Mackenzie COOPER · Prevention of Future Deaths report

On 17 October 2022 I commenced an investigation into the death of Mackenzie COOPER, aged 27. The investigation concluded at the end of the inquest which took place before a jury on 12 July 2023. The conclusion of the jury was that:

Mackenzie Cooper died on 29 September 2022 at a private residential dwelling in ████████
████████, Nottinghamshire, as a result of cardiac arrhythmia induced by electrocution.

Mackenzie was a Plumber, qualified to NVQ level 2 and 3 in Domestic Plumbing and Heating, and Gas Safe Registered, with 5 years' experience working independently.

He was called out to a residential property to deal with an emergency leak, and he attended alone. The electricity was turned off before Mackenzie arrived. The power was turned on to enable Mackenzie to vacuum up water. He was electrocuted when kneeling in water, he touched or came into close proximity to a copper pipe that was inadvertently carrying a live electrical current when the power was switched on. This was due to a combination of two faults in the house electrical system:

1. The earth terminal in the fuse box was not connected to general mass of earth;
2. Faults or inadvertent connection between live and earth in the main socket circuit.

Both of these faults in combination caused the pipe to carry a live electrical current, once the power was switched on.

The occupier called 999, and commenced CPR, continuing until ambulance crews arrived. The homeowner fetched a community public access defibrillator, which was not functional due to missing pads. An ambulance arrived after 20 minutes, a short delay resulting from resource availability, but there was no evidence these factors contributed to his death as he was already asystole when ambulance crews arrived.

Mackenzie was pronounced deceased at the scene at 15.43.

The occupier of the private dwelling gave evidence that he and his wife were advised by the East Midlands Ambulance Service NHS Trust, during the course of the 999 call, to fetch a nearby community public access defibrillator from the Co-op store, 29 Doncaster Road, Carlton-in-Lindrick, Worksop, Nottinghamshire, S81 9JS.

The device was provided to the occupier by co-op staff. When the occupier arrived at Mackenzie’s side and opened the defibrillator pack, the audible instructions advised that the pads should be connected to the leads. On exploring the entirety of the device pack, it became apparent there were no pads, meaning the device could not be used. This delayed the use of a defibrillator, and the administration of a shock, if Mackenzie was in a shockable rhythm.

When the occupier later returned the device to the Co-op store, staff informed them that they knew the device was missing the pads because they had not been replaced since the device was last used.

I received evidence from East Midlands Ambulance Service NHS Trust that responsibility for maintaining the defibrillator device and associated equipment, including replacement pads, rests with the “guardian” of the device, not with the ambulance service. The ambulance service simply has access to a list of the locations of community public access defibrillators and advise callers of their nearest device in a cardiac arrest scenario.

I understand there were other community access defibrillators very close by which the occupier could have accessed if the ambulance service had known the device in the co-op store was “offline”.

I understand there is no single database listing the location and status of community public access defibrillators, rather a number of charity organisations provide such a service (NDDb and the British Heart Foundation) and I am unclear how the ambulance service are to know when a listed device is non-functional.

Central England Co-operative

1. The community public access defibrillator in your store was supplied to a member of the public in a non-workable condition. There appears to be either no system for replacing the pads between uses, or an unsafe system in operation.
2. There appears to be either a training or communication issue in that staff appear to have known the device was missing vital equipment, but the device was supplied anyway.

The Department for Health and Social Care

3. In December 2022, the Government committed to making available over £1 million for the purchase of more community public access defibrillators, in recognition of the fact that these devices have the potential to save lives. I am concerned that without a clear system for ensuring (a) the maintenance and good order of all community public access defibrillators, and (b) a system for sharing with all ambulance Trusts the current status of defibrillators i.e. when they are out of service due to missing parts/maintenance, members of the public might be directed to a device that cannot be used, as in this case.