1 Dec 2021 Kaja Weronika SPIEWAK · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 4 Failure to provide control-room staff with appropriate information for responding to concern-for-welfare reports View source Failure to appropriately share and report concern-for-welfare information with relevant agencies View source Failure to log all actions taken after concern-for-welfare reports View source Failure to ensure proper training of frontline and control-room staff in dealing with vulnerable or suicidal persons 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
Kaja Weronika SPIEWAK · 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 7 April 2021, Kaja Weronika SPIEWAK was identified as vulnerable while travelling by train and was later declared deceased at 1.07pm after being at Southbourne Station. The report raised concerns about inadequate training, inappropriate control-room guidance, incomplete recording of actions, and failures to share welfare concerns with relevant agencies.
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 Govia Thameslink Railway Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to provide control-room staff with appropriate information for responding to concern-for-welfare reports
Wider context from the report “(2) I heard evidence that Govia Thameslink Railway Ltd staff control room staff relied upon a protocol entitled ‘Person ill on a train’ when a vulnerable person was reported to them . The witness responsible for the Govia Thameslink Railway control room team accepted that this was not an appropriate document to rely upon as it made no mention of vulnerable persons .
I am therefore concerned that the control room staff do not have the appropriate information to assist their colleagues and to arrange an appropriate response when a ‘concern for welfare’ report is made to them .
” 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 Govia Thameslink Railway Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to appropriately share and report concern-for-welfare information with relevant agencies
Wider context from the report “(4) The Govia Thameslink Railway Ltd control room staff did not contact British Transport Police, 999 nor share the information about this ‘concern for welfare’ report with Network Rail despite having a joint control room.
I heard evidence that there was no written protocol covering when Govia Thameslink Railway Ltd staff should share a ‘concern for welfare’ report with Network Rail staff in the shared control room .
I am concerned that there is not appropriate information sharing and reporting to other agencies, including British Transport Police, when a ‘concern for welfare’ is raised .
” 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 Govia Thameslink Railway Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to log all actions taken after concern-for-welfare reports
Wider context from the report “(3) I heard evidence that the Govia Thameslink Railway Ltd control room staff did not log all actions taken after the concern for welfare report .
I am concerned that it is not possible to assess whether all reasonable and appropriate actions were taken by the control room staff and whether individuals or teams have further training needs.
” 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 Govia Thameslink Railway Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure proper training of frontline and control-room staff in dealing with vulnerable or suicidal persons
Wider context from the report “(1) I heard evidence from the Suicide Prevention Manager for Govia Thameslink Railway Ltd that training on dealing with vulnerable persons was not mandatory for frontline staff .
In fact only 583 out of 7,500 staff had attended a course run by the Samaritans entitled Managing Suicidal Contacts , 40% had completed some e-learning and an unknown number had completed an internal course. In addition refresher training on this issue was an aspiration only and had not been rolled out by Govia Thameslink Railway Ltd.
I also heard evidence that the Suicide Prevention Manager for Govia Thameslink Railway Ltd did not have any input into the training for their team based on the joint control room .
I am therefore concerned that those members of staff most likely to have contact with vulnerable or suicidal persons, as well as those responsible for assisting frontline staff, are not all properly trained to deal with the situation in the best possible way .
” 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 Hold Operations Development Days on responding consistently to vulnerable people and welfare concerns.
Verbatim wording from the response “The range of possible responses to a non-emergency concern for welfare is, as you have witnessed, less well defined. Between the 9th February and 16th March, the Sussex Control centre will be holding a series of Operations Development Days, covering dealing with vulnerable people / cause for concern, which GTR staff will take part in to raise consistency in response to these situations. Learning from these development days will be incorporated, under subject of concern for welfare reports, into the Joint Incident Management Framework, in a new section covering Safety Incidents & Emergencies. This will reinforce the requirement of all staff in the Control Room to report every incident involving vulnerable people (or other emergency such as damage to infrastructure, trespass etc.) to Network Rail Controllers.” Source location 2022-0052-Response-from-Govia-Thameslink-Railway-Ltd_Published
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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 Incorporate learning from the Operations Development Days into a new welfare-reporting section of the Joint Incident Management Framework.
