Recurring concern

Unreliable emergency evacuation arrangements for people requiring assisted removal

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First reported 30 Oct 2015•Latest report 14 Jul 2023

Definition

What this concern includes

Includes dedicated arrangements for assisted emergency evacuation or extrication of people unable or unwilling to leave independently, including planning, participant or resident-specific evacuation needs, evacuation facilities and equipment, local-agency coordination, drills, testing, auditing and implementation across organised trips, residential accommodation and comparable settings.

Not included

  • Excludes ordinary evacuation routes and emergency egress where no need for assisted removal or person-specific evacuation arrangement is identified.
  • Excludes generic emergency-service response, ambulance attendance or hospital treatment failures after a person has been safely evacuated or extricated.
  • Excludes general risk assessments, staffing, training or audit deficiencies that are not directly part of assisted emergency evacuation or extrication arrangements.
  • Excludes routine transport or patient-transfer failures where no emergency evacuation or extrication requirement is involved.
Reports
3

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2015–2023

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.

Cygnet Newton House1
HM Prison and Probation Service1
International Maritime Organization1
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. Northamptonshire

    AI-generated summary

    Sean Anthony Heeney · 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

    Sean Anthony Heeney was found unresponsive at Bridgewood House on 22 September 2019 and died in hospital on 26 September 2019 after suffering cardiac arrest during efforts to extricate him from the building. The principal concerns were delays caused by the lack of a clear extrication plan, the building’s restrictive layout, and the absence of a plan for evacuating a person unable or unwilling to leave during a medical emergency. The inquest narrative also stated that the initial emergency call was incorrectly categorised and that ambulance staff did not properly appreciate the seriousness and urgency of his condition.

    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

    Failure to maintain a first-floor medical-emergency extrication plan for residents unable or unwilling to leave

    Wider context from the report

    “The evidence suggested a lack of a clear or settled plan amongst the EMAS personnel and police officers as to how Mr Heeney was to be extricated. This caused a delay in removing Mr Heeney to hospital. Whilst I recognise that any extrication is unlikely to be something done by the Approved Premises staff on their own or at all, I am concerned that Bridgewood House did not and still does not have a plan on how to extricate from the first-floor of the building a person who is unable and/or unwilling to leave in the case of a medical emergency. In this respect, I note the following: 1. The layout of the building and the restrictions which that creates was and remains a known issue: a former manager of Bridgewood House described how it did not take “any residents with mobility issues, because of the stairs”. 2. HMPPS have identified a requirement for Personal Emergency Evacuation Plans. I was referred to the ‘Approved Premises Safe Working Practice Document’ for Bridgewood House which provides: “Personal Emergency Evacuation Plans (PEEP) must be put in place for any building user who would encounter a problem and need assistance in exiting the building in an emergency. Staff must be aware of individual residents and colleagues who are on PEEP. Separate PEEP forms are for both staff and residents.” 3. HMPPS have properly identified that individuals recently released from prison have a heightened risk of accidental overdose as they may have lost tolerance to drugs which they had previously used. This is reflected in the induction paperwork provided to residents at Approved Premises. 4. It is to be anticipated that residents within Approved Premises may be more reluctant to cooperate with emergency service personnel, in particular the police. This may make extrication more difficult. 5. It is to be anticipated that residents who have overdosed may be administered Naloxone. This is reflected in HMPPS’ roll-out of Naloxone to all Approved Premises since Mr Heeney’s death. As witnesses explained, a known side-effect of Naloxone is increased agitation. ”

    Source location

    Sean Anthony Heeney · 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

    Consult local emergency services to prepare a recorded plan for evacuating medically incapacitated or unwilling people from Bridgewood House.

    Verbatim wording from the response

    “In response, please be assured that Bridgewood House Approved Premises is consulting with the local emergency services on the preparation of a plan to deal with evacuation from the building in a medical emergency. As you helpfully identified the extrication itself is something that would not be undertaken by the Approved Premises staff but it is accepted that a clearly recorded understanding between the agencies involved in such a procedure should ensure a successful evacuation should a similar situation arise in the future.”

    Source location

    Response from HM Prison and Probation Service
    Page 1 · response
    Published 21 July 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Approved Premises staff will not undertake medical-emergency extrication; local emergency services are responsible for this evacuation work.

    Verbatim wording from the response

    “In response, please be assured that Bridgewood House Approved Premises is consulting with the local emergency services on the preparation of a plan to deal with evacuation from the building in a medical emergency. As you helpfully identified the extrication itself is something that would not be undertaken by the Approved Premises staff but it is accepted that a clearly recorded understanding between the agencies involved in such a procedure should ensure a successful evacuation should a similar situation arise in the future.”

