Sarah Cunningham

16 June 2025 

HM Senior Coroner Mary Hassell 
Inner North London 
St Pancras Coroner’s Court  
Camley Street 
London, N1C 4PP 

By email only –

Dear Madam,  

Chief Operating Officer  

Transport for London 
Palestra  
197 Blackfriars Road 
London  
SE1 8NJ 

Inquest touching on the death of Sarah Cunningham 

I  write  on  behalf  of  Transport  for  London  (TfL)  regarding  the  Senior  Coroner’s 
Regulation  28  Prevention  of  Future  Deaths  (PFD)  report  dated  16  April  2025 
following the inquest touching on the death of Sarah Cunningham.  

Ms Cunningham’s inquest and the Prevention of Future Deaths (PFD) report 

The  inquest  touching  on  the  death of  Sarah  Cunningham  took  place  on 9  April 
2025 at Poplar Coroner’s Court. TfL was an Interested Person in the inquest and 
witnesses from TfL attended to give evidence. 

I  would  like  to  take  this  opportunity  to  repeat,  on  behalf  of  TfL,  our  sincere 
condolences to the family and friends of Ms Cunningham for their tragic loss. 

After the inquest, the Senior Coroner sent a PFD report to TfL raising the following 
matter of concern: 

‘I heard evidence at inquest that London Underground passenger intoxication is 
recognised  as  a  risk  to  London  Underground  staff.  Extreme  intoxication  is  also 
known to be a risk to the individual who is intoxicated. However, it struck me that 
the risk to the individual is not necessarily at the forefront of TfL corporate thinking. 

Clearly, individuals have responsibility for their own drinking and/or drug taking and 
the consequences thereof. Intoxication carries additional risk whatever the activity.  

However, public transport is encouraged for many good reasons. Not least, it is a 
matter of public policy that those who are or may become intoxicated should make 
travel  plans  that  do  not  involve  being  in  charge  of  a  vehicle.  The  London 
Underground is an obvious alternative.  

 
 
 
 
  
                                                           
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Realistically, some London underground passengers will be intoxicated, and that 
has to inform TfL’s corporate planning. I heard that there was a TfL investigation 
following Sarah Cunningham’s death, but the learning from that appears at present 
to be somewhat aspirational, without a concrete plan.’  
I am grateful to the Senior Coroner for raising these concerns and we set out below 
TfL’s  response in  four  sections.  The  first  section  sets  out  the  actions  that  have 
been  developed  in  the  light  of  our  Formal  Investigation  into  the  incident  and  in 
response to the area of concern made in the PFD report, with the following sections 
expanding on our current work to address the risks from intoxication; our internal 
approach to responding to and learning from formal incident investigations; and 
finally a summary of the technology trials underway to reduce the risk of customers 
getting hurt on the platform edge.  

Response to PFD report 

TfL  has  well-established  policies  and  procedures  for  safeguarding  children  and 
adults at risk. For example, we have established training, awareness-raising and 
co-operative working with the Police, charities and other partners to prevent people 
dying by suicide on our services.  

However, through recent events, including the tragic death of Ms Cunningham, we 
recognise  that  as  an  organisation,  a  significant  step  change  is  required  in  our 
approach and how we protect our customers who are vulnerable in the moment, 
for example through intoxication, from coming to harm when using our services. A 
systemic approach is required to protecting vulnerable customers so that they get 
home safely using our services. We are committed to embedding a comprehensive 
understanding  in  our  operating  procedures  and  through  staff  awareness  and 
behaviour.  

We have used insight from our work with others on safeguarding, to determine a 
clear action plan to address temporary vulnerability. An adult may be ‘temporarily’ 
vulnerable through a range of factors, including intoxication from alcohol or drugs, 
emotional distress or short-term illness putting them at greater risk of coming to 
harm, through accident or injury or through being a victim of crime on our services. 
Our priority is to embed ways to prevent intoxicated customers coming to harm as 
recommended in the PFD report, but we must also consider similar circumstances 
so that change is comprehensive and ultimately reduces the likelihood of death, 
injury or serious harm on our services. 

Our actions underway include: 

•  Completing  a  comprehensive  review  of  current  safeguarding  risk 
management  across  every  TfL  mode  to  identify  gaps  and  priorities  in 
protection of vulnerable customers. We will complete this assessment by 30 
August 2025. This review will result in a tailored action plan for each of our 
transport modes. TfL’s Executive Safety Sub-Group will oversee progress 
and hold each mode to account on their progress in implementing their plan 
to  prevent  intoxicated  and  other  vulnerable  passengers  coming  to  harm 
when using TfL’s services.  

 
 
 
 
 
 
 
 •  Widespread  adoption  across  our  frontline  customer  facing  teams  of  the 
Vulnerability Assessment Framework (VAF). The VAF is a systematic tool 
used  by  policing  and  emergency  services  to  quickly  identify,  assess  and 
respond to an individual. Its purpose is to ensure that a vulnerable person 
receives appropriate support and protection. The VAF will be briefed out to 
all frontline teams and be embedded in policies, procedures and rule books 
– this process will be completed by March 2026. 

•  Overhaul  of  our  safeguarding  and  vulnerability  training  for  all  frontline 
customer facing teams and make it a core, mandatory part of competency 
management and on-going professional development.  

