10 Jul 2023 Mr Christian Kwame Tuvi · Prevention of Future Deaths report Inner South London
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Concerns raised 5 Unavailability of training for cleaners to inch and operate travellator controls View source Failure to allocate responsibilities and powers for training and travellator-operation competence in cleaning contracts View source Failure to assess cleaners against an agreed competence standard for inching View source Failure to ensure cleaners understand the full technical method of work View source Failure to provide a movement-communication system that does not rely solely on verbal communication 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
Mr Christian Kwame Tuvi · 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
Mr Christian Kwame Tuvi, an escalator cleaner aged 44, died at Waterloo Station after the traveller moved while he was in a gap, causing blunt force trauma to the chest. The jury identified inadequate briefing, failure to complete a site-specific risk assessment, failure to give an audible warning, and failures concerning the inching pendant and compliance with the method statement. The report also raised continuing concerns about unresolved responsibility for training and competence to operate the travellator during cleaning.
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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 Office of Rail and Road; that does not assign responsibility.
PFD Monitor interpretation Unavailability of training for cleaners to inch and operate travellator controls
Wider context from the report “The ORR informed the coroner that in 2020 an improvement notice was served on Cleshar Cleaners, requiring them to provide a safe system of work for communicating the movement of the conveyor which does not rely solely on verbal communication.
Cleshar has appealed the Improvement Notice and the Employment Tribunal have stayed the notice until 2024. Although the improvement notice is under appeal Cleshar has made some changes to improve their safe system of work. These included a padlock for the operative to place on the nearest isolator switch before entering the gap, pressing the stop button in, KONE discussing with Cleshar where the gap is to be left prior to handing over control of the machine and the risk assessment and method statement now identify the need for a middle person to relay messages.
The improvements that Cleshar made have allowed them to resume the deep clean of Waterloo moving walkway. However, the TfL familiarisation training for working in a plant room no longer provides inching as part of the course . TfL expects their contractors to provide inching training for their operatives. Without the evidence of competence to inch the machine the isolation/inching function remains with KONE as a temporary solution.
It is unclear why this cannot be a permanent solution. I heard from witnesses that it would be safer for engineers, who are present during deep cleans, to operate the movements of the traveller, but I was told that it would lead to a lack of clarity as to who was in charge. This seems not to be insoluble given different contractors with different employees is a norm on building sites working safely under HSE rules across the country. More likely there are undisclosed issues perhaps related to assumption of responsibility for risk or financial considerations which explain the resistance.
The inquest heard that prior to the accident, cleaners would attend a TfL training course with a signed form which TfL observed was a certificate of competence to inch and operate the controls of the traveller. But the issuing manager and cleaners thought that the TfL course provided that training. The withdrawal of that training and the inability to find another training facility, has led to the cleaners not being trained and so not permitted to operate the travellator .
Cleshar Cleaners management have not in the past assessed their cleaners for competence to inch and there is no agreed standard of competence. Concerns were expressed in the inquest that most of the cleaners did not have English as their first language and that the risk assessment method statement was a huge technical document, with which the cleaners were not familiar and they all required training in the whole method of work, and not just the person in charge.
MY CONCERN and reason for reporting this matter to the minister and not just the regulator and contractors, is that nearly four years have passed and there remains an impasse between the organizations as to whom should train whom, and the competence required to operate the travellator whilst it is being cleaned. It seems that TfL has the power to produce a resolution, but is leaving matters to others to resolve. It is hard not to conclude that there is corporate reluctance to assume risk for an important public service. The regulatory bodies and contractors in the supply chain have allowed this matter to remain unresolved for an unacceptable length of time and there may be a system failure in the allocation of responsibilities and powers in the process of contracting for cleaning escalators.
” 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 Office of Rail and Road; that does not assign responsibility.
PFD Monitor interpretation Failure to allocate responsibilities and powers for training and travellator-operation competence in cleaning contracts
Wider context from the report “The ORR informed the coroner that in 2020 an improvement notice was served on Cleshar Cleaners, requiring them to provide a safe system of work for communicating the movement of the conveyor which does not rely solely on verbal communication.
