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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× 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 Ministry of Culture, Tourism and Civil Aviation (Nepal); 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 Ministry of Culture, Tourism and Civil Aviation (Nepal); 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 Ministry of Culture, Tourism and Civil Aviation (Nepal); 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 Ministry of Culture, Tourism and Civil Aviation (Nepal); 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 Ministry of Culture, Tourism and Civil Aviation (Nepal); 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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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations