Daniela Pani

PRIVATE AND CONFIDENTIAL 

Robert Simpson 
Assistant Coroner for Berkshire 
Coroner’s Office 
Reading Town Hall 
Blagrave Street 
Reading 
RG1 1QH 

22nd May 2024 

London House 
London Road 
Bracknell 
Berkshire 
RG12 2UT 

Tel: 

Re: Inquest touching the death of Daniela Vitalia Pani 

Dear Sir 

I write in relation to the above inquest which concluded on 28 March 2024.  

On 28 March 2024 you made a report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 
and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. Your report was sent to: 

 – CEO Berkshire Healthcare NHS Foundation Trust 

British Transport Police 

 – Interim Managing Director South-Western Railway 

I am writing to provide you with the Berkshire Healthcare response which relates to your concerns about 
training  and  guidance  for  staff  on  how  to  deal  with  service  users  declining  a  72-hour  review  meeting. 
Specifically, staff not being able to carry our face-to-face assessments in all possible cases.  

The Trust recognise how challenging it is for clinicians when a patient prefers not to have a face-to-face 
review within the expected 72-hour period. Our existing training and guidance focused on staff making a 
clinical decision based on their knowledge of the patient, input from family/carer where possible  and the 
current risk assessment. There is national guidance available, and this informed our approach. This NICE1 
guidance states: 

1.  Ensure  the  aim  of  care  and  support  of  people  in  transition  is  person-centred  and  focused  on 

recovery. 

2.  Work with people as active partners in their own care and transition planning.  
3.  Support people in transition in the least restrictive setting available (in line with the Mental Health 

Act Code of Practice). 

4.  Record the needs and wishes of the person at each stage of transition planning and review. 

1 Overview | Transi�on between inpa�ent mental health se�ngs and community or care home se�ngs | Guidance | NICE 

 
 
 
 
 
 
 
 
 
 
 
  
 
 5.  Identify the person's support networks. Work with the person to explore ways in which the people 

who support them can be involved throughout their admission and discharge. 

This guidance goes on to say:   

"Health and social care practitioners in the hospital and community should plan discharge with the 
person  and  their  family,  carers  or  advocate.  They  should  ensure  that  it  is  collaborative,  person-
centred and suitably paced, so the person does not feel their discharge is sudden or premature".  

In light of the guidance and also our clinical experience the Trust do not feel having a blanket rule about 
enforcing a face-to-face meeting in all possible cases would be helpful for the patient/practitioner 
relationship, nor would this approach prevent a future death, it may even increase the risk of suicide by 
adversely impacting the therapeutic relationship and increasing feelings of hopelessness.  

Therefore, the approach the Trust  has taken focuses on enhancing the existing clinical risk training and 
guidance for staff to include an increased focus on a collaborative risk formulation and safety planning. This 
includes a specific skills component on: 

1.  Engaging with the patient to understand why they do not want the face-to-face review. 
2.  Escalating to supervisor to consider decision making collaboratively. 
3.  Involving the family/carer if possible. 

In addition to this we have provided additional guidance for 72-hour follow up and a short film clip for staff 
on how to deal with a person refusing or postponing the face-to-face appointment (this approach would still 
require a clinical judgement).  

Trust Guidance for 72-hour follow up:  

1.  Establish  the  reason  why  the  person  cannot/prefers  not  to  attend.  Do  this  by  engaging  with  the 

person, asking specifically about the following: 

•  What is the reason they cannot attend?  
•  What can we do to support them to attend?  
•  Explain why this follow up is important (it can be a time of increased risk/need for 
some people, we want to help and it is an opportunity to see how they are getting on 
having been recently discharged) 

2.  Explain the importance of the appointment and attempt to be as flexible as possible with the 72-hour 

window. Offer a choice of location to overcome practical barriers.   

3.  Refer to the safety plan and the recent discharge plan.  

4.  Rule out imminent risks associated with withheld suicidal intent or ambivalence.  

5.  Involve family/carers if possible (see film clip).  

6.  Involve your manager or supervisor.  

7.  Options if you are concerned the person may be concealing their intent or they are at risk of harming 

themselves or others:  

•  Cold calling anyway (see guidance on how to approach this),  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 •  Arranging  a  Mental  Health  Act  assessment,  the  family/carer  if  possible  and  MDT 

should be involved in the decision making to request this. 

8.  If you feel there is a legitimate practical reason to postpone the face to face and you have determined 
it is safe to do so, you must discuss this and seek support from service manager or their deputy and 
the patient's family/carer if possible. If all agree you can then arrange a telephone or video call with 
the face to face to follow asap (see guidance on what to cover in the follow up if you are unsure).  

9.  Always clearly record all steps taken in RiO. 

In addition to the above, we have also provided additional pre discharge guidance for staff in the inpatient 
setting on including the detail, expectations and importance of 72-hour reviews within the discharge safety 
plan. During this conversation any barrier to attending the 72-hour review will also be explored.  

