Terence Vincent Anthony FERNANDES · Prevention of Future Deaths report

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Issued 12 May 2014•Bedfordshire and Luton

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
5

Described in responses

Recipients and published responses

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Lack of basic first aid training for personnel responding to unwell passengers
    Part of recurring concern: Inadequate staff competence to provide first aid

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.5

  1. ATOC Limited

    Send members an electronic notification about the death, recovery position, and consideration of changes to station first-aid arrangements.

  2. ATOC Limited

    Remind members about the changed emphasis on first-aid provision for members of the public under amended regulations.

  3. ATOC Limited

    Facilitate a further TOC discussion on first-aid provision at the next Safety Forum.

  4. ATOC Limited

    Issue guidance recommending that TOCs identify suitable route stations for transferring seriously ill passengers directly to ambulance staff.

  5. ATOC Limited

    Review passenger illness assistance and share TOC approaches to first-aid training and briefing through the Safety Forum and Operations Council.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. ATOC Limited

    Individual train operating companies decide and implement proportionate responses to passenger illness risks based on their own risk assessments.

    Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  2. ATOC Limited

    Individual companies’ ongoing review of existing first-aid arrangements is considered a sufficient national response, rather than requiring prescriptive uniform measures.

    Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of basic first aid training for personnel responding to unwell passengers

Wider context from the report

“(1) Terence Fernandes had become seriously unwell during the journey from Blackfriars to St. Albans whilst a passenger on a train. He was taken off the train by the driver, security staff and staff in attendance at the station and yet none of the personnel had even basic first aid training. If someone had had even limited first aid knowledge they may have been able to recognise that Terence’s airway had become partially occluded. ”

Is this part of a recurring concern?

Yes — Inadequate staff competence to provide first aid.

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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

Send members an electronic notification about the death, recovery position, and consideration of changes to station first-aid arrangements.

Verbatim wording from the response

“Your Report has led to a further review of how passengers who are taken ill are assisted and sharing of TOC approaches to first aid training and briefing. These detailed discussions took place within the quarterly ATOC Safety Forum in June and at the quarterly Operations Council meeting in July. One of the actions arising from these discussions was for the Council to direct ATOC to write to its members to explicitly alert them to the circumstances of Mr Fernandes’ death and suggest that they consider, as part of each TOC’s continuous obligation to keep its risk assessments under review, whether any changes should be made to the first aid arrangements they have in place at each of their stations. The discussions also reminded members of the importance of the proper recovery position, and casualty management of unconscious persons, which are very infrequent events per location.”

Source location

2014-0220-Response
Page 2 · response
Published 12 May 2014

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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

Remind members about the changed emphasis on first-aid provision for members of the public under amended regulations.

Verbatim wording from the response

“We have also reminded them of the changed emphasis on first aid provision for members of the public introduced as part of the amendments made in October 2013 to the Health & Safety (First Aid) Regulations 1981.”

Source location

2014-0220-Response
Page 2 · response
Published 12 May 2014

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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

Facilitate a further TOC discussion on first-aid provision at the next Safety Forum.

Verbatim wording from the response

“Beyond this, ATOC will facilitate a further discussion on first aid provision amongst the TOCs at the next Safety Forum. We anticipate this will allow them to share any changes in practice following receipt of ATOC’s notification of the details surrounding Mr Fernandes’ death.”

Source location

2014-0220-Response
Page 3 · response
Published 12 May 2014

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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

Issue guidance recommending that TOCs identify suitable route stations for transferring seriously ill passengers directly to ambulance staff.

Verbatim wording from the response

“ATOC works with its members and other parties as necessary to identify and provide guidance on matters that are common to the majority of its members. A good example of this is the ATOC Guidance Note ‘Responding to Ill Customer on Trains’, issued in October 2013. Rather than suggest prescriptive arrangements, this includes a recommendation that TOCs should identify suitable stations along each line of route over which they operate at which a passenger who has a life-threatening or other illness can be passed directly into the care of ambulance staff. Clearly the number of such suitable stations is highly dependent on the geography – in some areas there may be considerable distances between stations which are staffed and offer more than the most basic of shelter facilities.”

Source location

2014-0220-Response
Page 2 · response
Published 12 May 2014

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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

Review passenger illness assistance and share TOC approaches to first-aid training and briefing through the Safety Forum and Operations Council.

Verbatim wording from the response

“Your Report has led to a further review of how passengers who are taken ill are assisted and sharing of TOC approaches to first aid training and briefing. These detailed discussions took place within the quarterly ATOC Safety Forum in June and at the quarterly Operations Council meeting in July. One of the actions arising from these discussions was for the Council to direct ATOC to write to its members to explicitly alert them to the circumstances of Mr Fernandes’ death and suggest that they consider, as part of each TOC’s continuous obligation to keep its risk assessments under review, whether any changes should be made to the first aid arrangements they have in place at each of their stations. The discussions also reminded members of the importance of the proper recovery position, and casualty management of unconscious persons, which are very infrequent events per location.”

Source location

2014-0220-Response
Page 2 · response
Published 12 May 2014

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

Individual train operating companies decide and implement proportionate responses to passenger illness risks based on their own risk assessments.

Verbatim wording from the response

“As noted in my previous letter, ATOC is answerable to its members – it does not direct them; they direct it. However, groups such as the Council and Forum make it possible to alert members to risks associated with their operations and the safety and welfare of their passengers and staff – including those taken ill – and to influence how they respond through facilitation and cross-member discussions.”

Source location

2014-0220-Response
Page 1 · response
Published 12 May 2014

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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

Individual companies’ ongoing review of existing first-aid arrangements is considered a sufficient national response, rather than requiring prescriptive uniform measures.

Verbatim wording from the response

“ATOC works with its members and other parties as necessary to identify and provide guidance on matters that are common to the majority of its members. A good example of this is the ATOC Guidance Note ‘Responding to Ill Customer on Trains’, issued in October 2013. Rather than suggest prescriptive arrangements, this includes a recommendation that TOCs should identify suitable stations along each line of route over which they operate at which a passenger who has a life-threatening or other illness can be passed directly into the care of ambulance staff. Clearly the number of such suitable stations is highly dependent on the geography – in some areas there may be considerable distances between stations which are staffed and offer more than the most basic of shelter facilities.”

Source location

2014-0220-Response
Page 2 · response
Published 12 May 2014

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026