Priscilla Tropp

Her Majesty’s Coroner for the 
Northern District of Greater London 
(Harrow, Brent, Barnet, Haringey and Enfield) 

North London Coroners Court, 
29 Wood Street, 
Barnet EN5 4BE 

Telephone 0208 447 7680 
0208 447 7689 
Fax 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO: 
Department for Transport 
Great Minster House 
33 Horseferry Road 
London 
SW1P 4DR 

1 

CORONER 

I am Andrew Walker, senior coroner, for the coroner area of Northern District of Greater 
London 

2 

CORONER’S LEGAL POWERS 

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 

3 

INVESTIGATION and INQUEST 

On the 28th of November 2018 I opened an investigation touching the death of Priscilla 
Tropp. I opened an inquest on the 4th December 2018. The inquest concluded on the 
23rd April 2019. The conclusion of the inquest was “Consequences of a fall down stairs 
at a railway station". The medical cause of death was 1a Traumatic Splenic Rupture, 11 
Myeloproliferative disorder. 

4 

CIRCUMSTANCES OF THE DEATH 
On the Twenty-Seventh of November 2018 at a little before 16.30 hrs in the afternoon 
Priscilla Tropp fell down steps at Mill Hill Broadway Station and was taken to the Royal 
Free Hospital where Mrs Tropp died as a consequence of the injuries sustained in the 
fall . The nature of the access to the platforms, there being no step free access, 
resulted in Mrs Tropp falling despite using the handrail and being supported by her 
husband. The incident was not appropriately managed and Mrs Tropp was left to be 
treated as passengers made their way past with no steps taken to divert passengers. 

5 

CORONER’S CONCERNS 

During the course of the inquest the evidence revealed matters giving rise to concern. In 
my opinion there is a risk that future deaths will occur unless action is taken. In the 
circumstances it is my statutory duty to report to you. 

The MATTERS OF CONCERN are as follows. – 

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 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Her Majesty’s Coroner for the 
Northern District of Greater London 
(Harrow, Brent, Barnet, Haringey and Enfield) 

any potential injury to the person who may themselves have been injured or to any one 
else using the station. 

6 

ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe you 
[AND/OR your organization] have the power to take such action. 

7 

YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, 
namely by the 19th August 2019 I, the coroner, may extend the period. 

Your response must contain details of action taken or proposed to be taken, setting out 
the timetable for action. Otherwise you must explain why no action is proposed. 

8 

COPIES and PUBLICATION 

I have sent a copy of my report to the Chief Coroner and to the following Interested 
Persons;- 

Representatives for the Train Company, Network Rail, Department of Transport and the 
Family. 

I am also under a duty to send the Chief Coroner a copy of your response. 

The Chief Coroner may publish either or both in a complete or redacted or summary 
form. He may send a copy of this report to any person who he believes may find it useful 
or of interest. You may make representations to me, the coroner, at the time of your 
response, about the release or the publication of your response by the Chief Coroner. 

9 

24-6-2019

ajesty’s Coroner for the Northern 
District of Greater London 
(Harrow, Brent, Barnet, Haringey and Enfield) 

North London Coroners Court, 
29 Wood Street, 
Barnet EN5 4BE 

Telephone 0208 447 7680 
0208 447 7689 
Fax 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO: 

Occupational Safety Manager 
Go-Ahead House, 
26 – 28 Addiscombe Road, Croydon. CR9 5GA. 

1 

CORONER 

I am Andrew Walker, senior coroner, for the coroner area of Northern District of Greater 
London 

2 

CORONER’S LEGAL POWERS

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 

3 

INVESTIGATION and INQUEST

On the 28th of November 2018 I opened an investigation touching the death of Priscilla 
Tropp. I opened an inquest on the 4th December 2018. The inquest concluded on the 
23rd April 2019. The conclusion of the inquest was “Consequences of a fall down stairs 
at a railway station". The medical cause of death was 1a Traumatic Splenic Rupture, 11 
Myeloproliferative disorder. 

