Plymouth woman's death at Derriford Hospital could spark major change

A coroner has said he intends to send a Prevention of future Deaths report to the transport minister requesting a new database of hospital landing sites, following the death of an 87-year-old grandmother at Derriford Hospital.

Jean Langan from Crownhill Road, suffered serious head injuries when she was blown backwards by the gusts - known as 'downwash' - caused by the Sikorsky helicopter. At the time it was landing at the helipad at Derriford Hospital on March 4, 2022, carrying a patient.

Mrs Langan had been at the hospital just moments beforehand with her niece, getting new hearing aids fitted. As they walked back across Car Park B the blast of air from the approaching helicopter knocked her backwards, her head hitting the ground, leaving her with unsustainable injuries.

She died just a few hours later in Derriford's A&E department. After hearing two days worth of evidence at Exeter County Hall, now the main coroner's court for all of Devon, a jury returned a conclusion of accidental death.

Senior coroner Ian Arrow, who was brought out of retirement for this inquest, thanked them for their work before continuing, hearing statements from a number of representatives of key organisations involved.

The Air Accident Investigation Branch (AAIB), the Civil Aviation Authority, the Health and Safety Executive, South West Ambulance Service Trust, HM Coastguard, the crew of the Coastguard helicopter, University Hospitals Plymouth NHS Trust and Bristow Helicopters were all included in the three day inquest.

A statement from Graham Hamilton, of Bristow Helicopters' UK Search and Rescue (SAR) Director, was read out and explained the UK SAR service was provided under contract with the Maritime Coastal Agency which was awarded following a competitive bidding process "which considered all aspects of Bristows' operation and expertise in this area".

At the time this was described in some quarters as the privatisation of the nation's search and rescue helicopters which raised safety fears. In the Spring of 2013 the Department for Transport was due to award a 10-year £3bn contract to a private company or companies to run SAR services in the UK. A report in one national paper in March 2013 revealed that the search and rescue service was to be run by Bristow - originally a British firm but later acquired by an American helicopter operator - for £1.6bn.

The report noted that Bristow already operates search-and-rescue operations in the UK and also in the Netherlands, Norway, Trinidad, Australia, Russia, Brazil and Canada.

Mr Arrow, reading the statement from Mr Hamilton, said that the 10-year contract began in 2015. He said the UK SAR service had been managed "through both civilian contracts with Bristow, CHC Helicopters and the military, through the Royal Navy and Royal Air Force".

He said a new contract has been agreed covering from September 30, 2024 to December 31, 2036. The statement explained that Bristow aimed to enhance the UK's SAR capabilities by increasing response times to high risk areas, introducing new technologies and SAR helicopters and developing a rescue simulation training facility.

The court heard that between April 1, 2015 and November 2021 across all UK SAR Bristow was tasked 15,654 times, rescuing 3,419 people and assisting a further 7,951 people. It currently operates UK SAR from 10 bases around the UK, using 10 Sikorsky S-92A and 10 Augusta Westland AW189 helicopters with two operating from each base.

Following the incident at Derriford, Bristow immediately suspended flights of its aircraft into the Derriford Hospital Landing Site (HLS). Since then Bickleigh Barracks has been made the alternative landing site and there were no plans by the hospital to resume the landing of the larger helicopters at Derriford.

The statement noted that "operations were also suspended at several other hostile congested hospital helicopter landing sites pending a full review of the measures in place to secure the landing sites and areas adjacent".

The court heard that out of approximately 200 HLS in the UK "only 44 are currently approved" for use by the larger UKSAR helicopters but that Bristow was constantly liaison with all NHS Trusts which had a helicopter landing site.

Where a site had been removed from the list of available landing sites on safety grounds, the court was told Bristow had written to the NHS Trust to inform them of the reason for doing so and "was working with those to assist them to identify and implement measures to enable UK SAR to resume to their sites".

Mr Arrow read: "Plainly, reinstatement of a site to the approval list will only be permitted once Bristow has been assured that there are appropriate safeguarding measures in place around the site.

