Lucy Francesca Goldstone · Prevention of Future Deaths report

The deceased, Lucy Francesca Goldstone, DoB 4.10.1997 died on 7 April 2016 at Manchester Royal Infirmary. I dealt with the inquest into her death on 24 February 2017 and recorded the pathological cause of death as:

1a Bronchial asthma and aspiration of food material

The deceased had a history of chronic asthma had a severe asthma attack and became unresponsive on a tram in Manchester City centre shortly after boarding at approximately 22.15hrs on 7 April 2016. Bystander Cardio Pulmonary Resuscitation (CPR) was carried out. North West Ambulance Service attended and administered CPR in accordance with Advance Life Support protocols. The deceased was transferred to Manchester Royal Infirmary where despite further CPR death was confirmed at 23.29hrs. I returned a Natural Causes Conclusion.

I heard from a witness who was the Safety Health and Environment Manager for Metrolink RATM DeV Limited (MRDL) who at the time of this incident was contracted by Transport for Greater Manchester to operate the tram network known as Metrolink that covers the Greater Manchester area. I was informed that in relation to the availability of Automated Electronic Defibrillator that no AEDs are provided on any of the trams or any of the tram stops on the network, and that it is not a legal requirement or industry standard practise for AEDs to be available across the various tram networks in the United Kingdom. I was also informed that some of the larger rail and bus stations now have AEDs available and that in the absence of a Defibrillator the process in an emergency is to contact the emergency services immediately. In this case there was no evidence that the present of a Defibrillator on the tram would have made a difference to the outcome on the balance of probabilities, however at the conclusion at the inquest I indicated that I would submit a Regulation 28 report to the Department of Health and the Department of Transport to be updated as to the current provision and guidance as to the availability of AEDs.