Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0276, written 20 Aug 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Aug 2021 |
|---|---|
| Reference | 2021-0276 |
| Deceased | Sheldon Marshall |
| Coroner | Anna Crawford |
| Coroner area | Surrey |
| Category | Emergency services related deaths (2019 onwards) · 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.
IN THE SURREY CORONER’S COURT
IN THE MATTER OF:
__________________________________________________________
The Inquest Touching the Death of Sheldon Marshall
A Regulation 28 Report – Action to Prevent Future Deaths
__________________________________________________________
1 THIS REPORT IS BEING SENT TO:
Mr
Founder and Managing Director of the Mayday Group
Unit 1
Clifton Mews
Clifton Hill
Brighton
BN1 3HR
2 CORONER
Miss Anna Crawford, HM Assistant Coroner for Surrey
3 CORONER’S LEGAL POWERS
I make this report under paragraph 7(1) of Schedule 5 to The Coroners
and Justice Act 2009.
4
INQUEST
An investigation into the death of Sheldon Marshall was commenced on
10 January 2018 and an inquest into his death was opened on 5 February
2018. The inquest was resumed on 30 June 2021 and concluded on 16 July
2021.
The medical cause of Mr Marshall’s death was:
1a. Cardio-Respiratory Arrest
1b. Bronchopneumonia with Adult Respiratory Distress Syndrome and
Pneumothoraces (treated by chest drains) AND Right Haemothorax
resulting from a Pleural Injury caused by the right chest drain
1c. High Altitude Induced Pulmonary Oedema AND Fracture of Left Rib
2. Left Ventricular Hypertrophy
1
The inquest concluded with a narrative conclusion, which is set out
below.
5 CIRCUMSTANCES OF THE DEATH
On 4 November 2017 Mr Marshall arrived in Kathmandu, Nepal to
participate in a group trek to Mount Everest Base Camp. On the morning
of 5 November 2017 the group flew to Lukla and began their trek.
During the period from 5–10 November Mr Marshall participated in the
trek without raising any particular concerns, albeit he walked at a slower
pace than the rest of the group.
On 11 November 2017, however, Mr Marshall found the trek difficult and
walked behind the rest of the group accompanied by an Assistant Guide.
At Dukla Mr Marshall hired a horse to enable him to continue to Lobuche,
which was the next destination on the trek. However, after about fifteen
to twenty minutes on the horse the saddle buckle broke and Mr Marshall
fell off sustaining a left rib fracture.
Following Mr Marshall’s arrival at Lobuche it was decided that it was not
suitable for him to continue the trek and it was arranged that Mr Marshall
would fly off the mountain the following day. Later than night Mr
Marshall began to show signs of suffering from High Altitude
Pulmomary Oedema (HAPE).
On 12 November 2017, Mr Marshall was admitted to the CIWEC Hospital
in Kathmandu where he was diagnosed with HAPE, a fractured left rib
and subsequently diagnosed with fungal pneumonia.
Following his admission to the hospital his condition he did not respond
to treatment and he deteriorated significantly.
2
By 28 November 2017 he met the criteria for Severe Acute Respiratory
Distress Syndrome (ARDS) and on the same day he was intubated and
begun on mechanical ventilation.
On 6 December 2017 Mr Marshall was transferred by Air Ambulance
from the CIEWC Hospital in Kathmandu to the Indraprastha Apollo
Hospital in New Delhi.
On 7 December 2017 Mr Marshall was diagnosed with a left sided
pneumothorax and on 12 December 2017 he was diagnosed with a right
sided pneumothorax, as a result of which chest drains were inserted. The
pneumothoraces were in part due to his underlying condition and in part
to his ongoing mechanical ventilation.
On 16 December 2017 an attempt was made to repatriate Mr Marshall to
the UK on compassionate grounds, albeit by this stage he was critically ill
and his death was inevitable whether he remained in New Delhi or
returned to the UK.
