Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0043, written 9 Feb 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Feb 2016 |
|---|---|
| Reference | 2016-0043 |
| Deceased | Eitvydas Zdanys |
| Coroner | Thomas Osborne |
| Coroner area | Bedfordshire and Luton |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Thomas R. Osborne
Senior Coroner - Bedfordshire and Luton
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
The Chief Constable
Bedfordshire Police
Police Headquarters
Woburn Road
Kempston
Bedfordshire.
MK43 9AX
1
CORONER
I am Thomas R. Osborne, Senior Coroner for Bedfordshire and Luton
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.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
3
INVESTIGATION and INQUEST
On 5th August 2015 I commenced an Investigation into the death of Eitvydas
ZDANYS, aged 19 years . The Investigation concluded at the end of the inquest
on 9th February 2016. The Conclusion of the Inquest was ‘Road Traffic
Collision’. The medical cause of death was:
Ia Multiple Traumatic Injuries
II Alcohol Intoxication
4
CIRCUMSTANCES OF THE DEATH
On Sunday the 2nd August 2015, whilst intoxicated and carrying a pillion
passenger, the deceased was riding a motor cycle along the A505 Dunstable
Road, Luton, when he collided with another vehicle and sustained serious
injuries. He died at the scene on 2nd August 2015
Senior Coroner, The Court House, Woburn Street, AMPTHILL, Bedfordshire, MK45 2HX
Tel 0300-300-6559 | Fax 0300-300-8267
5
ORONER’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:
During the course of the Investigation my attention was drawn to the video footage from
the Officers who originally attended this road traffic incident. It would appear that these
Officers were unable to assess a seriously injured motorcyclist and were unable to
commence what could have been life-saving resuscitation. There perhaps needs to be a
review of the training of all Police Officers to ensure that they have all received training
in basic life support if they are at any time expected to take on the role of ‘first
responder’. One of the Officers who investigated the collision was of the opinion
“…CPR should have been administered at a much earlier stage…..” I am satisfied that
the delay in attending to the deceased did not in any way contribute to his death.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you
as Chief Constable of Bedfordshire Police 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 5th April 2016. 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
Family -
(cousin)
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
Senior Coroner, The Court House, Woburn Street, AMPTHILL, Bedfordshire, MK45 2HX
Tel 0300-300-6559 | Fax 0300-300-8267
Coroner, at the time of your response, about the release or the publication of
your response by the Chief Coroner.
9
Dated 9th February 2016
………………………………………..
THOMAS R. OSBORNE
Senior Coroner
Bedfordshire and Luton
Senior Coroner, The Court House, Woburn Street, AMPTHILL, Bedfordshire, MK45 2HX
Tel 0300-300-6559 | Fax 0300-300-8267
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.
JON BOUTCHER CHIEF CONSTABLE BEDFORDSHIRE POLICE Pretectiog Poapie and Fighting Crimea. Kempston, Bedford, MK43 SAX Force Headquarters, Woburn Road Together Telephone: 01234 846986 Fax: 01234 — 6" April, 2016 Mr. T. Osborne, Senior Coroner for Bedfordshire & Luton, The Court House, Woburn Street, Ampthill, Beds. MK45 2HX Dear Mr Osborne, Thank you for the letter from your offices dated 12 February 2016 enclosing a report to prevent future deaths pursuant to Regulation 28 of the Coroners (investigations) Regulations 2013 following the inquest touching upon the death of Eitvydas Zdanys. Bedfordshire Police approach such reports with the upmost seriousness. We are always keen to enhance good practice within the force wherever possible. Therefore upon receipt of your report we launched an investigation into the events of the night of 2 August 2015. In particular the force have sought input from a paramedic trainer, who was asked to review the body worn footage and consider what lessons can be learnt from this incident. The body worn camera was worn by the police officer giving first aid to Mr Zdanys at the incident. He remained with Mr Zdanys until the paramedics arrived. One other female officer was also present for this period. it is clear that the officers were faced with a challenging emergency situation whereby a seriously injured individual was wearing a helmet and leathers, had his leg trapped by the motorbike and was reasonably suspected to have suffered major head and spinal injuries. The two above mentioned officers were provided with first aid training when they joined the force, which included a component on when and how to give CPR. Notwithstanding the risks of head or spinal injury officers are trained that if the signs of life cease, CPR should be commenced. First aid and CPR training is refreshed for every officer annually. The reviewing paramedic trainer considers that some of the initial steps taken by the officers were satisfactory. They checked for a pulse and for breathing. They moved the motorbike and put Mr Zdanys in the recovery position. There was however a delay in providing CPR once it was considered the Mr Zdanys was no longer breathing. The first responder at the scene has informed that he was concerned not to move Mr Zdanys for fear of exacerbating any injuries he had already sustained and another officer who was on the phone to the ambulance controller was passing on the advice given to them which was not to move Mr Zdanys and to await the arrival of the paramedic. A member of the public, who claimed to be an army medic, was also providing advice at the scene that Mr Zdanys should not be moved. All this advice clearly confused the situation. Nevertheless the first responder accepts that a point came when he should, in accordance with his training, have commenced CPR despite the risks involved. The abovementioned officers will shortly receive training on when and how to administer CPR so that they are better equipped to make the right decisions should such an emergency decision arise in the future. Furthermore all officers will be reminded during their annual refresher training of when it is necessary and appropriate to commence CPR. Our investigation has further sought to consider why the officers failed to commence CPR at the appropriate time. Clearly this was a stressful and difficult situation. We however consider that such issues could have ameliorated substantially by better management of the scene on the night. Channels of communication were not clear. A member of the public was allowed to interfere with police operations. We therefore propose to train all officers further as to the management of scenes following a RTC where a major injury is suspected. We hope that our actions to date and our plan of action in the future reassures you that we are seeking to make important improvements following this tragic incident. We note that you are satisfied that that any delay in administering CPR did not contribute to the death in any way. Please do not hesitate to contact me further if | can assist in any way. May | also take this opportunity on behalf of myself and the force to extend my condolences to the Mr Zdany’s family following this very sad road traffic accident. Yours sincerely, ‘ On behalf of Jon Boutcher, Chief Constable QPM Mst (Cantab)
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