Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0046, written 4 Feb 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Feb 2014 |
|---|---|
| Reference | 2014-0046 |
| Deceased | Samuel Boon |
| Coroner | Selena Lynch |
| Coroner area | South London |
| Category | Alcohol, drug and medication related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
In the South London Coroners Court
Inquest touching the death of Samuel Boon
Regulation 28 Report to Prevent Future Deaths
THIS REPORT IS BEING SENT TO:
The Rt Hon Michael Gove MP, Secretary of State for Education
1 CORONER
I am Selena Lynch, Assistant Coroner for the coroner area of South London
2 CORONER’S LEGAL POWERS
I 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 25 July 2012 an inquest was opened into the death of Samuel Boon. The
investigation concluded at the end of the inquest on 13 January 2013. The conclusion
of the inquest was misadventure.
In the South London Coroners Court
Inquest touching the death of Samuel Boon
Regulation 28 Report to Prevent Future Deaths
4 CIRCUMSTANCES OF THE DEATH
On 17th July 2012 Samuel Boon (aged 17) collapsed while trekking in temperatures of
about 39ºC on a school trip to the foothills of the High Atlas mountains in Morocco.
The trip was arranged through a school expedition company. Leaders rendered first
aid, attempted to cool him and asked the local guide to get an ambulance. Over an
hour later, a minibus arrived. An ambulance was either not available or requested, and
would in any event have had no medical equipment or personnel on board.
Cardio pulmonary resuscitation (CPR) was performed by the leaders but this had to
stop when Samuel was placed in the minibus because of lack of space and he died
some time during the 25 minute journey to a local medical centre.
The cause of Samuel’s death was either exertional heatstroke and/or hyponatremia
caused by excessive intake and/or retention of water. Samuel may have taken
desmopressin in the recent past which can cause or contribute to hyponatremia, but it
is not possible to determine whether he did so, and if so, whether it did in fact
contribute to the cause of his death.
The cause of Samuel’s death was contributed to by his obesity and lack of fitness and
acclimatisation. These risk factors and his tiredness and obvious difficulty in keeping
up with the trek were not fully recognised by the leaders, who were inexperienced and
lacking in local knowledge.
Samuel and his parents were given inadequate and misleading information about the
level of fitness required or the risks involved in the trip and how they would be
managed. Samuel was not adequately assessed as to his physical ability to
participate. Formal risk assessments were inadequate and inaccurate with regard to
the risk of heat illness and/or hyponatremia, and the risk of medical emergency
generally. Information provided by the expedition company was not sufficiently
accessed and considered either prior to or during the trip.
Plans for evacuation relied almost entirely upon local agents to find and obtain
appropriate facilities. They were appointed without their qualifications being checked
or references obtained, and were not given any formal training. There were no
arrangements in place for an ambulance with medical equipment and/or personnel to
be provided in an emergency, and the facilities at local medical centres had not been
assessed.
In the South London Coroners Court
Inquest touching the death of Samuel Boon
Regulation 28 Report to Prevent Future Deaths
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. –
(1) Preparation
•
•
•
•
The school, parents and children were not given sufficient and accurate
information to allow them to make informed choices about participation and
preparation for the trip. Differences in ambulance and medical facilities in
Morocco were not fully explained.
Risk assessments did not include the risks associated with insufficient fitness
and preparation, acclimatisation, and evacuation in the event of a medical
emergency.
Individual participants were not formally assessed as to their fitness for the
activity. There was an apparent onus on the parents and participants to assess
fitness, though they had no real knowledge or understanding of the environment
in which the child would be staying or the activities involved.
Up to date medical information about the participants was not proactively
obtained shortly before departure.
Evacuation:
•
•
•
Exertional heatstroke and (dependent upon the cause) hyponatremia, are
preventable but life-threatening conditions, requiring urgent and appropriate
evacuation to advanced medical facilities. In an environment such as the
foothills of the Atlas Mountains, the focus is likely be on prevention, because it is
clear that urgent evacuation is not usually possible.
Expedition and school leaders were not given sufficient information and training
as to the dangers of heatstroke and hyponatremia, how to recognise the risk of
occurrence in a given individual, how to recognise the symptoms and how to
manage them if they occurred.
Procedures and facilities for urgent evacuation were not fully and formally
assessed, tested and audited. Arrangements were reliant upon local agencies
individuals and facilities which had not been subjected to adequate checking and
scrutiny.
NOTE: The expedition company has made a number of changes since Samuel’s
death, but the purpose of this report is to raise concerns more widely.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe your
Department has the power to take such action.
In the South London Coroners Court
Inquest touching the death of Samuel Boon
Regulation 28 Report to Prevent Future Deaths
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 2nd April 2014. 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 Chief Coroner and to the following Interested
Persons :
•
•
•
•
World Challenge Expeditions Limited
The Business Academy Bexley
and to the LOCAL SAFEGUARDING BOARD
I have also sent copies to the Health and Safety Executive, the Royal Geographical
Society, and the Medicines and Healthcare products Regulatory Agency (MHRA) who
may find it useful or of interest.
I 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.
9
4th February 2014 Selena Lynch
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