4 

CIRCUMSTANCES OF THE DEATH
On the Twenty-Seventh of November 2018 at a little before 16.30 hrs in the afternoon 
Priscilla Tropp fell down steps at Mill Hill Broadway Station and was taken to the Royal 
Free Hospital where Mrs Tropp died as a consequence of the injuries sustained in the 
fall . The nature of the access to the platforms, there being no step free access, 
resulted in Mrs Tropp falling despite using the handrail and being supported by her 
husband. The incident was not appropriately managed and Mrs Tropp was left to be 
treated as passengers made their way past with no steps taken to divert passengers. 

5 

CORONER’S CONCERNS 

During the course of the inquest the evidence revealed matters giving rise to concern. In 
my opinion there is a risk that future deaths will occur unless action is taken. In the 
circumstances it is my statutory duty to report to you. 

The MATTERS OF CONCERN are as follows. – 

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 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Her Majesty’s Coroner for the 
Northern District of Greater 
London 
(Harrow, Brent, Barnet, Haringey and Enfield) 

any potential injury to the person who may themselves have been injured or to any one 
else using the station. 

6 

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and I believe you 
[AND/OR your organization] have the power to take such action. 

7 

YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, 
namely by the 19th August 2019 I, the coroner, may extend the period. 

Your response must contain details of action taken or proposed to be taken, setting out 
the timetable for action. Otherwise you must explain why no action is proposed. 

8 

COPIES and PUBLICATION

I have sent a copy of my report to the Chief Coroner and to the following Interested 
Persons;- 

Representatives for the Train Company, Network Rail, Department of Transport and the 
Family. 

I am also under a duty to send the Chief Coroner a copy of your response. 

The Chief Coroner may publish either or both in a complete or redacted or summary 
form. He may send a copy of this report to any person who he believes may find it useful 
or of interest. You may make representations to me, the coroner, at the time of your 
response, about the release or the publication of your response by the Chief Coroner. 

9 

24-6-2019

Department for Transport
Great Minster House

Department 33 Horseferry Road

London
for Transport Fat 0800 330 3000
Web Site: www.gov.uk/dift
Mr A Walker Our Ref: 261177
Senior Coroner , 16 August 2019

North London Coroners Court
29 Wood Street

Barnet

EN5 4BE

Dear Mr Walker
Regulation 28 Report: Mrs Priscilla Tropp

Thank you for forwarding your Regulation 28 report of 24 June 2019,
following the inquest into the death of Mrs Priscilla Tropp at Mill Hill Broadway
station on 27 November 2018.

Our sympathies go out to the family and friends of Mrs Tropp.

Safety is the top priority for the railway. Each of the various organisations
involved has its own specific safety responsibilities to ensure that the overall
railway can operate safely, for passengers and employees.

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.

Whilst we do of course use our influence in engaging with the industry, these
dedicated organisations are tasked with confronting these issues, and you
may wish to consider forwarding your findings to these organisations
(addresses below’).

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.

1 RSSB, The Helicon, 1 South Place, London, EC2M 2RB
Office of Rail and Road, One Kemble Street, London, WC2B 4AN

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:

e Anew Staff Aide-memoire for station staff on dealing with accidents and
emerging incidents on stations;

e The update of associated Local Incident Response Plans; and

e New equipment, including privacy screens, for key locations across the
Thameslink and Great Northern operating area.

The Department is satisfied that these measures should resolve your ‘Matters
of Concern’.

As part of the commercial management process we have discussed this
incident with GTR at monthly compliance meetings, and are content that it
has responded appropriately, and will continue to assimilate these new
measures into its operation of the franchise.

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.