Cleshar has appealed the Improvement Notice and the Employment Tribunal have stayed the notice until 2024. Although the improvement notice is under appeal Cleshar has made some changes to improve their safe system of work. These included a padlock for the operative to place on the nearest isolator switch before entering the gap, pressing the stop button in, KONE discussing with Cleshar where the gap is to be left prior to handing over control of the machine and the risk assessment and method statement now identify the need for a middle person to relay messages.
The improvements that Cleshar made have allowed them to resume the deep clean of Waterloo moving walkway. However, the TfL familiarisation training for working in a plant room no longer provides inching as part of the course. TfL expects their contractors to provide inching training for their operatives. Without the evidence of competence to inch the machine the isolation/inching function remains with KONE as a temporary solution.
It is unclear why this cannot be a permanent solution. I heard from witnesses that it would be safer for engineers, who are present during deep cleans, to operate the movements of the traveller, but I was told that it would lead to a lack of clarity as to who was in charge. This seems not to be insoluble given different contractors with different employees is a norm on building sites working safely under HSE rules across the country. More likely there are undisclosed issues perhaps related to assumption of responsibility for risk or financial considerations which explain the resistance.
The inquest heard that prior to the accident, cleaners would attend a TfL training course with a signed form which TfL observed was a certificate of competence to inch and operate the controls of the traveller. But the issuing manager and cleaners thought that the TfL course provided that training. The withdrawal of that training and the inability to find another training facility, has led to the cleaners not being trained and so not permitted to operate the travellator.
Cleshar Cleaners management have not in the past assessed their cleaners for competence to inch and there is no agreed standard of competence. Concerns were expressed in the inquest that most of the cleaners did not have English as their first language and that the risk assessment method statement was a huge technical document, with which the cleaners were not familiar and they all required training in the whole method of work, and not just the person in charge.
MY CONCERN and reason for reporting this matter to the minister and not just the regulator and contractors, is that nearly four years have passed and there remains an impasse between the organizations as to whom should train whom, and the competence required to operate the travellator whilst it is being cleaned . It seems that TfL has the power to produce a resolution, but is leaving matters to others to resolve. It is hard not to conclude that there is corporate reluctance to assume risk for an important public service. The regulatory bodies and contractors in the supply chain have allowed this matter to remain unresolved for an unacceptable length of time and there may be a system failure in the allocation of responsibilities and powers in the process of contracting for cleaning escalators .
” 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 Office of Rail and Road; that does not assign responsibility.
PFD Monitor interpretation Failure to assess cleaners against an agreed competence standard for inching
Wider context from the report “The ORR informed the coroner that in 2020 an improvement notice was served on Cleshar Cleaners, requiring them to provide a safe system of work for communicating the movement of the conveyor which does not rely solely on verbal communication.
Cleshar has appealed the Improvement Notice and the Employment Tribunal have stayed the notice until 2024. Although the improvement notice is under appeal Cleshar has made some changes to improve their safe system of work. These included a padlock for the operative to place on the nearest isolator switch before entering the gap, pressing the stop button in, KONE discussing with Cleshar where the gap is to be left prior to handing over control of the machine and the risk assessment and method statement now identify the need for a middle person to relay messages.
The improvements that Cleshar made have allowed them to resume the deep clean of Waterloo moving walkway. However, the TfL familiarisation training for working in a plant room no longer provides inching as part of the course. TfL expects their contractors to provide inching training for their operatives. Without the evidence of competence to inch the machine the isolation/inching function remains with KONE as a temporary solution.
It is unclear why this cannot be a permanent solution. I heard from witnesses that it would be safer for engineers, who are present during deep cleans, to operate the movements of the traveller, but I was told that it would lead to a lack of clarity as to who was in charge. This seems not to be insoluble given different contractors with different employees is a norm on building sites working safely under HSE rules across the country. More likely there are undisclosed issues perhaps related to assumption of responsibility for risk or financial considerations which explain the resistance.
The inquest heard that prior to the accident, cleaners would attend a TfL training course with a signed form which TfL observed was a certificate of competence to inch and operate the controls of the traveller. But the issuing manager and cleaners thought that the TfL course provided that training. The withdrawal of that training and the inability to find another training facility, has led to the cleaners not being trained and so not permitted to operate the travellator.
