Source · Prevention of Future Deaths

Janet Richardson

Ref: 2013-0261 Date: 16 Oct 2013 Coroner: David Roberts Area: Cumbria (North & West) 2 responses identified · 3 indexed addressees View PDF

AI-generated concerns summaryThe coroner noted concerns regarding the circumstances in which the deceased fell into the sea during a medical evacuation rescue.

Date 16 Oct 2013

56-day deadline 11 Dec 2013 est. estimated from the report date

Responses identified 2 of 3

Other related deaths

Coroner's concerns

AI summary

The coroner noted concerns regarding the circumstances in which the deceased fell into the sea during a medical evacuation rescue.

View full coroner's concerns

That the deceased fell into the sea during a rescue medical evacuation

Responses

2 respondents

Newmarket Promotions Ltd

PDF

AI-classified response stance Noted

AI-generated response summary

• The respondent's clients will ensure that the Coroner's recommendations are forwarded to their suppliers, including Cruise Maritime Services International Ltd (CMV). • The respondent's clients will request that their suppliers implement the forwarded recommendations.

View full response

NHL NZJJ uopuo7 783/S peoig PIO SZ 'Zv Jamog "pI7 sileIxaH ,8JI0 pavaisifad L8COLS JON Davaisifay - KUOVIV uojeinbay SJIpIOS &41 /q pajembed pue pasuouinv 3210 SIUI /2 uoijjadsul JOJ uado Sjojjaip /0 ISIY 6229890 'ON pajaisibiad S3j2M pueigug pajaisiGa) p3lQWuI7 e S1 PI7 SieixaH "awes a41 quauaidu Kayl 1eyi bunsenbar 'AWJ asinov jo buipnjoui 'sjaiddns sjuaipp Jno 0} papiemuoy auJe Juapioui sl4 buimoloy J3uQJo? suoilepuauuojaj 42ns 1241 aunsua IIM sjuai? Jno ua4} 'suovepuauuooal Uieue) pajsabbns pue pajapisuov pue 'AWJ pug SOQO4nty a25a4 UBibeMON &4 WOJ} pJeay se4 JauojoJ &4 &uo Je4 paieoipui BEY sjuaip JnO quapioul %iben pue ajeunuojun si4 01 pJebaj 4IIM AWJ 0} awejq Kue uouodde 1OU pIp Jauojoj 841 124} AWJ WQU puejsjapun sjuaip Jno "sanbui a4 buimoioy 8,J8u0103 341 JOJ &AeS eejd Yoo} JeYM Apexa 01 se abpapoux payuij 912y pue JeysueJ} /enj2g 84} Ul paNOAUI JOU 8J3M sjuai? Jno 'saunpajojd Kquabiaua J0 ajeme 4bnoyv saiuounv anosa& a4J0 spuey a41 U1 aq pinom sainpaooud 42nS Jo J0JUOJ &4 434 sainpajoud uogenoeaa jeoipau pueoquo yons 01 puebeu 4IM 'Kjeaio 'paseajap 341 6uOAUI Jajsuej} djys 0 diys a41 0J puebau 4M AW? pue Sauoyinv a3sa3 UeibaMJON a4} 0} UaHIM osje 312Y 8140 $,Jauojo3 84 1e41 puejsjapun #M {(Jaleuiajay AWJ) sabekoA awuew 8 &sinu3 SYIL pI7 Ieuoueuajui SOJIN8S &uQIeW 8S1n2 'S8Q13S asinj? yons jo Japioud &4 pue sjuai? Jno 4bnojy Kepioy asinuo Jia4 pabuejje "pueqsny Jay pue 'uospuey?ly Jauer 'paseajap a41 'Jalal 87 uolepn6ay &4 0} esuodsaJ e 0 pebau 41M suoijonuisui ,sjuai2 Jno u8x21 8ABY &M pue pY7 SUOJOWold IBxEWMaN Jo Jieyaq UO JO 0} anuijuo? &M "p17 suolouold IaXEUM?N 'Juaipp S,WJY S144 01 pessaippe Jajal 82 uoleinbad buisojoua €LOZ Jagopp0 91 pajep Jejjai Jnok JOY nok xueyL ElOz 7aqopo Glivl Tsanbul Tpaseabad) uospieypiy iauer JIS Jeaq ELOZ Joquavad V Ls6gl+LSBOZIg3CNX 'ay Jno !WSOPIZIIOXI47Q Jay Jnoj 1OO ElVO euqung 4inoujaxpo? peoy Ybnjdue7 + poomjuog SSZVZ[ Xa xed ssauisng puejaxe7 3 pue @S 62LO ZSEL Oz (0) +++ ?[u1speq JaU0Jo) Joiu8S WH O020 Z8EL O7 (0) +++ >uoyd?pL suaqoy 7 pIAeQ JWN 4JS €IWJ xossy 'pOOMJuJJJ KapJeM1 Jea.) 'J41J( 341 *JsnoH %3piqn[ 51O1?TOS a17 STTVLXHH 3e Kueduoo 341 WoJ sbuipuv