Yours sincerely

bad be

David Gott

es
OFFICE OF RAIL AND ROAD

FAO: Senior Coroner Mr Andrew Walker.
North London Coroners Court

29 Wood Street

Barnet

EN5 4BE

Also sent be email to: Clerk.inquests@hme-northlondon.co.uk

Regulation 28 Report to Prevent Future Deaths dated 24 June 2019.
Arising out of the Inquest touching the death of Mrs Priscilla Tropp opened on the 4
December 2018.

Dear Senior Coroner Walker,

The ORR is grateful for the receipt of your letter and accompanying Regulation 28 (of the
Coroners [Investigation] Regulations 2013 ‘the Regulations’) Report to prevent future deaths
dated 24 June 2019.

This letter is intended to be the ORR’s formal response under Regulation 29 of the
Regulations addressing the Coroner's concerns as set in paragraph 5 of the Regulation 28
Report.

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.

To give context to this submission it is the ORR’s understanding that the Coroner is
concerned that Mill Hill Broadway Station lacked a flow chart or plan (taking into account the
design and layout of the station) that covered the procedure for dealing with a person when
taken ill on the station, or in any area of the station that was used for the movement of people
around the station. We understand the Coroner’s primary concern to be that there were a
lack of prescribed sensible steps for staff to take in such circumstances to assist them in
mitigating any potential injury to a person who may themselves be injured or to anyone else
using the station.

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Head Office: One Kemble Street, London WC2B 4AN T: 020 7282 2000 orr.gov.uk

Page 1 of 7

It is apparent by virtue of service of the report upon the ORR that the Coroner believes the
ORR has the authority to take action to ensure a flowchart or plan is designed and put in
practice by either the station operator (GTR) or the infrastructure owner (Network Rail).

The ORR also note the Coroner's conclusion that Mrs Tropp’s tragic and untimely death was
as a result of the “consequences of a fall down stairs at a railway station” and the medical
cause of death was “1a traumatic splenic rupture, 11 myeloproliferative disorder”. It is the
ORR’s understanding that the safety management system in place at Mill Hill Broadway
Station and, in particular, the processes and procedures for managing casualties and the
movement of other station users around casualties, as implemented by GTR, whilst not
considered sufficient by the Coroner, were not concluded to be causative of, or contributory
to Mrs Tropp’s death.

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.

As the regulator of the rail industry the ORR’s primary function is to ensure duty holders
comply with health and safety legislation and the accompanying regulations. The ORR
promotes compliance through industry engagement, advice and guidance. It seeks to
monitor compliance via inspections and in certain circumstances the exercise of its statutory
investigative powers. It also has the ability to take enforcement action. The enforcement
action can take two forms; firstly through the issuing of licence agreements and assessing
duty holders systems against licence requirements. Secondly, through the issuing of
improvement notices, prohibition notices and the prosecution of duty holders. Much of the
enforcement action involving notices and prosecutions is reactive where action is taken
against duty holders for issues that have been identified during investigations or because of
incidents which have occurred as a result of health and safety breaches.

The ORR’s authority to intervene extends only to situations where the duty holders fall short
of the legal standards required of them. In the event that a duty holder is in compliance with
the minimum standards set out in law the ORR is able to provide advice and guidance to
the industry but is not in a position to take any enforcement action or revoke a licence. In
essence the ORR’s influence and ability to enact change is somewhat limited where the
legal requirements on the duty holder are met.

It is for the reasons set out above, that the ORR respectfully suggests that the report would
be better served upon the station operator (GTR) and infrastructure owner (Network Rail),
who have the power to implement the changes suggested by the Coroner to prevent further
deaths or to explain why they propose that no action is required. The ORR conducted a
thorough investigation into this sad incident and found that there were no grounds for

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Head Office: One Kemble Street, London WC2B 4AN T: 020 7282 2000 orr.gov.uk

Page 2 of 7

enforcement action. It was determined that the safety management systems in place
relevant to the incident were in compliance with the minimum standards of health and safety
law given the layout and design of the station. The ORR found that the safety management
plans in place were able to safely manage the situation at the station following Mrs Tropp’s
fall and understand, by virtue of his findings at Inquest, that the Coroner accepts the
arrangements in place did not cause or contribute to Mrs Tropp’s death. However, insofar
as was possible the ORR has used its influence within the industry in attempt to ensure
minor issues that were discovered were addressed and improvements made voluntarily by
the station operator to improve the safety systems in general.