Cleshar Cleaners management have not in the past assessed their cleaners for competence to inch and there is no agreed standard of competence . Concerns were expressed in the inquest that most of the cleaners did not have English as their first language and that the risk assessment method statement was a huge technical document, with which the cleaners were not familiar and they all required training in the whole method of work, and not just the person in charge.
MY CONCERN and reason for reporting this matter to the minister and not just the regulator and contractors, is that nearly four years have passed and there remains an impasse between the organizations as to whom should train whom, and the competence required to operate the travellator whilst it is being cleaned. It seems that TfL has the power to produce a resolution, but is leaving matters to others to resolve. It is hard not to conclude that there is corporate reluctance to assume risk for an important public service. The regulatory bodies and contractors in the supply chain have allowed this matter to remain unresolved for an unacceptable length of time and there may be a system failure in the allocation of responsibilities and powers in the process of contracting for cleaning escalators.
” 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 Office of Rail and Road; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure cleaners understand the full technical method of work
Wider context from the report “The ORR informed the coroner that in 2020 an improvement notice was served on Cleshar Cleaners, requiring them to provide a safe system of work for communicating the movement of the conveyor which does not rely solely on verbal communication.
Cleshar has appealed the Improvement Notice and the Employment Tribunal have stayed the notice until 2024. Although the improvement notice is under appeal Cleshar has made some changes to improve their safe system of work. These included a padlock for the operative to place on the nearest isolator switch before entering the gap, pressing the stop button in, KONE discussing with Cleshar where the gap is to be left prior to handing over control of the machine and the risk assessment and method statement now identify the need for a middle person to relay messages.
The improvements that Cleshar made have allowed them to resume the deep clean of Waterloo moving walkway. However, the TfL familiarisation training for working in a plant room no longer provides inching as part of the course. TfL expects their contractors to provide inching training for their operatives. Without the evidence of competence to inch the machine the isolation/inching function remains with KONE as a temporary solution.
It is unclear why this cannot be a permanent solution. I heard from witnesses that it would be safer for engineers, who are present during deep cleans, to operate the movements of the traveller, but I was told that it would lead to a lack of clarity as to who was in charge. This seems not to be insoluble given different contractors with different employees is a norm on building sites working safely under HSE rules across the country. More likely there are undisclosed issues perhaps related to assumption of responsibility for risk or financial considerations which explain the resistance.
The inquest heard that prior to the accident, cleaners would attend a TfL training course with a signed form which TfL observed was a certificate of competence to inch and operate the controls of the traveller. But the issuing manager and cleaners thought that the TfL course provided that training. The withdrawal of that training and the inability to find another training facility, has led to the cleaners not being trained and so not permitted to operate the travellator.
Cleshar Cleaners management have not in the past assessed their cleaners for competence to inch and there is no agreed standard of competence. Concerns were expressed in the inquest that most of the cleaners did not have English as their first language and that the risk assessment method statement was a huge technical document, with which the cleaners were not familiar and they all required training in the whole method of work, and not just the person in charge .
MY CONCERN and reason for reporting this matter to the minister and not just the regulator and contractors, is that nearly four years have passed and there remains an impasse between the organizations as to whom should train whom, and the competence required to operate the travellator whilst it is being cleaned. It seems that TfL has the power to produce a resolution, but is leaving matters to others to resolve. It is hard not to conclude that there is corporate reluctance to assume risk for an important public service. The regulatory bodies and contractors in the supply chain have allowed this matter to remain unresolved for an unacceptable length of time and there may be a system failure in the allocation of responsibilities and powers in the process of contracting for cleaning escalators.
” 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 Office of Rail and Road; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a movement-communication system that does not rely solely on verbal communication
Wider context from the report “The ORR informed the coroner that in 2020 an improvement notice was served on Cleshar Cleaners, requiring them to provide a safe system of work for communicating the movement of the conveyor which does not rely solely on verbal communication .
Cleshar has appealed the Improvement Notice and the Employment Tribunal have stayed the notice until 2024. Although the improvement notice is under appeal Cleshar has made some changes to improve their safe system of work. These included a padlock for the operative to place on the nearest isolator switch before entering the gap, pressing the stop button in, KONE discussing with Cleshar where the gap is to be left prior to handing over control of the machine and the risk assessment and method statement now identify the need for a middle person to relay messages.
