Jeremy Sutch
PFD Report
Partially Responded
Ref: 2019-0065
Coroner's Concerns (AI summary)
Medical evacuation was severely delayed by crew unfamiliarity with a wheelchair extraction stretcher, its incompatibility with ship equipment, and lack of evacuation drills, posing a risk for future survivable injuries.
View full coroner's concerns
the MATTERS OF CONCERN as follows:- It was heard in evidence that the captain of the MV Platinum Explorer; on hearing that Jeremy had suffered crush injuries to the chest referred to The Ship Captain'$ Medical Guide. The court was told that this book, or similar; is carried on every vessel to advise a ship's captain on what action to take in relation to the treatment of the casualty. Following the guidance given in The Ship Captain's Medical Guide the captain instructed the crew that they must not Jeremy down and he should be evacuated in the sitting position. Jeremy was in such pain that he could physically lie down in any event: As a result Jeremy was not placed in a 'basket' or 'Neil Robinson' stretcher but was sat in a 'wheelchair' type extraction chair. In evidence it was heard that there had never been an evacuation drill undertaken on board using an extraction chair (a basket type stretcher and mannequin always being used). Further; the captain said in his 42 years at sea he had never seen a medical evacuation drill; or real medical evacuation using a wheelchair type extraction chair: The fact that the crew were unfamiliar with the wheelchair extraction stretcher needed in Jeremy's case, led to the follow. Unlike a basket stretcher the wheelchair extraction stretcher had no independent points so could not be lowered to the tender by crane_ It therefore was necessary to lower the wheelchair in the crane work basket The wheelchair stretcher would not fit in the crane work basket had to be dynamically modified in order for it to fit: The crane work basket was too large and to be manoeuvred into the rear of the waiting tender (which was fibreglass and risked damage): The crane work basket was therefore lowered onto roof of the tender wheel house: The wheelchair stretcher would not fit down the spiral stairs leading to the passengerlcasualty space inside the tender: get_ lay not lifting and heavy the
Initially the tender tried to make shore with Jeremy on the roof of the wheel house but the handrail began to give way in heavy-seas s0 the tender had to return to the lee ward side of the MV Platinum Explorer Despite his injuries Jeremy had to physically lower himself one step at a time into the passenger space of the tender before he be taken ashore to receive medical attention: It was clear from the evidence that the issues identified above led to delay in Jeremy's medical evacuation: It was also clear that without Jeremy's own personal strength and determination he would not have been able to get inside the tender to be taken ashore_ It was confirmed by a forensic pathologist at the inquest that in his opinion Jeremys injuries were survivable and that any delay in his medical evacuation did not affect the tragic outcome of this case: That said, am concerned that should a similar situation arise with a casualty whose injuries may be survivable, their chance of survival would be reduced by the delays caused by the difficulties identified in this case. am also concerned that other captains on other ships may be unaware of the difficulties posed in the medical evacuation of a casualty when The Ship Captain's Medical Guide dictates that they must be kept in a seated position: am further concerned by the apparent lack of knowledge of this type of casualty extraction device, which in turn resulted in an apparent iack of training drills designed specifically with its use in mind.
Initially the tender tried to make shore with Jeremy on the roof of the wheel house but the handrail began to give way in heavy-seas s0 the tender had to return to the lee ward side of the MV Platinum Explorer Despite his injuries Jeremy had to physically lower himself one step at a time into the passenger space of the tender before he be taken ashore to receive medical attention: It was clear from the evidence that the issues identified above led to delay in Jeremy's medical evacuation: It was also clear that without Jeremy's own personal strength and determination he would not have been able to get inside the tender to be taken ashore_ It was confirmed by a forensic pathologist at the inquest that in his opinion Jeremys injuries were survivable and that any delay in his medical evacuation did not affect the tragic outcome of this case: That said, am concerned that should a similar situation arise with a casualty whose injuries may be survivable, their chance of survival would be reduced by the delays caused by the difficulties identified in this case. am also concerned that other captains on other ships may be unaware of the difficulties posed in the medical evacuation of a casualty when The Ship Captain's Medical Guide dictates that they must be kept in a seated position: am further concerned by the apparent lack of knowledge of this type of casualty extraction device, which in turn resulted in an apparent iack of training drills designed specifically with its use in mind.
