Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0506, written 18 Sep 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 18 Sep 2024 |
|---|---|
| Reference | 2024-0506 |
| Deceased | Ali Nazemi |
| Coroner | Oliver Longstaff |
| Coroner area | West Yorkshire (East) |
| Category | Emergency services related deaths (2019 onwards) · Product 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.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Schindler Ltd, North Office, Wilson House, Crab Lane, Fearnhead, Warrington WA2 0XP 1 CORONER I am Oliver Longstaff, Area Coroner for the Coroner area of West Yorkshire (Eastern) 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 25/01/2024 I commenced an investigation into the death of Ali Mohammed Nazemi, aged 53. The investigation concluded at the end of the Inquest on 17/09/2024. The conclusion of the Inquest was that this was a death due to natural causes, the certified cause of death being 1a) Sepsis leading to multi organ failure; b) Aspiration pneumonia c) Acute stroke 2) Ex-intravenous drug use. 4 CIRCUMSTANCES OF THE DEATH Mohammad Nazemi died from natural causes on 18th January 2024 in Pinderfields Hospital where he had been admitted from home the previous day having sustained an acute stroke and aspirated in the early morning. Paramedics were called some hours after the onset of symptoms. Mr Nazemi's transfer to hospital was delayed when he and the attending paramedics became trapped in the lift at his home address, the oxygen that he was receiving from the paramedics running out before they were rescued, and being restored when he was placed in the ambulance. On the balance of probabilities, he was so unwell by the time of the paramedics' first attendance that the delay in his arrival at hospital did not cause or contribute to the already inevitable outcome. 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. – The lift that trapped Mr Nazemi and the attending paramedics is identified in an e- Worksheet generated by Schindler (copy attached) as a 20049625 MOD Replacement 6300. The lift was examined by Schindler on the day of the incident, and it was found that “the uncontrolled movement device had been activated by persons using the lift”. The lift was 1 being used by four paramedics who were transporting Mr Nazemi in a carry chair, the lift being too small to accommodate a stretcher. None of the paramedics were aware of having activated the uncontrolled movement device. The evidence suggested that that was no way to reset the uncontrolled movement device once it had been activated, and that a call to the 24/7 helpline displayed in the lift could not help. Ultimately those trapped within the lift had to wait for the Fire & Rescue Service to break the lift door down. Although Mr Nazemi was so ill that the 45 minute delay caused by the activation of the uncontrolled movement device made no difference to his outcome, there is a concern that others in his position may be seriously affected by the unintentional (and unnoticed) triggering of the uncontrolled movement device and by the fact that nothing apparently can be done to reverse any such unintentional triggering, such that those affected have to await rescue by the Fire & Rescue Service. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 13/11/2024. 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:- Yorkshire Ambulance Service; Wakefield District Housing. I have also sent it to the West Yorkshire Fire and Rescue Service who may find it useful or of interest. 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 coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 Signed: OLIVER LONGSTAFF Area Coroner West Yorkshire (E) Date: 18 September 2024 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.
Schindler Ltd 400 Dashwood Lang Road, Bourne Business Park, Weybridge, Addlestone, KT15 2HJ Response to Regulation 28 Report to Prevent Future Deaths By email ( ) and by post FAO – Oliver Longstaff Dear Sir, RE: Response to Regulation 28 Report to Prevent Future Deaths We refer to your report sent via email to “RE: Coroner’s report – Wakefield” and provide our response to your concerns as follows: dated 27 September 2024 with the subject Unintended Care Movement Protection After investigation of the incident of entrapment dated 17 January 2024, the root cause of the initial breakdown related directly to damage of the car doors and safety edge which further led to the misalignment of the car door electrical contact. We believe that this damage was caused by the paramedics when they entered and moved around inside the lift cabin. Subsequent passenger movement within the car during the lift travel by the paramedics and Mr Nazemi along with their equipment caused an interruption of the car door safety circuits which was recorded in the control panel as an Unintended Car Movement Protection (UCMP) error occurred. The UCMP is a safety measure to protect passengers in a lift where an error occurs, and the car door cannot properly close. UCMP monitors the car movement with open doors and will stop the car if it detects the car or landing doors being open whilst the lift is moving outside of a door zone. This protection is a stringent safety measure which has been required on all new lifts by the lift regulations since 2009. Once the UCMP detects a potentially dangerous situation, the lift controller must be reset by authorised lift personnel after thorough technical examination in accordance with EN81-20. We believe there has been a misunderstanding of what is meant by the UCMP being activated by the passengers. The passengers cannot activate the UCMP, the UCMP is purely a processor monitoring function embedded within the architecture of the lift control panel. The lift control panel is normally situated on the top floor landing adjacent to the lift entrance. The UCMP monitors a given situation where the car door electrical contact may have inadvertently opened (opened safety circuit) due to the suspected damage whilst the lift was travelling. The measures are activated through the control system when a potentially dangerous situation occurs due like when damage occurs to the lift car door. These measures are activated to protect passengers within the lift. The UCMP functioned as required by bringing the lift car to a stop upon detection of misalignment of the car door electrical contact. In instances where there is misalignment of the car door contact, there is a potential health and safety risk for the lift to travel with the car doors open which could cause potential death if it travels while the car door remains open. Schindler is fully compliant with international standards on lift safety. Entrapment Release There was a delay on the Schindler engineer and local Fire and Rescue Service attending site. This affected both the Schindler Technician and the local Fire and Rescue Services. This was caused by unforeseen circumstances due to traffic, which were out of the control of the technician. Schindler Ltd 400 Dashwood Lang Road, Bourne Business Park, Weybridge, Addlestone, KT15 2HJ In summary, the lift functioned as required when detecting a potential safety error. The delays thereafter in releasing the trapped passengers were caused by the attending Fire and Rescue Service being unfamiliar with the equipment and passenger release process. The passenger release information is contained within the lift control panel and the owner’s manual. In addition, the Schindler technician via telephonic communications advised the Fire and Rescue Service how to release the passenger, the Fire and Rescue Service was unable to follow the advice and attempted a manual release. From a health and safety standpoint, the measures taken regarding the release of entrapped passengers is in line with EN81-20 (lift regulations) which are the safety rules for the construction and installation of lifts. BS72-55 is a code of practice on the safe working on lifts, giving further guidance on relevant health and safety standards. Clause 5.10 – BS72-55 Clause 5.10 of BS72-55 addresses the release of passengers trapped in a lift and states “Although release procedures are not to be delayed, undue haste can lead to disregard of the recommended procedures for the release of passengers. For these reasons, it is usually preferable for the owner to arrange for trained lift industry personnel to release trapped passengers. Schindler are compliant with this clause. The process for when there is an entrapment is that a call is raised to the Schindler call centre who then contacts a nearby Schindler Engineer to attend a call out and release the entrapped passenger. All Schindler Engineers who attend call outs are trained and authorised. The recommended procedures should be followed for the release of passengers, and it is preferable for trained lift industry personnel to release trapped passengers as opposed to lay people. The reasoning behind this is that if any lay person could open the lift, the risk of death increases substantially. Clause 5.10.1 – BS72-55 Clause 5.10.1 of BS72-55 states that “The owner should authorize only persons trained in the release procedure for the particular lift to release passengers trapped in a car” further stating “Where a lift is provided with instructions for the release of trapped passengers, the owner should make these instructions available in the machinery space and only to trained persons.” Schindler are compliant with this clause. Further to clause 5.10, 5.10.1 further emphasises the point that only authorised and trained personnel should release trapped passengers. Unauthorised and untrained personnel releasing trapped passengers could malfunction the lift or cause damage to the lift, putting all passengers in serious danger. In accordance with clause 5.10.1 of BS72-55, Schindler provided instructions for the release of passengers in the control panel of the lift. This is available to the engineers attending call outs and the fire service who attend in case of emergency. Clause 5.10.2 – BS72-55 Clause 5.10.2 states that “Failure to adopt proper procedures can increase the risk to trapped persons or those undertaking the rescue.” in addition, “All release operations to be adopted should be carried out in accordance with the manufacturer’s, or other, authorized instructions”. Further to this, the clause details “Before commencing manual movement of a lift machine, the electrical supply should be isolated and locked off”. Schindler Ltd 400 Dashwood Lang Road, Bourne Business Park, Weybridge, Addlestone, KT15 2HJ This clause details that there are certain safety procedures that should be put in place before resetting a lift and commencing manual movement such as isolating and locking off the electrical supply. If these procedures are not complied with, the lift could be damaged, leading to both short and long term health and safety risks for current and future passengers. Allowing lay people to reset a lift or manually commence travel of a lift if it has entrapped passengers would not only contradict the safety standard of BS72-55 but also compromise the safety of the lift. Summary We therefore propose that no further action be taken as the lift fully conforms and operates as expected in accordance with EN81-20, BS72-55 and the Lift Regulations 2009. In addition, full passenger release information is available to the emergency services within the control panel of the lift. It is duty given that any persons performing passenger release should familiarise themselves with the process. We hope this clarifies your concern and should you require further information, please reach out to our legal department for clarification. Regards Legal Counsel
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