The improvements that Cleshar made have allowed them to resume the deep clean of Waterloo moving walkway. However, the TfL familiarisation training for working in a plant room no longer provides inching as part of the course. TfL expects their contractors to provide inching training for their operatives. Without the evidence of competence to inch the machine the isolation/inching function remains with KONE as a temporary solution.
It is unclear why this cannot be a permanent solution. I heard from witnesses that it would be safer for engineers, who are present during deep cleans, to operate the movements of the traveller, but I was told that it would lead to a lack of clarity as to who was in charge. This seems not to be insoluble given different contractors with different employees is a norm on building sites working safely under HSE rules across the country. More likely there are undisclosed issues perhaps related to assumption of responsibility for risk or financial considerations which explain the resistance.
The inquest heard that prior to the accident, cleaners would attend a TfL training course with a signed form which TfL observed was a certificate of competence to inch and operate the controls of the traveller. But the issuing manager and cleaners thought that the TfL course provided that training. The withdrawal of that training and the inability to find another training facility, has led to the cleaners not being trained and so not permitted to operate the travellator.
Cleshar Cleaners management have not in the past assessed their cleaners for competence to inch and there is no agreed standard of competence. Concerns were expressed in the inquest that most of the cleaners did not have English as their first language and that the risk assessment method statement was a huge technical document, with which the cleaners were not familiar and they all required training in the whole method of work, and not just the person in charge.
MY CONCERN and reason for reporting this matter to the minister and not just the regulator and contractors, is that nearly four years have passed and there remains an impasse between the organizations as to whom should train whom, and the competence required to operate the travellator whilst it is being cleaned. It seems that TfL has the power to produce a resolution, but is leaving matters to others to resolve. It is hard not to conclude that there is corporate reluctance to assume risk for an important public service. The regulatory bodies and contractors in the supply chain have allowed this matter to remain unresolved for an unacceptable length of time and there may be a system failure in the allocation of responsibilities and powers in the process of contracting for cleaning escalators.
” Open source report
29 May 2020 Flora Shen · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 4 Dependence on multiple manual actions to activate the emergency brake View source Dependence on train passengers to notice hazards and contact the Passenger Services Agent in time View source Inability of the central CCTV monitoring system to watch all stations simultaneously View source Dependence on members of the public to notice hazards and activate alarms 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
Flora Shen · 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
Flora Shen died on 6 January 2020 at Lime House station after falling from the platform and being struck by a train. The report raised concerns about the reliance on members of the public to notice hazards and activate alarms, and about limited CCTV coverage and the response process on the driverless DLR system.
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 Office of Rail and Road; that does not assign responsibility.
PFD Monitor interpretation Dependence on multiple manual actions to activate the emergency brake
Wider context from the report “(1) If a member of the public on the train sees a person or hazard on the track ahead they have to go to one of the doorways to activate the passenger alarm. The Passenger Services Assistant then goes to the telephone which is accessed by a key to ask why the passenger alarm has been activated. In order to stop the train the Passenger Services Agent then needs to replace the phone, lock the phone compartment and use a key to activate the emergency brake.
” 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 Office of Rail and Road; that does not assign responsibility.
PFD Monitor interpretation Dependence on train passengers to notice hazards and contact the Passenger Services Agent in time
Wider context from the report “(2) The ability to respond to a danger or hazard on the line seems sometimes to be dependent on this being noticed by a member of the public on a train and them being able to contact the Passenger Services Agent in time for the train to be stopped.
” 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 Office of Rail and Road; that does not assign responsibility.
PFD Monitor interpretation Inability of the central CCTV monitoring system to watch all stations simultaneously
Wider context from the report “(3) The central DLR CCTV monitoring system cannot watch all stations at the same time and the safety of persons slipping, falling or collapsing on to a line on the DLR system seems to rely on ability of members of the public to notice the hazard and activate the alarm on either the platform or the train.
” 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 Office of Rail and Road; that does not assign responsibility.
