Andrew Westlake

JAMES E. THOMPSON – HM ASSISTANT CORONER FOR COUNTY DURHAM 

AND DARLINGTON 

INVESTIGATION INTO THE DEATH OF ANDREW PAUL WESTLAKE  

CIVIL AVIATION AUTHORITY RESPONSE TO A REPORT ON ACTION TO PREVENT 

OTHER DEATHS PURSUANT TO REGULATIONS 28 & 29 OF THE CORONERS 

(INVESTIGATIONS) REGULATIONS 2013 

The Civil Aviation Authority (CAA) has considered carefully the report of the Assistant 

Coroner to prevent future deaths and the concerns raised: 

•  Training for airline and ground staff (employed by UK airlines) on vulnerability of lone 

passengers when disembarked overseas. 

•  Procedures for safeguarding vulnerable passengers such as Mr Westlake. 

Introduction 

The CAA was not an Interested Person at this inquest. As such, we did not have access to 

the evidence. To understand the background to this case, we have relied on knowledge 

gained from reviewing press articles and information contained in the Regulation 28 Report 

received from the Assistant Coroner.   

The CAA has no direct regulatory oversight of UK airline operators’ overseas passenger 

disembarkation training and procedures. There is no specific aviation legislation that 

supports the CAA’s formal intervention concerning safeguarding vulnerable passengers. 

Nevertheless, the CAA does recognise the significance of its role regulating to safety and 

consumer protection in UK aviation, including the statutory requirement to have due regard 

to further certain societal objectives relating to equality when carrying out its functions.1   

1 Equality Act 2010 section 149(1).  

1 

 
 
 
 
 
 
 We consider that it may be of assistance to the Assistant Coroner for the CAA to provide 

comment on Jet2.com’s decision to disembark Mr Westlake from the aircraft on or about 28 

May 2018. Colleagues in the CAA’s Safety and Airspace Regulation Group can see no 

reason to question that decision. It is a basic tenet of aviation safety that an aircraft Captain 

has absolute control of the aircraft and must take appropriate action to ensure the safety of 

the aircraft and the passengers on board.  

Furthermore, upon receipt of the Regulation 28 report the CAA contacted Jet2.com to 

discuss the steps the airline operator intended to take to respond to the concerns raised by 

the Assistant Coroner (set out above). Representatives in the CAA’s Safety and Airspace 

Regulation Group (aviation safety) and Consumers and Markets Group (consumer 

protection) then reviewed the Jet2.com Ground Operations Policy Update that we are 

instructed will be sent separately to the Assistant Coroner by Jet2.com in response to his 

report. We are now able to confirm the approach now adopted by Jet2.com is what the CAA 

would expect from a responsible operator in terms of dealing with vulnerable passengers 

such as Mr Westlake.   

Vulnerable Consumers 

The CAA’s Consumer Panel2 recently invited the CAA to take steps to improve the support 

that is provided to those consumers who are vulnerable in order to gain a better experience 

whilst they interact with UK airlines and airports.   

The CAA’s accepted definition of consumer vulnerability is set out below:  

“When a consumer’s personal circumstance or characteristics combine with the way the 

aviation market operates to mean they are less likely to be able to engage effectively in the 

market and more likely to be more severely affected or suffer greater detriment.  Industry 

actions can reduce or exacerbate consumer vulnerability in aviation.”  

The Consumer Panel has also provided the following key points to add context to the 

definition: 

• 

It is clear that circumstance can affect a consumer’s vulnerability, not just their 

characteristics, so anyone can be vulnerable in particular circumstances; 

•  A consumer’s vulnerability can be either visible or invisible: this does not solely 

capture those with reduced mobility; 

2 The CAA Consumer Panel is a non-statutory body established, amongst other things, to help the CAA to 
understand fully, and take account of, the interests of consumers in its policy development and decisions.  
More information here: https://www.caa.co.uk/Our-work/About-us/CAA-consumer-panel/ 

2 

 
 
 
 •  Vulnerability can be temporary or transient, it doesn’t have to be permanent to be 

captured by the definition; 

• 

It is very clear that industry has a role to play in improving the situation for vulnerable 

passengers, and it is equally clear that industry can make it worse by their actions. 

