Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0074, written 25 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 | 25 Feb 2014 |
|---|---|
| Reference | 2014-0074 |
| Deceased | Rachel Burke |
| Coroner | Andrew Harris |
| Coroner area | London Inner (South) |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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.
Senior Coroner, London Inner South, UK Re: Rachel Ann Burke, case ref 1141-11, REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Re. Adventure Company 1 Cross and Pillory Lane, Cross and Pillory House, Alton, Hampshire, GU34 1HL Managing Director, Himalayan Encounters, PO Box 21218 (Courtyard Kathmandu Guest House) Thamel, Kathmandu, Nepal 3, Mr Mark Tanzer Chief Executive, The Federation of Tour Operators ABTA - The Travel Association 30 Park Street, London SE1 9EQ Head of Legal, The Association of Independent Tour Operators 133a St Margarets Road, Twickenham TW1 1RG 5. Mr. Ram Kuma Shrestha Honourable Minister for Tourism, The Government of Nepal Ministry of Culture, Tourism and Civil Aviation, Singha Durbar, Katmandu, Nepal | CORONER | am Andrew Harris, senior coroner for the jurisdiction of London Inner South 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. INVESTIGATION and INQUEST On 8" November 2011 | opened an inquest into the death of Rachel Ann Burke, aged 28 years, date of death 23° April 2011. The inquest was concluded on 15" January 2014. The cause of death was found to be High altitude cerebral oedema and high altitude pulmonary oedema. A UK Professor of Pathology gave evidence (citing internationally recognized Davies criteria) that Coronary arteriosclerosis was very unlikely to be present in an athletic 28 year old and that it did not cause her death, despite that being found by the autopsy in Kathmandu on 25" April 2011 (ref 68-0047). However the state of the coronary arteries were not recorded, nor was histology studied by the Kathmandu Autopsy Center, which would be expected if such a rare finding were suspected. CIRCUMSTANCES OF THE DEATH Ms Burke went on a high altitude trek in the Himalayas in trek organised by Himalayan Encounters (HE) with guides and experienced leader. She made an ascent of 600m from Nanche Bazaar to Dole (day 6) on 20" April. The next day she was slower than others and developed breathlessness and fatigue. Later she developed central cyanosis. She slept poorly, having to be upright and in the morning of gon April she was ataxic, cyanosed, unable to eat properly or do her shoes. She was slow in admitting her health problems and was reluctant to descend. She had High altitude cerebral oedema (HACE) and high altitude pulmonary oedema (HAPE) that were not recognised. She did not attend the health post some 12 minutes away but descended with support to Dole, but making very poor progress. She was found on the way to be confused and despite treatment on the slope by passing doctor and barometric oxygen in Dole, died later at 00:45 in Dole from HACE and HAPE. Factors contributing to her death were non recognition of HAPE and HACE at Machermo, walking under her own steam down to Dole, sending her down the mountain with a guide unfamiliar with acute mountain sickness and her not attending the health post in Machermo, about which the leader but not herself knew. Not taking her to the health post amounted to neglect. CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. The MATTERS OF CONCERN are as follows. — (1) The Adventure Company (TAC) Everest Gokyo Lakes Trek had advertised the ascent from Namche Bazaar at 3440m to Dole at 3780m, when in fact it was 4050m. This was an ascent of 610m in one day, whilst its preferred code of practice identified Id be a maximum of 300m per day. An expert in mountain sickness, iat... that the speed of ascent was the one factor that limits the incidence of altitude sickness. He said that the sleeping altitude (above 3000 metres) should never be more than about 300 or 400 metres above the previous night and that every 3 days or 1000 metres of additional ascent, an additional rest day would be needed. He described the ascent to Dole on this trek as excessive, being double the safe recommended ascent rate. It was noted that TAC hold a high altitude trek in Peru where the limits are strictly complied with, due to local legislation. (2) The HE trek leader was concerned about the costs of accessing services from the Health Centre and of making satellite phone calls, possibly mindful of the TAC manual for overseas group leaders, which states under “emergency” on page 20, that priority must be given to finding a cost effective solution. Despite having a satellite phone at Machermo and being 12 minutes from a health post, neither was used, when the trekker needed urgent medical care. (3) The severity of her illness was not appreciated by the trek leader. The expert said that it was very well known in the trekking community that people were loathe to admit they were as ill as they were and that a good mountain guide was as capable of picking up the subtle signs of mountain sickness as most doctors. Nevertheless, this severely sick trekker with ataxia and cyanosis, signs of HACE and HAPE, was asked by the trek leader to descend under her own steam with a Himalayan Encounters guide who had inadequate or no training in acute mountain sickness. This should not happen, the expert said, since exercise worsens HAPE. Ideally she should descend passively or be treated at the health centre. The information about the training of each leader and guide was not passed to TAC, who assured themselves of the adequacy of training by statements of general compliance from HE. Whilst the companies report that action has been taken to address this, there may remain a similar risk for other trek organizers. (4) The cause of death was found to be High altitude cerebral oedema and high altitude pulmonary oedema. Coronary arteriosclerosis did not cause death in this 28 year old, despite that being found by the autopsy in Nepal. 2 ACTION SHOULD BE TAKEN (1) The Adventure Company, Himalayan Encounters and British Tour organizers should consider for high altitude treks: a) ensuring that planned treks comply with the limits of ascent in one day, and days rest and other safety requirements in the co, jdelines approved by the Wilderness Medicine Society, (as recommended . fe b) where, because the terrain does not permit, informing trekkers who book when treks do not comply with these guidelines and the steps taken to mitigate the risk so that they may take informed decisions about their participation. (2) TAC and Himalayan Encounters and tour organizers for high altitude treks should consider reviewing the knowledge of and guidance to trek leaders about the health insurance of trekkers and the cost of accessing health and emergency care, so that cost considerations do not prevent appropriate access to medical advice and care. (3) The Government of Nepal may wish to consider whether it would wish to take any action to assure visitors and UK travel companies on three matters: (a) either legislative prescription of trek safety requirements (as in Peru) or guidance to Nepali trekking companies, of the safety of treks, especially with regard to ensuring that planned treks comply with the limits of ascent in one day and days rest, as approved by the Wilderness Medicine Society, and (b) that trekking organizations ensure their leaders are not disinhibited from enabling access of insured westerners to medical and rescue facilities, and (c) either by enquiry or guidance about the adequacy or independence of pathology services for trekkers, in light of the apparent error or invalidity of the autopsy report in the Kathmandu Autopsy Centre. YOUR RESPONSE Other than the Government of Nepal, which is merely invited to respond, you are under a duty to respond to this report within 56 days of the date of this report, namely by Monday, April 21*' 2014. |, 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested next of kin from Plexus Law for The Adventure Company irector of The Adventure Company | am also copying it to The Young Explorers Trust, The Duke of Edinburgh Award Scheme, The Expedition Providers Association, the British Mountaineering Council, British Mountain Guides and the Wilderness Medicine Society who may find it useful or of interest. | 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. If - would like further a a - ™ " ™_ “ht my officer: [DATE] [SIGNED BY CORONER] / too (44 erreeplect) f] 5
1 response 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.
