Recurring concern

Inadequate training for emergency patient extraction

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First reported 30 Mar 2015•Latest report 22 Feb 2019

Definition

What this concern includes

Includes failures to provide, practise, assess or maintain training and competence for extracting patients or casualties during emergency evacuation or transport, including device-specific drills and alternative extraction techniques.

Not included

  • Excludes routine patient moving and handling, lifting or transfer failures that are not part of emergency extraction or evacuation.
  • Excludes general emergency-response or ambulance training where emergency patient extraction is not the deficient function.
  • Excludes equipment availability, compatibility or serviceability failures where no training or competence deficiency is identified.
  • Excludes clinical treatment, transport or rescue failures after the patient has been safely extracted.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2015–2019

First to latest report issue date

Stated actions
2

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

College of Paramedics1
International Maritime Organization1
London Ambulance Service NHS Trust1
NHS England1
Vantage Drilling Company1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Suffolk

    AI-generated summary

    Jeremy Sutch · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Jeremy Sutch, a trainee driller aboard the MV Platinum Explorer, was crushed by a Riser Feeding Machine and later died in hospital from blunt chest trauma. His evacuation to shore was delayed by difficulties using a wheelchair-type extraction stretcher, raising concerns about crew familiarity, suitable equipment, and the lack of specific evacuation drills for casualties who must remain seated.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of training drills using the wheelchair extraction stretcher

    Wider context from the report

    “In evidence it was heard that there had never been an evacuation drill undertaken on board using an extraction chair (a basket type stretcher and mannequin always being used). Further, the captain said in his 42 years at sea he had never seen a medical evacuation drill, or real medical evacuation using a wheelchair type extraction chair. The fact that the crew were unfamiliar with the wheelchair extraction stretcher needed in Jeremy’s case, led to the follow. • Unlike a basket stretcher the wheelchair extraction stretcher had no independent lifting points so could not be lowered to the tender by crane. • It therefore was necessary to lower the wheelchair in the crane work basket. • The wheelchair stretcher would not fit in the crane work basket and had to be dynamically modified in order for it to fit. • The crane work basket was too large and heavy to be manoeuvred into the rear of the waiting tender (which was fibreglass and risked damage). • The crane work basket was therefore lowered onto the roof of the tender wheel house. • The wheelchair stretcher would not fit down the spiral stairs leading to the passenger/casualty space inside the tender. • Initially the tender tried to make shore with Jeremy on the roof of the wheel house but the handrail began to give way in heavy-seas so the tender had to return to the lee ward side of the MV Platinum Explorer. • Despite his injuries Jeremy had to physically lower himself one step at a time into the passenger space of the tender before he could be taken ashore to receive medical attention. It was clear from the evidence that the issues identified above led to delay in Jeremy’s medical evacuation. It was also clear that without Jeremy’s own personal strength and determination he would not have been able to get inside the tender to be taken ashore. It was confirmed by a forensic pathologist at the inquest, that in his opinion Jeremy’s injuries were not survivable and that any delay in his medical evacuation did not affect the tragic outcome of this case. That said, I am concerned that should a similar situation arise with a casualty whose injuries may be survivable, their chance of survival would be reduced by the delays caused by the difficulties identified in this case. I am also concerned that other captains on other ships may be unaware of the difficulties posed in the medical evacuation of a casualty when The Ship Captain’s Medical Guide dictates that they must be kept in a seated position. I am further concerned by the apparent lack of knowledge of this type of casualty extraction device, which in turn resulted in an apparent lack of training drills designed specifically with its use in mind. ”

    Source location

    Jeremy Sutch · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Include medivac chair-type stretcher evacuation in drills every six months, with lessons captured and compliance audited through the safety management system.

    Verbatim wording from the response

    “Since the event involving Mr Sutch, evacuation using wheelchairs have been included in evacuation drills (see below).”

    Source location

    2019-0065-Response-by-Vantage-Drilling-Company
    Page 1 · response
    Published 2 June 2019

    Open published response

  2. Inner North London

    AI-generated summary

    Sabrina Stevenson · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Sabrina Stevenson, aged 28, died on 16 December 2012 from a ruptured ectopic pregnancy after delays in ambulance response and assessment. The report identified concerns about ambulance response times, staffing vacancies, outstanding training issues, the absence of certain call-handling and clinical systems, pre-hospital assessment, extraction techniques, and governance processes.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Insufficient crew knowledge of alternative patient extraction techniques

    Wider context from the report

    “(3) Several training issues were prominent at the inquest and evidence has been provided as to how some issues have been addressed. However, I am concerned that some training issues remain outstanding; (a) I heard from the consultant Gynaecologist that all women of child-bearing age, with abdominal pain, should be considered to be pregnant, until proven otherwise through pregnancy testing. This contrasts with the training material provided by LAS and also with their stance on not (currently) testing for pregnancy on the scene; (b) Given the issues raised by the independent expert regarding extraction techniques, I remain concerned that the crews had insufficient knowledge of alternatives steps, which could have been taken to remove Sabrina to the ambulance; (c) Evidence has been provided that specific training ‘case studies’ will be or have been published on the issues of ectopic pregnancy and transient capacity. Given that issues arose during the inquest, as to whether such case studies appropriately covered the relevant points, I seek confirmation that these case studies have been published (through provision of copies), so that I can be reassured that these training issues have been addressed; ”

    Source location

    Sabrina Stevenson · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Issue a clinical bulletin reminding staff about alternative methods and resources for moving patients from scenes.

    Verbatim wording from the response

    “The advice from the Medical Directorate in the Clinical Routine Information Bulletin to be issued on 26 May 2015 to all staff is given below.”

    Source location

    2015-0126-Response-by-London-Ambulance-Service
    Page 4 · response
    Published 30 March 2015

    Open published response
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Data last updated 7 September 2026