PFD report

Sarah Alison CUNNINGHAM · Prevention of Future Deaths report

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Issued 16 Apr 2025•Inner North London

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
9

Described in responses

Recipients and published responses

Source document

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 raised2

  1. Failure to translate investigation learning into a concrete plan
    Part of recurring concern: Failure to establish effective plans to address identified safety concerns
  2. Failure to incorporate the risk of passenger intoxication to individuals into corporate planning
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. Action

    Implement the revised process for managing Formal Incident Review recommendations, with accountable officers and directors developing actions to address identified risks.

    Stated by Transport for LondonStated completedThe respondent said that this action was complete when they made their response on 24 April 2025.
  2. Action

    Complete a cross-mode safeguarding risk review and produce tailored action plans for protecting intoxicated and other vulnerable passengers.

    Stated by Transport for LondonStated in progressThe respondent said that this action was in progress when they made their response on 24 April 2025.

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

Failure to translate investigation learning into a concrete plan

Wider context from the report

“I heard evidence at inquest that London Underground passenger intoxication is recognised as a risk to London Underground staff. Extreme intoxication is also known to be a risk to the individual who is intoxicated. However, it struck me that the risk to the individual is not necessarily at the forefront of TfL corporate thinking. Clearly, individuals have responsibility for their own drinking and/or drug taking and the consequences thereof. Intoxication carries additional risk whatever the activity. However, public transport is encouraged for many good reasons. Not least, it is a matter of public policy that those who are or may become intoxicated should make travel plans that do not involve being in charge of a vehicle. The London Underground is an obvious alternative. Realistically, some London Underground passengers will be intoxicated, and that has to inform TfL’s corporate planning. I heard that there was a TfL investigation following Sarah Cunningham’s death, but the learning from that appears at present to be somewhat aspirational, without a concrete plan. ”

Is this part of a recurring concern?

Yes — Failure to establish effective plans to address identified safety concerns.

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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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to incorporate the risk of passenger intoxication to individuals into corporate planning

Wider context from the report

“I heard evidence at inquest that London Underground passenger intoxication is recognised as a risk to London Underground staff. Extreme intoxication is also known to be a risk to the individual who is intoxicated. However, it struck me that the risk to the individual is not necessarily at the forefront of TfL corporate thinking. Clearly, individuals have responsibility for their own drinking and/or drug taking and the consequences thereof. Intoxication carries additional risk whatever the activity. However, public transport is encouraged for many good reasons. Not least, it is a matter of public policy that those who are or may become intoxicated should make travel plans that do not involve being in charge of a vehicle. The London Underground is an obvious alternative. Realistically, some London Underground passengers will be intoxicated, and that has to inform TfL’s corporate planning. I heard that there was a TfL investigation following Sarah Cunningham’s death, but the learning from that appears at present to be somewhat aspirational, without a concrete plan. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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

Implement the revised process for managing Formal Incident Review recommendations, with accountable officers and directors developing actions to address identified risks.

Verbatim wording from the response

“TfL has recently implemented a number of significant changes to the process around critical health and safety investigations, including changes to the management of recommendations arising from Formal Incident Reviews (FIRs). This new way of working means that the investigation team complete the investigation report with recommendations for the business.”

Source location

Response from Transport for London
Page 4 · response
Published 24 April 2025

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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

Complete a cross-mode safeguarding risk review and produce tailored action plans for protecting intoxicated and other vulnerable passengers.

Verbatim wording from the response

“Our actions underway include:”

Source location

Response from Transport for London
Page 2 · response
Published 24 April 2025

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.7

  1. 1

    Embed the Vulnerability Assessment Framework across frontline teams, policies, procedures and rule books.

    Stated by Transport for LondonStated plannedThe respondent said that this action was planned when they made their response on 24 April 2025.
  2. 2

    Trial camera and sensor technologies on the Docklands Light Railway, Central line and Piccadilly line to identify track incidents and trigger operational responses.

    Stated by Transport for LondonStated plannedThe respondent said that this action was planned when they made their response on 24 April 2025.
  3. 3

    Complete planning and preparation for five-station trials testing operational measures to reduce intoxicated customers’ risk of harm.

    Stated by Transport for LondonStated in progressThe respondent said that this action was in progress when they made their response on 24 April 2025.
  4. 4

    Double the night team of accredited, safeguarding-trained Transport Support and Enforcement officers patrolling the night tube and stations.