307*9l0rrwz9rizttt OTSTIXAH Kunlyley sm0A 'sn IDeJu03 0} aelisay JoU pInoys aJ0 SJauojog 941 ua41 Jauojo3 a41 01 aueisisse Jayuny Kue J0 &q uej sluaip? Jno JI 'WJaJUl &41 UI suollepualwojal S,auojoo 341 01 puebax 4im ajio S,auojoo ay1 WOJY buueay 01 PJEMIOL Yoo| ajojajayl #M 0l75pi*h

Cruise Maritime Services International Limited

PDF

AI-classified response stance Action Taken

AI-generated response summary

• The respondent stated its existing procedure is to follow the procedures set out by the appropriate rescue service during a rescue operation. • The respondent noted that the Norwegian Rescue Service has changed its procedures since the accident. • The respondent committed to following the new procedures adopted by the Norwegian Rescue Service for future passenger transfers to their vessels.

View full response

"TS6 27/coquani7 'ajenbs s,nve 75 ON j0 0jHio paja1siba4 SII 6/07120 Nuowinv uoneinbay {ojpijos a4} Kq paleingau pue Pasuoyine 51 d77 uosuIDIA IH Jaqlunu pajjjsi6*u 4iim Saiem PUr pueibu3 pauaisBa diysjauled AJliAe I Pallur 477 uosunjia IA uopuo7jo N1ID OSS Xa "Plalays pue Jais34duew 'Ioodjanr7 'Oxcuow 'ajodrfuis 'snaelld 'uopuo7 Pvll E82L Oz(0) 77+ XeJ so3uh40 Sc4 dnoj? 5o3i4a5 [06a7 uosuIYJIA IIIH B4L EE06 EBCL Oz(o) vv+ 'IaL WOD UOSUIXJIPIIIY MaZ V233 uopuO7 1aa415 asOJUUd 0z Jamol ajebpeoj8 d77 uosuix?ia IiiH ajinuaS anosaj eeudoudde 34} Kq 1no Ja8 sajnpapoud 841 MOIIO} 0} Sl 'siasse4 enosaJ 0} suabuassed jo suajsuen Jaylo Ile 0} uolleiaj Ul pue Iessa^ anosaj e 01 Jabuassed e JO Jeisuel} Sl4} 0} uolleje Ul AW? Kq paidope aunpapoud 'aJolejayl "8Jll Jo sso| ua^a pue Kunlul 'uoisnjuos 01 peai pino? sI4L uonejado aosa! 34} Ino Bulke) ISIIYM 32INJas anosau 841 Kq pajdope &q pinoys J2Y} saunpajoud aoinas an3saj a4} 01 aiepoip 04 "331nu8S anoseJ 34} WOJI ajueisisse paisanbaj SeY 1eY} (ess3^ Jay1o Kue paapul J0 'diys asinuo e JO} aeudojdde joU S! Hl suoilipuo? a4} pue Iassa^ anosa] 341 JO azis a41 'sunojo anosal 34} 4JI4M UI SOQuEISUn?JI? a4} uodn Buipuadap saunpajoud Juauaip a1EY sajinaS anosal Juajalia "PHJOM a41 Ul aJayMKuz eeid Sl uollejado anosaj uaym uoneniis Ieujou a41 SI SI4L 'uoneJado &n3s81 84} Jo |0JJUO? Ul aJaM 3J1NOS &nosay ueibaMoN 84} 1ey} Isanbul 841 Je Jeajj apeW sem 1!l Jey} uojuido &41 Jo aje pue anaileq Kibuojs AW? Kojdep auo pue aoioeud aiqe1dajoe UE SEM SIOUX L Ie Jay1ab0} builiaeJ} siassan 41oq Kq 1paja uollons a41 1ey} paidajoe SeM Mebo_ JM JO ejuapia 2y1 'Jayiabo1 pal} uaaq #^BY pinoys sjassa^ 841 Jayieym 0} se anssi 01 uollejaj UI pue spoyjauu aNIoadsaj a41 Jo sabejueapesipisabejueape &4} u3N6 Ienba seM uolenoeia Jie 01 pajeduoj ajuajajajd JO suJa} uI uollenoeaa J0 poyiau 1ey} eiqeuoseaj Kjajllua SEM anosal U! pasn 431e4 a41 1e41 papnijuo? SeM 1! Jey} a1ou AW? 'paapul 'AW? Jo Muewuns J0 Juauabpnf Jnof Jaylia U! Jlasunof Kq pasieJ uaaq bul1BY suusipiluu? Kue Kqluapi Jouue? pue Isanbui 84} Je papinoJd aouap1a 34 [eMH Tuo4u1G] 'Iasuno? Jia4} 4JM uoljounjuo? Ul pamaiaJ 31eY AWJ Kunlui Bulayns slualed J0 YSu 341 buisqujuju 01 MOi^ e Yiim suollenoeaa Ieoipau diys 01 diys 01 Buneja1 Juaudinba pue Juaussasse XSU sajieud 'saunpapoud MalaJ 0} Sl Jsab6ns noK uoljoe 341 1e41 pue UOlpe Yons axe} 0} JaMod 341 sey AWD Je4} 'syleap aJniny Ju?AaJd O} Uaxe} &q pinoys uonoe uojuido Jnof U! Je4} pue uolleneia Ieoipau ansaj e buuunp eas &4} OJul Ilay paseajap &4} 1BY} Sl UJaouo? Jnok Je4} &ou AW? "Janal 82 uoneinbaJ Jnok 0} puodsau 0} Jleyaq J8y} UO pajonusul ua3q 8BY # '(AW?,) sabeko^ aWIeW pue asinu? se buipeJ} 'pa1ul7 IBUOIJeUJBJUI SaJineS aunueW pue asinu3 'Juaip? S WJI S/4} 0} passauppe Jalal 87 uojeinbal Buisoppua €LOZ Jaqo1pO 91 pejep Jeval Jnok JOy nok xueyl Eloz Jaqo1jo Sllvl Jsanbul (paseazap) uospjey?iy Jauer JIS Jeea saippe? uyor JO} yse aseald 4nobrejqunJ@nsamyuoujouoojuy "Ilewa Kq 8 1sod Ka WOJ uosuxoiplYosaippes uyol 1OO €lVO 0626 O8ZL Oz(0) +i+ :aur7 1oajial euqun) 'Yinoujaxoo3 SLOZ Jaquajad 9 :&1ea peoy Ybniduue7 1 Ol8veeizi xed ssauisng puejaxe7 3 pue @ $ VS C6z6VHD@'OrV "48y Jno Jauojoj Joiuas WH LL/EObfioaw47a " Joy Jnox suaqoy | 7 pleG JW NOSNIYDIA 77IH ju ay1 'Kelap 3y1 buixel Kay} a4y1 ay1 9y1 "d

