Dear Madam,

Inquest touching on the death of Sarah Cunningham

I write on behalf of Transport for London (TfL) regarding the Senior Coroner’s Regulation 28 Prevention of Future Deaths (PFD) report dated 16 April 2025 following the inquest touching on the death of Sarah Cunningham.

Ms Cunningham’s inquest and the Prevention of Future Deaths (PFD) report

The inquest touching on the death of Sarah Cunningham took place on 9 April 2025 at Poplar Coroner’s Court. TfL was an Interested Person in the inquest and witnesses from TfL attended to give evidence.

I would like to take this opportunity to repeat, on behalf of TfL, our sincere condolences to the family and friends of Ms Cunningham for their tragic loss.

After the inquest, the Senior Coroner sent a PFD report to TfL raising the following matter of concern:

‘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.’ I am grateful to the Senior Coroner for raising these concerns and we set out below TfL’s response in four sections. The first section sets out the actions that have been developed in the light of our Formal Investigation into the incident and in response to the area of concern made in the PFD report, with the following sections expanding on our current work to address the risks from intoxication; our internal approach to responding to and learning from formal incident investigations; and finally a summary of the technology trials underway to reduce the risk of customers getting hurt on the platform edge.

Response to PFD report

TfL has well-established policies and procedures for safeguarding children and adults at risk. For example, we have established training, awareness-raising and co-operative working with the Police, charities and other partners to prevent people dying by suicide on our services.

However, through recent events, including the tragic death of Ms Cunningham, we recognise that as an organisation, a significant step change is required in our approach and how we protect our customers who are vulnerable in the moment, for example through intoxication, from coming to harm when using our services. A systemic approach is required to protecting vulnerable customers so that they get home safely using our services. We are committed to embedding a comprehensive understanding in our operating procedures and through staff awareness and behaviour.

We have used insight from our work with others on safeguarding, to determine a clear action plan to address temporary vulnerability. An adult may be ‘temporarily’ vulnerable through a range of factors, including intoxication from alcohol or drugs, emotional distress or short-term illness putting them at greater risk of coming to harm, through accident or injury or through being a victim of crime on our services. Our priority is to embed ways to prevent intoxicated customers coming to harm as recommended in the PFD report, but we must also consider similar circumstances so that change is comprehensive and ultimately reduces the likelihood of death, injury or serious harm on our services.

Our actions underway include:

• Completing a comprehensive review of current safeguarding risk management across every TfL mode to identify gaps and priorities in protection of vulnerable customers. We will complete this assessment by 30 August 2025. This review will result in a tailored action plan for each of our transport modes. TfL’s Executive Safety Sub-Group will oversee progress and hold each mode to account on their progress in implementing their plan to prevent intoxicated and other vulnerable passengers coming to harm when using TfL’s services.

• 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.

• 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.

• 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:

o Dedicated, specially trained teams providing safeguarding patrols on platforms and trains for night tube; o Increasing frequency of security patrols by station teams in the evenings and into the night at quiet stations; o Enhanced CCTV monitoring through station operations rooms and central control centre of platforms and public areas to monitor vulnerable customers; o Appraisal of SMART cameras technology to detect erratic or unusual behaviour and alert staff; and o Adapting our ‘turn up and go procedure’ to get intoxicated and other vulnerable customers home safe.

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.

TfL policies on intoxication

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

This activity includes:

• Multi-channel customer communication campaigns encouraging customers to take greater care after drinking alcohol. Increasing the

coverage and spread of activity during key times of year, including summer and the winter festive period;
• On-network signage notifying customers of the ban on consuming alcohol on public transport services;
• Colleague training and briefings to assist station staff to safely manage intoxicated customers, including spotting and supporting vulnerable customers and conflict management skills to prevent work-related violence and aggression;
• Deployment of staff to higher risk locations within stations, such as the top of escalators and platforms; and
• Collaboration with local authorities to manage the impacts of intoxication and provide targeted support at key locations before customers get on the tube.

Most recent data from staff and incident reporting suggests that the hotspot locations of the West End and City, and traditional times for intoxicated related incidents, are changing. The following recommendations were made from the most recent activity:

• Broaden activity to cover the entire week, not just Thursdays, Fridays and weekend.
• Expand the number of targeted stations for additional communications and signage and staff patrols to stations in the top 25 hotspots, ensure all colleagues at these locations are briefed on how to support intoxicated customers and reduce the risk of customers coming to harm.

This work to address the impact of intoxication will now be fully incorporated into our review on how we manage safeguarding risk and the improvement programme approach set out above.

TfL’s approach to FIR recommendations

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.

Under the new process, the Chief Safety, Health and Environment Officer is accountable for ensuring that business areas develop appropriate and effective actions. Directors of the respective business areas are directly responsible for formulating relevant actions to address recommendations, to contribute to mitigating risks and addressing causal factors comprehensively. This takes place in the weeks following completion of the investigation report. The enhanced level of accountability has brought a focus around investigation recommendations with the aim of bringing them to the forefront of corporate thinking. The actions set out above reflect the recommendations made in TfL’s Formal Investigation into the incident.

Work on improving safety of the Platform Train Interface

We recognise that some of our customers may access the track environment either deliberately or unintentionally and may be unaware of the potential danger that they are in.

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.

The trials will use a mixture of existing and new camera technology and sensors to identify incidents and will trigger an operational response to alert staff. As this technology is new, we want to learn more about the efficacy of different technologies in different locations and different environments. These trials, which will start in autumn 2025, are being carried out with a clear view to the future. We will therefore have the potential to use this technology across TfL services where it can be demonstrated that it will help keep our customers safe.

Conclusion

I would like to offer again my heartfelt sympathy and condolences to Ms Cunningham’s family and friends. We are determined as an organisation to learn lessons from this tragic incident and to make our network as safe as possible for all customers, particularly those who may be vulnerable.

I hope this response is helpful and welcome. Please contact me if I can be of any further assistance.