PFD report

Priscilla Tropp · Prevention of Future Deaths report

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Issued 24 Jun 2019•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.

View original report
Concerns
3

Raised in this report

Recipients
4

Named on the report

Responses found
3

Of 4 recipients

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 raised3

  1. Lack of a station-specific plan for responding to illness or injury in station areas
    Part of recurring concern: Unreliable emergency response arrangements at railway stations
  2. Lack of a station-specific plan for responding to illness or injury in station areas
    Part of recurring concern: Unreliable emergency response arrangements at railway stations
  3. Lack of a station-specific plan for responding to illness or injury in station areas
    Part of recurring concern: Unreliable emergency response arrangements at railway stations
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

    Produce and issue the “Caring for our Customers” staff aide-mémoire for station managers and staff.

    Stated by Govia Thameslink Railway LimitedStated completedThe respondent said that this action was complete when they made their response on 25 August 2019.
  2. Action

    Update Local Incident Response Plans to incorporate the aide-mémoire requirements and PAPI acronym.

    Stated by Govia Thameslink Railway LimitedStated plannedThe respondent said that this action was planned when they made their response on 25 August 2019.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

    Govia Thameslink Railway is responsible for managing and operating Mill Hill Broadway station as its station facility owner.

    Stated by Department for TransportRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 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. ”

Is this part of a recurring concern?

Yes — Unreliable emergency response arrangements at railway stations.

Open source report

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 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. ”

Is this part of a recurring concern?

Yes — Unreliable emergency response arrangements at railway stations.

Open source report

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 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. ”

Is this part of a recurring concern?

Yes — Unreliable emergency response arrangements at railway stations.

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

Produce and issue the “Caring for our Customers” staff aide-mémoire for station managers and staff.

Verbatim wording from the response

“Since the inquest, we have developed some guidance for managers and staff when dealing with ill or injured persons on stations. This guidance is designed as a straightforward aide-mémoire to supplement the existing training and will complement our recent training programme for dealing with people ill or in trains. Operating stations of varied design with different risk factors, means each location is subject to its own risk assessment, with its own mitigations and access to certain equipment. These differences are identified to staff on their local induction.”

Source location

2019-0213-Response-by-Thameslink
Page 1 · response
Published 25 August 2019

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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

Update Local Incident Response Plans to incorporate the aide-mémoire requirements and PAPI acronym.

Verbatim wording from the response

“• Local Incident Response Plans (LIRP) to be updated to include the requirements of the Staff Aide-Mémoire “Caring for our Customers” and the PAPI acronym to provide a consistent approach to incident management – Planned completion of revised and updated LIRPs by 31st August 2019.”

Source location

2019-0213-Response-by-Thameslink
Page 1 · response
Published 25 August 2019

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

Govia Thameslink Railway is responsible for managing and operating Mill Hill Broadway station as its station facility owner.

Verbatim wording from the response

“Govia Thameslink Railway (GTR), as a franchisee of the Department for Transport, is the train operating company that is responsible, as station facility owner, for managing and operating Mill Hill Broadway station.”

Source location

2019-0213-Response-by-Department-for-Transport
Page 1 · response
Published 25 August 2019

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 Department considers GTR’s measures sufficient to resolve the identified matters of concern.

Verbatim wording from the response

“Jerome Pacatte, Head of Customer Service at Thameslink / Great Northern (a part of GTR) wrote to you on 2 August 2019, to set out the measures that GTR is undertaking in response to your stated ‘Matters of Concern’. These measures are:”

Source location

2019-0213-Response-by-Department-for-Transport
Page 2 · response
Published 25 August 2019

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

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
Page 2 · response
Published 25 August 2019

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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

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
Page 2 · response
Published 25 August 2019

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

    Highlight the accident through commercial management procedures to ensure train operators mitigate the risk of similar incidents.

    Stated by Department for TransportStated plannedThe respondent said that this action was planned when they made their response on 25 August 2019.
  2. 2

    Incorporate learning from the incident into risk controls and mitigation measures.

    Stated by Govia Thameslink Railway LimitedStated completedThe respondent said that this action was complete when they made their response on 25 August 2019.
  3. 3

    Deliver new privacy screens to key locations across the Thameslink and Great Northern routes under the equipment delivery plan.

    Stated by Govia Thameslink Railway LimitedStated plannedThe respondent said that this action was planned when they made their response on 25 August 2019.
  4. 4

    Request and warn GTR to make accessibility information leaflets available at London Bridge and Mill Hill Broadway stations.

    Stated by Office of Rail and RoadStated completedThe respondent said that this action was complete when they made their response on 25 August 2019.
  5. 5

    Request proactive correction of identified stair and other minor safety issues before they become hazards.

    Stated by Office of Rail and RoadStated completedThe respondent said that this action was complete when they made their response on 25 August 2019.
  6. 6

    Review the station-specific risk assessment and identify discrepancies requiring correction.

