Harry Dunn: Prevention of Future Deaths Report (3)
Hospital Death (Clinical Procedures and medical management) related deathsRoad (Highways Safety) related deaths
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Date of report: 04/07/2024
Ref: 2024-0413
Deceased name: Harry Dunn
Coroner name: Anne Pember
Coroner Area: Northamptonshire
Category: Road (Highways Safety) related deaths | Hospital Death (Clinical Procedures and medical management) related deaths
This report is being sent to: Department of Health and Social Care | The Medicines and Healthcare products Regulatory Agency
| REGULATION 28 REPORT TO PREVENT DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: Secretary of State for Health and Social Care The Medicines and Healthcare Products Regulatory Agency | |
| 1 | CORONER I am Anne Pember, HM Senior Coroner for Northamptonshire |
| 2 | CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
| 3 | INVESTIGATION and INQUEST 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 |
| 4 | CIRCUMSTANCES OF THE DEATH 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 [REDACTED] 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 [REDACTED] 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. |
| 5 | CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) (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. |
| 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. |
| 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by August 29, 2024. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. |
| 8 | COPIES and PUBLICATION I have sent a copy of my report to the Family of the Deceased and to the Chief Coroner. I have also sent a copy of this report to West Northamptonshire Council, Northamptonshire Police, to the Chief Executive of East Midlands Ambulance Service and the solicitors on behalf of [REDACTED]. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. |
| 9 | Dated: 4th July 2024 Mrs Anne Pember His Majesty’s Senior Coroner for the County of Northamptonshire |