PFD Monitor interpretation Dependence on members of the public to notice hazards and activate alarms
Wider context from the report “(3) The central DLR CCTV monitoring system cannot watch all stations at the same time and the safety of persons slipping, falling or collapsing on to a line on the DLR system seems to rely on ability of members of the public to notice the hazard and activate the alarm on either the platform or the train.
” 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 Challenge DLR on the reasonable practicability of providing additional emergency stop facilities throughout the vehicles.
Verbatim wording from the response “ORR has challenged DLR on the reasonable practicability of providing emergency stop facilities within all the vehicles on the system. DLR have advised us that the vehicles already have 10 locations where a member of staff can activate an emergency brake application. Two of these are within the manual driving panels at each end of the vehicle and the other eight are located one at each doorway and activated by the member of staff inserting their key. This does appear to give a reasonable level of access to staff. Experience in mainline trains suggests that providing passengers with means to stop trains can lead to misuse, which in turn can create different risks; including significant disruption to networks, overcrowding on trains, and ultimately passengers self-detraining from stalled trains with all the risk this brings.” Source location 2020-0115-Response-from-Office-of-Rail-and-Road_Redacted.pdf
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 Discuss with DLR the reasonable practicability of technological solutions to detect people on the track and stop approaching vehicles.
Verbatim wording from the response “ORR has discussed with DLR the reasonable practicability of providing further technological solutions that could detect persons on the track and take action to stop approaching vehicles. DLR have advised us that they have investigated the availability of such technologies and are currently seeking a partner to conduct a study into potential on-train obstacle detection systems. It is clear that DLR is keeping this topic under review and actively seeking solutions.” Source location 2020-0115-Response-from-Office-of-Rail-and-Road_Redacted.pdf
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 risk controls were considered appropriate and reasonably practicable, so additional platform screen doors were not required.
Verbatim wording from the response “ORR has confirmed that the risk assessments jointly undertaken by DLR and KAD include for the events of a person falling or jumping onto the track and the consequent potential events. This assessment identifies a range of control and mitigation measures for these events. These include, amongst other things, the alarm points on stations and random CCTV monitoring, and station signage, platform markings and surface finish. Measures also include wider initiatives such as proactive liaison with local police and mental health services.” Source location 2020-0115-Response-from-Office-of-Rail-and-Road_Redacted.pdf
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 Passenger-activated train stops could cause misuse, network disruption, overcrowding and unsafe self-detraining, creating greater risks than they solve.
Verbatim wording from the response “ORR has challenged DLR on the reasonable practicability of providing emergency stop facilities within all the vehicles on the system. DLR have advised us that the vehicles already have 10 locations where a member of staff can activate an emergency brake application. Two of these are within the manual driving panels at each end of the vehicle and the other eight are located one at each doorway and activated by the member of staff inserting their key. This does appear to give a reasonable level of access to staff. Experience in mainline trains suggests that providing passengers with means to stop trains can lead to misuse, which in turn can create different risks; including significant disruption to networks, overcrowding on trains, and ultimately passengers self-detraining from stalled trains with all the risk this brings.” Source location 2020-0115-Response-from-Office-of-Rail-and-Road_Redacted.pdf
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 DLR, KAD and TfL held responsibility and power to investigate and implement additional technological or operational safety solutions.
Verbatim wording from the response “It is for these reasons that ORR considers that the concerns in the Coroner’s report would be better directed to DLR, KAD and TfL. These organisations hold the responsibility for health and safety and have the power to investigate and implement additional or alternative new technological and operational solutions that could reduce further the risks to persons on the track.” Source location 2020-0115-Response-from-Office-of-Rail-and-Road_Redacted.pdf
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 Reliable commercial technologies for detecting people on tracks and stopping trains were not yet available off the shelf.
Verbatim wording from the response “ORR has discussed with DLR the reasonable practicability of providing further technological solutions that could detect persons on the track and take action to stop approaching vehicles. DLR have advised us that they have investigated the availability of such technologies and are currently seeking a partner to conduct a study into potential on-train obstacle detection systems. It is clear that DLR is keeping this topic under review and actively seeking solutions.” Source location 2020-0115-Response-from-Office-of-Rail-and-Road_Redacted.pdf
Open published response
19 Nov 2019 James Joseph Fennell · Prevention of Future Deaths report Berkshire
View report summary
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.