At some point following Mr Marshall’s departure from the Indraprastha
Apollo Hospital in New Delhi on 16 December 2017, and prior to the
clinical assessment undertaken at the airport by the Air Ambulance team,
Mr Marshall sustained a pleural injury due to the presence of the right
chest drain, which resulted in active bleeding from the chest drain. The
exact mechanism of how the injury occurred is not known.
As a result of the injury Mr Marshall’s already critical condition
deteriorated further and the Air Ambulance team advised that he be
returned to the Indraprastha Apollo Hospital.
During the return journey Mr Marshall sustained a cardiac arrest and was
resuscitated before being readmitted to the Intensive Care Unit at the
Indraprastha Apollo Hospital.
On 17 December 2017 he sustained a further cardiac arrest and died in the
Intensive Care Unit of the Indraprastha Apollo Hospital.
His death was due to a combination of HAPE and a fractured left rib
which led to Bronchopneumonia with ARDS and related
pneumothoraces.
3
His death was hastened by the pleural injury sustained on 16 December
2017 and contributed to by his underlying condition of Left Ventricular
Hypertrophy.
4
6 CORONER’S CONCERNS
During the course of the inquest the court heard evidence that:
Mr Marshall booked his trek with a company called Exodus Travels
Limited. Prior to travelling he bought an insurance policy which included
cover for emergency repatriation and air ambulance charges. The court
heard that Mr Marshall bought the policy through Exodus Travels
Limited with the ultimate insurer being Inter-Partner Assistance SA (IPA),
a company based in Belgium. Global Benefits Europe BV (GBE) was
responsible for selling IPA’s insurance policies and managing any related
claims. GBE had contracted with Mayday Assistance Limited to provide
overseas medical assistance to policy holders such as Mr Marshall.
Senior clinical input at Mayday Assistance Limited
At the conclusion of the inquest the court found that there was an
omission on the part of Mayday Assistance Limited to ensure that their
Medical Director was aware of, and providing clinical leadership in
relation to, Mr Marshall, from at least 22 November 2017.
Whilst the court was not persuaded that this omission caused or
contributed to the particular facts of Mr Marshall’s death, the Coroner is
concerned that the level of senior clinical input at Mayday Assistance
Limited remains insufficient and may have a negative impact on the
medical management of current and future policy holders and therefore
presents a risk of future deaths.
The medical management of patients once Mayday Assistance Limited
has instructed an Air Ambulance provider
During the course of the inquest the court heard evidence that on 24
November 2017 Mayday Assistance Limited instructed Tyrol Air
Ambulance (TAA) to repatriate Mr Marshall from Nepal to the UK.
The court heard that the repatriation to the UK did not ultimately go
ahead as Mr Marshall was not considered fit enough to undergo the flight
on the dates that TAA had an available aircraft.
The court found that during the period from 24 November to 4 December
2017 there was a lack of clarity as between Mayday Assistance Limited
and TAA with regards to who was responsible for Mr Marshall’s overall
5
medical management, and as a result neither Mayday Assistance Limited
nor TAA were monitoring Mr Marshall’s ongoing condition with a view
to reviewing and advising on (i) whether the UK was the appropriate
destination for Mr Marshall and identifying potential regional alternatives
and (ii) the overall risk/benefits of him remaining in Nepal versus being
transferred to another country in the region.
Whilst the court was not persuaded that this omission caused or
contributed to the particular facts of Mr Marshall’s death, the Coroner is
concerned that this lack of clarity remains today, not only as between
Mayday Assistance Limited and TAA but potentially as between Mayday
Assistance Limited and other air ambulance providers, which presents a
risk of future death.
The MATTER OF CONCERN is:
1. The Coroner is concerned that the level of senior clinical input at
Mayday Assistance Limited is insufficient and considers that this
may have a negative impact on the medical management of current
and future policy holders and therefore presents a risk of future
deaths. Mayday Assistance Limited is invited to consider whether
the current level of senior clinical input is sufficient.
