Source · Prevention of Future Deaths

Mark Foley

Ref: 2015-0204 Date: 1 Jun 2015 Coroner: Philip Sharp Area: Cumbria 1 response identified · 3 indexed addressees View PDF

AI-generated concerns summaryThe coroner noted the driver had insufficient experience in controlling the vehicle during difficulties, despite being qualified. There was also a practice of commanders not wearing safety harnesses and a lack of enforcement of standing orders by senior officers.

Date 1 Jun 2015

56-day deadline 27 Jul 2015 est. estimated from the report date

Responses identified 1 of 3

Service Personnel related deaths

Coroner's concerns

AI summary

The coroner noted the driver had insufficient experience in controlling the vehicle during difficulties, despite being qualified. There was also a practice of commanders not wearing safety harnesses and a lack of enforcement of standing orders by senior officers.

View full coroner's concerns

1. Although the Army has taken action following a land accident prevention and investigation team report I was concerned although was qualified to drive the vehicle he had insufficient experience in encountering difficulties in controlling the vehicle.

2. Although standing orders had been in place following a previous similar accident there was a practice among commanders of vehicles not to wear safety harnesses and failure to enforce such standing orders by senior officers.

Responses

1 respondent

Department of Health

Central Government

Indexed date: 30 Jul 2015 PDF

AI-classified response stance Disputed

AI-generated response summary

• The Department of Health acknowledged the coroner's concerns regarding an omission in the call handling system. • The Department of Health stated it could not provide further assistance in implementing the suggested changes, explaining that users of the Advanced Medical Priority Dispatch System must contact the supplier directly. • The Department of Health indicated it would support the coroner in writing to Priority Dispatch UK to request consideration of the recommended changes.

View full response

From Ben Gummer MP Parliamentary Under Secretary of State for Care Quality Department of Health Richmond House 79 Whitehall London SWIA 2NS POCS 938155 Tel: 020 7210 4850 Mr J. Pollard Senior Coroner 30 JUL 2015 Coroner' s Court Mount Tabor Street Stockport SKI 3AG Kec Asllcs k Thank you for letter of 29th 2015 following the inquest into the death of Elizabeth Lester: I was very sorry to hear of Ms Lester'$ death and wish to extend my sincere condolences to her family. Your concerns in this case are levelled at the clinical call handling system used by the call handlers at the North West Ambulance Service (NWAS) to determine the category of ambulance response time which should be allocated to emergency calls. You consider that a vital question related to chest is excluded from the scripted questions used when the patient has breathing difficulties. As a result of this, the call handler initially failed to ask a question in determining Ms Lester's condition and significant delay was caused in prioritising her transport to hospital. You raise the following concerns: You believe there is an omission in the questions that are included on the breathing difficulties card. You ask for this to be rectified with the addition of a question about chest You have been told that the local ambulance service cannot alter the wording themselves as it must be done by the software suppliers [understand that the call system used by NWAS is the Advanced Medical Priority Dispatch System (AMPDS) developed by the Priority Dispatch Corporation, an independent body. AMPDS is an international call handling system which is used by some; but not all NHS ambulance services in England: The other used by providers is NHS Pathways. It is open to ambulance trusts to choose which of these two systems to use: May ` your pain key pain. system

Users of AMPDS must contact Priority Dispatch directly if they feel that an element of the system needs to be reviewed and changed. I understand NWAS has responded to your report suggesting that you write directly to the AMPDS contact at Priority Dispatch UK asking for the changes that you have recommended to be considered I would support this [am SOrry that the Departmeht cannot be of further help in implementing the changes you suggestyHoweNer; I hope that you find this reply helpful and [ am grateful to you for biingingfthe circumstances of Ms Lester'$ death to my attention. Il~~ BEN GUMMER any

Report sections

Investigation and inquest

On the 11th June 2014 I commenced an investigation into the death of Sgt Mark Colin Foley who was born on the 3rd August 1982. The investigation concluded at the end of the inquest on 1st May 2015. The conclusion of the inquest was that Mark died from

(1) Multiple injuries and his death was an accident

Circumstances of the death

On the 4th June 2014 at a local Army training area an RMWIK converted Land Rover was being driven by It went out of his control due to his inexperience in driving the vehicle. The deceased who was commander of the vehicle and a front seat passenger was ejected from the vehicle as it left the road he having not put on his safety harness. He landed in front of the vehicle which proceeded to roll over him causing the fatal multiple injuries. I concluded that the accident was caused by the inexperience of the driver and Sgt Foley’s death was caused by the failure to wear a safety harness. I concluded that Sgt Foley’s failure to wear a safety harness was as a result of a combination of a discretion to given to commanders of vehicles not to wear safety harness, a failure to enforce standing orders by senior officers requiring the wearing of safety harnesses.

Action should be taken

In my opinion action should be taken to prevent future deaths and I believe you to take such action. I my view therefore you should consider: -

1. Some form of additional training for inexperienced drivers, under safe conditions, to test them in dealing with a loss of control of the vehicles in which they are learning to drive.

2. To devise a system and/or audit procedure to check that :-

(a) Commanders are abiding by the rules on the wearing of safety harnesses and (b) Senior officers are enforcing and checking the compliance with the standing orders.

Similar PFD reports

Shared signals

Report details

Reference: 2015-0204
Date of report: 1 June 2015
Coroner: Philip Sharp
Coroner area: Cumbria

Responses identified

Responses identified 1 of 3

2 responses not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 27 Jul 2015 (estimated from the report date).

Sent to

Minister of Defence

British Army

the suppliers of the software

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

Contains public sector information licensed under the Open Government Licence v3.0.