477 uosulxpia IIIH Kvingywe} sinox "eo1nu?S onosey ueibaMON 941 Kq paidope saunpaoojd Mau a41 MOIIO} IIIM aM 'IeSsa^ $,aJ18S anos8y ueIbaMON e 0} paajsueJ} aq 0} /assa^ AW? E LOJI Jabuassed e JOL paau e SI 3J84} !! auniny Ul !! OS pue 6upun33oaJ WOJ} JuapIpDE SIY} JUBAaJd 01 Japjo Ul saunpapojd Ji8y} pabuey? B1EY O3iN8s anosay UEIbaMON ay} Juapioje S1y1 &juis 1ey1 pueisjapun #M

Report sections

Investigation and inquest

On 28th April 2011 commenced an investigation into the death of Janet Richardson DOB 10/08/1938. The investigation concluded at the end of the inquest on 15th October 2013. The conclusion of the inquest was On the 29uh March 2011 whilst on holiday aboard a cruise ship in Norwegian waters the deceased became seriously unwell It was necessary to get her ashore for Hospital treatment: It was decided that she be transferred ship to ship On to the aft of the rescue boat whilst strapped to a stretcher: In the process of transferring the stretcher the rescue boat moved away from the side of the cruise ship. Those on the rescue boat holding one end of the stretcher were no longer able to maintain their grip. Those On the cruise ship retained their grip slightly longer: The stretcher swung back against the side of the cruise ship into a vertical position and then it and the deceased fell into the sea. The deceased came free of the stretcher: She was pulled from the sea some minutes later and transferred to a Hospital on the Norwegian mainland. During the transfer the deceased was wearing life jacket or buoyancy aid The stretcher was not attached to any line Or rope. The two vessels were not tied together. After medical treatment in Norway the deceased was transferred to the Cumberland Infirmary; Carlisle on the 13"h April 2011 where after further medical treatment she died On the 21s April 2011. The deceased had a medical history of Chronic Renal Failure. Diabetes high blood pressure_ She had had two recent Hospital admissions in the previous December and January-She died as a consequence of her pre-existing chronic medical condition; the cirrhosis of the liver well established not and being

The immersion in cold seawater was a serious and significant factor in her death. Although the primary cause of her death was due t0 her
-existing cO-morbidities, on the balance of probabilities, the accidental plunge into the sea accelerated her death.

Circumstances of the death

Are as set out above_

Action should be taken

In my opinion action should be taken to prevent future deaths and believe is to your organisation have the power to take such action_ The action to review the procedures practices risk assessments and equipment relating to ship to ship medical evacuations with a view to minimising the risk of the patient suffering injury whether by the patient entering the sea or by other means

Copies sent to

duty days

Similar PFD reports

Shared signals

Report details

Reference: 2013-0261
Date of report: 16 October 2013
Coroner: David Roberts
Coroner area: Cumbria (North & West)

Responses identified

Responses identified 2 of 3

1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 11 Dec 2013 (estimated from the report date).

Sent to

Cruise and Maritime Services International Limited

Newmarket Promotions Limited

Redningsselskapet

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

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