"Bristow has been a strong proponent of the creation and the implementation of a dedicated National Hospital Helicopter Landing Site Database that can be updated in an operation environment by both helicopter operators and hospital landing site keepers since long before the tragic accident at Derriford."

The database would include hospital HLS details "but also safety features which can affect safe helicopter landing, such as live information inputted by the Trust, closure warnings, work in progress, warnings, instant reporting, safety information" to ensure the safety of uninvolved persons.

Dr Stuart Windsor, the future hospital director at Derriford Hospital, confirmed that Car Park B where the accident took place has now been permanently closed to the public and was used as an overflow for ambulances waiting for the A&E department.

Members of staff who used the car park were given training regarding "downwash" to keep themselves and patients safe and handrails were now in place to assist anyone caught in the open, along with a red flashing light and warning alarm when smaller helicopters, such as Devon Air Ambulance landed.

With regards to the new permanent UK SAR landing site of Bickleigh Barracks being used, Mr Arrow asked Abigail Knill, specialist practice operations manager from the South Western Ambulance Service Trust, how long it was now taking to transfer patients to the A&E department, noting that it could take almost an hour in total.

Ms Knill confirmed there was now an extra step in the transport of patients from the barracks to the emergency department by ambulance, which it had not had to carry out prior to the cancellation of UK SAR helicopters landing at Derriford.

She said since March this year there had been 12 SAR landings in Plymouth and "within that, there is not only the transport time, but also the effect that it there is a handover time as well. It takes some time to hand over clinically. The patient also needs to be moved in a safe manner from one helicopter to the other [site]."

She added that "in an already pressurised system [this has] meant that we have had to provide ambulances to transport those patients where we did not previously."

She said the time it took to get a patient from Bickleigh to Derriford depended on a lot of factors, saying that "from the time of being tasked, if they were locally in Plymouth, it may take them five minutes 10 minutes to get there [Bickleigh], an additional 15 minutes to half an hour to get the patient to the hospital and then if they are able to hand over immediately, then probably another 15 minutes to hand over and clean the ambulance afterwards, as is required.

"If their clinical condition does not demand an immediate handover at hospital and the hospital is under pressure, it may result in the patient being held in the ambulance until there is space for them to be offloaded, so it could be significantly longer. It will depend on traffic and the clinical handover time which I can estimate from the time that either the helicopter or the ambulance arrives, whichever is second and then the time that they leave the scene is between 8 and 15 minutes.

"It would be beneficial to be able to land the larger helicopters in a place where it doesn't require an ambulance transfer, however, I would not want this done at the cost of safety."

Closing the hearing, Mr Arrow that it appeared to him that the key step needed was progress within the Onshore Safety Leadership Group to make the database work, saying "it seems to me a key feature of an ongoing safe service is to have this database in place and it seems to be a frustration to those people who are trying to affect that database that it is not happening."

He said he would ask Bristow to write to him with a detailed letter setting out "what is needed to march this on. It appears to me that you need to have a clear leadership role established, which I think is established, but you need the resources and the input from other agencies in particular."

He said this would greatly assist him in preparing his Prevention of Future Deaths report which would then be sent to the Department of Transport.

He then turned to the family of Jean Langan and thanked them for their attendance before telling them that an inquest was a "summary inquiry, it is not a public inquiry".

He added: "Obviously there are many other areas that I feel the family would have liked to explore. I'm aware of that. We have been constrained by case law and I'm sorry for you that has happened.

"I do hope having considered some of the things that have flown on from Jean's death, that it gives you a better insight into the fact that people are alert to what has happened, that lessons have been learned, that lessons have been reported on.

"I do hope society improves and adapts accordingly. I would like to say how very sorry I am for your loss. It must have been a shocking day when you were just attending an ordinary hospital appointment and for the incident to develop as it did. It's something that shouldn't have happened. I understand that.

"Thank you for the way you've dealt with this inquest. Most importantly, thank you, members of the family for the dignity and the interest you have taken in trying to prevent this happening to other people.

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