Source · Prevention of Future Deaths

Rachel Burke

Ref: 2014-0074 Date: 25 Feb 2014 Coroner: Andrew Harris Area: London (Inner South) Responses identified: 1 / 6 View PDF

An adventure company misrepresented ascent altitudes, leading to unsafe rates for altitude sickness prevention. The trek leader prioritized cost over urgent medical care and failed to appreciate illness severity due to inadequate training.

Date 25 Feb 2014

56-day deadline 22 Apr 2014 est.

Responses identified 1 of 6

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Coroner's concerns

AI summary

View full coroner's concerns

During the course of the inquest the evidence revealed matters giving rise to concern. _ (1) The Adventure Company (TAC) Everest Gokyo Lakes Trek had advertised the ascent from Namche Bazaar at 3440m to Dole at 3780m, when in fact it was 4050m_ This was an ascent of 610m in one day, whilst its preferred code of practice identified Jhat ascents should be a maximum of 300m per An expert in mountain sickness { Isaid that the speed of ascent was the one factor that limits the incidence of altitude sickness. He that the sleeping altitude (above 3000 metres) should never be more than about 300 or 400 metres above the previous night and that every 3 days or 1000 metres of additional ascent, an additional rest would be needed. He described the ascent to Dole on this trek as excessive, being double the safe recommended ascent rate. It was noted that TAC hold a high altitude trek in Peru where the limits are strictly complied with, due to local legislation.

(2) The HE trek leader was concerned about the costs of accessing services from the Health Centre and of making satellite phone calls, possibly mindful of the TAC manual for overseas group leaders, which states under "emergency" on page 20, that priority must be given to finding a cost effective solution: Despite having a satellite phone at Machermo and being 12 minutes from a health post; neither was used, when the trekker needed urgent medical care.

(3) The severity of her illness was not appreciated by the trek leader: The expert said that it was very well known in the trekking community that people were loathe to admit they were as ill as they were and that a good mountain guide was as capable of picking up the subtle signs of mountain sickness as most doctors. Nevertheless, this severely sick trekker with ataxia and cyanosis, signs f HACE and HAPE, was asked by the trek leader to descend under her own steam with a Himalayan Encounters guide who had inadequate or no training in acute mountain sickness_ This should not happen, the expert said, since exercise worsens HAPE: Ideally she should descend passively or be treated at the health centre. The information about the training of each leader and was not passed to TAC who assured themselves of the adequacy of training by statements of general compliance from HE: Whilst the companies report that action has been taken to address there may remain a similar risk for other trek organizers _ (4) The cause of death was found to be High altitude cerebral oedema and high altitude pulmonary oedema: Coronary arteriosclerosis did not cause death in this 28 year old, despite that found by the autopsy in Nepal: 20"h _ day guide day: said day guide this, being

Responses

1 respondent

The Family Adventure Company

14 Apr 2014 PDF

Action Taken

The Adventure Company has reviewed its Nepal high altitude treks against Wilderness Medical Society guidelines and implemented changes to reduce some altitude increases, to be fully implemented by the start of the new trekking season in September. They have also removed a manual that referred to finding cost effective solutions. (AI summary)

View full response

Dear Dr Harris Inquest touching the death of Rachel Ann Burke write in response to the Regulation 28 report to prevent future deaths touching on the death of Rachel Ann Burke. In section 6 relating to action that should be taken the report detailed two areas for The Adventure Company to address regarding the itineraries and information provided to passenger and the knowledge of trek leaders in reference to travellers' health insurance and the accessing of medical services. Regarding the rate of ascent and altitude between sleeping altitudes The Adventure Company has reviewed the expert guidance provided. The Wilderness Medical Society consensus guidelines provide suggested approach to AMSIHACEIHAPE prevention: These guidelines state that above 3000m people should not exceed 500m gain in elevation between sleeping elevation and to include acclimatisation days where there is no gain between nightstops every 3 or 4 days_ We have reviewed all our Nepal high altitude treks against Wilderness Medical Society guidelines Whilst trips had been designed and running with safe ascent levels in mind we were able to identify a couple of adjustments to reduce some of the altitude increases_ The changes identified have been implemented on the ground the end of the current trekking season and will form part of our published itineraries for the start of the new trekking season in September: In some circumstances the Iocal infrastructure available for commercial group trekking means that it is necessary to exceed the 50Om a day guideline provided by the Wilderness Medical Society: We only do this on what are generally considered to be well established, standard routes_ In line with the recommendation made by the Coroner where this does occur we have now introduced additional information regarding this into our Notes for the relevant treks_ This information highlights the higher increase on these days s0 our trekkers are fully aware of the strenuous nature of the trip and the larger ascents included: Our Trip Notes hold the full description of the trip and are available to all passengers prior to their booking a trip as well as being sent to them as the key element of our literature for a particular trip. The information from the Wilderness Medical Society along with input from medical professionals, high altitude trekking and expedition safety experts are Advenlures Woeltxide Ltd trading as Tie Adventure Company memhe of PFAR Adventur? Travel GroupLid_ Rejisrered Olfke: TUI Trarel Xouse Crailey Businass Qvartec Fleniing Wa% Crarley West Sussec RHIO SQL {p{ease do nol send any correspondence this adress) Registered: England _ (Yales Fo: 1826936.VAT No; 103 2168 35. Th? Adrenture Ccmpany is an Appo nted Fejxesentative Campb:"l Irvinaitd #hoare aurharised znd tegulated b; the Financial Services Authority: ABTA Thiscan be checked cn the FSA $ rejgister b} visiting WirirJsagov utreg ster = Dy caling (245 605 123+. Ocn IATA ABTA No.Y0766 Pillory We gains the daily for Trip being Ps9 -