Verbatim wording from the response “The range of possible responses to a non-emergency concern for welfare is, as you have witnessed, less well defined. Between the 9th February and 16th March, the Sussex Control centre will be holding a series of Operations Development Days, covering dealing with vulnerable people / cause for concern, which GTR staff will take part in to raise consistency in response to these situations. Learning from these development days will be incorporated, under subject of concern for welfare reports, into the Joint Incident Management Framework, in a new section covering Safety Incidents & Emergencies. This will reinforce the requirement of all staff in the Control Room to report every incident involving vulnerable people (or other emergency such as damage to infrastructure, trespass etc.) to Network Rail Controllers.” Source location 2022-0052-Response-from-Govia-Thameslink-Railway-Ltd_Published
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 Employ a dedicated Suicide Prevention Manager to promote awareness, signpost support and develop staff training with the Samaritans.
Verbatim wording from the response “GTR is the only Train Operating Company in UK Rail to employ a dedicated Suicide Prevention Manager. They play an active role in promoting awareness of the issues of vulnerable people coming on to our Network, signposting support channels to rail users and Staff through organised events to such as ‘Small Talk Saves Lives’, ‘Brew Monday’ and ‘Affirmation Art’ campaigns. They also work closely with the Samaritans to develop training courses for staff to help them feel more confident approaching a vulnerable person and giving them the tools and knowledge to make a safe intervention. These initiatives together have, since having a dedicated Suicide Prevention Manager, doubled the number of interventions made by staff, with 456 recorded in the last year.” Source location 2022-0052-Response-from-Govia-Thameslink-Railway-Ltd_Published
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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 Record welfare incidents and control-room actions in the Control Centre Incident Log, including retrospective updates with actual times.
Verbatim wording from the response “Concern for welfare incidents are logged on Control Centre Incident Log (CCIL) and all those involved in managing the incident within control update the log with their actions/updates. Actions and updates from those outside of control are recorded by their contact in control. Everyone is encouraged to update the log in a timely fashion, but relevant data can be retrospectively added at the earliest convenience with the time amended to reflect actual times. The CCTV monitoring team are notified and asked to monitor stations. Messages are sent out via Tyrell (a dedicated Rail Industry information system) and on the different Team's chats.” Source location 2022-0052-Response-from-Govia-Thameslink-Railway-Ltd_Published
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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 Assess control-room staff annually through a practical exercise on responding to help-point calls from suicidal people.
Verbatim wording from the response “On occasion the control room might take a call, via a station call point, from a member of the public or the vulnerable person themselves. GTR’s suicide Prevention Manager is working with the Samaritans to develop a training course specific to dealing with vulnerable people over the phone and help points. Learning will be underpinned with a practical assessment for GTR control room staff, which is done annually, on how they would deal with a help point call from a suicidal person.” Source location 2022-0052-Response-from-Govia-Thameslink-Railway-Ltd_Published
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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 Audit the training programme’s impact and provide the results to the Office of Rail and Road.
Verbatim wording from the response “We at GTR are confident that this approach gives us the best and quickest penetration to enable those members of staff, most likely to have contact with vulnerable or suicidal persons, to make a safe intervention. However, we want to test both the breadth and depth of understanding of this important subject, amongst those in this cohort. GTR will conduct audit to assess the impact of its programme, the results of which will be used to identify improvements which could be made and will be made available to the rail regulator, the Office of Rail and Road (ORR), by the end of April.” Source location 2022-0052-Response-from-Govia-Thameslink-Railway-Ltd_Published
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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 training course for handling vulnerable people’s calls through telephones and station help points.
Verbatim wording from the response “On occasion the control room might take a call, via a station call point, from a member of the public or the vulnerable person themselves. GTR’s suicide Prevention Manager is working with the Samaritans to develop a training course specific to dealing with vulnerable people over the phone and help points. Learning will be underpinned with a practical assessment for GTR control room staff, which is done annually, on how they would deal with a help point call from a suicidal person.” Source location 2022-0052-Response-from-Govia-Thameslink-Railway-Ltd_Published
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 Strengthen guidance on non-emergency welfare concerns through training and staff briefings, reinforcing contact with British Transport Police.
Verbatim wording from the response “threshold. I agree that this ambiguity needs to be eradicated. The output from the Operational Deployment Days will be used to strengthen guidance to aid better decisions in respect to non-emergency concerns for welfare.” Source location 2022-0052-Response-from-Govia-Thameslink-Railway-Ltd_Published
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 suicide-prevention training through staff briefings and induction, including Mental Health Nurse input for new starters.
