28 Mar 2024 Daniela Vitalia PANI · Prevention of Future Deaths report Berkshire
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Concerns raised 5 Lack of Samaritan signs at the train station View source Failure to implement identified suicide-risk mitigation measures at the train station View source Training and guidance failing to address service users declining a visit or meeting View source Inability of staff to carry out face-to-face assessments in all possible cases View source Car park line-side fencing being too low View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Daniela Vitalia PANI · 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
Daniela Vitalia PANI died on 29 June 2023 after entering a train station, jumping onto the tracks and being struck by a train. Concerns were raised that potential suicide-risk mitigation measures at the station had not been implemented, and that mental-health staff lacked specific guidance and training for situations where service users declined face-to-face 72-hour reviews.
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× 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 First MTR South Western Trains Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of Samaritan signs at the train station
Wider context from the report “1. A lack of Samaritan signs on the platforms or within the stations.
The mitigation proposed was conspicuously placed posters and/or additional signage.
” 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 First MTR South Western Trains Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to implement identified suicide-risk mitigation measures at the train station
Wider context from the report “The report was submitted on the 25th July 2023. Despite the passage of nearly 9 months from submission of the report to the date of the inquest the BTP officer giving evidence could not inform me whether these changes had been actioned. I was advised that this information had been requested from South Western Railways but had not been provided.
On the 18th March 2024 I requested an update from BTP about the actions taken and invited them to attend the final hearing on the 25th March 2024. No information was submitted and no-one from BTP attended the final hearing.
I am therefore concerned that measures to mitigate the risk of future suicides at the train station have not been implemented .
” 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 First MTR South Western Trains Limited; that does not assign responsibility.
PFD Monitor interpretation Training and guidance failing to address service users declining a visit or meeting
Wider context from the report “I heard evidence from a number of members of the CMHT regarding the policies, procedures and training around the completion of this important review meeting.
During the course of this I heard that training and guidance did not specifically address how to deal with service users declining a visit or meeting.
This is a complex area with competing demands of the duty of care, mental capacity and the autonomy of an individual to make decisions about their own care and treatment. The evidence from the CMHT Joint Service Manager was that guidance and/or training would be important for staff seeking to deal with this challenging area .
” 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 First MTR South Western Trains Limited; that does not assign responsibility.
PFD Monitor interpretation Inability of staff to carry out face-to-face assessments in all possible cases
Wider context from the report “I am concerned that the staff not being able to carry out face to face assessments in all possible cases gives rise to the risk of future deaths.
” 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 First MTR South Western Trains Limited; that does not assign responsibility.
PFD Monitor interpretation Car park line-side fencing being too low
Wider context from the report “2. Car park line side fencing being too low.
The proposed mitigation was replacement of the fencing.
” Open source report
Concerns raised 4 Lack of public announcements directing people to obtain assistance View source Failure to fully implement identified station security recommendations View source Insufficient CCTV surveillance and platform visibility View source Limited staffing at the railway station View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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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.
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× 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 First MTR South Western Trains Limited; that does not assign responsibility.
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.
” 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 First MTR South Western Trains Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to fully implement identified station security recommendations
Wider context from the report “(2) The post-incident site report further identified that Portchester Railway station is an impending ‘escalated’ location. Since 2017 there have been 2 previous fatalities in similar circumstances at the station – which is now recognised as having lower levels of surveillance – with Mr Davies’ death being the third. Although recommendations were made after the first incident, the above recommendations and identified risks (at 1) have not yet been (fully) addressed or implemented .
” 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 First MTR South Western Trains Limited; that does not assign responsibility.
PFD Monitor interpretation Insufficient CCTV surveillance and platform visibility
Wider context from the report “(1) The post-incident site report presented by British Transport Police (in conjunction with the Design Out Crime Unit) and completed on 22 July 2021 identified that there was (and remains) limited staffing and CCTV surveillance at Portchester Railway Station and limited visibility of the platforms - requiring a security risk assessment with a view to increasing staffing (at the ticket office and on the platform) with increased RCO Patrols and platform surveillance and that additional CCTV installation and coverage was required (of the platforms and public areas) with real time capability .