    Stated by Transport for LondonStated completedThe respondent said that this action was complete when they made their response on 24 April 2025.
  5. 5

    Overhaul safeguarding and vulnerability training for frontline customer-facing teams and make it mandatory within competency management and professional development.

    Stated by Transport for LondonStated in progressThe respondent said that this action was in progress when they made their response on 24 April 2025.
  6. 6

    Operate a multi-strand intoxication-safety programme using customer communications, signage, staff training, targeted deployment and local-authority collaboration.

    Stated by Transport for LondonStated completedThe respondent said that this action was complete when they made their response on 24 April 2025.
  7. 7

    Establish five-station trials of safeguarding patrols, security patrols, enhanced monitoring, behaviour-detection technology and safer travel procedures.

    Stated by Transport for LondonStated plannedThe respondent said that this action was planned when they made their response on 24 April 2025.

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

Embed the Vulnerability Assessment Framework across frontline teams, policies, procedures and rule books.

Verbatim wording from the response

“• Widespread adoption across our frontline customer facing teams of the Vulnerability Assessment Framework (VAF). The VAF is a systematic tool used by policing and emergency services to quickly identify, assess and respond to an individual. Its purpose is to ensure that a vulnerable person receives appropriate support and protection. The VAF will be briefed out to all frontline teams and be embedded in policies, procedures and rule books – this process will be completed by March 2026.”

Source location

Response from Transport for London
Page 3 · response
Published 24 April 2025

Open published response

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

Trial camera and sensor technologies on the Docklands Light Railway, Central line and Piccadilly line to identify track incidents and trigger operational responses.

Verbatim wording from the response

“As explained in TfL’s witness evidence at the inquest, we are prioritising action to address this risk and will trial a number of new technologies this financial year aimed at keeping our customers safe. We plan to trial technologies which will allow us to identify customers on the track and allow us to respond so that we can keep them safe. We will start these technology trials on the Docklands Light Railway, the Central line and on the Piccadilly line.”

Source location

Response from Transport for London
Page 5 · response
Published 24 April 2025

Open published response

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

Complete planning and preparation for five-station trials testing operational measures to reduce intoxicated customers’ risk of harm.

Verbatim wording from the response

“• Establish trials at five London Underground stations to test and learn from deploying operational staff in different ways to further reduce the risk of customers coming to harm when intoxicated. The purpose of running trials is to assess feasibility and impact before scaling up across London Underground stations. We are currently undertaking the planning and preparatory work before mobilising to intervention phase in Autumn 2025. The measures we plan to trial include:”

Source location

Response from Transport for London
Page 3 · response
Published 24 April 2025

Open published response

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

Double the night team of accredited, safeguarding-trained Transport Support and Enforcement officers patrolling the night tube and stations.

Verbatim wording from the response

“In May this year, we doubled the size of our night team of Transport Support and Enforcement officers. These officers, accredited by the police and trained in safeguarding, patrol the night tube, getting off at every station to check for vulnerable customers including on the platforms, to make sure everyone gets home safely.”

Source location

Response from Transport for London
Page 3 · response
Published 24 April 2025

Open published response

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

Overhaul safeguarding and vulnerability training for frontline customer-facing teams and make it mandatory within competency management and professional development.

Verbatim wording from the response

“• Overhaul of our safeguarding and vulnerability training for all frontline customer facing teams and make it a core, mandatory part of competency management and on-going professional development.”

Source location

Response from Transport for London
Page 3 · response
Published 24 April 2025

Open published response

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

Operate a multi-strand intoxication-safety programme using customer communications, signage, staff training, targeted deployment and local-authority collaboration.

Verbatim wording from the response

“More broadly, since 2019, TfL has increasingly sought to mitigate the impacts of intoxication on the network with a multi-strand approach.”

Source location

Response from Transport for London
Page 3 · response
Published 24 April 2025

Open published response

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

Establish five-station trials of safeguarding patrols, security patrols, enhanced monitoring, behaviour-detection technology and safer travel procedures.

Verbatim wording from the response

“• Establish trials at five London Underground stations to test and learn from deploying operational staff in different ways to further reduce the risk of customers coming to harm when intoxicated. The purpose of running trials is to assess feasibility and impact before scaling up across London Underground stations. We are currently undertaking the planning and preparatory work before mobilising to intervention phase in Autumn 2025. The measures we plan to trial include:”

Source location

Response from Transport for London
Page 3 · response
Published 24 April 2025

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