Kaja Spiewak
1 Dec 2021 · Coroner Robert Simpson · West Sussex
The coroner's concerns
1. lack of mandatory training for frontline staff on vulnerable persons
“training on dealing with vulnerable persons was not mandatory for frontline staff”
2. inappropriate protocol for vulnerable persons
“protocol entitled 'Person ill on a train' when a vulnerable person was reported to them”
3. inadequate logging of actions
“control room staff did not log all actions taken after the concern for welfare report”
4. failure to contact emergency services and share information
“did not contact British Transport Police, 999 nor share the information about this 'concern for welfare' report with Network Rail”