Recipient

London Underground Limited

First report 15 Nov 2013•Latest report 27 Nov 2017

Recipient record

Reports, concerns and published responses

Other public bodies · Urban transport operator. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 2
Published responses: 50%
Concerns addressed: 4
Stated actions: 7

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

50%published responses found

7stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

27 Nov2017
East London
Concerns raised5
1. Failure to disseminate policies and procedures to staff
2. Lack of clear staff guidance on use of recorded CCTV
3. Difficulty accessing recorded CCTV
1. Failure to carry out confirmatory checks before relying on assumptions about trespasser movements
2. Lack of clear written procedures for lone-working staff responding to likely trespassers
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.
AI-generated summary

Bernard Aziengbe Ovu · 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

Bernard Aziengbe Ovu entered a non-public area of Canning Town Station and was later seen falling down emergency exit stairs to the DLR platforms. He was found several hours later and died from a head injury. Concerns included an incorrect assumption that he had left the non-public area, the lack of clear written procedures for lone-working staff, difficulties accessing recorded CCTV, and inconsistent dissemination of policies and procedures.

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 London Underground Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to disseminate policies and procedures to staff
Wider context from the report
“The evidence during the course of the Inquest raised some concern in relation to dissemination of policies and procedures to staff. If a written procedure is to be prepared, I should be grateful for confirmation as to how this will be disseminated to staff. ”
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 London Underground Limited; that does not assign responsibility.
PFD Monitor interpretation
Lack of clear staff guidance on use of recorded CCTV
Wider context from the report
“There was an inconsistency amongst witnesses as to whether the recorded CCTV should be accessed by staff. Indications were given that access to the recorded CCTV can be practically difficult (the recorded CCTV being BTP equipment and not LU). Recourse to the CCTV would have provided a confirmatory check in these circumstances. It would be helpful for staff to be clear about the use of the recorded CCTV and for ease of access to it. ”
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 London Underground Limited; that does not assign responsibility.
PFD Monitor interpretation
Difficulty accessing recorded CCTV
Wider context from the report
“There was an inconsistency amongst witnesses as to whether the recorded CCTV should be accessed by staff. Indications were given that access to the recorded CCTV can be practically difficult (the recorded CCTV being BTP equipment and not LU). Recourse to the CCTV would have provided a confirmatory check in these circumstances. It would be helpful for staff to be clear about the use of the recorded CCTV and for ease of access to it. ”
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 London Underground Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to carry out confirmatory checks before relying on assumptions about trespasser movements
Wider context from the report
“It was clear from the evidence that the emergency exit gate into the non-public area had been opened. It was clear from the evidence that the emergency exit gate to Silvertown Way had not been opened. It would appear that there was an incorrect assumption by the member of staff that the trespasser entering the gate may have come back through it. There was no confirmatory check to ensure that this was the case. ”
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 London Underground Limited; that does not assign responsibility.
PFD Monitor interpretation
Lack of clear written procedures for lone-working staff responding to likely trespassers
Wider context from the report
“The evidence at the Inquest hearing established that there was no clear written procedures to lone working staff on what action should be taken in the event of a likely trespasser in the non-public area, beyond the emergency exit gates. Practice differed from witness to witness as to what should be done in these circumstances. A clear written procedure may assist staff in dealing with these circumstances in the future. ”
Open source report
15 Nov2013
Inner North London
Concerns raised2
1. Failure to have a process to shut down both lines simultaneously at an intersecting station
2. Failure to alert the driver by the most direct and effective method about a person’s presence on the track
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.
AI-generated summary

Andrew PHRYDAS · 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

Andrew Phrydas died after being struck by a London Underground train near Finsbury Park Station after entering the tunnel and crossing between the Victoria and Piccadilly lines. The report identified concerns about London Underground’s lack of a process to shut down both lines simultaneously and its failure to alert the driver about Andrew’s presence on the track by the most direct and effective method.

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 London Underground Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to have a process to shut down both lines simultaneously at an intersecting station
Wider context from the report
“Although a person in the tunnel was an unprecedented event, there was a failure by London Underground to have a process in place to shut down both lines simultaneously at a station where two lines intersect. There was also a failure by London Underground to alert the driver in the most direct and effective method about Andrew’s presence on the track. ”
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 London Underground Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to alert the driver by the most direct and effective method about a person’s presence on the track
Wider context from the report
“Although a person in the tunnel was an unprecedented event, there was a failure by London Underground to have a process in place to shut down both lines simultaneously at a station where two lines intersect. There was also a failure by London Underground to alert the driver in the most direct and effective method about Andrew’s presence on the track. ”
Open source report

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

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised5

Failure to disseminate policies and procedures to staff

Lack of clear staff guidance on use of recorded CCTV

Difficulty accessing recorded CCTV

Failure to carry out confirmatory checks before relying on assumptions about trespasser movements

Lack of clear written procedures for lone-working staff responding to likely trespassers

Concerns raised2

Failure to have a process to shut down both lines simultaneously at an intersecting station

Failure to alert the driver by the most direct and effective method about a person’s presence on the track