Verbatim wording from the response “It is our intent that all GTR colleagues benefit from this programme, so in addition to being included as part of an individuals’ briefing cycle, this course is delivered to all new starters in the ‘Caring for the Vulnerable’ session of the company induction. This gives the opportunity to enhance it further, with a session delivered by a Mental Health Nurse to help prepare people, new to Rail, should find themselves in a situation with someone in crisis in a precarious position. So far 860 new people have benefited from this course.” Source location 2022-0052-Response-from-Govia-Thameslink-Railway-Ltd_Published
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 in-house online Suicide Prevention course to frontline colleagues and keep it available for knowledge refreshment.
Verbatim wording from the response “We recognised the importance for everyone to have the skills to identify someone who is vulnerable and have the confidence to make an intervention, so have developed, in-house, the ‘Suicide Prevention’ course. It is based on the content of the Samaritans MSC course, designed with interactive learning cemented with quizzes and is delivered via an e-learning platform, meaning that it can reach more people. So far 3045 GTR colleagues have completed this course and being online, it remains accessible to all, on any device, so that knowledge can be refreshed at any time.
This number accounts for 70% of our Customer facing, frontline teams completing this course.” Source location 2022-0052-Response-from-Govia-Thameslink-Railway-Ltd_Published
Open published response
7 Aug 2019 Carl Richard KLIMYATYS · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 6 Lack of up-to-date contact details for Bronze View source Lack of safety-critical communication training for emergency call takers View source Failure to verify reported incident locations against available physical information View source Failure to escalate emergency calls from initial call takers to team leaders View source Failure to enter the correct train headcode View source Failure to contact train drivers when the train describer system is unavailable View source See 3 more concerns
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
Carl Richard KLIMYATYS · 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
Carl Richard KLIMYATYS’s body was found at Preston Park Station, where incorrect information about its location was communicated within the Regional Operating Centre. This contributed to an approaching train not being stopped and striking and carrying the body away. The report raises concerns about safety-critical communication training, the handling and verification of emergency information, the use of resources, and outdated contact details in the operating centre.
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 Govia Thameslink Railway Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of up-to-date contact details for Bronze
Wider context from the report “Three Bridges Regional Operating Centre (ROC)
A member of the public arriving at Preston Park Station saw Carl’s body at Platform 2.
He used the help phone pressing the emergency button to inform of this.
The call was answered promptly by the initial call taker called a Resilience Customer Ambassador (RCA). This person had not been given the safety critical communication training. He had only been employed recently as an agency person to provide cover in the RCA over the Christmas period.
The Inquest heard that when an emergency call comes in to the ROC there is a red flashing light and a buzzer to announce that this is an emergency call.
The Inquest heard that the RCA should have picked up the telephone and handed it to his team leader who was shadowing him and sitting opposite him doing his own work.
At 0602 the member of the public pressed the emergency button at the help phone.
In fact the RCA answered the member of public’s call, took details from him which were correct as to the location of Carl’s body, said goodbye and terminated the call which lasted eleven seconds.
The Inquest heard that almost immediately he passed information that the body was not on Track 2 but on Track 1.
The Inquest heard that the Team Leader tried to phone the member of public back on the help phone but could not get an answer.
It was not until 0609 hrs that the Team Leaders was able to speak to the member of public and ask for confirmation of the location of Carl’s body. This time the member of public appears to be saying that the body was straddling Tracks 1 and 2 (in fact he was straddling Tracks 3 and 2).
The Team Leader should have known from the information available to him in the ROC that for Carl’s body to be straddling Tracks 2 and 1 was a physical impossibility since they are separated by a large island Platform.
His call to the member of public lasted nineteen seconds.
As a result of this incorrect and impossible information it was believed that Carl’s body would not be disrupted by the train 9T90 approaching from Brighton and due to arrive in Preston Park Station on Line 2 at 0611.
The plan was to prevent the train stopping at the station for reasons which were explained at the Inquest, but because of the inputting of the wrong headcode and the fact that the train describer system was down the driver of 9T90 was not contacted, came into Preston Park Station arriving on the track where Carl’s body was lying, decapitating and then disrupting it, stopping at the station for approximately two minutes before leaving carrying Carl’s body with it.
The other matter which caused concern from the point of view of what was going on in the ROC was that they apparently did not have up to date contact details for Bronze.
Having set out these facts the purpose of this Regulation 28 Report is to refer to the failings in the ROC and to request that actions are taken regarding appropriate training and use of resources for those who work in that operating centre.
” 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 Govia Thameslink Railway Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of safety-critical communication training for emergency call takers
Wider context from the report “Three Bridges Regional Operating Centre (ROC)
A member of the public arriving at Preston Park Station saw Carl’s body at Platform 2.
He used the help phone pressing the emergency button to inform of this.