    Stated by Office of Rail and RoadStated completedThe respondent said that this action was complete when they made their response on 25 August 2019.
  7. 7

    Issue revised Accessible Travel Policy Guidance for operators’ passenger-assistance arrangements.

    Stated by Office of Rail and RoadStated completedThe respondent said that this action was complete when they made their response on 25 August 2019.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    Rail safety issues should be referred to RSSB and the Office of Rail and Road, which are tasked with addressing them.

    Stated by Department for TransportRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  2. 2

    The station operator and infrastructure owner have responsibility and authority to implement the proposed station safety and layout changes.

    Stated by Office of Rail and RoadRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Highlight the accident through commercial management procedures to ensure train operators mitigate the risk of similar incidents.

Verbatim wording from the response

“More widely, the Department will continue to manage all of its franchises through its normal commercial management procedures, of which safety is a key requirement. This tragic accident will be highlighted as part of this, to ensure that train operators do everything possible to mitigate against the risk of a similar incident.”

Source location

2019-0213-Response-by-Department-for-Transport
Page 2 · response
Published 25 August 2019

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

Incorporate learning from the incident into risk controls and mitigation measures.

Verbatim wording from the response

“We have listened to the concerns raised by the family at the inquest and we have factored in the learning from this incident into our risk controls and any mitigation, ensuring that all relevant influencing factors are included, so far as is reasonably practicable.”

Source location

2019-0213-Response-by-Thameslink
Page 1 · response
Published 25 August 2019

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

Deliver new privacy screens to key locations across the Thameslink and Great Northern routes under the equipment delivery plan.

Verbatim wording from the response

“• Equipment order, including new privacy screens, for key locations across the Thameslink and Great Northern routes and planned delivery dates as per programme – Equipment Delivery Plan enclosed.”

Source location

2019-0213-Response-by-Thameslink
Page 2 · response
Published 25 August 2019

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

Request and warn GTR to make accessibility information leaflets available at London Bridge and Mill Hill Broadway stations.

Verbatim wording from the response

“GTR also had informative posters at Mill Hill Broadway advising that the station is not step free and that there was assistance available to passengers if they required it. Through its investigation into this accident the ORR did establish that GTR’s “Making rail accessible: helping older and disabled passengers” document was not available in the form of a leaflet or an equivalent alternative at either London Bridge or Mill Hill Broadway stations, these being the stations travelled to and from by Mrs Tropp. ORR requested that this be addressed by GTR. The ORR’s licensing department have also written to GTR warning them of potential non-compliance with their licence requirements if they do not make such leaflets available at the stations in question.”

Source location

2019-0213-Response-by-ORR
Page 4 · response
Published 25 August 2019

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

Request proactive correction of identified stair and other minor safety issues before they become hazards.

Verbatim wording from the response

“The ORR reviewed the station specific risk assessment document and considered that it adequately covered the risks to passengers and staff. However, there were some minor discrepancies which were raised and which GTR have now addressed.”

Source location

2019-0213-Response-by-ORR
Page 3 · response
Published 25 August 2019

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

Review the station-specific risk assessment and identify discrepancies requiring correction.

Verbatim wording from the response

“Risk Assessment and Risk Control:”

Source location

2019-0213-Response-by-ORR
Page 3 · response
Published 25 August 2019

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

Issue revised Accessible Travel Policy Guidance for operators’ passenger-assistance arrangements.

Verbatim wording from the response

“GTR, as a station operator, and as part of its licence conditions has to establish and comply with a Disabled People’s Protection Policy (DPPP). The ORR has recently issued new guidance which will remain new / revised DPPPs as Accessible Travel Policies (ATP). The licence condition also stipulates that licence holders must have due regard to the Design Standards for Accessible Railways: A Joint Code of Practice published by the Department for Transport (DfT) and Transport Scotland. ATPs have to be approved by ORR before a licence is granted to an operator.”

Source location

2019-0213-Response-by-ORR
Page 4 · response
Published 25 August 2019

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

Rail safety issues should be referred to RSSB and the Office of Rail and Road, which are tasked with addressing them.

Verbatim wording from the response

“The RSSB (originally known as the Rail Safety and Standards Board) is a membership-based rail industry body designed to help the railway become safer and more sustainable for passengers, the workforce and the wider public, whilst the Office of Rail and Road is the independent body, established by Government, that monitors and enforces compliance with health and safety legislation on Britain’s rail network.”

Source location

2019-0213-Response-by-Department-for-Transport
Page 1 · response
Published 25 August 2019

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 station operator and infrastructure owner have responsibility and authority to implement the proposed station safety and layout changes.

Verbatim wording from the response

“Having considered the matter carefully the ORR’s position, with respect to the Coroner, is that this report would be better served upon the station operator (Govia Thameslink Railway Ltd (‘GTR’) and the infrastructure manager (Network Rail) as the ORR does not have the power to take the action proposed by the Coroner in paragraphs 5 and 6 of his report.”

Source location

2019-0213-Response-by-ORR
Page 1 · response
Published 25 August 2019

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