Dear Sir, Reference: REGULATION 28 REPORT TO PREVENT DEATHS Thank you for the report from your investigation, regarding the tragic death of Kaja Weronika. It revealed matters giving rise to your concerns which you addressed with me. I welcome you drawing attention to points to prevent future deaths. Sadly over 31 people have gone on to complete suicide on our part of the network in the past year, making death as a result of suicide or trespass one of our highest risks. As one of our most significant risks we at GTR, with our industry partners, employ an array of mitigations to prevent suicide or trespass. This includes physical infrastructure to deter trespass, such as platform end gates, anti-trespass matting, prohibition signage and extensive CCTV. There is messaging directly to the vulnerable, in the form of strategically placed Samaritans signage, to break their chain of thoughts and signpost support. We routinely check physical measures are in place and conduct post incident site visits with the British Transport Police and Network Rail to optimise the design and placement of mitigations at Stations. GTR is the only Train Operating Company in UK Rail to employ a dedicated Suicide Prevention Manager. They play an active role in promoting awareness of the issues of vulnerable people coming on to our Network, signposting support channels to rail users and Staff through organised events to such as ‘Small Talk Saves Lives’, ‘Brew Monday’ and ‘Affirmation Art’ campaigns. They also work closely with the Samaritans to develop training courses for staff to help them feel more confident approaching a vulnerable person and give them the tools and knowledge to make a safe intervention. These initiatives together have, since having a dedicated Suicide Prevention Manager, doubled the number of interventions made by staff, with 456 recorded in the last year. We do recognise that every death is one too many and strive to continually reduce the number of suicides and trespasses on our network, so we are welcoming your findings. I will address each of the areas of concern raised in turn:

Govia Thameslink Railway Monument Place, 24 Monument Street, London, EC3R 8AJ Registered in England under number: 7934306. Registered office: 3rd Floor, 41-51 Grey Street, Newcastle upon Tyne, NE1 6EE

(1) 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.

Those that work at stations and in customer facing roles onboard trains are the people most likely to encounter a vulnerable person who might be at risk of doing themselves harm. We closely monitor the locations where interventions are made, as well as where people go on to complete suicide and prioritise training for people working at these locations. Up until recently this training has been provided by the Samaritans ‘Managing Suicidal Contacts’ course. This is a face to face training session, which does limit its reach, but we can confirm that 608 priority people have attended this course.

We recognised the importance for everyone to have the skills to identify someone who is vulnerable and have the confidence to make an intervention, so have developed, in-house, the ‘Suicide Prevention’ course. It is based on the content of the Samaritans MSC course, designed with interactive learning cemented with quizzes and is delivered via an e-learning platform, meaning that it can reach more people. So far 3045 GTR colleagues have completed this course and being online, it remains accessible to all, on any device, so that knowledge can be refreshed at any time. This number accounts for 70% of our Customer facing, frontline teams completing this course.

It is our intent that all GTR colleagues benefit from this programme, so in addition to being included as part of an individuals’ briefing cycle, this course is delivered to all new starters in the ‘Caring for the Vulnerable’ session of the company induction. This gives the opportunity to enhance it further, with a session delivered by a Mental Health Nurse to help prepare people, new to Rail, should find themselves in a situation with someone in crisis in a precarious position. So far 860 new people have benefited from this course.

We at GTR are confident that this approach gives us the best and quickest penetration to enable those members of staff, most likely to have contact with vulnerable or suicidal persons, to make a safe intervention. However, we want to test both the breadth and depth of understanding of this important subject, amongst those in this cohort. GTR will conduct audit to assess the impact of its programme, the results of which will be used to identify improvements which could be made and will be made available to the rail regulator, the Office of Rail and Road (ORR), by the end of April.

Govia Thameslink Railway Monument Place, 24 Monument Street, London, EC3R 8AJ Registered in England under number: 7934306. Registered office: 3rd Floor, 41-51 Grey Street, Newcastle upon Tyne, NE1 6EE

(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.

The ‘Passenger ill on Train’ is a process which describes the steps toward assessing whether it would be safe to extradite someone, onboard a train, who requires medical attention, to allow the train to proceed, which would otherwise cause widespread network disruption. It was incorrectly referenced as a protocol appropriate for dealing with a person for whom we had identified a concern for welfare.

If there is a report of a person in a precarious position, for example on a station platform, who is believed to be in immediate danger from the continued passage of trains, there are protocols whereby the Signaller would be notified to caution the passage of trains; the BTP would then co-ordinate a response to make an intervention, deploying resources which include their own officers, verified contractors such as Vital or Land Sheriffs, or GTR’s Rail Enforcement Officers. These calls are mostly made directly to the signaller and the BTP. However, where it involves a person not in immediate danger and without an apparent intent to do themselves harm, there will inevitably be a nuanced response to a concern for welfare.

Typically, non-emergency calls are made to the Network Operations control room. This is an integrated control room led by Network Rail, under a joint incident management standard, with standard and formal incident management protocols well defined. The Control Team have all undertaken the MSC training, so that when receiving a call, they should recognise what the appropriate response should be and they share information widely via a dedicated Instant Messaging system channel for suicidal and vulnerable persons, to alert the rest of the control room and give opportunity to escalate the response if necessary.