The call was answered promptly by the initial call taker called a Resilience Customer Ambassador (RCA). This person had not been given the safety critical communication training. He had only been employed recently as an agency person to provide cover in the RCA over the Christmas period.
The Inquest heard that when an emergency call comes in to the ROC there is a red flashing light and a buzzer to announce that this is an emergency call.
The Inquest heard that the RCA should have picked up the telephone and handed it to his team leader who was shadowing him and sitting opposite him doing his own work.
At 0602 the member of the public pressed the emergency button at the help phone.
In fact the RCA answered the member of public’s call, took details from him which were correct as to the location of Carl’s body, said goodbye and terminated the call which lasted eleven seconds.
The Inquest heard that almost immediately he passed information that the body was not on Track 2 but on Track 1.
The Inquest heard that the Team Leader tried to phone the member of public back on the help phone but could not get an answer.
It was not until 0609 hrs that the Team Leaders was able to speak to the member of public and ask for confirmation of the location of Carl’s body. This time the member of public appears to be saying that the body was straddling Tracks 1 and 2 (in fact he was straddling Tracks 3 and 2).
The Team Leader should have known from the information available to him in the ROC that for Carl’s body to be straddling Tracks 2 and 1 was a physical impossibility since they are separated by a large island Platform.
His call to the member of public lasted nineteen seconds.
As a result of this incorrect and impossible information it was believed that Carl’s body would not be disrupted by the train 9T90 approaching from Brighton and due to arrive in Preston Park Station on Line 2 at 0611.
The plan was to prevent the train stopping at the station for reasons which were explained at the Inquest, but because of the inputting of the wrong headcode and the fact that the train describer system was down the driver of 9T90 was not contacted, came into Preston Park Station arriving on the track where Carl’s body was lying, decapitating and then disrupting it, stopping at the station for approximately two minutes before leaving carrying Carl’s body with it.
The other matter which caused concern from the point of view of what was going on in the ROC was that they apparently did not have up to date contact details for Bronze.
Having set out these facts the purpose of this Regulation 28 Report is to refer to the failings in the ROC and to request that actions are taken regarding appropriate training and use of resources for those who work in that operating centre.
” 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 Govia Thameslink Railway Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to verify reported incident locations against available physical information
Wider context from the report “Three Bridges Regional Operating Centre (ROC)
A member of the public arriving at Preston Park Station saw Carl’s body at Platform 2.
He used the help phone pressing the emergency button to inform of this.
The call was answered promptly by the initial call taker called a Resilience Customer Ambassador (RCA). This person had not been given the safety critical communication training. He had only been employed recently as an agency person to provide cover in the RCA over the Christmas period.
The Inquest heard that when an emergency call comes in to the ROC there is a red flashing light and a buzzer to announce that this is an emergency call.
The Inquest heard that the RCA should have picked up the telephone and handed it to his team leader who was shadowing him and sitting opposite him doing his own work.
At 0602 the member of the public pressed the emergency button at the help phone.
In fact the RCA answered the member of public’s call, took details from him which were correct as to the location of Carl’s body, said goodbye and terminated the call which lasted eleven seconds.
The Inquest heard that almost immediately he passed information that the body was not on Track 2 but on Track 1.
The Inquest heard that the Team Leader tried to phone the member of public back on the help phone but could not get an answer.
It was not until 0609 hrs that the Team Leaders was able to speak to the member of public and ask for confirmation of the location of Carl’s body. This time the member of public appears to be saying that the body was straddling Tracks 1 and 2 (in fact he was straddling Tracks 3 and 2).
The Team Leader should have known from the information available to him in the ROC that for Carl’s body to be straddling Tracks 2 and 1 was a physical impossibility since they are separated by a large island Platform.
His call to the member of public lasted nineteen seconds.
As a result of this incorrect and impossible information it was believed that Carl’s body would not be disrupted by the train 9T90 approaching from Brighton and due to arrive in Preston Park Station on Line 2 at 0611.
The plan was to prevent the train stopping at the station for reasons which were explained at the Inquest, but because of the inputting of the wrong headcode and the fact that the train describer system was down the driver of 9T90 was not contacted, came into Preston Park Station arriving on the track where Carl’s body was lying, decapitating and then disrupting it, stopping at the station for approximately two minutes before leaving carrying Carl’s body with it.
The other matter which caused concern from the point of view of what was going on in the ROC was that they apparently did not have up to date contact details for Bronze.