There is substantial overlap between the concept of consumer vulnerability (and the 

Consumer Panel’s ambitions for the CAA in this area) and the requirements imposed on the 

CAA under the Public Sector Equality Duty. 

This tragic case has emphasised the need for the CAA to further the initiative proposed by 

the CAA Consumer Panel and encourage those we regulate to respond appropriately to the 

needs of a wide range of vulnerable people at all stages of their interaction with the UK 

aviation industry. The CAA is confident that working with the UK aviation industry will lead to 

a better understanding of the potential needs of passengers like Mr Westlake, whether they 

are traveling alone or with others. Our aim is to encourage all sectors in the UK aviation 

industry to adopt procedures that recognise and respond effectively to those who may 

require enhanced individual support.  

The CAA Executive will receive a report from colleagues during the first quarter of 2021, 

using the adopted definition above on proposed improvements to the treatment of vulnerable 

consumers by the UK aviation industry.  The report will include initial proposals for the CAA 

Executive to consider increasing our engagement with industry, starting with the CAA Chair, 

, raising this issue with larger regulated organisations. This report will also 

emphasise the need for the CAA to encourage its own staff, and in the case of front-line 

staff, receive training on the needs of vulnerable individuals when engaging with our 

stakeholders.    

The CAA’s intention is for this initiative to be regularly reviewed by the CAA Executive so 

that we can learn the lessons from our progress and ensure that the focus of this work is 

maintained.    We anticipate this work will lead to real progress on improvements to the care 

of those who are more vulnerable in our society when engaging, at all stages, with the UK 

aviation industry. 

Conclusion    

There are no regulations that would enable the CAA to mandate changes to UK airline 

procedures and training for the disembarkation of vulnerable lone passengers overseas. We 

will however continue our work to support the UK aviation industry make improvements to 

the treatment of vulnerable consumers. The CAA is actively taking steps to increase our 

engagement with UK aviation stakeholders including airline operators, to enhance the 

3 

 
 support they offer to all consumers who may be considered vulnerable, whether that be from 

a known condition or as a result of unexpected circumstances.   

CAA 

22 January 2021 

4

JAMES E THOMPSON 
H M Assistant Coroner for  
County Durham and Darlington 
H.M. Coroners Office 
PO Box 282 
Bishop Auckland 
Co Durham 
DL14 4FY 

Your Ref: 

By Email Only to: 

22 January 2021 

Dear Mr Thompson, 

Re: Andrew Paul Westlake Deceased  

Further to your Report to Prevent Future Deaths made under Schedule 5, paragraph 7 Coroners and 
Justice  Act  2009  and  Regulation 28  Coroners  (Investigations)  Regulations 2013,  dated  3  December 
2020  (“the  PFD  Report"),  I  am  writing  to  provide  you  with  Jet2.com’s  response  as  required  by  27 
January 2021.  

Please find enclosed: 

1.  PDF  document  which  explains  our  Ground  Handling  procedures  and  training  review, 

conclusions and action plan. 

2.  Ground Operations Instruction document which update Jet2.com’s Ground Handling Manual. 
3.  Email from the CAA to Jet2.com dated 15.01.21 confirming approval of Jet2.com’s amended 

procedures.  

In the PFD Report your concerns were centred on the following: 

•  Training for airline and ground staff (employed by UK Airlines) on vulnerability of lone 

               passengers when disembarked overseas. 

•  Procedures for safeguarding vulnerable passengers such as Mr Westlake. 

Jet2.com has a strong reputation for providing excellent customer service and a genuine desire to look 
after all customers. In addition, there is an established and robust training programme in place for 
colleagues across the Ground Operations environment. In the light of the case of Mr Westlake, we 
have taken the opportunity to review and update our existing policies, procedures, and training. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 In addition, we have liaised with the CAA, for approval of the updates made. This is detailed below.  