To ensure the new training and guidance is impactful the Trust has developed a targeted risk audit that 
focuses on more complex cases where refusal may be more likely. A peer review process was already in 
place, and it now includes a focus on post discharge follow up and the safety planning process. We are also 
using the NCISH2 safer wards audit tool which focuses on 72-hour follow up.  The Trust Quality and Safety 
meetings  at  service  and  executive  level  already  monitor  72-hour  follow  up  as  it  is  a  tracker  metric,  the 
compliance is high (100% in March 24).  

As  a  Trust,  the  safety  and  wellbeing  of  those  we  provide  services  to  is  paramount  and  despite  the 
unfortunate  circumstances  in  which  this  query  has  arisen,  we  welcome  the  opportunity  HM  Assistant 
Coroner has provided for us to review and enhance the training and guidance for staff on how to deal with 
service users declining a 72-hour review meeting. 

Yours sincerely 

Chief Executive 

2 NCISH | Resources (manchester.ac.uk)

Strictly Private and Confidential 
For the attention of Robert Simpson 
Assistant Coroner for Berkshire 

Dear Assistant Coroner Simpson 

Regulation 28 Report: Daniela Vitalia Pani  

We refer to your Regulation 28 report dated 28 March 2024 (the “Report”) regarding the death of Daniela Vitalia Pani (“Ms 
Pani”) on the railway tracks at Bracknell Train Station on 29 June 2023.  

SWR would like to take this opportunity to express its sincere condolences to Ms Pani’s family and friends.  

1 

1.1 

1.2 

1.3 

1.4 

1.5 

2 

2.1 

SWR ENGAGEMENT 

Within section 5 of the Report, you have made reference to the difficulties you experienced in seeking confirmation 
regarding what steps had been taken following the preparation of a ‘Post Incident Site Report’ into Ms Pani’s death 
undertaken by the British Transport Police (“BTP”). There is reference to SWR failing to provide information about 
whether recommendations made by the Report had been actioned. 

SWR would like to assure you from the outset that it takes its engagement with Coronial investigations seriously 
and is committed to assisting Coroners where SWR holds relevant information. SWR would like to start by providing 
you with an explanation for any confusion or miscommunication which may have impacted your investigation and 
prevented SWR from assisting you. 

SWR  were  involved  in  the  immediate  response  to  the  incident  and  fully  cooperated  with  BTP’s  post  incident 
investigations. This included having an SWR Representative, RCO Barry Osborne, present at the post incident site 
visit (the investigation which preceded the post incident site report) conducted by BTP. 

BTP  sent  the  post  incident  site  report  to  SWR  following  the  investigation,  but  SWR  were  not  informed  of  the 
commencement of the Inquest. It has come to SWR’s attention that BTP tried to contact SWR about the Inquest 
using an incorrect email address, but due to the error in the contact address used this was not received by SWR. 
As a result, SWR were unaware of the Inquest and the subsequent request for information.  

SWR has taken steps to make sure that BTP has the correct contact details. We would also ask that if any further 
contact is needed, correspondence is sent to SWR’s Head of Security and Safety Assurance, Mr O’Riordan, who 
has provided his contact details to your office separately. Mr O’Riordan will act as a single point of contact and will 
be able to assist if information is required in any future investigations. 

THE REPORT 

Within section 5 of the Report, which sets out the basis for your concern that there is a risk that future deaths could 
occur unless action is taken, you have set out areas of concern regarding Bracknell train station, specifically two 
areas of concern arising from the post-incident site report prepared by BTP: 

(a) 

(b) 

A lack of Samaritan signage; and 

Car park line fencing being too low. 

 
 
 2.2 

SWR has considered these areas of concern and sets out its response to each of them below.  

3 

3.1 

3.2 

SAMARITAN SIGNAGE 

Signage at the station 

There are 4 Samaritan signs on the platform at Bracknell train station. These are in prominent locations, including 
on all platform end gates and on a lamppost. 

3.3 

SWR have included photographs of these signs for your consideration at Annex A. 

3.4 

3.5 

3.6 

3.7 

3.8 

3.9 

3.10 

4 

4.1 

There is 1 Samaritan sign situated within the station, which is located near the ticket office. The station itself is 
staffed  by means of a gate line between 06.00 and 22.00  hours,  meaning there is a member of either SWR or 
contracted staff always present at the station between these times.  

Since this incident, no additional signs have been placed at Bracknell station and there is currently no intention to 
place  any  additional  signs  at  Bracknell  station.  The  signage  has  been  reviewed  and  has  been  assessed  as 
appropriate. SWR have set out the background to that conclusion below to assist you in understanding what steps 
have been taken following this incident. 

