Harry Peter DUNN · Prevention of Future Deaths report

On 04 September 2019 I commenced an investigation into the death of Harry Peter DUNN aged 19. The investigation concluded at the end of the inquest on 13 June 2024. The conclusion of the inquest was:

Road Traffic Collision

The circumstances of the death are as follows: -

On 27 August 2019 at about 2030 hours there was a head on collision between a car driven by ████████ an employee of the US Government who had not long been in the UK and whose husband worked out of the nearby RAF Croughton, and a motorcycle ridden by Mr ████████ Harry Dunn. The cause of the collision was that on exiting RAF Croughton inadvertently moved onto the incorrect side of the B4301 rural road and travelled about 350 meters on the wrong side of the road prior to the head on collision with Mr Dunn, who was on the correct side of the road travelling out of the village of Croughton.

Mr Dunn suffered catastrophic injuries including fractures to all four limbs, some of which were open in nature and a fracture to his pelvis with the concomitant severe internal blood loss commonly associated with such serious injuries.

He was attended to by an advanced medical team including a Consultant Anaesthetist and Critical Care paramedics and then conveyed to hospital where he died shortly after arrival.

(1) As a result of the collision Mr Dunn landed in a prone position (on his front). In order for him to be treated by the pre hospital team he had to be moved out of this position to give ready access to his injuries. This necessitated the administration of analgesia. However, due to his positioning and the location of his injuries in conjunction with the extent of blood loss intravenous analgesics could not be administered.
(2) Due to the experience level and qualifications of the pre hospital team in attendance, which included a Consultant Anaesthetist, an alternative form of analgesia, namely nasal morphine could be administered.
(3) However, evidence was heard at the inquest that had the first attending team been a paramedic team they could not have administered this potentially lifesaving treatment as analgesia’s which can be delivered either nasally or buccally (via the cheek) are not presently available to paramedics despite being available to UK military personnel and mountain rescue teams.
(4) I am concerned that the unavailability of such analgesics to paramedics to assist them to deliver potentially life saving pre hospital treatments or to enable a faster extraction of a patient where time is of the essence for medical treatment reflects a risk of deaths into the future.