Responses
Action Taken
Vantage Drilling Company updated its HSE Manual to include reference to different stretcher types. They also added 'Drill Medivac Chair Type Stretcher' to the Emergency Response Drill Matrix, requiring drills every six months, and updated the Rig Specific Emergency Response Manual to detail different stretcher types. (AI summary)
Vantage Drilling Company updated its HSE Manual to include reference to different stretcher types. They also added 'Drill Medivac Chair Type Stretcher' to the Emergency Response Drill Matrix, requiring drills every six months, and updated the Rig Specific Emergency Response Manual to detail different stretcher types. (AI summary)
View full response
Dear Sirs Inquest touching on the death of Mr Jeremy Sutch Regulation 28: Report to prevent future deaths We write on behalf of Vantage Drilling Company ("Vantage") by way of response to the Regulation 28: Report to prevent future deaths (1) dated 22 February 2019 and in particular by way of response to paragraph 7 of same ("Your Response"). You have asked us to provide details of action taken or proposed to be taken and the timetable for action: Introduction We wish to reiterate, on our own behalf and on behalf of Vantage, our condolences for Jeremy's family' s terrible loss_ Since this event; Vantage reflected upon all of the facts of the incident as identified by various investigations (including the Coroner'$ own) in order to learn as much as possible: Vantage is always concerned to ensure that its evacuation procedures are fit for purpose, affording those injured the best opportunity to reach expert medical attention in the most timely fashion. It is not possible to foresee and anticipate every possible scenario (hindsight provides improved illumination on the situation) and it is important to recognise that what happened on board the Platinum Explorer was fact specific and highly unusual, being outside the experience of very experienced Mariners_ Since the event involving Mr Sutch, evacuation using wheelchairs have been included in evacuation drills (see below). As referred to during the Inquest: - Weightmans LLP is a limited liability partnership registered in England Wales with registered number 0C326117 and its registered office at 100 Old Hall Street, Liverpool L3 90J.A full list of members is available at the registered office:The term "partner" , If used, denotes member of Weightmans LLP or senior employee of Weightmans LLP with equivalent standing and qualifications Authorised and regulated by the Solicitors Regulation Authority: has
Page Our ref: 784554-8/PJame/3667 Your ref: Vantage arranged for a medic to be on the vessel despite this not a requirement; Vantage'$ MERP involved a recognised international agency a5 a partner (Vantage were doing things properly); Il: Vantage are not aware of any advice or industry practice to suggest other operators involved in similar operations, in similar environments, have been taking a difference approach; IV Patient extraction from a whole range of occupational settings, even ashore, is often compromised and at least challenging: Speed of response, whilst always desirable, cannot always be achieved or guaranteed because not all factors which impact on speed of response can be controlled_ Even ashore, ambulances may be delayed by traffic or weather conditions or simply by demand exceeding supply; Air ambulances are not a state funded provision in all areas, less still an infinite resource; VI: Being aboard a vessel at sea presents a different and additional range of challenges which Vantage sought to address in the MERP they devised; Vantage is proud of the resourcefulness and the dedication of the crew in dealing with such an unusual scenario and was pleased to have been able to assist the enquiry So openly and fully. Regulation 28 Response Please find attached: _
1) Updated HSE Manual dated 7 March 2019. Please refer in particular to Section 4.25.7 which includes specific reference to the different stretcher types which may be required to be used.
2) Emergency Response Drill Matrix: Please see (new) item 26 which is described as 'Drill Medivac Chair Type Stretcher" This requires a drill to be carried out every six months. This spreadsheet also identifies the date on which the next drill will take place, in this case 16 April 2019. Including medivac by way of chair type stretchers in the Drill Matrix ensures that the exercise of utilising the chair type stretcher is scheduled and actioned and any lessons learned are captured: Documenting these drills in our Safety Management Systems ensures compliance is managed and audited.
