AtOc BEDFORD Association of Train OperatngComPanies 2 | Jul 2014 Mr Tom Osborne LL.B OFFICE HM Senior Coroner (Bedfordshire & Luton) HM Coroners Office The Court House Woburn Street AMPTHILL MK45 2HX 18 July 2014 Ox nc Osborn RE;_Inquest touching the death of Terence Vincent Anthony FERNANDES Inquest held on 29 April 2014at Coroner's Court_Ampthill Further to my letter of 23 May 2014, am now in a position to provide a response to your Report as sent to Michael Roberts by letter dated 12 May 2014 Your agreement to an extension ofthe original 56 day response period is very much appreciated. As previously indicated, this has allowed us to discuss the circumstances surrounding the death of Mr: Fernandes at the recent meetings of our Safety Forum and Operations Council. The Forum is the foremost meeting of Train Operating Company (TOC) safety professionals while the Council is the most senior cross-TOC body that meets to consider all aspects of relevance to passenger train operation over the UK Network Rail managed rail network The content of this response reflects the views of members of each of these groups. As noted in my previous letter, ATOC is answerable to its members it does not direct them; they direct it_ However, groups such as the Council and Forum make it possible to alert members to risks associated with their operations and the safety and welfare of their passengers and staff _ including those taken ill and to influence how respond through facilitation and cross-member discussions_ As with all the risks associated with their operations and in line with the obligations under the Health and Safety at Work Act and specific railway legislation, the steps each TOC takes to deal with passengers taken ill flow from a risk assessment TOCs determine what response is proportionate to the risk, and hence what measures are reasonably practicable to take: The assessment of risk and measures implemented are then subject to on-going review: Instances of passengers being taken ill and requiring first aid are fortunately not that frequent: oc_"m- P-ki--ont Ziw AWAWv i'W :6!Jh X3 WWMX ~; Xaoo QW"; aa 1i5 > M 7uouv)} ATOc NationaRMMEne} Ranemlenent Ra#so fTnvei 3 To? ? CoROA AM they "'7 " P:f

AtOc Association ofTrannCperjungCompames TOCs considerably in the nature of their operations this includes the sorts of services operate (long distance InterCity, commuter, rural, etc:), the types of train run, the types of passenger they carry and the types of station they primarily serve. Therefore measures implemented are likely to be different; reflecting their individual circumstances, even where risks initially appear similar. ATOC works with its members and other parties as necessary to identify and provide guidance on matters that are common to the majority of its members. example of this is the ATOC Guidance Note 'Responding to Ill Customer on Trains' , issued in October 2013. Rather than suggest prescriptive arrangements, this includes a recommendation that TOCs should identify suitable stations along each line of route over which they operate at which a passenger who has a life- threatening or other illness can be passed directly into the care of ambulance staff. Clearly the number of such suitable stations is highly dependent on the geography - in some areas there may be considerable distances between stations which are staffed and offer more than the most basic of shelter facilities The London Ambulance Service has been (and continues to be) involved in discussions on the best approach to dealing with passengers who are taken ill. The TOCs take a business need and risk based approach to assessing staffing levels and the number of first aid trained staff on duty at any particular time and station: Essentially the larger stations, including those directly managed by Network Rail, have first aid trained employees on site during the period in which the station is open whilst medium sized stations are staffed to reflect demand and accordingly are more likely to have a qualified first aid provision during periods. Some stations are wholly unstaffed: AIl TOCs have procedures for dealing with vulnerable passengers, which include those who may require medical assistance: Additionally there has been an increase in the provision of first aid equipment (including defibrillators) during the last couple of years at the larger stations Your Report has led to a further review of how passengers who are taken ill are assisted and sharing of TOC approaches to first aid training and briefing: These detailed discussions took place within the quarterly ATOC Safety Forum in June and at the quarterly Operations Council meeting in July: One of the actions arising from these discussions was for the Council to direct ATOC to write to its members to explicitly alert them to the circumstances of Mr Fernandes' death and suggest that they consider, as part of each TOC' s continuous obligation to keep its risk assessments under review, whether any changes should be made to the first aid arrangements they have in place at each of their stations_ The discussions also reminded members of the importance of the proper recovery position, and casualty management of unconscious persons, which are infrequent events per location. We have also reminded them of the changed emphasis on first aid provision for members of the public introduced as part of the amendments made in October 2013 to the Health & Safety (First Aid) Regulations 1981 A18C0o"- Prxc:_ Jm 2 : J67: ete= Exifn-D 8 4 : Vi.{ XW K-oWWJab Av m1 4 j: ^ Nv $9p8; Atoc ManwmRamEnuo; RmnS-mesentPln RomSnTcave1 4 <X 73 "% they vary they: good busy very

ATOc AssociatonofTriinOperating Comcanies The actions we have taken or propose to take in response to your letter are: The matter was considered in detail at the meeting of the ATOC Safety Forum in June, the discussion focussing on what happened and what the Train Operator community should do in light both ofthe incident itself and the content of your Report: 2 A similar detailed discussion took place at the more senior and wider remitted ATOC Operations Council meeting in July 3 Asa consequence of the above discussions, ATOC has been directed by the Council to write to its members to explicitly alert them to the circumstances of Mr Fernandes death and suggest that they consider whether any changes should be made to the first aid arrangements they have in place at each oftheir stations and the importance of the recovery position. A copy of the letter, which was sent out electronically today, is enclosed for your information. It is the consensus view of our members that proportionate action taken by individual TOCs in line with the above may be expected to lead to some reduction in the risk of similar deaths in the future. It is our and their assertion that each business reviewing its arrangements constitutes a national response and this will drive the most proportionate solutions and pass the test of reasonable practicability: Beyond this, ATOC will facilitate a further discussion on first aid provision amongst the TOCs at the next Safety Forum: We anticipate this will allow them to share any changes in practice following receipt of ATOC's notification of the details surrounding Mr Fernandes' death.