” 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 First MTR South Western Trains Limited; that does not assign responsibility.
PFD Monitor interpretation Limited staffing at the railway station
Wider context from the report “(1) The post-incident site report presented by British Transport Police (in conjunction with the Design Out Crime Unit) and completed on 22 July 2021 identified that there was (and remains) limited staffing and CCTV surveillance at Portchester Railway Station and limited visibility of the platforms - requiring a security risk assessment with a view to increasing staffing (at the ticket office and on the platform) with increased RCO Patrols and platform surveillance and that additional CCTV installation and coverage was required (of the platforms and public areas) with real time capability.
” 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 Install trespass gates, witches hats and anti-tread guards at the ends of Portchester station platforms.
Verbatim wording from the response “18. Response to Paragraph 2: Previous incidents” Source location Response from South West Trains
Open published response
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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 No increase in Portchester ticket-office staffing is required following consideration of the incident.
Verbatim wording from the response “7. At Portchester Station, there is a member of staff present in the ticket office during commuter times (Monday to Friday 05:50 to 10:40 and Saturday 07:50 to 14:20). However, outside of these hours there are no staff present in the ticket office.” Source location Response from South West Trains
Open published response
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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 No platform staff need to be introduced at Portchester following review of the station’s platform and train-interface assessment.
Verbatim wording from the response “9. SWR conducts ‘platform/train interface assessments’ which informs decisions on staffing arrangements at platforms. For example, at some stations there may be a high frequency of trains stopping at the station, a high footfall of passengers and/or special events (such as at Twickenham station on match days) which may require platform staff to be present.” Source location Response from South West Trains
Open published response
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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 Network-wide CCTV cannot be monitored in real time or proactively because staffing every camera continuously is impracticable.
Verbatim wording from the response “15. The purpose of CCTV at train stations is largely twofold: first, to try to deter criminal activity, and secondly to provide a record of any incidents that occur, which can be used in the course of any investigation. Given the number of CCTV cameras across the whole of the SWR network, it would not be practicable to have staff monitoring every camera 24 hours a day, and so the CCTV system cannot be used proactively to try to prevent criminal activity or other incidents.” Source location Response from South West Trains
Open published response
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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 Portchester’s low-risk classification means regular, predetermined Railway Community Officer patrols are not required.
Verbatim wording from the response “(c) Railway Community Officer patrols” Source location Response from South West Trains
Open published response
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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
Open published response
30 Mar 2020 JORDAN MICHAEL AIRA · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 4 Lack of physical boundaries preventing public access to railway tracks View source Failure of warning signs to warn of the risk of immediate death from touching the live rail View source Lack of a national curriculum requirement to teach pupils about the risk posed by the live rail View source Emergency telephone located adjacent to railway track View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
JORDAN MICHAEL AIRA · 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
Jordan Michael Aira was electrocuted after walking onto the railway lines at Ashford Station in the early hours of 23 March 2019. The concerns included inadequate physical barriers, the location of the emergency telephone, warning signs that did not explicitly warn of immediate death from touching the live rail, and no national curriculum requirement to teach pupils about the risk posed by live rails.
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 First MTR South Western Trains Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of physical boundaries preventing public access to railway tracks
Wider context from the report “1. There were no physical boundaries at the end of the platform preventing members of the public accessing the railway tracks .
” 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 First MTR South Western Trains Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of warning signs to warn of the risk of immediate death from touching the live rail
Wider context from the report “3. The warning signs in place which are standard in the rail industry do not in terms warn of the risk of immediate death if you touch the live rail .
” 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 First MTR South Western Trains Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of a national curriculum requirement to teach pupils about the risk posed by the live rail
Wider context from the report “4. There is no requirement in the national curriculum to teach pupils about the risk posed by the live rail .
” 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 First MTR South Western Trains Limited; that does not assign responsibility.
