PFD report

Janet Richardson · Prevention of Future Deaths report

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Issued 16 Oct 2013•North and West Cumbria

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
3

Named on the report

Responses found
2

Of 3 recipients

Stated actions
2

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Fall into the sea during rescue medical evacuation
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. Action

    Review CMV procedures that led to delay, confusion, injury and loss of life during rescue medical evacuations.

    Stated by Cruise and Maritime Services International Limited, trading as Cruise and Maritime Voyages (“CMV”Stated in progressThe respondent said that this action was in progress when they made their response on 16 October 2013.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    Medical evacuation procedures were controlled by the relevant rescue authorities rather than the client.

    Stated by North West Promotions LtdRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Fall into the sea during rescue medical evacuation

Wider context from the report

“That the deceased fell into the sea during a rescue medical evacuation. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Review CMV procedures that led to delay, confusion, injury and loss of life during rescue medical evacuations.

Verbatim wording from the response

“CMV note that your concern is that the deceased fell into the sea during a rescue medical evacuation and that the action and the power to take such action and that the action you suggest is to revise procedures. CMV was at the time of the accident in consultation with their Counsel, Dr Anthony Howard. The evidence provided at the inquest was carefully reviewed and we are currently undertaking a review of the procedures that led to the delay, confusion, injury and even loss of life. Therefore, the procedure adopted by CMV in this situation is being reviewed and, in the meantime, the response service has requested assistance from the rescue service, or direct to the rescue service provider, and the rescue service should be at liberty to take whatever action they consider appropriate.”

Source location

2013-0261-Response-by-Cruise-Maritime-Services-International-Limited
Page 1 · response
Published 16 October 2013

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Medical evacuation procedures were controlled by the relevant rescue authorities rather than the client.

Verbatim wording from the response

“We understand that the Coroner's Office also wrote to the Norwegian Rescue Authority and [████████] with regard to the ship that carried the deceased. Clearly, the two principal medical evacuation procedures then the control of such procedures would be in the hands of the Rescue Authorities.”

Source location

2013-0261-Response-by-Newmarket-Promotions-Ltd
Page 1 · response
Published 16 October 2013

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

A single rescue procedure is inappropriate because rescue circumstances, vessel size and location differ.

Verbatim wording from the response

“When a rescue operation is taking place there are different procedures depending upon the circumstances in which the rescue occurs, the size of the vessel and the location of the rescue. It is not appropriate for a single rescue procedure to cover all possible scenarios. The Norwegian Rescue Service were in control of the rescue operation. This is the normal situation when a rescue operation is taking place aboard a cruise ship. The Norwegian Rescue Service procedure allows for a different procedure depending upon the circumstances in which the rescue occurs, the size of the vessel and the location of the rescue. This could lead to delay, confusion, injury and even loss of life.”

Source location

2013-0261-Response-by-Cruise-Maritime-Services-International-Limited
Page 1 · response
Published 16 October 2013

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The Norwegian Rescue Service controlled the rescue operation and determined the appropriate rescue action.

Verbatim wording from the response

“When a rescue operation is taking place there are different procedures depending upon the circumstances in which the rescue occurs, the size of the vessel and the location of the rescue. It is not appropriate for a single rescue procedure to cover all possible scenarios. The Norwegian Rescue Service were in control of the rescue operation. This is the normal situation when a rescue operation is taking place aboard a cruise ship. The Norwegian Rescue Service procedure allows for a different procedure depending upon the circumstances in which the rescue occurs, the size of the vessel and the location of the rescue. This could lead to delay, confusion, injury and even loss of life.”

Source location

2013-0261-Response-by-Cruise-Maritime-Services-International-Limited
Page 1 · response
Published 16 October 2013

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Request assistance from the rescue service or its direct provider during rescue operations.

    Stated by Cruise and Maritime Services International Limited, trading as Cruise and Maritime Voyages (“CMV”Stated completedThe respondent said that this action was complete when they made their response on 16 October 2013.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Request assistance from the rescue service or its direct provider during rescue operations.

Verbatim wording from the response

“CMV note that your concern is that the deceased fell into the sea during a rescue medical evacuation and that the action and the power to take such action and that the action you suggest is to revise procedures. CMV was at the time of the accident in consultation with their Counsel, Dr Anthony Howard. The evidence provided at the inquest was carefully reviewed and we are currently undertaking a review of the procedures that led to the delay, confusion, injury and even loss of life. Therefore, the procedure adopted by CMV in this situation is being reviewed and, in the meantime, the response service has requested assistance from the rescue service, or direct to the rescue service provider, and the rescue service should be at liberty to take whatever action they consider appropriate.”

Source location

2013-0261-Response-by-Cruise-Maritime-Services-International-Limited
Page 1 · response
Published 16 October 2013

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026