Prevention of Future Deaths reports · 2013

Janet Richardson

Regulation 28 report to prevent future deaths, reference 2013-0261, written 16 Oct 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report16 Oct 2013
Reference2013-0261
DeceasedJanet Richardson
CoronerDavid Roberts
Coroner areaCumbria (North & West)
CategoryOther related deaths
Sourcejudiciary.uk record · original PDF
Responses published2

The report

Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)

NOTE: This form is to be used after an inquest.

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
RE: JANET RICHARDSON Deceased
THIS REPORT IS BEING SENT TO:

1. Redningsselskapet, PB 103, 1325 Lysaker, Norway

2. Cruise & Maritime Services International Limited, 4" Floor, 5-7 John
Princes Street, London. W1G OJN.

3. Newmarket Promotions Limited, McMillan House, Cheam Common Road,
Worcester Park, Surrey. KT4 8RQ.

1 | CORONER

| am David Llewelyn Roberts, Senior Coroner for North & West Cumbria.

2 | CORONER’S LEGAL POWERS

| make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

3 | INVESTIGATION and INQUEST

On 28" April 2011 | commenced an investigation into the death of Janet Richardson —
DOB — 10/08/1938. The investigation concluded at the end of the inquest on 15”
October 2013. The conclusion of the inquest was On the 29" March 2011 whilst on holiday
aboard a cruise ship in Norwegian waters the deceased became seriously unwell.

It was necessary to get her ashore for Hospital treatment. It was decided that she be transferred
ship to ship on to the aft of the rescue boat whilst strapped to a stretcher.

In the process of transferring the stretcher the rescue boat moved away from the side of the
cruise ship. Those on the rescue boat holding one end of the stretcher were no longer able to
maintain their grip. Those on the cruise ship retained their grip slightly longer. The stretcher
swung back against the side of the cruise ship into a vertical position and then it and the deceased
fell into the sea. The deceased came free of the stretcher. She was pulled from the sea some
minutes later and transferred to a Hospital on the Norwegian mainland.

During the transfer the deceased was not wearing a life jacket or buoyancy aid. The stretcher was
not attached to any line or rope. The two vessels were not tied together.

After medical treatment in Norway the deceased was transferred to the Cumberland Infirmary,
Carlisle on the 13" April 2011 where after further medical treatment she died on the 21" April
2011.

The deceased had a medical history of Chronic Renal Failure, Diabetes and high blood pressure.
She had had two recent Hospital admissions in the previous December and January.

She died as a consequence of her pre-existing chronic medical condition; the cirrhosis of the liver
being well established.

The immersion in cold seawater was a serious and significant factor in her death.

Although the primary cause of her death was due to her pre-existing co-morbidities, on the
balance of probabilities, the accidental plunge into the sea accelerated her death.

4 | CIRCUMSTANCES OF THE DEATH

Are as set out above.

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. —

That the deceased fell into the sea during a rescue medical evacuation.
6 | ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe is to your
organisation have the power to take such action. The action to review the procedures
practices risk assessments and equipment relating to ship to ship medical evacuations
with a view to minimising the risk of the patient suffering injury whether by the patient
entering the sea or by other means.

7 | YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report,
namely by 13" December 2012. 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

| have sent a copy of my report to the Chief Coroner and to the following Interested
Persons iE Viessrs. Pannone Solicitors.
| am also under a duty to send the Chief Coroner a copy of your response.

The Chief Coroner may publish either or both in a complete or redacted or summary
form. He may send a copy of this report to any person who he 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 by the Chief Coroner.

|

Date 16th October 2013

D. LI. Roberts

Responses

2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response from Cruise Maritime Services International Limited (PDF)
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