Having set out these facts the purpose of this Regulation 28 Report is to refer to the failings in the ROC and to request that actions are taken regarding appropriate training and use of resources for those who work in that operating centre.
” 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 Govia Thameslink Railway Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate emergency calls from initial call takers to team leaders
Wider context from the report “Three Bridges Regional Operating Centre (ROC)
A member of the public arriving at Preston Park Station saw Carl’s body at Platform 2.
He used the help phone pressing the emergency button to inform of this.
The call was answered promptly by the initial call taker called a Resilience Customer Ambassador (RCA). This person had not been given the safety critical communication training. He had only been employed recently as an agency person to provide cover in the RCA over the Christmas period.
The Inquest heard that when an emergency call comes in to the ROC there is a red flashing light and a buzzer to announce that this is an emergency call.
The Inquest heard that the RCA should have picked up the telephone and handed it to his team leader who was shadowing him and sitting opposite him doing his own work.
At 0602 the member of the public pressed the emergency button at the help phone.
In fact the RCA answered the member of public’s call, took details from him which were correct as to the location of Carl’s body, said goodbye and terminated the call which lasted eleven seconds.
The Inquest heard that almost immediately he passed information that the body was not on Track 2 but on Track 1.
The Inquest heard that the Team Leader tried to phone the member of public back on the help phone but could not get an answer.
It was not until 0609 hrs that the Team Leaders was able to speak to the member of public and ask for confirmation of the location of Carl’s body. This time the member of public appears to be saying that the body was straddling Tracks 1 and 2 (in fact he was straddling Tracks 3 and 2).
The Team Leader should have known from the information available to him in the ROC that for Carl’s body to be straddling Tracks 2 and 1 was a physical impossibility since they are separated by a large island Platform.
His call to the member of public lasted nineteen seconds.
As a result of this incorrect and impossible information it was believed that Carl’s body would not be disrupted by the train 9T90 approaching from Brighton and due to arrive in Preston Park Station on Line 2 at 0611.
The plan was to prevent the train stopping at the station for reasons which were explained at the Inquest, but because of the inputting of the wrong headcode and the fact that the train describer system was down the driver of 9T90 was not contacted, came into Preston Park Station arriving on the track where Carl’s body was lying, decapitating and then disrupting it, stopping at the station for approximately two minutes before leaving carrying Carl’s body with it.
The other matter which caused concern from the point of view of what was going on in the ROC was that they apparently did not have up to date contact details for Bronze.
Having set out these facts the purpose of this Regulation 28 Report is to refer to the failings in the ROC and to request that actions are taken regarding appropriate training and use of resources for those who work in that operating centre.
” 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 Govia Thameslink Railway Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to enter the correct train headcode
Wider context from the report “Three Bridges Regional Operating Centre (ROC)
A member of the public arriving at Preston Park Station saw Carl’s body at Platform 2.
He used the help phone pressing the emergency button to inform of this.
The call was answered promptly by the initial call taker called a Resilience Customer Ambassador (RCA). This person had not been given the safety critical communication training. He had only been employed recently as an agency person to provide cover in the RCA over the Christmas period.
The Inquest heard that when an emergency call comes in to the ROC there is a red flashing light and a buzzer to announce that this is an emergency call.
The Inquest heard that the RCA should have picked up the telephone and handed it to his team leader who was shadowing him and sitting opposite him doing his own work.
At 0602 the member of the public pressed the emergency button at the help phone.
In fact the RCA answered the member of public’s call, took details from him which were correct as to the location of Carl’s body, said goodbye and terminated the call which lasted eleven seconds.
The Inquest heard that almost immediately he passed information that the body was not on Track 2 but on Track 1.
The Inquest heard that the Team Leader tried to phone the member of public back on the help phone but could not get an answer.
It was not until 0609 hrs that the Team Leaders was able to speak to the member of public and ask for confirmation of the location of Carl’s body. This time the member of public appears to be saying that the body was straddling Tracks 1 and 2 (in fact he was straddling Tracks 3 and 2).
The Team Leader should have known from the information available to him in the ROC that for Carl’s body to be straddling Tracks 2 and 1 was a physical impossibility since they are separated by a large island Platform.
His call to the member of public lasted nineteen seconds.
As a result of this incorrect and impossible information it was believed that Carl’s body would not be disrupted by the train 9T90 approaching from Brighton and due to arrive in Preston Park Station on Line 2 at 0611.
The plan was to prevent the train stopping at the station for reasons which were explained at the Inquest, but because of the inputting of the wrong headcode and the fact that the train describer system was down the driver of 9T90 was not contacted, came into Preston Park Station arriving on the track where Carl’s body was lying, decapitating and then disrupting it, stopping at the station for approximately two minutes before leaving carrying Carl’s body with it.