Ground Handling Manual  

As  is  the  case  with  all  airlines,  Jet2.com  maintain  a  Ground  Handling  Manual  -  a  comprehensive 
document approved by the CAA - which is available to ground crew at all stations, and which details  
the procedures to facilitate an aircraft turnaround, including those relating to passengers.  

Current Jet2.com policies contained within the manual refer to medical, physical, and mental health 
conditions in the context of supporting customers throughout their journey, whether pre-notified or 
otherwise.  There  is  a  strong  focus  on  ensuring  customers  with  medical  conditions  and  hidden 
disabilities  are  supported  appropriately  and  that  their  needs  are  met  to  the  extent  possible 
throughout their journey.   

We have reviewed and updated the content to address the fact that a passenger who is disembarked 
from an aircraft for any reason may equally be suffering from a hidden disability, such as a mental 
health  condition  or  crisis.  In  such  circumstances  the  passenger  may  be  vulnerable,  and  we  have 
provided  guidance  on  what  additional  assistance  should  be  considered  where  such  behaviour  is 
evident or otherwise identified.  

Section 4.2 of the Ground Handling Manual - Assistance Customers & Hidden Disabilities 

This section of the  Ground Handling Manual applies to passengers who require assistance with air 
travel, for conditions including hidden disabilities. The section setting out common types of hidden 
disability has been updated to encompass an acute mental health issue, such as that suffered by Mr 
Westlake, as an example of a mental health condition and to note that an acute mental health crisis 
may  require  special  additional  assistance.  The  revised  section  is  attached  and,  following  positive 
feedback from the CAA, has already been published.   

Section 3.3.19 of the Ground Handling Manual – Denied Boarding 

Section 3.3.19 of the Ground Handling Manual addresses the procedures to be followed by ground 
crew should a passenger be denied boarding. Denied boarding can take place for a number of reasons 
including disruptive  behaviour,  as was  the  case  with Mr Westlake.    The  procedure now  contains a 
provision that if a passenger is denied boarding, then ground crew should consider the immediate 
customer needs and assist the passenger to the extent practical in the circumstances.  In situations 
where the passenger may have become distressed, or is potentially vulnerable or displaying vulnerable 
behaviour,    then  the  procedure  now  provides  that  (to  the  extent  practical  in  the  circumstances)  
ground crew should consider whether it is possible to arrange additional support, such as assistance 
to  the  passenger  in  contacting  family  and  friends  (as  occurred  in  the  case  of  Mr  Westlake),  the 
appropriate Embassy or Consulate, or other services such as Police, medical services, or the airport 
chaplain. The revised procedure is attached and has also already been published.  

Training  

To further support our colleagues, training will be updated in line with the revised procedures set out 
above, and we will additionally use the case of Mr Westlake as a case study in our initial and recurrent 
training to ground crew. We also plan to introduce a further suitable external course for trainers on 
Mental Health Awareness.  We have set a deadline of 29 January 2021 to update the relevant training  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 material, and 21 March 2021 to deliver the updated training material, but this is of course subject to 
the recovery of the aviation industry and the return to flying operations in light of the current Covid-
19 pandemic. 

CAA  

Finally, we have liaised with the CAA in respect of our procedures and the matter of Mr Westlake. The 
CAA’s  Consumers  and  Markets  Group  (consumer  protection),  and  Safety  and  Airspace  Regulation 
Group  (aviation  safety)  have  now  reviewed  our  updated  procedures.  They  have  confirmed  in  the 
attached email dated 15.01.21, that the approach adopted by Jet2.com is what the CAA would expect 
from a responsible operator in terms of dealing with vulnerable passengers.  

We would like to take this opportunity to express our sincere condolences to Mr Westlake’s family 
and friends, for their loss. 

I trust that this response is to your satisfaction, but please do not hesitate to contact me with any 
queries.  

Yours sincerely, 

Group Legal Director & Company Secretary 
Jet2.com & Jet2holidays