Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0065, written 22 Feb 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Feb 2019 |
|---|---|
| Reference | 2019-0065 |
| Deceased | Jeremy Sutch |
| Coroner | Nigel Parsley |
| Coroner area | Suffolk |
| Category | Accident at Work and Health and Safety 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Secretary General International Maritime Organisation 4 Albert Embankment London SE17SR Vantage Drilling Company 777 Post Oak Blvd Suite 800 Houston Texas 77056 USA 1 CORONER | am Nigel Parsley, Senior Coroner, for the coroner area of Suffolk. 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 21* March 2016 | commenced an investigation into the death of Jeremy Sutch. The investigation concluded at the end of the inquest on 13 February 2019. The conclusion of the inquest was that; Jeremy Sutch died on the 25th February 2016 at 20:20 in Labuan Hospital, Labuan, Malaysia from injuries received earlier in the day (at around 14:50) on the MV Platinum Explorer, which was moored off the coast nearby. He sustained his injuries when he was crushed by a Riser Feeding Machine on board the vessel. His medical cause of death following a post-mortem examination was 1a Blunt Chest Trauma. 4 | CIRCUMSTANCES OF THE DEATH Jeremy Sutch was a Trainee Driller on board the MV Platinum Explorer, when it was moored in Kuraman Island Water, off Labuan, Malaysia on Thursday the 25" February 2016. At approximately 14.55 hours a telephone call was made to the bridge of the Platinum Explorer by Jeremy, requesting help in the Drillers Control Cabin. Other members of the crew attended the Driller's Control Cabin and found Jeremy injured on the floor. He told them he had been crushed by ‘the RFM bucket’ (on a Riser Feeding Machine). Jeremy was struggling to speak and when found by other members of the crew had injuries to his chest. Jeremy was given first aid attention by the on-ship paramedic. A ‘medevac’ casualty evacuation was arranged and carried out by a small tender vessel in order to get Jeremy to the nearest land (some 30 to 40 minutes away). Once ashore Jeremy was taken to the Hospital in Labuan where, he tragically passed away. 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 as follows:- It was heard in evidence that the captain of the MV Platinum Explorer, on hearing that Jeremy had suffered crush injuries to the chest referred to The Ship Captain’s Medical Guide. The court was told that this book, or similar, is carried on every vessel to advise a ship's captain on what action to take in relation to the treatment of the casualty. Following the guidance given in The Ship Captain’s Medical Guide the captain instructed the crew that they must not lay Jeremy down and he should be evacuated in the sitting position. Jeremy was in such pain that he could not physically lie down in any event. As a result Jeremy was not placed in a ‘basket’ or ‘Neil Robinson’ stretcher but was sat in a ‘wheelchair’ type extraction chair. In evidence it was heard that there had never been an evacuation drill undertaken on board using an extraction chair (a basket type stretcher and mannequin always being used). Further, the captain said in his 42 years at sea he had never seen a medical evacuation drill, or real medical evacuation using a wheelchair type extraction chair. The fact that the crew were unfamiliar with the wheelchair extraction stretcher needed in Jeremy's case, led to the follow. e Unlike a basket stretcher the wheelchair extraction stretcher had no independent lifting points so could not be lowered to the tender by crane. e It therefore was necessary to lower the wheelchair in the crane work basket. e The wheelchair stretcher would not fit in the crane work basket and had to be dynamically modified in order for it to fit. e Thecrane work basket was too large and heavy to be manoeuvred into the rear of the waiting tender (which was fibreglass and risked damage). e Thecrane work basket was therefore lowered onto the roof of the tender wheel house. e The wheelchair stretcher would not fit down the spiral stairs leading to the passenger/casualty space inside the tender. ° Initially the tender tried to make shore with Jeremy on the roof of the wheel house but the handrail began to give way in heavy-seas so the tender had to return to the lee ward side of the MV Platinum Explorer. e Despite his injuries Jeremy had to physically lower himself one step at a time into the passenger space of the tender before he could be taken ashore to receive medical attention. It was clear from the evidence that the issues identified above led to delay in Jeremy’s medical evacuation. It was also clear that without Jeremy's own personal strength and determination he would not have been able to get inside the tender to be taken ashore. It was confirmed by a forensic pathologist at the inquest, that in his opinion Jeremy's injuries were not survivable and that any delay in his medical evacuation did not affect the tragic outcome of this case. That said, | am concerned that should a similar situation arise with a casualty whose injuries may be survivable, their chance of survival would be reduced by the delays caused by the difficulties identified in this case. | am also concemed that other captains on other ships may be unaware of the difficulties posed in the medical evacuation of a casualty when The Ship Captain’s Medical Guide dictates that they must be kept in a seated position. | am further concerned by the apparent lack of knowledge of this type of casualty extraction device, which in turn resulted in an apparent lack of training drills designed specifically with its use in mind. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you or your organisation 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 18! April 2019. |, the Senior Coroner, may extend the period if | consider it reasonable to do so. 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. Members of Jeremy's family and International SOS. | am 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, at the time of your response, about the release or the publication of your response by the Chief Coroner. \ ya 22" February 2019 N [A Nigel Parsley
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.