2. The Coroner is concerned that there is a lack of clarity as between
Mayday Assistance Limited and the air ambulance providers they
instruct with regards to their relative responsibilities for the overall
medical management of patients and considers that this presents a
risk that such patients may not be effectively and comprehensively
managed and as such presents a risk of future death. Mayday
Assistance Limited is invited to take steps to clarify the position
with all the air ambulance providers they instruct.
7 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I
believe that the people listed in paragraph one above have the power to
take such action.
6
8 YOUR RESPONSE
You are under a duty to respond to this report within 56 days of its date; I
may extend that period on request.
Your response must contain details of action taken or proposed to be
taken, setting out the timetable for such action. Otherwise you must
explain why no action is proposed.
9 COPIES
I have sent a copy of this report to the following:
1. Chief Coroner
2. Mr Marshall’s family
3. Exodus Travels Ltd
4. Capital Air Ambulance
5. Global Benefits Europe BV
6. Tyrol Air Ambulance
7. European Aero Medical Institute (EURAMI)
10 Signed:
Anna Crawford
H.M Assistant Coroner for Surrey
Dated this 20th day of August 2021
7
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.
mayday/ assistance 1 Clifton Mews Clifton Hill Brighton East Sussex BNl 3HR www.maydayassistance.com Regulation 28: Prevention of Future Deaths Report (PFD) arising from the inquest into the death of Sheldon Marshall 10/11/2021 Dear Madam Thank you for your Regulation 28 Report dated 20 August 2021 setting out your recommendations for consideration. We would like to begin by again expressing our condolences to the family of Mr Marshall. The matters of concern are: 1. 2. The Learned Coroner is concerned that the level of senior clinical input at Mayday Assistance Limited is insufficient and considers that this may have a negative impact on the medical management of current and future policy holders and therefore presents a risk of future deaths. Mayday Assistance Limited is invited to consider whether the current level of senior clinical input is sufficient. The Learned Coroner is concerned that there is a lack of clarity as between Mayday Assistance Limited and the air ambulance providers they instruct with regards to their relative responsibilities for the overall medical management of patients and considers that this presents a risk that such patients may not be effectively and comprehensively managed and as such presents a risk of future death. Mayday Assistance Limited is invited to take steps to clarify the position with all the air ambulance providers they instruct. Senior Clinical Input , who took up the post when Dr Mayday Assistance now employs two doctors rather than only one. The Medical Director is now Dr stepped down in June 2018. A further doctor, Dr , has also been appointed to provide senior clinical input. We attach the CVs of both Dr . A doctor is always available to assist the Medical Team in decision making and discussion with third parties when required. There is no set weekly working pattern and both doctors are available on call. Dr current has no other clinical commitments. and Dr Mayday now have in place an internal escalation process, which ensures escalation for VSIL and SIL (very sick and seriously ill patients) to the senior clinical team. We attach the Escalation Matrix for medical management now in place. Company Registration: 05928173 Registered Address: 1 Clifton Mews. Clifton Hill, Brighton, East Sussex. BNl 3HR There is now a virtual weekly ward round during which all patients presenting with any concerns are reviewed. This is attended by Dr (RGN this/Paramedic Practitioner) and , (Operations Manager). During this weekly meeting there is a formal review of the management of any complex cases completed that provided clinical or logistical challenges. Instruction of Air Ambulance Providers An Air Ambulance Support Agreement is now in place with Mayday's Air Ambulance providers, as attached, to ensure that both parties are clear regarding their responsibilities and to ensure that there is a close working relationship on all cases. If a company declines to sign our agreement and cannot provide one with similar protocols they will be removed from Mayday's provider list. We hope this response is helpful in setting out steps taken by Mayday since the inquest in July 2021 and reassures the Learned Coroner, and the Marshall Family, regarding both the provision of senior clinical input and the protocols in place when Mayday engages the services of Air Ambulance providers. Yours sincerely CEO Mayday Group Ltd
See every Prevention of Future Deaths report matching Emergency services related deaths (2019 onwards), 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.