The other matter which caused concern from the point of view of what was going on in the ROC was that they apparently did not have up to date contact details for Bronze.
Having set out these facts the purpose of this Regulation 28 Report is to refer to the failings in the ROC and to request that actions are taken regarding appropriate training and use of resources for those who work in that operating centre.
” 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 Govia Thameslink Railway Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to contact train drivers when the train describer system is unavailable
Wider context from the report “Three Bridges Regional Operating Centre (ROC)
A member of the public arriving at Preston Park Station saw Carl’s body at Platform 2.
He used the help phone pressing the emergency button to inform of this.
The call was answered promptly by the initial call taker called a Resilience Customer Ambassador (RCA). This person had not been given the safety critical communication training. He had only been employed recently as an agency person to provide cover in the RCA over the Christmas period.
The Inquest heard that when an emergency call comes in to the ROC there is a red flashing light and a buzzer to announce that this is an emergency call.
The Inquest heard that the RCA should have picked up the telephone and handed it to his team leader who was shadowing him and sitting opposite him doing his own work.
At 0602 the member of the public pressed the emergency button at the help phone.
In fact the RCA answered the member of public’s call, took details from him which were correct as to the location of Carl’s body, said goodbye and terminated the call which lasted eleven seconds.
The Inquest heard that almost immediately he passed information that the body was not on Track 2 but on Track 1.
The Inquest heard that the Team Leader tried to phone the member of public back on the help phone but could not get an answer.
It was not until 0609 hrs that the Team Leaders was able to speak to the member of public and ask for confirmation of the location of Carl’s body. This time the member of public appears to be saying that the body was straddling Tracks 1 and 2 (in fact he was straddling Tracks 3 and 2).
The Team Leader should have known from the information available to him in the ROC that for Carl’s body to be straddling Tracks 2 and 1 was a physical impossibility since they are separated by a large island Platform.
His call to the member of public lasted nineteen seconds.
As a result of this incorrect and impossible information it was believed that Carl’s body would not be disrupted by the train 9T90 approaching from Brighton and due to arrive in Preston Park Station on Line 2 at 0611.
The plan was to prevent the train stopping at the station for reasons which were explained at the Inquest, but because of the inputting of the wrong headcode and the fact that the train describer system was down the driver of 9T90 was not contacted , came into Preston Park Station arriving on the track where Carl’s body was lying, decapitating and then disrupting it, stopping at the station for approximately two minutes before leaving carrying Carl’s body with it.
The other matter which caused concern from the point of view of what was going on in the ROC was that they apparently did not have up to date contact details for Bronze.
Having set out these facts the purpose of this Regulation 28 Report is to refer to the failings in the ROC and to request that actions are taken regarding appropriate training and use of resources for those who work in that operating centre.
” 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 Provide staff with online Track Access and Stations Made Easy resources showing station access, facilities, and track information.
Verbatim wording from the response “Information resources now include access to a ‘Track Access’ system that can be viewed on line with video and associated track map, and the Stations Made Easy section of National Rail Enquiries, to provide an interactive view of the station and its facilities such as ticket offices etc.” Source location 2019-0276-Response-by-GTR
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 Include safety-critical communications training in the Customer Ambassador competency standard.
Verbatim wording from the response “The Resilience Customer Ambassador (RCA) role provides a valuable interface for our customers which can respond directly to their questions about live network operations. Where we anticipate greater demand, agency staff will supplement the normal establishment. Temporary staff are subject to the same training and competency assessment regime as permanent staff. This now includes safety-critical communications training, which is assessed as part of the Customer Ambassador standard, so there is no longer a reliance on a Team Leader to establish a clear understanding about an emerging situation.” Source location 2019-0276-Response-by-GTR
Open published response
24 Jun 2019 Priscilla Tropp · Prevention of Future Deaths report North London
View report summary
Concerns raised 3 Lack of a station-specific plan for responding to illness or injury in station areas View source Lack of a station-specific plan for responding to illness or injury in station areas View source Lack of a station-specific plan for responding to illness or injury in station areas View source
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
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. The report was sent to Govia Thameslink Railway Limited; that does not assign responsibility.
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.
” 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 Govia Thameslink Railway Limited; that does not assign responsibility.
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.
” 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 Govia Thameslink Railway Limited; that does not assign responsibility.
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 .
” 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 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
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 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
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations