Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0060, written 28 Feb 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 28 Feb 2018 |
|---|---|
| Reference | 2018-0060 |
| Deceased | Andrea McHugh |
| Coroner | Anne Pember |
| Coroner area | Northamptonshire |
| 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.
REGULATION 28 REPORT ON ACTION TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Group General Counsel and Company Secretary for Thomas Cook, South Building, 200 Aldersgate Street, London, EC1A 4HD 2. Groupo de Turismo Gaviota S.A, Business Center Alameda de Paula, Office 504, Desamparados, Haban Vieja, Cuba, gaviota@gaviota.cu 1 CORONER I am Anne Mary Christine Pember, Senior Coroner for the coroner area of Northampton. 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 27/07/2016 I commenced an investigation into the death of Andrea McHugh whose date of birth was 10/07/1988. The investigation concluded at the end of the inquest on 31/01/2018. The medical cause of death was: 1a) Drowning The conclusion was Accidental death 4 CIRCUMSTANCES OF THE DEATH Andrea Marie McHugh went on holiday to Cuba in June 2016. She was a young lady who was diagnosed in 2006 with epilepsy. In 2015 she was diagnosed with temporal lobe epilepsy and had a brain operation. Following the surgery she continued to experience seizures around once per month. Andrea booked her holiday with Thomas Cook. She arranged to go on a boat trip on 17th June 2016 to swim with the dolphins and later snorkel which was organised by Groupo Turismo Gaviota S.A. Whilst snorkelling it was noted that Andrea was floating in the sea. She was brought onto the boat where resuscitation measures were attempted and she was later conveyed to hospital where her death was confirmed on the same date at 11.20 hours. 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 could 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) Marinas Gaviota S.A allegedly require participants in the boat and snorkelling trip to sign a waiver. (copy attached). The waiver does not mention the dangers of swimming in the sea if a participant suffers from epilepsy. 2) Additionally the waiver does not request details of participants past medical history. 1 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you AND/OR your organisation, 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 25/04/2018. 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:- 1. Mother of Andrea McHugh 2. Thomas Cook Similarly, you are 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. 9 [DATE] [SIGNED BY CORONER] 28 February 2018 2
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.
Our Ref: Legal & Compliance/AM/PP Your Ref: Thomas Cook Tour Operations Ltd Westpoint, Peterborough Business Park Lynch Wood Peterborough PE2 6FZ Tel: 01733 416467 Fax: 01733 416484 25 April 2018 Mrs Anne Pember HM Coroner for the County of Northampton 110 Whitworth Road Northampton NN1 4HJ Dear Madam Inquest into the death of Andrea McHugh We acknowledge receipt of your letter dated 27 February 2018 and accompanying prevention of future deaths report. In particular we note the observations in the section of your report which deals with your concerns. Before responding to your observations, we would like to express our sincere sympathy to the family of Ms McHugh and our sadness at her death. Thomas Cook has assessed the position carefully and has decided to immediately engage with Groupo Turismo Gaviota S.A. (“Gaviota”) to request that they amend their waiver form for the Sunrise excursion to include reference to epilepsy as a relevant medical condition which may make it dangerous for our customers to go in to the sea due to the increased risk of injury. Thomas Cook then intends to review whether we request Gaviota make further amendment to their waiver to include reference to any medical history that may make it dangerous for our customers to go in to the sea and therefore should be included in the waiver. If further amendment is required it is envisaged that it will be necessary for Thomas Cook to obtain expert medical advice in respect of this to ensure appropriate relevant medical history is included. Thomas Cook will also conduct a wider review of our supplier processes in connection with sea based excursions to ensure any risks to our customers are reduced as far as reasonably practicable. Thank you for the opportunity to respond to your observations. Yours faithfully Group General Counsel and Company Secretary Registered Office and address for legal service of documents Westpoint, Peterborough Business Park Lynch Wood, Peterborough PE2 6FZ Company Registration Number 3772199 England & Wales
See every Prevention of Future Deaths report matching Anne Pember, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.