Sarah Cunningham: Prevention of Future Deaths Report
Alcohol, drug and medication related deathsRailway related deaths
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Date of report: 16/04/2025
Ref: 2025-0195
Deceased name: Sarah Cunningham
Coroners name: Mary Hassell
Coroners Area: Inner North London
Category: Alcohol, drug and medication related deaths | Railway related deaths
This report is being sent to: Transport for London
| Regulation 28: Prevention of Future Deaths report | |
|---|---|
| THIS REPORT IS BEING SENT TO: 1. Chief Executive Transport for London (TfL) 5 Endeavour Square London E20 1JN | |
| 1 | CORONER I am: Coroner ME Hassell Senior Coroner Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP |
| 2 | CORONER’S LEGAL POWERS I make this report under the Coroners and Justice Act 2009, paragraph 7, Schedule 5, and the Coroners (Investigations) Regulations 2013, regulations 28 and 29. |
| 3 | INVESTIGATION and INQUEST On 7 November 2024, one of my assistant coroners, Ian Potter, commenced an investigation into the death of Sarah Cunningham, aged 31 years. The investigation concluded at the end of the inquest on 9 April 2025. I made a determination at inquest of accidental death. |
| 4 | CIRCUMSTANCES OF THE DEATH Ms Cunningham jumped down onto the northbound track at Chalk Farm London Underground Station at approximately 3.30am on Saturday, 2 November 2024 and walked into the tunnel. She was killed by a train 18 minutes later. Although she jumped down onto the track rather than falling, she did not form the intention to take her own life. She jumped onto the track because she was intoxicated by a combination of alcohol, cocaine and ketamine, and was only a sporadic user of drugs on a recreational basis. |
| 5 | CORONER’S CONCERNS During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths will occur unless action is taken. In the circumstances, it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. 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. |
| 6 | ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and I believe that you have the power to take such action. |
| 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 16 June 2025. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. |
| 8 | COPIES and PUBLICATION I have sent a copy of my report to the following. The parents of Sarah Cunningham HHJ Alexia Durran, the Chief Coroner of England & Wales I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who she believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response. |
| 9 | DATE 16.04.25 SIGNED BY SENIOR CORONER ME Hassell |