PFD Monitor interpretation Emergency telephone located adjacent to railway track
Wider context from the report “2. The emergency telephone which may be used by members of the public is located adjacent to the railway track .
” 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 Deploy Rail Safety Accredited Security Officers to patrol for trespass and antisocial behaviour and target hotspot locations with partner agencies.
Verbatim wording from the response “Locally to SWR, we have Rail Safety Accredited Security Officers (Rail Community Officers) whose core activities include the following:” Source location 2020-0082-Response-from-South-Western-Railway_Redacted
Open published response
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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 Deliver the “You vs Train” campaign and virtual digital safety sessions through social media and education settings to warn young people about railway dangers.
Verbatim wording from the response “Additionally, in 2018 the “You vs Train” campaign was launched to the public using social media channels, targeting a younger audience making them aware of the dangers of the railway through Virtual Digital sessions delivered to primary and secondary schools as well as colleges. The campaign’s effectiveness is enhanced by the use of video accounts of survivors who came into contact with the third rail. The aim of this campaign was to:” Source location 2020-0082-Response-from-South-Western-Railway_Redacted
Open published response
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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 Deliver railway safety awareness sessions with Network Rail to educate pupils about third-rail, trespass and safe behaviour.
Verbatim wording from the response “SWR works very closely with NR to deliver Safety Awareness sessions at schools located near stations on our network. These educational sessions have been ongoing since 2017 and are delivered to pupils from Reception Year to Year 11. The focus of the sessions is to make the pupils aware of the dangers of the railway including the third rail, and how to behave without putting themselves and others in danger when on a station or near a level crossing.” Source location 2020-0082-Response-from-South-Western-Railway_Redacted
Open published response
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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 Ashford station signage conformed to national standards and was considered sufficient, so no further signage action was required.
Verbatim wording from the response “The signage in place at Ashford station conforms with the Station Infrastructure Standard (Rail Industry Standards 7700-INS – Issue 3, June 2018) which is applied nationally by the wider rail industry.” Source location 2020-0082-Response-from-South-Western-Railway_Redacted
Open published response
19 Nov 2019 James Joseph Fennell · Prevention of Future Deaths report Berkshire
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Concerns raised 2 Lack of tactile paving or crosshatch marking between platform safe-area and edge lines View source Lack of visible warnings about live-rail electrocution risk in platform waiting areas View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
James Joseph Fennell · 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
James Joseph Fennell left a train at Wokingham Station and climbed onto the tracks to cross to the other side. He slipped and made contact with the third rail, resulting in his instant death from electrocution. The principal concern was that warning signs about the risk of electrocution were small, distant, and not visible from the main areas where commuters waited, raising a potential risk at stations nationally.
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 First MTR South Western Trains Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of tactile paving or crosshatch marking between platform safe-area and edge lines
Wider context from the report “(2) Signage was reviewed at Wokingham Station following the incident by a Designing Out Crime Unit, and I have the report of ████████ in this respect. No recommendations were made with regard to signage at this station. We heard in evidence that there are small signs at either end of the platform at Wokingham Station, indicating that the lines should not be crossed because of the danger of electrocution. Neither of these signs would be visible from the main area where commuters stand to wait for trains. They are small and some distance away.
(3) There is a yellow painted line indicating the safe area away from the platform edge, as well as a white line on the platform edge. There is no tactile paving or crosshatch marking between these two lines.
(4) There is no warning of the risk of the live rail visible to commuters on the platform at this station. This is likely to be a situation which is replicated in many stations nationally.
(5) It was suggested in evidence that most people are aware of the risks of crossing train tracks in this way. I accepted the evidence of James' mother that he was not aware of this and I am aware of other cases in recent national press in which that was found to be the case. If indeed it is felt that the public is well aware of this risk, then there seems to be little point in having signs at the ends of the platform to warn the public of this. It seems incongruous that the public should need to be warned in an area where there is unlikely to be any member of the public present, but no warning in the areas where most of the members of the public stand to wait for trains.
