John Lobo · Prevention of Future Deaths report

On 9th July 2014 I commenced an investigation into the death of John Lobo, aged 77 years. The investigation concluded at the end of the inquest on 21st April 2015. The conclusion of the inquest was that his death was accidental.
The medical cause of death was
1a Bilateral bronchopneumonia 1b chronic obstructive airways disease Part II Ischaemic heart disease; cervical spine fracture and diabetes mellitus.

On 15th May 2014 Mr Lobo suffered a fall in his bathroom on the cruise ship Ventura, close to the Italian coast. He suffered two further falls on the 19th and 21st May 2014 which may have exacerbated the injury. He was then admitted to a hospital in Venice and was subsequently transferred to the United Kingdom in a private ambulance. He was transported by road and his neck was not immobilised at all times during the journey. A dispute with the insurance company meant that the family had to make a private arrangement for repatriation, and although the ambulance company were made aware that Mr Lobo had suffered a fracture at C7 they wrongly recorded that the fracture was at T7. The ambulance crew (which included a paramedic) were informed by the Italian hospital that he was fit to travel and should be immobilised at times of transfer only. There was no indication that the fracture was in fact unstable, which may have been as a result of language difficulties. Translation services were available but not used. The evidence disclosed that transport by road was not appropriate, and that Mr Lobo should have been immobilised at all times, and these failures contributed to the cause of death.

The evidence disclosed that assessment of fitness to travel and of the manner in which the patient should be transported requires medical knowledge over and above that of a paramedic, and that reliance should not be placed wholly on family members and hospitals in distant countries. In cases involving direct repatriation without the facilities provided by an insurance company, consideration might be given to obtaining independent medical assessment.