Fatal accident inquiry report

Western Isles health board failures to implement safety rules were “relevant” to how a young health worker died in severe weather on an exposed road, according to a fatal accident report.

Speech therapist Lorna Macdonald’s death may have been “prevented” if the health board warned her not to travel in the storm, says the report.

The 26-year-old, of Cross Street, Stornoway, died after her vehicle plunged into a freshwater loch in ferocious winds with roads flooded by torrential rain between Leverburgh and Tarbert in Harris in November 2011.

Fire crews were forced to watch for 40 minutes as the Mazda vehicle floated upside down across in Loch nan Uidhean with only the wheels visible. They were not trained to attempt a water rescue, a fatal accident inquiry into her death heard earlier this year.

The fatal accident inquiry found NHS Western Isles failed to implement relevant sections of its own Home Working Policy which aimed to protect the safety of staff working alone.

Sheriff David Sutherland who presided over the hearing said: “A reasonable precaution which might have prevented Miss Macdonald’s death was that her employers ensured that lone working employees did not make journeys to isolated and distant areas in adverse weather conditions predicting 65 to 75mph winds and flooding.”

The sheriff stated: “These failures while not justifying a determination that they contributed to the deceased’s death certainly might have prevented her death if her journey had not been undertaken.

“While every employee has a duty to look after their own health and safety, this does not remove the responsibility of employers.”

Sheriff Sutherland added: “Young professionals with a sense of responsibility for their clients and patients will always endeavour to do their best for them. Management has a duty to protect employees from risks resulting from this sense of duty.”

He highlighted the absence of a designated responsible person to check up on staff undertaking home visits.

Under the policy, it was the line manager’s responsibility to designated that person.

Neither was a diary of Lorna’s visits kept.

In addition, the risk of working alone should have been assessed and steps taken to ensure a worker’s safety.

Sheriff Sutherland concluded: “None of these parts of the policy were implemented.

“The only notification of where a lone worker had an appointment was on a white board in the speech therapy department in Stornoway which only had an administrator working in the mornings.”

Also “relevant to the circumstances of death,” was the failure to have procedures for “checking on staff regularly if they work alone with patients.”

Against usual practice, health staff were never advised of a yellow weather warning but similar “essential information” had been e-mailed to all employees the previous day, the health board’s emergency planning officer, Thomas Laverty, had told the inquiry.

The sheriff stated: “Clearly the weather in the Western Isles was worsening that day and a decision could have been taken by management (after the bad weather alert e-mail was forwarded to the Emergency Planning Public Health Incident Group) to cancel Lorna Macdonald’s journey to Leverburgh.”

He added: “By 2.30pm Mrs Lapsley had left a telephone message in the speech therapy department in Stornoway telling them to close and go home but had still not spoken to Lorna Macdonald or, as far as we are aware, anyone else in the community.”

After Lorna’s death, her employer, Western Isles NHS, introduced written guidance over bad weather working, a fatal accident inquiry heard earlier this year.

The inquiry heard there was no system in place to check if staff had failed to return from their journey.

Lorna’s boss told the inquiry, she did not know where Lorna was and “assumed she was fine.”

She said she closed her own office in Benbecula early due to the severe conditions that day and phoned the Stornoway office to suggest they do the same. But there was no-one there so she left a voice message to say, “go home- be careful.”

Despite a forecast of over 70mph winds, the Met Office only issued a Yellow - Be Aware alert, indicating a low risk of disruption, for the Western Isles for the day of Lorna‘s death.

Sheriff Sutherland pointed out: “There seems to have been a view taken that a yellow warning on the mainland was of higher significance than on the Western Isles, there being fewer trees and less people.”

He added: “We are used to stormy weather in the Western Isles and there is always the danger that people become complacent, especially with the number of weather warnings, many of which do not turn out to be as bad as feared.”

Giving evidence at the inquiry, Lorna’s mother, Peigi Flora Macdonald, repeatedly stressed she believed Western Isles Health Board should have “prevented anybody going out in such conditions.”

If they took measures like not sending employees out on the road or phoning them to stay where they were in worsening conditions then Lorna’s death “could have been prevented,” she said.

Sheriff Sutherland pointed out the accident scene was “not secured before the arrival of investigators and the vehicle had been removed prior to their arrival.

He urged police to ensure “such sites are preserved in future.”

The inquiry was told that - at one point some hours after the accident - no police officer was guarding the scene.

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2 December 2014