(6) If the purpose of the signs at the ends of the platform is to warn the public of the risk beyond the platforms areas (where the “third rail” is on the nearside of the track), then it seems to me that this risk is a much smaller one, given the much higher footfall in the platform areas – where there are no signs, and no indication whatsoever of this exceptionally high risk.
(7) I cannot conceive of many (if any) scenarios in which electrical power of this magnitude would be open and accessible without significant signage and warnings.
(8) Whilst James did initially step over the rail, as seen on CCTV, I do not accept that is evidence that James knew of the risk of electrocution. It is human nature to step over a rail when walking, particularly given that the third rail is somewhat elevated.
(9) I accept that excessive signage can carry its own risks. It is however surprising that there is no signage visible to members of the public, warning them of this risk, except in areas where they are unlikely to stand. Whilst members of the public may be aware that crossing a train line is dangerous, this may be because of a perception of the risk of oncoming trains, rather than the risk of electrocution.
(10)Whilst it is undoubtedly the case that James was intoxicated at the time of these events, this is not the first case of this nature. I consider that there is a risk of future deaths and that other members of the public are likely to be unaware of the significant risk involved in crossing tracks in this way, save in relation to the risk of oncoming trains.
(11) I believe this is an issue which is likely to be relevant to stations nationally, and not just to Wokingham Station.
” 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 First MTR South Western Trains Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of visible warnings about live-rail electrocution risk in platform waiting areas
Wider context from the report “(2) Signage was reviewed at Wokingham Station following the incident by a Designing Out Crime Unit, and I have the report of ████████ in this respect. No recommendations were made with regard to signage at this station. We heard in evidence that there are small signs at either end of the platform at Wokingham Station, indicating that the lines should not be crossed because of the danger of electrocution. Neither of these signs would be visible from the main area where commuters stand to wait for trains. They are small and some distance away.
(3) There is a yellow painted line indicating the safe area away from the platform edge, as well as a white line on the platform edge. There is no tactile paving or crosshatch marking between these two lines.
(4) There is no warning of the risk of the live rail visible to commuters on the platform at this station. This is likely to be a situation which is replicated in many stations nationally.
(5) It was suggested in evidence that most people are aware of the risks of crossing train tracks in this way. I accepted the evidence of James' mother that he was not aware of this and I am aware of other cases in recent national press in which that was found to be the case. If indeed it is felt that the public is well aware of this risk, then there seems to be little point in having signs at the ends of the platform to warn the public of this. It seems incongruous that the public should need to be warned in an area where there is unlikely to be any member of the public present, but no warning in the areas where most of the members of the public stand to wait for trains.
(6) If the purpose of the signs at the ends of the platform is to warn the public of the risk beyond the platforms areas (where the “third rail” is on the nearside of the track), then it seems to me that this risk is a much smaller one, given the much higher footfall in the platform areas – where there are no signs, and no indication whatsoever of this exceptionally high risk.
(7) I cannot conceive of many (if any) scenarios in which electrical power of this magnitude would be open and accessible without significant signage and warnings.
(8) Whilst James did initially step over the rail, as seen on CCTV, I do not accept that is evidence that James knew of the risk of electrocution. It is human nature to step over a rail when walking, particularly given that the third rail is somewhat elevated.
(9) I accept that excessive signage can carry its own risks. It is however surprising that there is no signage visible to members of the public, warning them of this risk, except in areas where they are unlikely to stand. Whilst members of the public may be aware that crossing a train line is dangerous, this may be because of a perception of the risk of oncoming trains, rather than the risk of electrocution.
(10)Whilst it is undoubtedly the case that James was intoxicated at the time of these events, this is not the first case of this nature. I consider that there is a risk of future deaths and that other members of the public are likely to be unaware of the significant risk involved in crossing tracks in this way, save in relation to the risk of oncoming trains.
(11) I believe this is an issue which is likely to be relevant to stations nationally, and not just to Wokingham Station.
