Kaja Weronika SPIEWAK · Prevention of Future Deaths report

On 15 April 2021 I commenced an investigation into the death of Kaja Weronika SPIEWAK aged 18. The investigation concluded at the end of the inquest on 24 November 2021. The conclusion of the inquest was that:

On the 7th April 2021 Kaja Weronika Spiewak died after deliberately ████████ ████████. She suffered from schizoaffective disorder and was under the care and treatment of mental health services.

On the 7th April 2021 an onboard supervisor (OBS) for Govia Thameslink Railway Ltd noticed Kaja on Barnham Station at about 8.00am. The same OBS noticed Kaja boarding her train at Barnham station at 11.05am. Kaja got off at another station but the OBS was concerned about her welfare. The OBS invited Kaja to get back onto the train and then contacted the Govia Thameslink Railway control room raising her concerns about Kaja’s vulnerability. The OBS did not report the concerns to the police and the Govia Thameslink Railways witnesses gave evidence that this would have been the recommended course of action.

The Govia Thameslink Railway control room staff agreed that the OBS would hand Kaja over to the station staff at Havant train station. The control room staff then made contact with Brighton train station (as Kaja’s reported destination), Havant station and conductors on a number of trains. After Kaja had left Havant station the control room staff were not able to ascertain where she had gone. By 12.04pm the control room staff had been informed that Kaja was not on the expected train. No further actions were recorded as being taken by control room staff until 1.40pm.

Kaja had actually arrived at Southbourne Station by 11.50am and remained on the platform until approximately 12.20pm. She then ████████ Kaja was declared deceased at 1.07pm.

(1) I heard evidence from the Suicide Prevention Manager for Govia Thameslink Railway Ltd that training on dealing with vulnerable persons was not mandatory for frontline staff.

In fact only 583 out of 7,500 staff had attended a course run by the Samaritans entitled Managing Suicidal Contacts, 40% had completed some e-learning and an unknown number had completed an internal course. In addition refresher training on this issue was an aspiration only and had not been rolled out by Govia Thameslink Railway Ltd.

I also heard evidence that the Suicide Prevention Manager for Govia Thameslink Railway Ltd did not have any input into the training for their team based on the joint control room.

I am therefore concerned that those members of staff most likely to have contact with vulnerable or suicidal persons, as well as those responsible for assisting frontline staff, are not all properly trained to deal with the situation in the best possible way.

(2) I heard evidence that Govia Thameslink Railway Ltd staff control room staff relied upon a protocol entitled ‘Person ill on a train’ when a vulnerable person was reported to them. The witness responsible for the Govia Thameslink Railway control room team accepted that this was not an appropriate document to rely upon as it made no mention of vulnerable persons.

I am therefore concerned that the control room staff do not have the appropriate information to assist their colleagues and to arrange an appropriate response when a ‘concern for welfare’ report is made to them.

(3) I heard evidence that the Govia Thameslink Railway Ltd control room staff did not log all actions taken after the concern for welfare report.

I am concerned that it is not possible to assess whether all reasonable and appropriate actions were taken by the control room staff and whether individuals or teams have further training needs.

(4) The Govia Thameslink Railway Ltd control room staff did not contact British Transport Police, 999 nor share the information about this ‘concern for welfare’ report with Network Rail despite having a joint control room.

I heard evidence that there was no written protocol covering when Govia Thameslink Railway Ltd staff should share a ‘concern for welfare’ report with Network Rail staff in the shared control room.

I am concerned that there is not appropriate information sharing and reporting to other agencies, including British Transport Police, when a ‘concern for welfare’ is raised.