The range of possible responses to a non-emergency concern for welfare is, as you have witnessed, less well defined. Between the 9th February and 16th March, the Sussex Control centre will be holding a series of Operations Development Days, covering dealing with vulnerable people / cause for concern, which GTR staff will take part in to raise consistency in response to these situations. Learning from these development days will be incorporated, under subject of concern for welfare reports, into the Joint Incident Management Framework, in a new section covering Safety Incidents & Emergencies. This will reinforce the requirement of all staff in the Control Room to report every incident involving vulnerable people (or other emergency such as damage to infrastructure, trespasser etc.) to Network Rail Controllers.

Govia Thameslink Railway Monument Place, 24 Monument Street, London, EC3R 8AJ Registered in England under number: 7934306. Registered office: 3rd Floor, 41-51 Grey Street, Newcastle upon Tyne, NE1 6EE

On occasion the control room might take a call, via a station call point, from a member of the public or the vulnerable person themselves. GTR’s suicide Prevention Manager is working with the Samaritans to develop a training course specific to dealing with vulnerable people over the phone and help points. Learning will be underpinned with a practical assessment for GTR control room staff, which is done annually, on how they would deal with a help point call from a suicidal person.

(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

Concern for welfare incidents are logged on Control Centre Incident Log (CCIL) and all those involved in managing the incident within control update the log with their actions/updates. Actions and updates from those outside of control are recorded by their contact in control. Everyone is encouraged to update the log in a timely fashion, but relevant data can be retrospectively added at the earliest convenience with the time amended to reflect actual times. The CCTV monitoring team are notified and asked to monitor stations. Messages are sent out via Tyrell (a dedicated Rail Industry information system) and on the different Team's chats. As mentioned above, the subject of welfare reports will be covered in the Joint Incident Management Framework, in a new section covering Safety Incidents & Emergencies, which will reinforce the requirement of all staff in the Control Room to report every incident involving vulnerable people (or any other emergency such as damage to infrastructure, trespass etc.) to Network Rail Controllers. Thereby raising consistency in the logging of important information.

(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.

When receiving concern for welfare reports it is standard practice to contact British Transport Police. We strongly encourage those colleagues who report welfare concerns to make this call personally and advise BTP of any references so these can be recorded in CCIL. However, we have come to understand that, in practice, the way colleagues report these events may vary and often depend on the circumstances and the individual colleague’s judgement. In the event a person is clearly without capacity or has clear intent to do themselves harm, this would almost certainly result in a call to the Police. There are, however, less well-defined options for those more nuanced cases which fall below this

Govia Thameslink Railway Monument Place, 24 Monument Street, London, EC3R 8AJ Registered in England under number: 7934306. Registered office: 3rd Floor, 41-51 Grey Street, Newcastle upon Tyne, NE1 6EE

threshold. I agree that this ambiguity needs to be eradicated. The output from the Operational Development Days will be used to strengthen guidance to aid better decisions in respect to non-emergency concerns for welfare.

This will reinforce the need to contact the BTP to frontline teams via training and staff briefings, supplementing the Samaritans TACTIC booklets, which have been reissued to GTR Onboard Supervisors as an aide memoire when helping a vulnerable person.

Chief Executive Officer

Finally I wish to, on behalf of GTR, express my deepest condolences to the family for their tragedy and we appreciate their unimaginable loss. Our thoughts remain with them.

Dear Mr Simpson, I am writing in response to the Prevention of Future Deaths Report relating to the sad death of Kaja Spiewak who tragically died at Southbourne Station, West Sussex on 7th April 2021. May I take this opportunity to express my condolences to Kaja’s family for their sad loss. Network Rail (NR) and Govia Thameslink Railway Ltd (GTR) operate a joint control for the Sussex route and, although the majority of the concerns detailed in the Prevention of Future Deaths Report relate to GTR, this response provides details of the action NR and GTR have taken together to improve knowledge and how we deal with situations where we have a concern for someone’s welfare as opposed to someone who is physically unwell. The concern in the Prevention of Future Deaths Report for NR and GTR to address jointly is as follows: “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.” NR and GTR have worked jointly to prepare a new section within our joint NR/GTR incident management standard. As a result, there is now a clear joined-up procedure between NR and GTR for dealing with vulnerable people or where there is a concern for someone’s welfare (termed ‘concern for welfare’ reports). This standard now specifically distinguishes between the ‘person ill on train’ procedure relating primarily to physical illness and a ‘concern for welfare’ procedure which can include situations where we have a concern for a person’s mental health, such as a person being distressed, vulnerable or in crisis. NR has worked with GTR to brief every member of control room staff, including those employed by both NR and GTR, with the ‘Concern for Welfare’ briefing, either in person or on MS teams. The briefings addressed the sequence of events that led to Kaja’s tragic death and highlighted the key learning and crucially the importance of all agencies including NR, GTR and notably the British Transport Police (BTP) sharing information relating to ‘Concern for Welfare’. A copy of this briefing is attached. NR has shared this ‘Concern for Welfare’ briefing internally, through face-to-face and virtual briefings with all route controls nationally, including NR route controls and other joint NR/Train Operating Company route controls similar to that in Three Bridges. I confirm that, as described above, NR and GTR have worked together to create a protocol and training so that GTR staff are aware of how to recognise a potential ‘concern for welfare’ report, exactly what to do upon a ‘concern for welfare’ report coming into the control and the importance of GTR staff sharing a ‘concern for welfare’ report with NR and or other agencies such as the BTP. Finally, we note that this Prevention of Future Deaths Report was dated 1 December 2021. However, due to a delay in the Report reaching NR, our response was requested by 2 May 2022.

OFFICIAL

Should you have any further questions please do not hesitate to contact me.

Kind regards, , Route Director

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