Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0204, written 1 Jun 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Jun 2015 |
|---|---|
| Reference | 2015-0204 |
| Deceased | Mark Foley |
| Coroner | John Pollard |
| Coroner area | Manchester South |
| Category | Service Personnel related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. 2. Minister of Defence The Army CORONER 1 I am Philip Alan Sharp, Assistant Coroner, for the coroner area of Cumbria 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 the 11th June 2014 I commenced an investigation into the death of Sgt Mark Colin Foley who was born on the 3rd August 1982. The investigation concluded at the end of the inquest on 1st May 2015. The conclusion of the inquest was that Mark died from (1) Multiple injuries and his death was an accident 4 CIRCUMSTANCES OF THE DEATH On the 4th June 2014 at a local Army training area an RMWIK converted Land Rover was being driven by It went out of his control due to his inexperience in driving the vehicle. The deceased who was commander of the vehicle and a front seat passenger was ejected from the vehicle as it left the road he having not put on his safety harness. He landed in front of the vehicle which proceeded to roll over him causing the fatal multiple injuries. I concluded that the accident was caused by the inexperience of the driver and Sgt Foley’s death was caused by the failure to wear a safety harness. I concluded that Sgt Foley’s failure to wear a safety harness was as a result of a combination of a discretion to given to commanders of vehicles not to wear safety harness, a failure to enforce standing orders by senior officers requiring the wearing of safety harnesses. 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. 1 6 The MATTERS OF CONCERN are as follows:- 1. Although the Army has taken action following a land accident prevention and investigation team report I was concerned although was qualified to drive the vehicle he had insufficient experience in encountering difficulties in controlling the vehicle. 2. Although standing orders had been in place following a previous similar accident there was a practice among commanders of vehicles not to wear safety harnesses and failure to enforce such standing orders by senior officers. 7 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you to take such action. I my view therefore you should consider: - 1. Some form of additional training for inexperienced drivers, under safe conditions, to test them in dealing with a loss of control of the vehicles in which they are learning to drive. 2. To devise a system and/or audit procedure to check that :- (a) Commanders are abiding by the rules on the wearing of safety harnesses and (b) Senior officers are enforcing and checking the compliance with the standing orders. 8 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the Report namely by 27th July 2015. I, the Coroner, may extend the period. Your response to this and details of action taken or proposed to be taken setting out the timetable for action. Otherwise you must explain why no action is proposed. 9 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely: the widow of Sgt Mark Colin Foley. 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 of the publication of your response by the Chief Coroner. 2 10 DATE : 1st June 2015 Signed by Coroner: Philip Alan Sharp P.A 3
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Secretary of State for Health. 1 | CORONER | am John Pollard, senior coroner, for the coroner area of South Manchester 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 22" December 2014 | commenced an investigation into the death of Elizabeth Anne Lester dob 17" June 1945. The investigation concluded on the 14" May 2015 and the conclusion was one of Misadventure. The medical cause of death was 1a Pulmonary Embolus 1b Deep vein thrombosis 1¢ Immobility due to right total knee replacement for osteoarthritis 4 | CIRCUMSTANCES OF THE DEATH This lady underwent a total knee replacement at Tameside General Hospital on the 23" November last. She needed to be readmitted thereafter as an emergency and because of the badly constructed algorithms used by the Ambulance Service, there was a significant delay in properly prioritising her transportation to hospital. 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. — As per National practice, the North West Ambulance Service uses Advanced Medical Dispatch System to prioritise calls, based on the answers to scripted questions. During the first call the call-handler asked the relevant questions and followed the “breathing difficulties” card. This card does not include any question as to whether the patient is suffering any chest pains. The call was allocated a green response and the “high volume script” was also given. In fact the patient was short of breath AND did have chest pains, but this was never enquired about. On the second call to the Ambulance service, this aspect was asked about and the call was escalated to a Red response. It is my firm belief, having come across this same issue in a number of inquests, that there is an omission in the ‘card’ for ALL breathing difficulties and it MUST be amended to include a question about chest pain. Breathing difficulties are frequently as a result of compromised heart and/or lung function and this should be queried. | am told that the local ambulance service cannot alter the wording used but that this must be done by the suppliers of the software. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 24" July 2015. |, 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 Persons ‘ane (3017 of the deceased) and North West Ambulance Service. | am also under a duty to send the Chief Coroner a copy of your response. The Chief Coron: jay publish either or both in a complete or redacted or summary form. He ay, copy of this report to any person who he believes may find it useful or of interest. You fnay 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. 29" Ma John Pollard, HM Senior Coroner
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.
AG From Ben Gummer MP Parliamentary Under Secretary of State for Care Quality Department of Health aero Whitehal London SWIA oe POCS5 938155 Tel: 020 7210 4850 Mr J. Pollard Senior Coroner 30 JUL 2015 Coroner’s Court 1 Mount Tabor Street Stockport SK1 3AG Lacs Uy dlext Thank you for your letter of 29" May 2015 following the inquest into the death of Elizabeth Lester. I was very sorry to hear of Ms Lester’s death and wish to extend my sincere condolences to her family. Your concerns in this case are levelled at the clinical call handling system used by the call handlers at the North West Ambulance Service (NWAS) to determine the category of ambulance response time which should be allocated to emergency calls. You consider that a vital question related to chest pain is excluded from the scripted questions used when the patient has breathing difficulties. As a result of this, the call handler initially failed to ask a key question in determining Ms Lester’s condition and a significant delay was caused in prioritising her transport to hospital. You raise the following concerns: e You believe there is an omission in the questions that are included on the breathing difficulties card. You ask for this to be rectified with the addition of a question about chest pain. e You have been told that the local ambulance service cannot alter the wording themselves as it must be done by the software suppliers. I understand that the call system used by NWAS is the Advanced Medical Priority Dispatch System (AMPDS) developed by the Priority Dispatch Corporation, an independent body. AMPDS is an international call handling system which is used by some, but not all NHS ambulance services in England. The other system used by providers is NHS Pathways. It is open to ambulance trusts to choose which of these two systems to use. Users of AMPDS must contact Priority Dispatch directly if they feel that an element of the system needs to be reviewed and changed. I understand NWAS has responded to your report suggesting that you write directly to the AMPDS contact at Priority Dispatch UK asking for the changes that you have recommended to be considered. I would support this. I am sorry that the Departmefit cannot be of any further help in implementing the changes you suggests However, I hope that you find this reply helpful and I am grateful to you for biingipé/the circumstances of éster’s death to my attention. Dr | Pn BEN GUMMER
® MINISTRY OF DEFENCE FLOOR 5 ZONE B MAIN BUILDING 5 WHITEHALL LONDON 1A 2HB Ministry sidecases I 3 i of Defence Telephone: 020 7218 9000 (Switchboard) MARK LANCASTER TD MP PARLIAMENTARY UNDER SECRETARY OF STATE AND MINISTER FOR DEFENCE PERSONNEL AND VETERANS MSU/4/7/1/is Zenuly 2015 ‘es [+l Sep Thank you for your letter of 1 June in which you enclose a copy of the Regulation 28 Report following the Inquest into the death of Sergeant Mark Foley As you will be aware, my Department takes very seriously its relationship with HM Coroners and we fully recognise how important it is that we learn all possible lessons to ensure that deaths under similar circumstances in the future can be prevented. In your report you have raised concerns about the training given to inexperienced drivers in dealing with the loss of control of vehicles, and reinforcement of the rules iegarding the wearing of safety harnesses. With regard to driver training, defensive driving is an integral element of all our vehicle instructor, commander and driver training. We have reviewed the feasibility of providing additional training for inexperienced drivers in case of the loss of control of vehicles, and concluded that it would be exceptionally difficult to replicate such circumstances without introducing a high degree of risk to those within the vehicle. We are currently looking at a potential requirement to create an online defensive driver training package to improve safety through inclusion of road awareness, vehicle control, driving styles and vehicle technology. As you have recognised, the policy for the wearing of seatbelts and safety harnesses is clearly set out in Armoured Vehicle Standing Orders, which are to be complied with by all crew members, regardless of rank. Commanders of wheeled armoured vehicle are now taught that they are responsible for ensuring that members of their crew wear safety harnesses at ail times uniess directed otherwise in relation to a specific tactical situation. Commanders are taught to reassess this as soon as the tactical situation Lt Col P Alan Sharp HM Assistant Coroner for Cumbria 65 Duke Street Barrow-in-Furness Cumbria LA14 1RW changes. For Revised Weapons Mounted Installation Kit + vehicles, this policy has been reinforced during new individuai driver and commander training since December 2013, and then annually through mandated currency training. | recognise that it has taken some time to address legacy users (such as those involved in this tragic incident), due to the number of drivers and availability of courses, however our current aim is for all crewman of all wheeled armoured vehicles to have received the revised training by April 2016. As you are aware, on conclusion of the Land Accident Investigation Team investigation into Sgt Foley’s death, a letter was sent to the Commanding Officers of all units equipped with wheeled armoured vehicles highlighting a range of safety concerns and directing the adoption of a number of measures to improve safe operation. Evidence from training suggests that this direction is being followed by both the chain of command and the user, with a negligible number of related incidents reported. Linked to changes in course content (including placing greater emphasis on the training of commanders) and training delivery, | am assured that the chain of command is meeting its responsibilities for the safe and effective operation of wheeled armoured vehicles. | would aiso like to reassure you that we are determined to ensure that the correct levels of knowledge and skill required to operate armoured vehicle is maintained through demanding and realistic training. | hope that this response helps to address your concerns. | am content for you to copy this response to the Chief Coroner and other interested persons. rs tr MARK LANCASTER TD MP
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