” Open source report
17 Jul 2019 ANNABEL NEWPORT · Prevention of Future Deaths report London Inner (South)
View report summary
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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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
ANNABEL NEWPORT · 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
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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× 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 First MTR South Western Trains Limited; 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.
” 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 First MTR South Western Trains Limited; 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 First MTR South Western Trains Limited; 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 First MTR South Western Trains Limited; 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 First MTR South Western Trains Limited; 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 Update Pass-Com emergency guidance so Drivers advise passengers to use another emergency alarm and Guards are reminded to reset the device.
Verbatim wording from the response “37 The Coroner suggested we might put signage next to the Pass-Com. However, our concern is that this might not be read by a passenger under the pressure of acting in an unexpected emergency. We think that the best way to address that concern is for Drivers, receiving a Pass-Com communication, to advise the passenger about this limitation. We have therefore updated the Driver’s section of the Booklet to reflect this. In particular, the start of the Driver’s step-by-step guide to responding to an ill passenger incident begins [emphasis added]:” Source location 2019-0240-Response-by-South-Western-Railways
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Distribute and embed the revised protocol through Guard and Driver access, Guard briefings, Development Days, Guard cue cards, and Control Centre prompt cards.
Verbatim wording from the response “(a) Each Guard will be issued with, and will have to sign for, a hard copy of the Booklet for their use;” Source location 2019-0240-Response-by-South-Western-Railways
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish a revised passenger-illness protocol booklet incorporating explicit life-threatening conditions, worst-case response guidance, and basic lifesaving and first-aid guidance.
Verbatim wording from the response “30 As noted during the Inquest, SWR had been preparing to revise the booklet containing our written protocol for dealing with passenger illness incidents, including cardiac arrest. SWR awaited the outcome of the Inquest so as to incorporate learning from it. We have since published a revised version of that protocol, incorporating a number of changes and improvements, in a booklet called “Caring for our Customers”.” Source location 2019-0240-Response-by-South-Western-Railways
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review AED provision at managed stations and determine additional installation locations.
Verbatim wording from the response “12. SWR has commenced a systematic and detailed review of the locations at which AEDs are installed at its managed stations. SWR anticipates this will result in the installation of AEDs at additional locations. It has not yet finalised the list of locations. We have also recently been approached by Network Rail to discuss a wider initiative which Network Rail is spearheading concerning further installations at stations on the national rail network. I am therefore positive there will be an increase in AEDs at our stations in the near future. Since the incident, in addition to the dedicated paramedic” Source location 2019-0240-Response-by-South-Western-Railways
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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 On-board AEDs are not required because frequent stops and ambulance-service equipment provide the appropriate emergency response.
Verbatim wording from the response “8. Much of SWR’s core business is the operation of suburban Metro-style services in and around London. These services run between Waterloo and Clapham Junction where they split into separate routes. These are frequent services with many interim stops, as well as further ‘through’ stations at which a train could stop in an emergency. For example, the peak-time 08:42 service from Reading to Waterloo is an 82-minute journey stopping at 18 stations, which is an average of one stop every 4½ minutes.” Source location 2019-0240-Response-by-South-Western-Railways
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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 Additional Pass-Com signage is unnecessary because Drivers now advise passengers to use another emergency alarm for further contact.
Verbatim wording from the response “36 We understand your concern is that it is not sufficiently apparent to passengers that once the Pass-Com has been used once, it cannot be used again without being reset by the Guard but that in those circumstances, they can immediately go to the next carriage to use the one there.” Source location 2019-0240-Response-by-South-Western-Railways
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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 Additional first-aid training would not improve Driver or Control Centre responses because their roles require communication and ambulance coordination.
Verbatim wording from the response “16. Having given proper consideration to the concern raised, it is not clear in what circumstances first aid training of Drivers and staff at the Control Centre would make a difference to the treatment of an on-board passenger. We would certainly never dissuade an employee in either role from taking a first aid course. However, in respect of passenger emergency responses, neither is in a position to administer first aid.” Source location 2019-0240-Response-by-South-Western-Railways
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations