Source · Prevention of Future Deaths
Rajesh Parkash
Ref: 2014-0207
Date: 8 May 2014
Coroner: Richard Travers
Area: Surrey
Responses identified: 0 / 2
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Failures in staff communication regarding updates and driving guidance, insufficient ongoing driver training, and inadequate supervision requirements for paramedics pose systemic risks.
Date
8 May 2014
56-day deadline
3 Jul 2014 est.
Responses identified
0 of 2
Coroner's concerns
Failures in staff communication regarding updates and driving guidance, insufficient ongoing driver training, and inadequate supervision requirements for paramedics pose systemic risks.
View full coroner's concerns
During the course of the inquest the evidence revealed a number matters that gave rise to a concern that circumstances creating a risk of other deaths will continue to exist in the future unless action is taken.
1. Action is required to ensure that ALL updates and bulletins advertised on the Routine Information Bulletin are seen and read by all relevant members of staff in a timely manner.
2. Action is required to ensure that all relevant staff fully understand that the measures and restrictions included in the Trust’s training and guidance that apply to motorway driving apply equally to ALL multi‐lane highways regardless of their designation.
3. Consideration should be given to ensuring that the role of a supervising paramedic extends to all aspects of their work, including driving, and is not limited to clinical decisions.
4. Consideration should be given to imposing some form of minimum experience requirement before a paramedic is able to act in the role of a supervising paramedic.
5. Consideration should be given to providing to all relevant staff regular, on‐going driver training over and above the anticipated statutory requirement for a five year assessment.
6. Action is required to improve communications between the control room and the personnel within an ambulance that is answering a call.
7. Action is required to improve communications between the London Ambulance Service and those ambulance services which border its area, such as the South East Coast Ambulance Service. RT3589
1. Action is required to ensure that ALL updates and bulletins advertised on the Routine Information Bulletin are seen and read by all relevant members of staff in a timely manner.
2. Action is required to ensure that all relevant staff fully understand that the measures and restrictions included in the Trust’s training and guidance that apply to motorway driving apply equally to ALL multi‐lane highways regardless of their designation.
3. Consideration should be given to ensuring that the role of a supervising paramedic extends to all aspects of their work, including driving, and is not limited to clinical decisions.
4. Consideration should be given to imposing some form of minimum experience requirement before a paramedic is able to act in the role of a supervising paramedic.
5. Consideration should be given to providing to all relevant staff regular, on‐going driver training over and above the anticipated statutory requirement for a five year assessment.
6. Action is required to improve communications between the control room and the personnel within an ambulance that is answering a call.
7. Action is required to improve communications between the London Ambulance Service and those ambulance services which border its area, such as the South East Coast Ambulance Service. RT3589
Report sections
Investigation and inquest
The inquest into Rajesh Parkash’s death was opened on the 19th March 2013 and was concluded, following an adjournment, on 29th April 2014. The cause of death was: 1a – Multiple Injuries. I concluded with a narrative conclusion:
Mr Parkash died as a result of accidentally colliding with an ambulance that had been left parked in a dangerous position obstructing lane 3 of the southbound A3 in Surrey. The driver of the vehicle and the supervising paramedic failed to undertake any or any effective risk assessment of the dangers that the ambulance posed to others by reason of the position in which it had been left. In addition, by leaving or allowing the ambulance to be left in that position, they failed to follow the letter or the spirit of the guidance and / or directions given by the LAS to all their staff relating to their duty to protect the safety and wellbeing of their patients, passengers, and most importantly in this case, other road users.
Mr Parkash died as a result of accidentally colliding with an ambulance that had been left parked in a dangerous position obstructing lane 3 of the southbound A3 in Surrey. The driver of the vehicle and the supervising paramedic failed to undertake any or any effective risk assessment of the dangers that the ambulance posed to others by reason of the position in which it had been left. In addition, by leaving or allowing the ambulance to be left in that position, they failed to follow the letter or the spirit of the guidance and / or directions given by the LAS to all their staff relating to their duty to protect the safety and wellbeing of their patients, passengers, and most importantly in this case, other road users.
Circumstances of the death
At shortly before 10.00 hours on the 14th March 2013 Mr Parkash, a 43 RT3589 year old dentist and father of two, was riding his BMW motorbike southbound on the A3. A short distance beyond the Hook underpass, at which point the A3 is a three lane highway, his motorcycle collided with the rear, nearside corner of an ambulance which had been parked in lane 3 of the A3.
Copies sent to
Richard TraversDATED this 8th day of May 2014RT3589 3
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Report details
- Reference
- 2014-0207
- Date of report
- 8 May 2014
- Coroner
- Richard Travers
- Coroner area
- Surrey
Responses identified
Responses identified
0 of 2
2 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 3 Jul 2014 (estimated).
Sent to
- Association of Ambulance Chief Executives
- London Ambulance Service