Daniel Maurice McMahon
21 Nov 2013 · Coroner Andrew Walker · London
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. trespassing on railway line
“steps should be taken to ensure that when report is passed to the police concerning a person who is seen to be trespassing on the railway line that correct information is gathered to locate that person and the section of the track that person is on so that this information can be passed to those responsible for contacting the network covering that section of the track”
2. patient difficulties during leave
“Consideration to be given to using a feedback form, where a patient is on S17 of the MHA 1983 leave, to be completed by those caring for the patient in the community and the professional staff at the hospital to ensure that any difficulties that a patient has while on leave are picked up”
3. unwell trespasser on railway line
“The Rule book be amended to require that trains stop, (signals are set to danger), when a person who is identified as being unwell or there is reason to believe might be unwell is trespassing on the line”
4. use of bilateral needle decompression without valve
“The LAS consider the guidance on the use of lung decompression needles and whether these should be used with a valve”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“The Rule book be amended to require that trains stop, (signals are set to danger), when a person who is identified as being unwell or there is reason to believe might be unwell is trespassing on the line.”
Later report
“That the RSSB Rule Book allows trains to be stopped only in circumstances where that person may cause damage to a train, but does not allow for trains to be stopped where the person may be in danger form a train.”
Responses
2013-0271-Response.pdf ↗· Department of Health and Social Care
2013-0271-Response-R.pdf ↗· LAS Legal Services
Stated action
“The LAS have reviewed the matter and I hope that you find the following explanation helpful: Purpose of needle chest decompression Needle Chest Decompression forms an important part of the management of chest trauma in the pre hospital environment by paramedic staff.”