•  Establish trials at five London Underground stations to test and learn from 
deploying  operational  staff  in  different  ways  to  further  reduce  the  risk  of 
customers coming to harm when intoxicated. The purpose of running trials 
is  to  assess  feasibility  and  impact  before  scaling  up  across  London 
Underground  stations.  We  are  currently  undertaking  the  planning  and 
preparatory work before mobilising to intervention phase in Autumn 2025. 
The measures we plan to trial include: 

o  Dedicated, specially trained teams providing safeguarding patrols 

o 

on platforms and trains for night tube; 
Increasing frequency of security patrols by station teams in the 
evenings and into the night at quiet stations;  

o  Enhanced CCTV monitoring through station operations rooms and 
central control centre of platforms and public areas to monitor 
vulnerable customers; 

o  Appraisal of SMART cameras technology to detect erratic or 

unusual behaviour and alert staff; and 

o  Adapting our ‘turn up and go procedure’ to get intoxicated and other 

vulnerable customers home safe.   

In May this year, we doubled the size of our night team of Transport Support and 
Enforcement  officers.  These  officers,  accredited  by  the  police  and  trained  in 
safeguarding,  patrol  the  night  tube,  getting  off  at  every  station  to  check  for 
vulnerable  customers  including  on  the  platforms,  to  make  sure  everyone  gets 
home safely.  

TfL policies on intoxication 

More broadly, since 2019, TfL has increasingly sought to mitigate the impacts of 
intoxication on the network with a multi-strand approach. 

This activity includes: 

•  Multi-channel customer communication campaigns encouraging 

customers to take greater care after drinking alcohol. Increasing the 

 
 
 
 
 
 
 
 
 
 
 coverage and spread of activity during key times of year, including 
summer and the winter festive period; 

•  On-network signage notifying customers of the ban on consuming alcohol 

on public transport services; 

•  Colleague training and briefings to assist station staff to safely manage 
intoxicated customers, including spotting and supporting vulnerable 
customers and conflict management skills to prevent work-related violence 
and aggression;  

•  Deployment of staff to higher risk locations within stations, such as the top 

of escalators and platforms; and 

•  Collaboration with local authorities to manage the impacts of intoxication 

and provide targeted support at key locations before customers get on the 
tube.  

Most  recent  data  from  staff  and  incident  reporting  suggests  that  the  hotspot 
locations  of  the  West  End and City,  and  traditional  times  for  intoxicated  related 
incidents, are changing. The following recommendations were made from the most 
recent activity: 

•  Broaden activity to cover the entire week, not just Thursdays, Fridays and 

weekend. 

•  Expand the number of targeted stations for additional communications and 
signage and staff patrols to stations in the top 25 hotspots, ensure all 
colleagues at these locations are briefed on how to support intoxicated 
customers and reduce the risk of customers coming to harm. 

This work to address the impact of intoxication will now be fully incorporated into 
our review on how we manage safeguarding risk and the improvement programme 
approach set out above. 

TfL’s approach to FIR recommendations 

TfL  has  recently  implemented  a  number  of  significant  changes  to  the  process 
around  critical  health  and  safety  investigations,  including  changes  to  the 
management of recommendations arising from Formal Incident Reviews (FIRs). 
This  new  way  of  working  means  that  the  investigation  team  complete  the 
investigation report with recommendations for the business.  

Under  the  new  process,  the  Chief  Safety,  Health  and  Environment  Officer  is 
accountable  for  ensuring  that  business  areas develop  appropriate  and  effective 
actions.  Directors  of  the  respective  business  areas  are  directly  responsible  for 
formulating  relevant  actions  to  address  recommendations,  to  contribute  to 
mitigating risks and addressing causal factors comprehensively. This takes place 
in the weeks following completion of the investigation report. The enhanced level 
of accountability has brought a focus around investigation recommendations with 
the aim of bringing them to the forefront of corporate thinking. The actions set out 
above  reflect  the  recommendations  made  in  TfL’s  Formal  Investigation  into  the 
incident. 

 
 
 
 
 
 
 
 
 Work on improving safety of the Platform Train Interface 

We recognise that some of our customers may access the track environment either 
deliberately  or  unintentionally  and  may  be unaware  of  the potential  danger  that 
they are in.  

As explained in TfL’s witness evidence at the inquest, we are prioritising action to 
address  this  risk  and  will  trial  a  number  of  new  technologies  this  financial  year 
aimed at keeping our customers safe. We plan to trial technologies which will allow 
us to identify customers on the track and allow us to respond so that we can keep 
them safe. We will start these technology trials on the Docklands Light Railway, 
the Central line and on the Piccadilly line.  

The trials will use a mixture of existing and new camera technology and sensors 
to identify incidents and will trigger an operational response to alert staff. As this 
technology  is  new,  we  want  to  learn  more  about  the  efficacy  of  different 
technologies in different locations and different environments. These trials, which 
will start in autumn 2025, are being carried out with a clear view to the future. We 
will therefore have the potential to use this technology across TfL services where 
it can be demonstrated that it will help keep our customers safe.  

Conclusion 

I  would  like  to  offer  again  my  heartfelt  sympathy  and  condolences  to  Ms 
Cunningham’s family and friends. We are determined as an organisation to learn 
lessons from this tragic incident and to make our network as safe as possible for 
all customers, particularly those who may be vulnerable.  

I hope this response is helpful and welcome. Please contact me if I can be of any 
further assistance.   

Yours sincerely 

Chief Operating Officer 
Transport for London