We hope that the Coroner will be encouraged by the following action which the ORR has
taken, as summarised below, and that these steps will go some way to alleviating the
concerns the Coroner has set out in his report.

Emergency Procedures:

The ORR confirmed that the station operator had emergency procedures in their safety
management system including:

a. Adisruption management plan for Mill Hill Broadway station. The purpose is to
provide guidance to staff on the expected actions in response to varying levels of
passenger disruption at the station.

b. Acrowd control guidance document for Mill Hill Broadway. It explains what station
staff should do if overcrowding occurs at the station, for a range of situations.

c. A local Incident Response Plan for Mill Hill Broadway which gives clear guidance for
station staff on the arrangements to be adopted in the event of an incident at the
station.

The above documents are kept on the Health & Safety notice board in the station office.

The ORR was also provided with evidence that the station staff are briefed on the plans
referred to above in accordance with GTR’s safety management system.

Risk Assessment and Risk Control:

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.

GTR completed a post incident inspection of the stairs to platform 2. The findings of that
inspection reported that, although not below the necessary standard, there were “two
areas that have the potential to be of concern” (relating to the condition of the mid-landing
and steps). The ORR requested GTR to address these concerns when reasonably
practicable. The advice from the ORR was that GTR seek to remedy any minor issues

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Head Office: One Kemble Street, London WC2B 4AN T: 020 7282 2000 orr.gov.uk

Page 3 of 7

proactively and to prevent them from ever falling below the minimum standards required.
Essentially, GTR have been encouraged to avoid a reactive approach to health and safety.
GTR responded positively to that advice and intend to address issues before they present
a potential hazard.

Passenger Information:

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 rename 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.

GTR have a DPPP that was approved by the ORR. As part of their DPPP GTR were
required to have a document entitled “Making rail accessible: helping older and disabled
passengers” available to station users. GTR had such a document in place which advised
passengers of the alternative arrangements available to them if their personal needs
meant additional assistance was required.

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 GTRs “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 Hil! 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.

This ongoing engagement between GTR and ORR, coupled with the recent publication of
our new Accessible Travel Policy Guidance, should ensure that, passengers will be better
informed of the assistance available to them should they require it.

Access for all project:

GTR is not the infrastructure owner. They are the station operator. This means GTR do not
have the authority to make alterations to the station layout to improve access to vulnerable
passengers or to aid in the management of passenger movement around the station. In
short, GTR have to operate within the parameters of the station as it is currently laid out.

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Head Office: One Kembie Street, London WC2B 4AN T: 020 7282 2000 orr.gov.uk

Page 4 of 7

The power to alter the infrastructure lies with the infrastructure owner (Network Rail).
Network Rail are aware of the increasing need for step free access to stations to assist
more vulnerable passengers with their journeys and has been in consultation with ORR
amongst other stakeholders for some time on the issue. As a result Network Rail was, and
continues to be, engaged in a nationwide project called ‘Access for All’ which is specifically
focused on identifying stations most in need of step free access.

The project is run by the Department for Transport and has a specific budget to fund any
approved works. Network Rail and GTR are engaging in the process together and applied
for funding for Mill Hill Broadway station. It is ORR’s understanding that funding has been
granted for this during Control Period 6, i.e. from April 2019 to March 2024. The ORR is
also aware that the original intention was to introduce step free access to all platforms at
the station. Platform 1 was to be accessible via a lift from the bus station at ground level.
The remaining platforms (2-4) were to then be accessible step free from platform 1 via a
footbridge scaling all 4 platforms. The intention being for the footbridge to be fitted with lift
access on each platform up to the bridge. If the original plan is implemented this would
also offer an alternative route off the platforms as opposed to via the underpasses.
Consequently, this would aid the management of passenger movement should an incident
occur in one of the stairwells from the underpass to the platform in future.

