Kaja Spiewak

Robert SIMPSON 
Assistant Coroner for 
West Sussex Coroners Service 

Chief Executive Officer 
Govia Thameslink Railway Limited 
Monument Place 
24 Monument Street 
London 
EC3R 8AJ 
4th February 2022 

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. 

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. 

Yours sincerely, 

Chief Executive Officer 

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

OFFICIAL 

26 April 2022 

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 

Network Rail Infrastructure Limited Registered Office: Network Rail, One Eversholt Street, London, NW1 2DN 
Registered in England and Wales No. 2904587 www.networkrail.co.uk