Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0147, written 29 Apr 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 Apr 2019 |
|---|---|
| Reference | 2019-0147 |
| Deceased | Faye Allen |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Alcohol, drug and medication related deaths · Emergency services related deaths (2019 onwards) |
| 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 | REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Chief Executive of the Health and Safety Executive, Director of the National Ambulance Resilience Unit '1 | CORONER | am Alison Mutch, 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 [ INVESTIGATION and INQUEST On 3 May 2016 I commenced an investigation into the death of Faye Allen. The investigation concluded on the 5 March 2019 and the conclusion was one of Drug-Related Death L | 4 | CIRCUMSTANCES OF THE DEATH | On 18! May 2016 Faye Allen attended an event, at the Victoria | Warehouse. Once in the event she consumed MDMA that had been | brought into the venue by another person. At 03:47 she was clearly | unwell and taken to the medical porta cabin arriving at about 04:02. Observations showed she was clearly unwell. At 04:33 an ambulance was Called. One arrived at 04:54. As Faye Allen was being transported to the Manchester Royal Infirmary, she went into respiratory arrest. On arrival at Manchester Royal Infirmary, unsuccessful attempts were made to resuscitate her. She died at Manchester Royal Infirmary on 2" May 2016. [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. — During the course of the inquest the issue of the availability of paramedics and other medical assistance was considered. The inquest was referred to the National Ambulance Service Guidance for preparing an Emergency Plan specifically Annex B which feeds into the Purple Guide. The annex and its tables set out staffing levels that are recommended for different event types. However, it became clear during the evidence that the recommended levels of staffing could be interpreted in different ways and that for example fist aiders deployed in areas other than the medical cabin area were being counted as part of the resource. This meant that the actual staff directly deployed to deal with medical issues in the medical area could vary widely and be significantly below the numbers set out in the tables. 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" June 2019. 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely Mrs Maxine Allen, Faye Allen's mother, 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. Alison Mutch OBE HM Senior Coroner 29.04.2019
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.
se eee NHS
NARU
National Ambulance Resilience Unit
College of Policing
HM Senior Coroner Ryton on Dunsmore
Manchester South CV8 3EN
Coroner's Court B
4 Mount Tabor Street Telephone: 0121 172 6073
Website: www.naru.org.uk
Stockport
SK1 3AG
20 JUN 2019 18" June 2019
HM CORONER Your Ref: 4364/CLB
MANCHESTER SOUTH
Dear Ms Mutch
RE: Faye ALLEN
Further to my letter dated the 17" May 2019, | write to provide you with a further update
regarding our efforts to address the concems raised in your Reguiation 28 Report and letter
to me of the 29" of April 2079.
To date, the following work has been completed.
¢ Anational review has been completed, examining the content and provisions
contained within the guidance document entitled ‘National Ambulance Service
Guidance for Preparing an Emergency Plan’ with particular reference to the
provisions contained within Annex B.
e | have briefed our parent body, NHS England, on your report findings and our
planned actions.
« My Compliance & Quality Team have drafted a number of amendments to be
included within the guidance document to add clarity and address the specific
concems raised within the Regulation 28 report findings.
e The next stage will be for that draft text to go out to consultation with relevant
Stakeholders. We will then make the necessary changes and alm to publish a
revised version of the guidance before the end of September 2019.
Yours sincerely,
he Rr PUR
Keith Prior
Director
National Ambulance Resilience Unit
Reg.28 ALLEN | 18/06/19 {| NARU-C+Q | CC/KP | Page 1 of 1
Health and Safety
Executive
Alison Mutch OBE
HM Senior Coroner
Coroner’s Court
41 Mount Tabor St. Health and Safety Executive
Stockport Redgrave Court
SK1 3AG Merton Road
Bootle
Merseyside
L20 7HS
4% June 2019
Dear Ms Mutch,
Thank you for your letter dated 29" May to fF which has
been passed to me as Head of HSE's First Aid at Work policy to respond.
The Health and Safety Executive (HSE) leads on national occupational health
and safety policy for the entertainments and leisure sector, whilst Local
Authorities are responsible for enforcing the law at individual events, such as
festivals, in their geographical area. In addition to health and safety law, some
events may also require licenses from local authorities
Festival organisers have responsibilities under Section 3 of the Health and
Safety at Work etc. Act 1974 (HSWA) to ensure, so far as is reasonably
practicable, the safety and health of members of the public affected by
their business. HSE guidance strongly recommends guidance that employers
include non-employees in the first aid provisions; however, the specific
requirements of the First Aid at Work Regulations 1981 apply only to the
provision of first aid for employees.
Both the National Ambulance Service Guidance (NARU) Annex B and Section
5 of the Purple Guide relating to medical provision operate a score and matrix
system, but the figures are for guidance only and individual circumstances
may require the figures to be modified from the tabular expectation depending
on the event risk assessment.
The key to any event is the pre-preparation and assessment of risk and this
will include the medical provision. The purple guide is a live event specific
document whereas the NARU document is for a wider focus of events. The
numbers and arrangements of medical provision will depend on several
factors such as crowd size, expected crowd behaviour, expected drug\alcohol
use and venue size (e.g. a Warehouse venue will require different planning
and medical provision to that of a large festival site). It is for the organiser to
ensure adequate provision during the set-up, duration and breakdown of the
event.
The interpretation of need for many aspects of a large event, including
medical provision, is the duty of organisers and the specifics of such planning
will vary from site to site as will the suitability of roles and locations of the
relevant tiers of medical provision identified. The Purple Guide is industry
owned guidance; and as such is open to interpretation and of course whilst
good practice there is no legal duty to follow this if following assessment, the
organisers, as with any industry, decide to put in place different provision or
practices. Of course, such provision must be able to be shown to be as safe if
not more so than that held within the guidance.
HSE has raised your concerms with representatives from the entertainment
industry. We will also arrange for your comments regarding general
emergency planning procedures in place at this event, along with a copy of
this letter to be sent to relevant Local Authority bodies, who have licensing
and enforcement responsibilities for such activities.
Yours sincerely
Head of Vulnerable Workers Policy Team
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