Weightmans LLP T +44(0)345 073 9900 Weightmans UWverpodl DX TIE100 Liverpool 16 Merseyside L3 9Q) www.weightmans.com FAO: Mr Nigel Parsley Snr. Coroner for the Coroner Contact: Phil James Area of Suffolk Suffolk Coroner’s Service. Ti 0151 243 9849 Beacon House E: eC 53-65 White House Road Ipswich Our ref: Po Suffolk IP] 5PB Your ref: 10 April 2019 Dear Sirs Inquest touching on the death of Mr Jeremy Sutch Regulation 28: Report to prevent future deaths We write on behalf of Vantage Drilling Company (“Vantage”) by way of response to the Regulation 28: Report to prevent future deaths (1) dated 22 February 2019 and in particular by way of response to paragraph 7 of same (“Your Response”). You have asked us to provide details of action taken or proposed to be taken and the timetable for action. Introduction We wish to reiterate, on our own behalf and on behalf of Vantage, our condolences for Jeremy’s family’s terrible loss. Since this event, Vantage has reflected upon all of the facts of the incident as identified by various investigations (including the Coroner’s own) in order to learn as much as possible. Vantage is always concerned to ensure that its evacuation procedures are fit for purpose, affording those injured the best opportunity to reach expert medical attention in the most timely fashion. It is not possible to foresee and anticipate every possible scenario (hindsight provides improved illumination on the situation) and it is important to recognise that what happened on board the Platinum Explorer was fact specific and highly unusual, being outside the experience of very experienced Mariners. Since the event involving Mr Sutch, evacuation using wheelchairs have been included in evacuation drills (see below). As referred to during the Inquest:- Weightmans LLP is a limited liability partnership registered in England & Wales with registered number 0C326117 and its registered office at 100 Old Hall Street, Liverpool L3 90). A full list of members is available at the registered office. The term “partner'’, if used, denotes a member of Weightmans LLP or a senior employee of Weightmans LLP with equivalent standing and qualifications, Authorised and regulated by the Solicitors Regulation Authority. Vi. Page 2 Our ref: 784554-8/PJame/3667 Your ref: Vantage arranged for a medic to be on the vessel despite this not being a requirement; Vantage’s MERP involved a recognised international agency as a partner (Vantage were doing things properly); Vantage are not aware of any advice or industry practice to suggest other operators involved in similar operations, in similar environments, have been taking a difference approach; Patient extraction from a whole range of occupational settings, even ashore, is often compromised and at least challenging. Speed of response, whilst always desirable, cannot always be achieved or guaranteed because not all factors which impact on speed of response can be controlled. Even ashore, ambulances may be delayed by traffic or weather conditions or simply by demand exceeding supply; Air ambulances are not a state funded provision in all areas, less still an infinite resource; Being aboard a vessel at sea presents a different and additional range of challenges which Vantage sought to address in the MERP they devised; Vantage is proud of the resourcefulness and the dedication of the crew in dealing with such an unusual scenario and was pleased to have been able to assist the enquiry so openly and fully. Regulation 28 Response Please find attached:— 1) 2) 3) Updated HSE Manual dated 7 March 2019. Please refer in particular to Section 4.25.7 which includes specific reference to the different stretcher types which may be required to be used. Emergency Response Drill Matrix. Please see (new) item 26 which is described as “Drill - Medivac Chair Type Stretcher”. This requires a drill to be carried out every six months. This spreadsheet also identifies the date on which the next drill will take place, in this case 16 April 2019. Including medivac by way of chair type stretchers in the Drill Matrix ensures that the exercise of utilising the chair type stretcher is scheduled and actioned and any lessons learned are captured. Documenting these drills in our Safety Management Systems ensures compliance is managed and audited. Rig Specific Emergency Response Manual dated 11 March 2019 which includes details of the different types of stretcher available on board. Yours faithfully eighhuans (LP Weightmans LLP
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