Davina Tavener · Prevention of Future Deaths report

On 11th November 2014 I commenced an Investigation into the death of Davina Tavener, 47 years, born on the 29th November 1966. The Investigation concluded at the end of the Inquest on the 15th June 2015.

The medical cause of death was 1a) Unascertained

The conclusion of the Inquest was Davina Tavener died as a consequence of naturally occurring diseases of unknown source.

1. Davina Tavener died at San Bartolome, Arrecife Airport, Lanzarote on the 1st November 2014.

2. On the 1st November 2014 Mrs Tavener was travelling with her husband on Ryanair Flight FR2131 from Manchester to Lanzarote.

During the final part of the journey, and approximately three hours into the flight, Mrs Tavener visited the toilet on the Aircraft and she was noted to be in the toilet for a prolonged period of time. When ████████ and the Ryanair cabin crew became concerned the toilet door was opened and Mrs Tavener was found in a standing but collapsed condition in the toilet. Mrs Tavener was removed from the toilet and she was laid on the floor of the Aircraft cabin for CPR, which was commenced immediately.

A passenger announcement was made for a medically qualified person and a Nurse and a Consultant Surgeon responded. The Consultant Surgeon was ████████, who is a Consultant Oncoplastic Breast Surgeon employed by the Royal Bolton Hospital NHS Foundation Trust.

3. ████████ began cardiopulmonary resuscitation using the pocket face mask provided by the cabin crew and chest compressions were given by the Nurse and the cabin crew.

4. ████████ asked the cabin crew for their medical equipment and she was told that the only relevant equipment on board the Aircraft was a pocket face mask.

████████ asked for an airway adjunct (a plastic tube that is inserted into the mouth or down the nose both of which prevent the tongue from occluding the airway and thereby allowing air to pass into the patient’s lungs). ████████ asked for suction equipment (equipment to remove blood/vomit from the patient’s mouth, enabling the airway to remain free of obstruction, so that air can pass into the patient’s lungs). ████████ asked for a bag-valve-mask and oxygen (a bag-valve-mask is basic airway management equipment that allows for oxygenation and ventilation of patient to which oxygen can be attached). ████████ asked for a defibrillator (a machine that delivers electrical energy to the heart and may treat life threatening heart conditions).

The cabin crew informed ████████ that they did not have any of the aforementioned equipment on the Aircraft.

5. The Aircraft continued to the nearest Airport which was the destination Airport at Lanzarote and resuscitation continued until the Aircraft landed at Arrecife Airport, Lanzarote.

6. After the Aircraft landed at Arrecife Airport paramedics came onto the Aircraft and confirmed that Mrs Tavener had died.

1. During the Inquest evidence was heard that

i. The Aircraft operated by Ryanair on Flight FR2131 carried six oxygen bottles, two pocket masks (resuscitation aids) and three first aid kits, the contents of which were approved by the Irish Aviation Authority. The equipment complied with the Regulations of the European Aviation Safety Authority.

ii. The European Aviation Safety Authority is responsible for the Regulations in relation to equipment to be carried on Aircraft operating in Europe and from bases in Europe and the competent national authority, namely the Civil Aviation Authority for UK based Airlines and the Irish Aviation Authority for Irish based Airlines including Ryanair, are responsible for oversight of compliance with the Regulations.

The Regulations do not require Aircraft to carry the equipment requested by ████████ and the minimum requirement is to carry the equipment carried by Ryanair on Flight FR2131. It was accepted that Ryanair was operating within the Regulations in relation to medical equipment on Flight FR2131.

iii. The evidence at the Inquest confirmed that some Airlines do carry the equipment requested by ████████, even though there is no Regulation for such equipment to be carried.

Evidence was given that the equipment is carried on some long haul flights as opposed to short haul flights but it was accepted that the differential is not relevant in view of the fact that a cardiac arrest can occur at any time whether the Aircraft is ten minutes into a flight or ten hours into a flight.

iv. ████████ gave evidence, supported by the Pathologist, that when someone has suffered a cardiac arrest, time is of the essence and the equipment requested by her could be critical in an attempt to save life.

████████ confirmed that a defibrillator would be critical to survival in cardiac events and a defibrillator would give someone the best chance of survival in a situation where there is a cardiac arrest. The evidence confirmed that for every one minute when activity in the heart has stopped the chance of survival reduces by ten percent and the availability of a defibrillator at the earliest time would increase the chance of survival.

Both ████████ and the Pathologist gave evidence that an airway adjunct, suction equipment, bag-valve-mask and a defibrillator should be carried on all Aircraft as a mandatory provision of medical equipment to assist in the treatment and resuscitation of a passenger on an Aircraft and to give a passenger the best chance of survival until the Aircraft can reach the nearest destination.

The provision of the aforementioned equipment would be used for the reasons explained in ████████ evidence and detailed in paragraph 4.4 of this report.

v. Evidence was given that all the above equipment is now available as relatively inexpensive portable equipment and, in particular, a defibrillator is very simple to operate in that the defibrillator will announce instructions in relation to use by the operator.

vi. It may be felt that cases of sudden cardiac arrest on Aircraft are very rare but Airlines carrying defibrillators have led to lives being saved and the saving of a single life would justify the availability of equipment on all Aircraft for use as and when a medical emergency arises.

The Federal Aviation Authority has required US Airlines to carry a defibrillator on flights since 1994.

vii. The evidence raised concerns that there is a risk that future deaths will occur unless action is taken to review the above issues.

2. I request you to consider the above concerns and to carry out a review with regard to the following:-

i. The Regulations in relation to mandatory and compulsory medical equipment to be carried on Aircraft operating both within Europe and out of bases in Europe.

ii. The medical equipment to be carried on Aircraft as a mandatory and compulsory provision with specific reference to airway adjuncts, suction equipment, bag-valve-mask equipment and a defibrillator.

iii. The compliance by Airlines under the control of the competent national authority, namely the Civil Aviation Authority in the United Kingdom and the Irish Aviation Authority in Ireland, to address any changes in the mandatory and compulsory provision of medical equipment to be carried on Aircraft.