×
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 Office of Rail and Road; 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 Office of Rail and Road; 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
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
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.
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 Office of Rail and Road; 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 Office of Rail and Road; 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 Office of Rail and Road; 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 Office of Rail and Road; 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 Office of Rail and Road; 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
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 Office of Rail and Road; 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 Office of Rail and Road; 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 Office of Rail and Road; 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 respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing safety management systems met minimum legal standards and were considered adequate to manage the relevant station risks.
Verbatim wording from the response “Whilst acknowledging and respecting the Coroner’s view on aspects of the safety management arrangements at the station, the ORR’s assessment is that if the safety management systems in place were not causative of or contributory to Mrs Tropp’s death and were in compliance with the minimum standards required by health and safety legislation then the ORR has no authority to alter those arrangements. It is the assessment of the Inspector that investigated this incident that the safety management systems that are in place do meet the minimum standards.” Source location 2019-0213-Response-by-ORR
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The regulator cannot alter compliant duty-holder arrangements or take enforcement action where minimum legal standards are met.
Verbatim wording from the response “Whilst acknowledging and respecting the Coroner’s view on aspects of the safety management arrangements at the station, the ORR’s assessment is that if the safety management systems in place were not causative of or contributory to Mrs Tropp’s death and were in compliance with the minimum standards required by health and safety legislation then the ORR has no authority to alter those arrangements. It is the assessment of the Inspector that investigated this incident that the safety management systems that are in place do meet the minimum standards.” Source location 2019-0213-Response-by-ORR
Open published response
30 Nov 2017 Sarah Athermith · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 3 Lack of effective protection or warning at the level crossing View source Pedestrian confusion about the presence of a further train on the opposite track View source Obscured visibility of opposing trains for train drivers 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.
×
AI-generated summary
Sarah Athermith · 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 26 September 2017, Sarah Athermith was struck and fatally injured by a train while crossing the unprotected Wallows Lane railway crossing after stopping for another train. Concerns included the lack of a warning system for approaching trains, the risk of pedestrians becoming confused when trains pass in opposite directions, and the obstruction of drivers’ views by double-height freight carriages.
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 Office of Rail and Road; that does not assign responsibility.
PFD Monitor interpretation Lack of effective protection or warning at the level crossing
Wider context from the report “1. Evidence emerged during the inquest that the Wallows Lane level crossing is an unprotected crossing and there is no method of warning of an approaching train .
2. There are whistle boards (train drivers should sound their whistles/horns on approach) in place to warn users. However, the crossing relies on users actively stopping, looking and listening for approaching trains before deciding if it is safe to cross .
” 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 Office of Rail and Road; that does not assign responsibility.
PFD Monitor interpretation Pedestrian confusion about the presence of a further train on the opposite track
Wider context from the report “3. There is a clear and present danger that pedestrians can become confused , as happened in this case when two trains pass each other at the same time and do not realise there is a further train on the opposite rail 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 Office of Rail and Road; that does not assign responsibility.
PFD Monitor interpretation Obscured visibility of opposing trains for train drivers
Wider context from the report “4. It also emerged that the freight train carriages were double height and obscured the opposite train drivers view .
” Open source report
27 Jan 2017 Derek Edward Hope THOMAS · Prevention of Future Deaths report Hampshire (North East)
View report summary
Concerns raised 4 Lack of protection at the crossing View source Obscured visibility at the crossing caused by a fence View source Lack of staffing at the crossing View source Inadequacy of direct warning of approaching trains at the crossing View source See 1 more concern
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
Derek Edward Hope THOMAS · 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
Derek Edward Hope THOMAS was struck by a non-stopping train while using the foot crossing at Bentley station on his mobility scooter on 5 October 2016, sustaining catastrophic injuries. Concerns included that the crossing was unmanned and unprotected, that the only direct warning was the train driver's horn, and that visibility was obscured by a fence.
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 Office of Rail and Road; that does not assign responsibility.
PFD Monitor interpretation Lack of protection at the crossing
Wider context from the report “(1) The crossing is unmanned and unprotected
” 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 Office of Rail and Road; that does not assign responsibility.
PFD Monitor interpretation Obscured visibility at the crossing caused by a fence
Wider context from the report “(3) Visibility is obscured by a fence although remedial action has been taken to reduce the height of it thereby improving visibility
” 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 Office of Rail and Road; that does not assign responsibility.
PFD Monitor interpretation Lack of staffing at the crossing
Wider context from the report “(1) The crossing is unmanned and unprotected
” 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 Office of Rail and Road; that does not assign responsibility.
PFD Monitor interpretation Inadequacy of direct warning of approaching trains at the crossing
Wider context from the report “(2) The only direct warning is the horn being sounded by the driver some 400 m from the crossing
” Open source report
13 Nov 2014 John Robert Wright · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 4 Failure to balance hearing protection with the ability to hear oncoming trains View source Failure to brief crews on potential train routes in areas with multiple lines View source Failure to brief and enforce safe methods of work View source Failure to maintain trackside maintenance crews’ vigilance around live railway lines View source See 1 more concern
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
John Robert Wright · 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
John Robert Wright, a Network Rail track maintenance worker, was struck by an oncoming train while working at Newark Northgate station on 22 January 2014 and died from his injuries on 31 January 2014. The concerns identified were the need for frequent reminders and training about vigilance, clearer briefings on train routes and safe working methods, and a balance between hearing protection and the ability to hear approaching trains.
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 Office of Rail and Road; that does not assign responsibility.
PFD Monitor interpretation Failure to balance hearing protection with the ability to hear oncoming trains
Wider context from the report “Despite its obviousness I am concerned that track side maintenance crew need frequent reminders/training as to the need to maintain vigilance at all times when working in the vicinity of lines along which trains can pass.
When working in the vicinity of stations and/or points on the network where there are multiple lines, crews should be fully briefed as to the potential route of trains through stations or across any such lines, including, where reasonably practicable, consulting timetables; and safe methods of work are briefed and enforced.
Further, I am concerned that there needs to be a balance struck between the ensuring that track side maintenance crews are provided with personal protective equipment such as hearing protection and an ability to hear oncoming locomotives/trains .
” 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 Office of Rail and Road; that does not assign responsibility.
PFD Monitor interpretation Failure to brief crews on potential train routes in areas with multiple lines
Wider context from the report “Despite its obviousness I am concerned that track side maintenance crew need frequent reminders/training as to the need to maintain vigilance at all times when working in the vicinity of lines along which trains can pass.
When working in the vicinity of stations and/or points on the network where there are multiple lines, crews should be fully briefed as to the potential route of trains through stations or across any such lines, including, where reasonably practicable, consulting timetables ; and safe methods of work are briefed and enforced.
Further, I am concerned that there needs to be a balance struck between the ensuring that track side maintenance crews are provided with personal protective equipment such as hearing protection and an ability to hear oncoming locomotives/trains.
” 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 Office of Rail and Road; that does not assign responsibility.
PFD Monitor interpretation Failure to brief and enforce safe methods of work
Wider context from the report “Despite its obviousness I am concerned that track side maintenance crew need frequent reminders/training as to the need to maintain vigilance at all times when working in the vicinity of lines along which trains can pass.
When working in the vicinity of stations and/or points on the network where there are multiple lines, crews should be fully briefed as to the potential route of trains through stations or across any such lines, including, where reasonably practicable, consulting timetables; and safe methods of work are briefed and enforced .
Further, I am concerned that there needs to be a balance struck between the ensuring that track side maintenance crews are provided with personal protective equipment such as hearing protection and an ability to hear oncoming locomotives/trains.
” 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 Office of Rail and Road; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain trackside maintenance crews’ vigilance around live railway lines
Wider context from the report “Despite its obviousness I am concerned that track side maintenance crew need frequent reminders/training as to the need to maintain vigilance at all times when working in the vicinity of lines along which trains can pass .
When working in the vicinity of stations and/or points on the network where there are multiple lines, crews should be fully briefed as to the potential route of trains through stations or across any such lines, including, where reasonably practicable, consulting timetables; and safe methods of work are briefed and enforced.
Further, I am concerned that there needs to be a balance struck between the ensuring that track side maintenance crews are provided with personal protective equipment such as hearing protection and an ability to hear oncoming locomotives/trains.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations