Lucy Goldstone

PFD Report Historic (No Identified Response) Ref: 2017-0168
Date of Report 26 May 2017
Coroner Fiona Borrill
Coroner Area Manchester (City)
Response Deadline est. 26 October 2017
Coroner's Concerns (AI summary)
There are no Automated Electronic Defibrillators (AEDs) available on trams or at tram stops across the Metrolink network.
View full coroner's concerns
I heard from a witness who was the Safety Health and Environment Manager for Metrolink RATM DeV Limited (MRDL) who at the time of this incident was contracted by Transport for Greater Manchester to operate the tram network known as Metrolink that covers the Greater Manchester area. I was informed that in relation to the availability of Automated Electronic Defibrillator that no AEDs are provided on any of the trams or at any of the tram stops on the network, and that it is not a legal requirement or industry standard practise for AEDs to be available across the various tram networks in the United Kingdom. I was also informed that some of the larger rail and bus stations now have AEDs available and that in the absence of a Defibrillator the process in an emergency is to contact the emergency services immediately. In this case there was no evidence that the present of a Defibrillator on the tram would have made a difference to the outcome on the balance of probabilities, however at the conclusion at the inquest I indicated that I would submit a Regulation 28 report to the Department of Health and the Department of Transport to be updated as to the current provision and guidance as to the availability of AEDs.
Sent To
  • Department for Transport
  • Department of Health and Social Care
Response Status
Linked responses 0 of 2
56-Day Deadline 26 Oct 2017
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
The deceased, Lucy Francesca Goldstone, DoB 4.10.1997 died on 7 April 2016 at Manchester Royal Infirmary. I dealt with the inquest into her death on 24 February 2017 and recorded the pathological cause of death as:

1a Bronchial asthma and aspiration of food material
Circumstances of the Death
The deceased had a history of chronic asthma had a severe asthma attack and became unresponsive on a tram in Manchester City centre shortly after boarding at approximately 22.15hrs on 7 April 2016. By-stander Cardio Pulmonary Resuscitation (CPR) was carried out. North West Ambulance Service attended and administered CPR in accordance with Advance Life Support protocols. The deceased was transferred to Manchester Royal Infirmary where despite further CPR death was confirmed at 23.29hrs. I returned a Natural Causes Conclusion.
Related Inquiry Recommendations

Public inquiry recommendations addressing similar themes

Out-of-school settings guidance update
Southport Inquiry
Emergency contingency plans
Police use of unarmed officers in immediate threat
Southport Inquiry
Emergency contingency plans
Second Force Incident Manager support
Southport Inquiry
Emergency contingency plans
NWAS Major Incident declaration procedures
Southport Inquiry
Emergency contingency plans
Pandemic Decision-Making Framework
COVID-19 Inquiry
Emergency contingency plans
Leadership Succession Arrangements
COVID-19 Inquiry
Emergency contingency plans
Central Emergency Taskforces
COVID-19 Inquiry
Emergency contingency plans
Civil Contingencies Act Review
COVID-19 Inquiry
Emergency contingency plans
Devolved Nations COBR Attendance
COVID-19 Inquiry
Emergency contingency plans
Four Nations Pandemic Structure
COVID-19 Inquiry
Emergency contingency plans

Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.