Network Rail and GTR submitted Mill Hill Broadway as a priority station for such funding.
Only Kentish Town station is considered higher in priority in the area. This is in recognition
of the population that Mill Hill Broadway station currently serves, the anticipated increase
in population, the percentage of station users over the age of 65 and the station’s access
to several local services that support vulnerable individuals including schools, hospitals
and clinics.

In support of their application Network Rail & GTR have been working with the local
Council (Barnet) and they have the support of the local MP, the Right Honorable Matthew
Offord, and Greater London Authority Member ee cfore submitting the
station for funding Network Rail and GTR consulted with local community groups including
the Mill Hill Neighbourhood Forum, Mill Hill Resident's Association, Hale Association and
Mill Hill Preservation Society and they have also consulted with and have the support of
Inclusion Barnet (a Peer-Led Deaf and Disabled People’s Organisation).

ORR sits on the ‘Access for All’ programme board. It reviews and comments on the criteria
necessary to secure funding for station alterations under the project but it is not involved in
the selection process. If the proposed works at Mill Hill Broadway proceed as originally
intended the ORR will monitor the process to ensure Network Rail are doing everything
reasonably practicable to deliver the enhancements at the station efficiently and safely and
are providing sufficient information to affected stakeholders in line with their licence duties.

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Head Office: One Kemble Street, London WC2B 4AN T: 020 7282 2000 orr.gov.uk

Page 5 of 7

If the infrastructure and layout of Mill Hill Broadway station were to undergo such
significant redesign the ORR would expect the safety management procedures, processes
and resulting risk assessments and plans to be re-evaluated. Such a re-design would
theoretically reduce the risk of a similar incident occurring in the future and would also
provide the opportunity for alternative arrangements for passenger movements around the
station to be implemented in the event of an accident.

If we can be of any further assistance to the Coroner or further information is required
regarding any of the information set out above please do not hesitate to contact us.

Yours faithfully,

c
Her Majesty’s Railway Inspectorate

Office of Rail and Road
One Kemble Street

London
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Head Office: One Kemble Street, London WC2B 4AN T: 020 7282 2000 orr.gov.uk

Page 6 of 7

| —
GN Gos ThamesLink/

eS GATWICK EXPRESS

Mr Andrew Walker

North London Coroners Court
29 Wood Street

Barnet

EN5 4BE

24 August 2019

Dear Mr Walker

Ref: Regulation 28 Report, Investigation and Inquest 28" November 2018,
Priscilla Tropp

In relation to the points that were raised in respect of the above case and specifically
the steps that we, as the station facility operator, are taking to improve the way in which
we manage this type of incident in the future, | can confirm that the following steps
have been or are planned to be implemented.

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.

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 on 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.

The following list shows the actions taken by GTR:

e Anew Staff Aide-Mémoire “Caring for our Customers” has been produced and
was issued on Monday 29" July to all station managers and staff as part ofa
briefing process to provide greater understanding and support to frontline
teams when dealing with incidents at station. The guidance will provide a
prompt to consider the broad range of factors when dealing with accidents and
emerging situations on stations. — Planned completion of staff briefings by 31%
August 2019.

e 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 315t August 2019.

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

> | :
GN ea ThamesLink/

GATWICK EXPRESS

e 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.

The tragic death of Mrs Tropp following the incident has necessitated that we review
our practices to improve the way in which we deal with similar incidents in the future.
As an organisation we take the safety and care of our passengers seriously, and |
believe that the above steps will help further improve the way in which we provide
support to those persons who may suffer an injury while at our locations.

Yours sincerely

Head of Customer Service Thameslink / Great Northern

Enc. Staff Aide-Mémoire, Mill Hill Broadway LIRP, Equipment Delivery Plan

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