPR. I heard evidence that there was a need for more public access defibrillators particularly in colleges and school. Further consideration needs to be given to the placement of public access defibrillators and education of the public in their use.
” Open source report × 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 British Heart Foundation; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of public access defibrillators in colleges and schools
Wider context from the report “1. Evidence at the inquest confirmed that the greatest chance of survival following an arrhythmic out of cardiac arrest is with early defibrillation and CPR. I heard evidence that there was a need for more public access defibrillators particularly in colleges and school . Further consideration needs to be given to the placement of public access defibrillators and education of the public in their use.
” Open source report
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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 Develop a guide explaining automated external defibrillators and their community deployment.
Verbatim wording from the response “In conjunction with the Resuscitation Council we have recently developed “A guide to Automated External Defibrillators” which provides information about PADs and how they can be deployed in the community to help resuscitate victims of sudden cardiac arrest.” Source location 2016-0376-Response-by-British-Heart-Foundation
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Public-policy CPR and defibrillator programmes cannot be carried out as public policy because the organisation is neither a government institution nor public authority.
Verbatim wording from the response “In summary we are actively engaged in providing access to training resources to teach CPR skills and PAD familiarisation on a range of programmes and provide access to funding for PADs but we have no authority to carry out these programmes as a matter of public policy as we are not a government institution or public authority. However, the BHF recommends that all young people are given access to CPR training and defibrillator awareness while at secondary school and ask that you support this recommendation by communicating this to the Department for Education.” Source location 2016-0376-Response-by-British-Heart-Foundation
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations