Russell Curwen: Prevention of future deaths report

Other related deathsRoad (Highways Safety) related deaths

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Date of report: 24/04/2020

Ref: 2023-0122

Deceased name: Russell Curwen

Coroner name: James Newman

Coroner Area: Lancashire and Blackburn with Darwen

Category: Other related deaths | Road (Highways Safety) related deaths

This report is being sent to: Department for Transport

The Right Honourable Grant Shapps – Secretary of State for Transport Great Minster House 33 Horseferry Road London SW1P4DR
I am James Newman, Area Coroner for Lancashire & Blackburn with Darwen
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.
http://www. legislation. 9/part/7/made
On the 15th May 20181 commenced an investigation into the death of Russell Curwen aged 49. An inquest has yet to be concluded.
On Saturday 5th May 2018 Mr Curwen, a volunteer with the North West Blood Bikes, was transporting blood samples from 5 patients at the Westmoreland General Hospital to the out-of­ hours biochemistry unit at the Royal Lancaster Infirmary. He was riding a BMW red and yellow liveried blood bike R1200, equipped with blue flashing lights and sirens. At around 19:45 he was riding his bike along the A6 Caton Road, Lancaster, ·using the fitted sirens and lights. Whilst travelling through the junction of the A683 and A589 he travelled through a traffic light, against the lights, colliding with a vehicle travelling through the lights, causing injuries that proved fatal later at the Royal Lancaster Infirmary.
During the course of the investigation information has come to my attention, giving rise to concerns. In my opinion there is a risk that future deaths will occur unless action is taken_ In the circumstances it is my statutory duty to report to you.   Firstly I must at this time indicate that this is not, nor should be considered as, criticism of the invaluable service that volunteers within the blood bike community provide to the National Health Service.  

The MATTERS OF CONCERN are as follows.
The samples being transported by Mr Curwen were routine in nature, transported under a contract of courier services, as agreed between the North West Blood Bikes and University Hospitals of Morecambe Bay NHS Foundation Trust, Southport and Ormskirk Hospitals, Lancashire Teaching Hospital, East Lancashire Hospital Trust and Blackpool Teaching Hospitals NHS Foundation Trust.
During the transfer lights and sirens fitted to the motorcycle provided by the North West Blood Bikes were activated.
The current legislation, as I understand provides exemptions to speed limits and permits the use of the emergency lighting. In terms of those exemptions and permissions it is my understanding that those are subject to:
Speed limits – Emergency vehicles are exempted from speed limits by s.87 of the Road Traffic Regulation Act 1984. Sub-sections (1A) and (18) were added to s.87 by s.50(5) of the Deregulation Act 2015. The addition included the words emphasised in bold below.
“87. Exemption of fire brigade, ambulance and police vehicles from speed limits.
(1)  No statutory provision imposing a speed limit on motor vehicles shall apply to any vehicle on an occasion when it is being used for fire and rescue authority, ambulance or police purposes, if the observance of that provision would be likely to hinder the use of the vehicle  for the purpose for which it is being used on that occasion.
(1A) Subsection (1) above applies in relation to a vehicle that, although not being used for ambulance purposes, is being used for the purpose of providing a response to an emergency at the request of an NHS ambulance service.
{18) In subsection (1A), “an NHS ambulance service” means-
(a)  an NHS trust or NHS foundation trust established under the National Health Service Act 2006 which has a function of providing ambulance services;
Blue lights – The use of blue lights is governed by reg.16 of the Road Vehicles Lighting Regulations 1989/1796, as interpreted by reg.3. Blue warning lights may only be used by
·emergency vehicles”. Again, words were added into this legislation by the Deregulation  Act 2015, by Sch.9 para.11(3), including the words emphasised below in bold:
“16. Restrictions on fitting blue warning beacons, special warning lamps and similar devices
No vehicle, other than an emergency vehicle or a vehicle used for special forces purposes, shall  be fitted with
(a)  a blue warning beacon or special warning lamp, or
(b)   a device which resembles a blue warning beacon or a special warning lamp, whether the same is in working order or not.
3. Interpretation “Emergency vehicle
A vehicle of any of the following descriptions
(aza) a vehicle used for ambulance purposes or for the purpose of providing a response to an emergency at the request of an NHS ambulance service;
(b)   an  ambulance,  being  a  vehicle  (other  than  an  invalid  carriage)  which  is  constructed  or adapted for the purposes of conveying sick, injured or disabled persons and which is used for such purposes•:
My concerns are fourfold:
1)     That the exemptions all relate to actions requiring an emergency response at the request of an NHS ambulance service:
There appears to be no traceable or auditable co­ ordination or control of the allocation or dispatch of vehicles by a NHS ambulance trust control centre. Allocation or dispatch appears to be actioned at the request of the four NHS trusts contracted to with North West Blood Bikes under contracts for courier services;
That there is no definition of what constitutes an emergency and in the cases of courier services no apparent auditable or co-ordinated determination of what is classified as an emergency in these cases.
In this instance it was identified that Mr Curwen was transporting blood samples for 5 patients from one hospital to another who provided for weekend cover. There does not appear to be any determination by an NHS Ambulance Trust co-ordinator or control room supervisor, or even a recorded clinical decision as to whether the situation truly requires an “emergency” response. It is not suggested at present that the samples were required for life saving treatment, or that delays could significantly reduce the life expectancy of the patients.
3)     That there is no auditable or co-ordinated review of the appropriateness of the urgency or emergency nature of the situation: – There does not appear to be any review of the urgency of the situation by control personnel, or continued assessment of the need to apply the exemptions or permissions referred to above.
4)     That there is no statutory requirement for training: – There appears to be no statutory requirement for even a basic level of training before using high powered motorcycles and applying the exemptions or permissions, nor does there appear to be any requirement for ongoing or refresher training.
This, as referred to above, is not intended to criticise or demonise the exceptional work that the blood bike charities provide to our National Health Service, but rather to highlight concerns and apparent incongruities in the current legislation. Accordingly I seek clarification as to whether the legislation as it currently stands requires amendment, or a policy/protocol be created, such that Blood Bikes or similar voluntary services do fulfil the criteria to apply liveried markings and emergency lighting and sirens, and would accordingly when responding to “emergency”  situations would benefit from the exemptions and/or permissions; or that they do not fulfil the criteria and accordingly should not be marked up and fitted with the emergency lights and sirens, and if already fitted, should not use them.
In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. It is not my place to seek to inform you of what your actions should be.
You are under a duty to respond to this report within 56 days of the date of this report, namely by
22nd June 2020. 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.
I have sent a copy of my report to the Chief Coroner and I have also sent it to: Lancashire Constabulary;
Nationwide Association of Blood Bikes;
North West Blood Bikes;
Police Commissioner for Devon and Cornwall;
who may find it useful or of interest.
I am also under a duty to send the Chief Coroner a copy of your response.
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 your response by the Chief Coroner.