Rachel Ann Burke · Prevention of Future Deaths report

On 8th November 2011 I opened an inquest into the death of Rachel Ann Burke, aged 28 years, date of death 23rd April 2011. The inquest was concluded on 15th January 2014. The cause of death was found to be High altitude cerebral oedema and high altitude pulmonary oedema.

A UK Professor of Pathology gave evidence (citing internationally recognized Davies criteria) that Coronary arteriosclerosis was very unlikely to be present in an athletic 28 year old and that it did not cause her death, despite that being found by the autopsy in Kathmandu on 25th April 2011 (ref 68-0047). However the state of the coronary arteries were not recorded, nor was histology studied by the Kathmandu Autopsy Center, which would be expected if such a rare finding were suspected.

Ms Burke went on a high altitude trek in the Himalayas in trek organised by Himalayan Encounters (HE) with guides and experienced leader. She made an ascent of 600m from Namche Bazaar to Dole (day 6) on 20th April. The next day she was slower than others and developed breathlessness and fatigue. Later she developed central cyanosis. She slept poorly, having to be upright and in the morning of the 22nd April she was ataxic, cyanosed, unable to eat properly or do her shoes. She was slow in admitting her health problems and was reluctant to descend. She had high altitude cerebral oedema (HACE) and high altitude pulmonary oedema (HAPE) that were not recognised. She did not attend the health post some 12 minutes away but descended with support to Dole but making very poor progress. She was found on the way to be confused and despite treatment on the slope by passing doctor and barometric oxygen in Dole, died later at 00:45 in Dole from HACE and HAPE.

Factors contributing to her death were non recognition of HAPE and HACE at Macheremo, walking under her own steam down to Dole, sending her down the mountain with a guide unfamiliar with acute mountain sickness and her not attending the health post in Macheremo, about which the leader but not herself knew. Not taking her to the health post amounted to neglect.

(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.

(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.

(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.

(4) The cause of death was found to be High altitude cerebral oedema and high altitude pulmonary oedema. Coronary arteriosclerosis did not cause death in this 28 year old, despite that being found by the autopsy in Nepal.