The Adventure Company Cross & Pillory House 1 Cross & Pillory Lane Alton GU34 THL United Kingdom Reservations: 0845 450 5311 Customer Service: 0845 450 5310 F:0845 450 5317 customerservice@adventurecompany.co.uk FIRST FOR ADVENTURE adventurecompany.co.uk Dr Andrew Harris Coroner for the Inner South District of Greater London Southwark Coroner’ Court 1 Tennis Street Southwark LONDON SE11YD 14" April 2014 Dear Dr Harris Inquest touching the death of Rachel Ann Burke We write in response to the Regulation 28 report to prevent future deaths touching on the death of Rachel Ann Burke. In section 6 relating to action that should be taken the report detailed two areas for The Adventure Company to address regarding the itineraries and information provided to passenger and the knowledge of trek leaders in reference to travellers’ health insurance and the accessing of medical services. Regarding the rate of ascent and altitude gains between sleeping altitudes The Adventure Company has reviewed the expert guidance provided. The Wilderness Medical Society consensus guidelines provide a suggested approach’ to AMS/HACE/HAPE prevention. These guidelines state that above 3000m people should not exceed 500m gain in elevation between sleeping elevation and to include acclimatisation days where there is no gain between nightstops every 3 or 4 days. We have reviewed all our Nepal high altitude treks against the Wilderness Medical Society guidelines. Whilst trips had been designed and running with safe ascent levels in mind we were able to identify a couple of adjustments to reduce some of the daily altitude increases. The changes identified have been implemented on the ground for the end of the current trekking season and will form part of our published itineraries for the start of the new trekking season in September. In some circumstances the local infrastructure available for commercial group trekking means that it is necessary to exceed the 500m a day guideline provided by the Wilderness Medical Society. We only do this on what are generally considered to be well established, standard routes. In line with the recommendation made by the Coroner where this does occur we have now introduced additional information regarding this into our Trip Notes for the relevant treks. This information highlights the higher increase on these days so our trekkers are fully aware of the strenuous nature of the trip and the larger ascents included. Our Trip Notes hold the full description of the trip and are available to all passengers prior to their booking a trip as well as being sent to them as the key element of our literature for a particular trip. The information from the Wilderness Medical Society along with input from medical professionals, high altitude trekking and expedition safety experts are being Adventures Worldwide Ltd wading as The Adventure Company is a member of PEAK Adventure Travel Group Ltd, Registered Office: TU! Travel House, Crawley Business Quarter, Fleming Way, Crawtey, West Sussex, RIO SQL (please do not send any correspondence to this address) _ . « Registered in England & Wales No: 1826936. VAT Reg No: 108 2468.35. @ ee sB ABTA ‘The Adventure Company is an Appointed Representative of Campbell vine itd, vho are authorised end regulated by the Financist Services Authority. ey TATA “I Thiscan be checked on the FSA's register by visiting ww fsa.gov-ub/register or by calling 0245 605 1234. Cress ABTA No.Y0766 incorporated into a new protocol for our high altitude treks. This protocol is being designed to not only to look after the safety of our passengers but also reflect the logistical realities of operating high altitude treks around the world. This protocol will be used for the ongoing review of our trips as well as the standard for designing any new itineraries. With regard to the knowledge of our trek leaders in respect of the travel insurance that passengers have we have reviewed the information and training that is provided to our trek leaders. This has always formed part of the training for our leaders and is incorporated into not only the initial training provided but also our ongoing refresher training. It is made clear to leaders that passengers take out travel insurance that will cover them for necessary medical expenses whilst on treks. It is further emphasised that the primary concern is always for the safety and wellbeing of the trekkers. Any decisions in this regard are to be made to provide the most suitable and effective remedy and not based on relative cost. Further guidelines on always consulting any nearby medical posts, such as the one at Macchermo, in cases of illness, inability to continue with a trip or suspected AMS have also been put in place. The general TAC overseas leader manual that did refer to finding cost effective solutions to more general situations has been removed from circulation to avoid any possibility of confusion in this regard. I hope the above is of assistance. if | can be of any further help, please do not hesitate to contact me. Yours si Managing Director
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