Consultation with the Samaritans 

A risk analysis is undertaken by the Samaritans at every station to determine the level of signage to implement. 
There  are  various  human  and  psychological  factors  which  must  be  measured  when  considering  the  number  of 
signs and the placement of the signs across the station. This assessment is necessary to balance the provision of 
information and support to deter suicide and suicide attempts against the unwanted advertisement of the suicide 
potential of a site. The risk of deliberate unauthorised access to the tracks must also be balanced against the control 
measures required to mitigate the risks of unintentional/accidental unauthorised access to the tracks. 

SWR  work  with  the  Samaritans  to  place  signage  where  both  parties  consider  it  to  have  the  most  effective 
engagement. SWR cannot, however, unilaterally increase the number of signs at a station without consultation and 
the consent of the Samaritans. 

As a result, the Samaritan signage is as listed at paragraph 3.1 above and no additional signage has been added. 
Bracknell train station was not considered a priority location for trespass and welfare concerns. The station has not 
experienced  a  prevalence  of  unauthorised  access  (either  into  the  confines  of  the  station  itself  by  those  not 
authorised to be in the station or from those within the station gaining access to prohibited areas such as the tracks) 
nor has it experienced a prevalence of suicide or suicide attempts. Please see paragraph 4 below for more details 
as to how SWR manages the risk of unauthorised access. 

SWR’s senior security manager, Matthew Smith, has also recently undertaken a full review of Samaritan signage 
across all stations on the SWR route. This was to check correct placement, wear and tear (fading), and the display 
of the correct information and phone numbers. Bracknell did not require any replacement signs as their signage in 
place was sufficient. As set out above, this did not include the provision for new signage as this is an agreed process 
with the Samaritans themselves. 

CAR PARK LINE FENCING 

The  car  park  perimeter  fencing  at  Bracknell  train  station  is  the  responsibility  of  Network  Rail  (“NR”),  not  SWR. 
Responsibility for management of the station infrastructure is governed by the lease agreement between SWR and 

 
 4.2 

4.3 

NR. If it assists the Coroner, SWR has provided further detail in the next paragraph on the general delineation of 
responsibilities between NR and SWR across the rail network. 

NR is responsible for the operation and management of railway infrastructure. They own, operate, maintain and 
develop  the  main  rail  network  in  Great  Britain  including  the  railway  tracks,  junctions,  bridges,  tunnels  and  level 
crossings. NR is also the landlord for almost all stations on the national network. SWR and other train-operating 
companies (“TOCs”) lease train stations from NR and manage them in accordance with lease agreements. Each 
specific  agreement  determines  responsibility  for  the  management  of  each  site,  but  NR  retains  responsibility  for 
aspects  of  the  infrastructure  (which  often  includes  fencing)  at  the  majority  of  stations.  Bracknell  train  station  is 
leased to SWR in this way. 

SWR is responsible for site management at the stations it leases from NR, including ticket barriers/ticket office, 
staffing  and  security.  SWR  has  the  following  arrangements  in  place  relevant  to  both  the  management  of 
unauthorised access and the risks associated with the platform train interface which are designed to mitigate the 
risks of both deliberate and accidental unauthorised access to the tracks at Bracknell train station: 

(a) 

(b) 

(c) 

(d) 

(e) 

(f) 

(g) 

(h) 

The station can only be accessed via the ticket office and is staffed from 06:00 – 22:00 seven days a week.  

Between these hours, there is a staffed gate to access the station. Outside of these hours, there is a night 
gate which allows passengers to enter and leave the station when their trains arrives or depart. 

All SWR staff at the station are trained to look out for passengers in distress or who may be a concern for 
welfare. Managing Suicide Contact is a course delivered both in house and by the Samaritans that is now 
mandatory for  all new employees of SWR, it  is also a course that all third-party  suppliers contracted to 
SWR must now deliver to their front facing staff. It is specifically in place to identify those in crisis. 

The placement of Samaritan signage as set out above at paragraph 3 and Annex A. 

Tactiles at the platform edge to assist vulnerable passengers in locating the platform edge. 

The platforms include signage relating to platform/train interface (e.g. the yellow line and the instructions 
to stand back). 

There  are  automated  tannoy  announcements  asking  passengers  to  stand  behind  the  yellow  line, 
announcing scheduled arrivals and warning of through trains (non-stop services). 

There are electronic timetables indicating the scheduled arrivals and which also display written warnings 
alongside the tannoy announcements at (g) regarding through trains (non-stop services). 

4.4 

A representative from  NR  was present at the post incident site visit and NR were  identified  by BTP  in the post 
incident  site  report  as  the  ‘Owner’  of  action  6  which  relates  to  car  park  lineside  fencing.  NR  are  therefore  best 
placed to respond to this concern. 

4.5 

Nevertheless, SWR work closely with NR and have flagged the issue raised by you of the lineside fencing.  

We trust that the above is of assistance but if you require any further information, please do not hesitate to contact us.  

Yours faithfully 

 
 
 
 
 Head of Security and Safety Assurance