3) Rig Specific Emergency Response Manual dated 11 March 2019 which includes details of the different types of stretcher available on board.
Page Our ref: 784554-8/PJame/3667 Your ref: Vantage arranged for a medic to be on the vessel despite this not a requirement; Vantage'$ MERP involved a recognised international agency a5 a partner (Vantage were doing things properly); Il: Vantage are not aware of any advice or industry practice to suggest other operators involved in similar operations, in similar environments, have been taking a difference approach; IV Patient extraction from a whole range of occupational settings, even ashore, is often compromised and at least challenging: Speed of response, whilst always desirable, cannot always be achieved or guaranteed because not all factors which impact on speed of response can be controlled_ Even ashore, ambulances may be delayed by traffic or weather conditions or simply by demand exceeding supply; Air ambulances are not a state funded provision in all areas, less still an infinite resource; VI: Being aboard a vessel at sea presents a different and additional range of challenges which Vantage sought to address in the MERP they devised; Vantage is proud of the resourcefulness and the dedication of the crew in dealing with such an unusual scenario and was pleased to have been able to assist the enquiry So openly and fully. Regulation 28 Response Please find attached: _
1) Updated HSE Manual dated 7 March 2019. Please refer in particular to Section 4.25.7 which includes specific reference to the different stretcher types which may be required to be used.
2) Emergency Response Drill Matrix: Please see (new) item 26 which is described as 'Drill Medivac Chair Type Stretcher" This requires a drill to be carried out every six months. This spreadsheet also identifies the date on which the next drill will take place, in this case 16 April 2019. Including medivac by way of chair type stretchers in the Drill Matrix ensures that the exercise of utilising the chair type stretcher is scheduled and actioned and any lessons learned are captured: Documenting these drills in our Safety Management Systems ensures compliance is managed and audited.
3) Rig Specific Emergency Response Manual dated 11 March 2019 which includes details of the different types of stretcher available on board.
Sent To
- International Maritime Organisation
- Vantage Drilling Company
Response Status
Linked responses
1 of 2
56-Day Deadline
28 Jul 2019
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 21st March 2016 commenced an investigation into the death of Jeremy Sutch: The investigation concluded at the end of the inquest on 13th February 2019. The conclusion of the inquest was that; Jeremy Sutch died on the 25th February 2016 at 20.20 in Labuan Hospital, Labuan, Malaysia from injuries received earlier in the day (at around 14.50) on the MV Platinum Explorer; which was moored off the coast nearby: He sustained his injuries when he was crushed by a Riser Feeding Machine on board the vessel, His medical cause of death following a post-mortem examination was Ia Blunt Chest Trauma;
Circumstances of the Death
Jeremy Sutch was a Trainee Driller on board the MV Platinum Explorer; when it was moored in Kuraman Island Water; off Labuan, Malaysia on Thursday the 25th February 2016_ At approximately 14.55 hours a telephone call was made to the bridge of the Platinum Explorer by Jeremy, requesting help in the Drillers Control Cabin: Other members of the crew attended the Driller's Control Cabin and found Jeremy injured on the floor He told them he had been crushed by 'the RFM bucket' (on a Riser Feeding Machine) To
Jeremy was struggling to speak and when found by other members of the crew had injuries to his chest: Jeremy was given first aid attention by the on-ship paramedic A 'medevac' casualty evacuation was arranged and carried out by a small tender vessel in order to Jeremy to the nearest land (some 30 to 40 minutes away): Once ashore Jeremy was taken to the Hospital in Labuan where; he tragically passed away:
Jeremy was struggling to speak and when found by other members of the crew had injuries to his chest: Jeremy was given first aid attention by the on-ship paramedic A 'medevac' casualty evacuation was arranged and carried out by a small tender vessel in order to Jeremy to the nearest land (some 30 to 40 minutes away): Once ashore Jeremy was taken to the Hospital in Labuan where; he tragically passed away:
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe yoU or your 'organisation have the power to take such action:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.