incorporated into a new protocol for our high altitude treks_ This protocol is designed to not only to look after the safety of our passengers but also reflect the logistical realities of operating high altitude treks around the world. This protocol will be used forithe ongoing review of our trips as well as the standard for designing new itineraries any With regard to the knowledge of our trek leaders in respect of the travel insurance that passengers have we have reviewed the information and training that is provided to our trek leaders This has always formed part of the training for our leaders and is incorporated into not only the initial training provided but also our ongoing refresher training It is made clear to leaders that passengers take out fravel insgranceehetwei cover them for necessary medical expenses whilst on treks, It is further emphasised that the primary concern is always the safety and wellbeing of the trekkers decisions in this regard are to be made to provide the most suitable and effective remedy and not based on relative cost_ Further guidelines on always consulting any nearby medical posts, such as the one at Macchermo, in cases of illness, inability to continue with trip or suspected AMS have also been in place_ The general TAC overseas leader manual that did refer to finding cost effective solutions to more general situations has been removed from circulation to avoid any possibility of confusion in this regard. hope the above is of assistance_ If can be of any further help, please do not hesitate to contact me_

Report sections

Investigation and inquest

On 8h November 2011 opened an inquest into the death of Rachel Ann Burke, aged 28 years, date of death 23r April 2011. The inquest was concluded on 15th January 2014. The cause of death was found to be High altitude cerebral oedema and high altitude pulmonary oedema: A UK Professor of Pathology gave evidence (citing internationally recognized Davies criteria) that Coronary arteriosclerosis was very unlikely to be present in an athletic 28 year old and that it did not cause her death, despite that being found by the autopsy in Kathmandu on 25"h April 2011 (ref 68-0047). However the state of the coronary arteries were not recorded, nor was histology studied by the Kathmandu Autopsy Center, which would be expected if such a rare finding were suspected.

Circumstances of the death

Ms Burke went on a high altitude trek in the Himalayas in trek organised by Himalayan Encounters (HE) with guides and experienced leader_ She made an ascent of 600m from Nanche Bazaar to Dole (day 6) on April: The next she was slower than others and developed breathlessness and fatigue. Later she developed central cyanosis. She slept poorly, having to be upright and in the morning of 22n April she was ataxic, cyanosed, unable to eat properly or do her shoes. She was slow in admitting her health problems and was reluctant to descend. She had High altitude cerebral oedema (HACE) and high altitude pulmonary oedema (HAPE) that were not recognised. She did not attend the health post some 12 minutes away but descended with support to Dole, but making very poor progress. She was found on the way to be confused and despite treatment on the slope by passing doctor and barometric oxygen in Dole, died later at 00.45 in Dole from HACE and HAPE Factors contributing to her death were non recognition of HAPE and HACE at Machermo, walking under her own steam down to Dole, sending her down the mountain with a unfamiliar with acute mountain sickness and her not attending the health post in Machermo, about which the leader but not herself knew: Not taking her to the health post amounted to neglect:

Action should be taken

(1) The Adventure Company, Himalayan Encounters and British Tour organizers should consider for high altitude treks: a) ensuring that planned treks comply with the limits of ascent in one day, and rest and other safety requirements in the consensus qluidelines approved by the Wilderness Medicine Society, (as recommended by_ and b) where, because the terrain does not permit; informing trekkers who book when treks do not comply with these guidelines and the steps taken to mitigate the risk so that may take informed decisions about their participation: (2) TAC and Himalayan Encounters and tour organizers for high altitude treks should consider reviewing the knowledge of and guidance to trek leaders about the health insurance of trekkers and the cost of accessing health and emergency care, so that cost considerations do not prevent appropriate access to medical advice and care. (3) The Government of Nepal may wish to consider whether it would wish to take any action to assure visitors and UK travel companies on three matters: (a) either legislative prescription of trek safety requirements (as in Peru) or guidance to Nepali trekking companies, of the safety of treks, especially with regard to ensuring that planned treks comply with the limits of ascent in one and days rest, as approved by the Wilderness Medicine Society, and (b) that trekking organizations ensure their leaders are not disinhibited from enabling access of insured westerners to medical and rescue facilities , and (c) either by enquiry or guidance about the adequacy or independence of pathology services for trekkers, in light of the apparent error or invalidity of the autopsy report in the Kathmandu Autopsy Centre.

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Report details

Reference: 2014-0074
Date of report: 25 February 2014
Coroner: Andrew Harris
Coroner area: London (Inner South)

Responses identified

Responses identified 1 of 6

5 responses not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 22 Apr 2014 (estimated).

Sent to

ABTA - The Travel Association

Himalayan Encounters

Ministry of Culture, Tourism and Civil Aviation

Adventure Company

Association of Independent Tour Operators

Federation of Tour Operators

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.