25 Feb 2014 Rachel Ann Burke · Prevention of Future Deaths report Inner South London
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Concerns raised 5 Failure to use available urgent medical services and communications View source Failure to recognise the severity and subtle signs of mountain sickness View source Failure to limit high-altitude ascents to safe rates View source Failure to ensure and verify guide training in acute mountain sickness View source Failure to provide passive descent or health-centre treatment for severe altitude illness View source See 2 more concerns
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Rachel Ann Burke · 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
Rachel Ann Burke died in Dole, Nepal, after developing high altitude cerebral oedema and high altitude pulmonary oedema during a Himalayan trek. Concerns included an excessive rate of ascent, failure to use a nearby health post or satellite phone for urgent care, failure to recognise the severity of her illness, and sending her to descend under her own steam with a guide who had inadequate or no training in acute mountain sickness.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Intrepid Travel Group UK Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to use available urgent medical services and communications
Wider context from the report “(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 Macheremo and 12 minutes from a health post, neither was used, when the trekker needed urgent medical care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Intrepid Travel Group UK Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise the severity and subtle signs of mountain sickness
Wider context from the report “(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 of 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 guide 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 this, there may remain a similar risk for other trek organizers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Intrepid Travel Group UK Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to limit high-altitude ascents to safe rates
Wider context from the report “(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 that ascents should be of a maximum of 300m per day. An expert in mountain sickness, ████████ said that the speed of ascent was the one factor that limits the incidence of altitude sickness. He said 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 day 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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Intrepid Travel Group UK Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure and verify guide training in acute mountain sickness
Wider context from the report “(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 of 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 guide 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 this, there may remain a similar risk for other trek organizers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Intrepid Travel Group UK Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to provide passive descent or health-centre treatment for severe altitude illness
Wider context from the report “(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 of 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 guide 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 this, there may remain a similar risk for other trek organizers.
” Open source report
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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 Implement adjustments reducing daily altitude increases on affected high-altitude treks.
Verbatim wording from the response “Regarding the rate of ascent and altitude gains between sleeping altitudes The Adventure Company has reviewed the expert guidance provided. The Wilderness Medical Society consensus guidelines provide a suggested approach to AMS/HACE/HAPE 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 the 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 daily altitude increases.” Source location 2014-0074-Response-by-The-Family-Adventure-Company
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the revised ascent profiles in itineraries for the new trekking season.
Verbatim wording from the response “The changes identified have been implemented on the ground for 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.” Source location 2014-0074-Response-by-The-Family-Adventure-Company
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Put guidelines in place requiring consultation with nearby medical posts for illness, inability to continue, or suspected altitude-related illness.
Verbatim wording from the response “Further guidelines on always consulting any nearby medical posts, such as the one at Macchermo, in cases of illness, inability to continue with a trip or suspected AMS have also been put in place.” Source location 2014-0074-Response-by-The-Family-Adventure-Company
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review all Nepal high-altitude treks against Wilderness Medical Society guidelines.
Verbatim wording from the response “Regarding the rate of ascent and altitude gains between sleeping altitudes The Adventure Company has reviewed the expert guidance provided. The Wilderness Medical Society consensus guidelines provide a suggested approach to AMS/HACE/HAPE 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 the 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 daily altitude increases.” Source location 2014-0074-Response-by-The-Family-Adventure-Company
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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 Review expert guidance on ascent rates and altitude gains for preventing altitude-related illness.
Verbatim wording from the response “Regarding the rate of ascent and altitude gains between sleeping altitudes The Adventure Company has reviewed the expert guidance provided. The Wilderness Medical Society consensus guidelines provide a suggested approach to AMS/HACE/HAPE 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 the 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 daily altitude increases.” Source location 2014-0074-Response-by-The-Family-Adventure-Company
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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 Develop a high-altitude trekking protocol incorporating medical and expedition safety expertise for ongoing trip reviews and new itineraries.
Verbatim wording from the response “The information from the Wilderness Medical Society along with input from medical professionals, high altitude trekking and expedition safety experts are being” Source location 2014-0074-Response-by-The-Family-Adventure-Company
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remove the overseas leader manual's guidance on finding cost-effective solutions from circulation.
Verbatim wording from the response “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.” Source location 2014-0074-Response-by-The-Family-Adventure-Company
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the information and training provided to trek leaders about passenger travel insurance and medical-care decisions.
Verbatim wording from the response “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 travel insurance that will cover them for necessary medical expenses whilst on treks. It is further emphasised that the primary concern is always for the safety and wellbeing of the trekkers. Any decisions in this regard are to be made to provide the most suitable and effective remedy and not based on relative cost.” Source location 2014-0074-Response-by-The-Family-Adventure-Company
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local infrastructure makes it necessary to exceed the 500-metre daily ascent guideline on some established routes.
Verbatim wording from the response “In some circumstances the local infrastructure available for commercial group trekking means that it is necessary to exceed the 500m 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 whilst this does occur we have now introduced additional information regarding this into our Trip Notes for the relevant treks. This information highlights the higher increase on these days so 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.” Source location 2014-0074-Response-by-The-Family-Adventure-Company
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations