Source · Prevention of Future Deaths

Eitvydas Zdanys

Ref: 2016-0043 Date: 9 Feb 2016 Coroner: Thomas Osborne Area: Bedfordshire and Luton Responses identified: 1 / 1 View PDF

Police officers responding to a road traffic incident lacked basic life support training, rendering them unable to assess or resuscitate a seriously injured motorcyclist.

Date 9 Feb 2016
56-day deadline 5 Apr 2016 est.
Responses identified 1 of 1
Other related deaths

Coroner's concerns

AI summary
Police officers responding to a road traffic incident lacked basic life support training, rendering them unable to assess or resuscitate a seriously injured motorcyclist.
View full coroner's concerns
During the course of the Investigation my attention was drawn to the video footage from the Officers who originally attended this road traffic incident. It would appear that these Officers were unable to assess a seriously injured motorcyclist and were unable to commence what could have been life-saving resuscitation. There perhaps needs to be a review of the training of all Police Officers to ensure that they have all received training in basic life support if they are at any time expected to take on the role of ‘first responder’. One of the Officers who investigated the collision was of the opinion “…CPR should have been administered at a much earlier stage…..” I am satisfied that the delay in attending to the deceased did not in any way contribute to his death.

Responses

1 respondent
E Zdanys
12 Feb 2016 PDF
Action Planned

The officers involved will shortly receive training on when and how to administer CPR, and all officers will be reminded during their annual refresher training of when it is necessary and appropriate to commence CPR; all officers will be trained further as to the management of scenes following a RTC where a major injury is suspected. (AI summary)

View full response
Dear Mr Osborne, Thank you for the letter from your offices dated 12 February 2016 enclosing a report to prevent future deaths pursuant to Regulation 28 of the Coroners (Investigations) Regulations 2013 following the inquest touching upon the death of Eitvydas Zdanys: Bedfordshire Police approach such reports with the upmost seriousness: We are always keen to enhance good practice within the force wherever possible. Therefore upon receipt of vour report we launched an investigation into the events of the night of 2 August 2015. In particular the force have sought input paramedic trainer, who was asked to review the body worn footage and consider what lessons can be learnt from this incident: The body worn camera was worn by the police officer giving first aid to Mr Zdanys at the incident: He remained with Mr Zdanys until the paramedics arrived: One other female officer was also present for this period. It is clear that the officers were faced with a challenging emergency situation whereby a seriously injured individual was wearing a helmet ad leathers, had his leg trapped by the motorbike and was reasonably suspected to have suffered major head and spinal injuries The two above mentioned officers were provided with first aid training when joined the force, which included a component on when and to give CPR. Notwithstanding the risks of head or spinal injury officers are trained that if the signs of life cease, CPR should be commenced. First aid and CPR training is refreshed for officer annually: The reviewing paramedic trainer considers that some of the initial steps taken by the officers were satisfactory: checked for a pulse and for breathing: They moved the motorbike and Mr Zdanys in the recovery position_ There was however a delay in providing CPR once it was considered the Mr Zdanys was no longer breathing: The first responder at the scene has informed that he was concerned not to move Mr Zdanys for fear of exacerbating any injuries he had already sustained and another officer who was on the phone to the ambulance controller was passing on the advice given to them which was not to move Mr Zdanys and to Togedhir from they how every They put

await the arrival of the paramedic: A member of the public, who claimed to be an army medic, was also providing advice at the scene that Mr Zdanys should not be moved_ All this advice clearly confused the situation: Nevertheless the first responder accepts that a point came when he should, in accordance with his training, have commenced CPR despite the risks involved_ The abovementioned officers will shortly receive training on when and how to administer CPR so that they are better equipped to make the right decisions should such an emergency decision arise in the future. Furthermore all officers will be reminded during their annual refresher training of when it is necessary and appropriate to commence CPR: Our investigation has further sought to consider why the officers failed to commence CPR at the appropriate time. Clearly this was stressful and difficult situation. We however consider that such issues could have ameliorated substantially by better management of the scene on the night. Channels of communication were not clear member of the public was allowed to interfere with police operations. We therefore propose to train all officers further a5 to the management of scenes following a RTC where a major injury is suspected We hope that our actions to date and our plan of action in the future reassures you that we are seeking to make important improvements following this tragic incident: We note that you are satisfied that that any delay in administering CPR did not contribute to the death in any way. Please do not hesitate to contact me further if | can assist in any way: May | also take this opportunity on behalf of myself and the force to extend my condolences to the Mr Zdany' s family following this sad road traffic accident.

Report sections

Investigation and inquest
On 5th August 2015 I commenced an Investigation into the death of Eitvydas ZDANYS, aged 19 years . The Investigation concluded at the end of the inquest on 9th February 2016. The Conclusion of the Inquest was ‘Road Traffic Collision’. The medical cause of death was:

Ia Multiple Traumatic Injuries II Alcohol Intoxication
Circumstances of the death
On Sunday the 2nd August 2015, whilst intoxicated and carrying a pillion passenger, the deceased was riding a motor cycle along the A505 Dunstable Road, Luton, when he collided with another vehicle and sustained serious injuries. He died at the scene on 2nd August 2015

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Report details

Reference
2016-0043
Date of report
9 February 2016
Coroner
Thomas Osborne
Coroner area
Bedfordshire and Luton

Responses identified

Responses identified 1 of 1
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 5 Apr 2016 (estimated).

Sent to

Bedfordshire Police

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