Terence Fernandes

yh. Oey
Ye BEDFORRGS of,

24 JUL 2nt

Mr Tom Osborne LL.B

HM Senior Coroner (Bedfordshire & Luton}
HM Coroners Office ao
The Court House

Woburn Street

AMPTHILL MK45 2HX

18 july 2014

Iya MN. Osborne ,

RE: Inquest touching the death of Terence Vincent Anthony FERNANDES — Inquest held on 29 April
2014 at 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 of the 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 they 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.

TOCs vary considerably in the nature of their operations — this includes the sorts of services they
operate (long distance InterCity, commuter, rural, etc.), the types of train they 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. A good 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 busy periods. Some
stations are wholly unstaffed. All 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 very 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.

The actions we have taken or propose to take in response to your letter are:

1. 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 of the incident itself and the content of your Report.

2. Asimilar detailed discussion took place at the more senior and wider remitted ATOC
Operations Council meeting in July.

3. As aconsequence 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 of their stations and the importance of the
recovery position. A copy of the letter, which was sent out electronically today, is enclosed
for your information.

4. 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.

Yours sincerely

020 7841 8169