    Source location

    Response from HM Prison and Probation Service
    Page 1 · response
    Published 21 July 2023

    Open published response

  2. 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

    Failure of casualty evacuation arrangements to enable timely transfer of a seated casualty

    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

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The incident was highly unusual, and no industry advice or practice indicated that similar operators should take a different approach.

    Verbatim wording from the response

    “Since this event, Vantage has reflected upon all of the facts of the incident as identified by various investigations (including the Coroner’s own) in order to learn as much as possible. Vantage is always concerned to ensure that its evacuation procedures are fit for purpose, affording those injured the best opportunity to reach expert medical attention in the most timely fashion. It is not possible to foresee and anticipate every possible scenario (hindsight provides no illumination on the situation) and it is important to recognise that what happened on board the Platinum Explorer was fact specific and highly unusual, being outside the experience of every experienced Mariner.”

    Source location

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

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Vantage considered its medic provision and recognised-agency emergency response plan an adequate response to the evacuation risks.

    Verbatim wording from the response

    “I. Vantage arranged for a medic to be on the vessel despite this not being a requirement; II. Vantage’s MERP involved a recognised international agency as a partner (Vantage were doing things properly); III. Vantage are not aware of any advice or industry practice to suggest other operators involved in similar operations, in similar environments, have been taking a different approach; IV. Patient extraction from a whole range of occupational settings, even ashore, is often compromised and at least challenging. Speed of response, whilst always desirable, cannot always be achieved or guaranteed because not all factors which impact on speed of response can be controlled. Even ashore, ambulances may be delayed by traffic or weather conditions or simply by demand exceeding supply; V. Air ambulances are not a state funded provision in all areas, less still an infinite resource; VI.”

    Source location

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

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Vantage could not guarantee faster patient extraction because response speed depends on external factors it cannot control, including traffic, weather and demand.

    Verbatim wording from the response

    “I. Vantage arranged for a medic to be on the vessel despite this not being a requirement; II. Vantage’s MERP involved a recognised international agency as a partner (Vantage were doing things properly); III. Vantage are not aware of any advice or industry practice to suggest other operators involved in similar operations, in similar environments, have been taking a different approach; IV. Patient extraction from a whole range of occupational settings, even ashore, is often compromised and at least challenging. Speed of response, whilst always desirable, cannot always be achieved or guaranteed because not all factors which impact on speed of response can be controlled. Even ashore, ambulances may be delayed by traffic or weather conditions or simply by demand exceeding supply; V. Air ambulances are not a state funded provision in all areas, less still an infinite resource; VI.”

    Source location

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

    Open published response

  3. Blackpool and the Fylde

    AI-generated summary

    Dennis Peter Stark · 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

    Dennis Peter Stark, who was detained at a rehabilitation unit, was found unresponsive in his second-floor bedroom on 27 May 2014 and later died after developing pneumonia and hypoxic brain injury. The report raised concerns that the absence of a lift and the difficulty of removing a person of his size from the second floor could delay emergency treatment and pose a risk to future patients requiring urgent medical attention.

    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 suitable means for safely removing people requiring urgent medical attention from second-floor accommodation

    Wider context from the report

    “1. During the course of the Inquest I heard evidence from a Paramedic Reynolds who had been called to Regency House (now Newton House) which is a rehabilitation unit that cares for individuals with mental health issues, Mr Stark having previously been diagnosed as suffering from schizophrenia. He was an obese gentleman who weighed in excess of 30 stones, and he had been found unresponsive in his room. He was residing in a second floor room at the premises. The premises have no lift. The Paramedic indicated that after her arrival, there followed a period of time during which Mr Stark had no pulse and required Cardio Pulmonary Resuscitation. However, once a pulse was noted it then took the ambulance crew approximately twenty-two minutes to leave the scene. She clearly felt that the time it took the crew to leave the premises was contributed to by the absence of a lift in the premises and to the extent that she felt at least half of the amount of time it took to leave the scene could have been avoided had a lift been in place. In reality Mr Stark had to be transported with some difficulty from his room, down some steps, and out to the ambulance and then taken to hospital. It could not be established from the evidence whether that increased amount of time contributed to Mr Stark’s eventual demise but I am concerned that a risk of future deaths may arise should someone requiring urgent medical attention be accommodated on the second floor of Newton House whose physical status is such that safe removal of that person from the building may be compromised and leave paramedics in similar difficulties. Although evidence was provided by the Nursing staff that when this gentleman was mobile he was able to use steps at the premises to get around, it appeared to me that there had been insufficient thought given to the prospect of him requiring urgent medical attention and whether his size may hinder his removal, particularly in the event of an emergency. ”

    Source location

    Dennis Peter Stark · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026