Fatal Accident Inquiry into the death of Margaret Allison Hume
A Summary of the Determination issued by Sheriff Desmond J Leslie,
Sheriff for North Strathclyde at Kilmarnock Sheriff Court is now available
Margaret Allison Hume was pronounced dead at Kilmarnock at 7.40 am on 26 July 2008, having been extracted from a collapsed mine shaft, attached to a decommissioned colliery known as Goatfoot Colliery, situated at Barrwood Gate, Galston. Mrs Hume suffered death after a prolonged period at the base of the mine shaft into which she had stepped shortly before or after midnight on 25 July 2008.
It took between 5 to 6 hours for Mrs Hume to be uplifted from the collapsed mine shaft from the time of arrival of Strathclyde Fire and Rescue Service. She had probably been in the shaft for about 2 hours before their arrival. By the time she was brought to the surface at 7.42am she was profoundly hypothermic. Her core body temperature was 24 degrees, 13 degrees below normal. She was in a critical physical condition having suffered a pneumothorax, broken ribs and a broken sternum.
The Inquiry arose from circumstances where the Lord Advocate considered it expedient and in the public interest. She petitioned the Sheriff Court for a warrant to do so on the grounds that the death of Mrs Hume was sudden, or suspicious, or unexplained, or had occurred in circumstances which had given rise to serious public concern.
This Inquiry is an examination of the circumstances of her fall and the rescue effort to save her.
Sheriff Leslie found that the death of Margaret Allison Hume may have been avoided had the following reasonable precautions been taken:
- Early identification by the Police and Strathclyde Fire and Rescue Services of the stability of the mine shaft and surrounding area
- Early assessment of Mrs Hume’s medical condition, and appraisal of the likely dangers of a prolonged stay in cold and wet conditions,
- A thorough understanding of the capability and properties of line rescue equipment known as safe working at height (SWAH) equipment, and the level of training of fire fighters in the use of that equipment,
- A rigorous and thorough risk assessment by Strathclyde Fire and Rescue Service balancing the conditions of the terrain with the condition of the Deceased and the passage of time to have prevailed over restrictive Strathclyde Fire and Rescue Service Corporate Policy,
Defects in the system of working which contributed to the death, or the accident resulting in the death of Margaret Allison Hume:
- Inadequate knowledge by Strathclyde Fire and Rescue Service and The Police of the range of potential rescue resources available to assist in a rescue operation and consequent failure to communicate with these resources.
- Lack of understanding and familiarity by rescue personnel of the potential for use of the differing medical and rescue equipment supplied to the rescue and emergency services.
- Lack of multi-ability training for emergency services personnel, and in particular lack of advance first aid training among Fire and Rescue Service personnel, lack of rope access capability amongst Fire and Rescue personnel and paramedical personnel
- Over reliance on the delegation of rescue functions by Strathclyde Fire Rescue Service.
- Inadequate pre-planning for mine and mine shaft rescue
The other facts relative to the circumstances of the death or the accident leading to the death:
- There should be continuous assessment of emergency and rescue resources by all rescue and emergency agencies and the capabilities of these resources regularly communicated throughout senior and junior management of each agency.
Sheriff Leslie acknowledged Mr Alexander Dunn’s bravery and selflessness in volunteering to provide succour to Mrs Hume as she lay at the bottom of the collapsed mineshaft. He also acknowledged the very considerable effort made by Mr Andrew Parker of Strathclyde Police Mountain Rescue Team who with Mr Dunn brought Mrs Hume to the surface. They were supported by colleagues from Strathclyde Fire and Rescue Service, Strathclyde Mountain Rescue Team and the Scottish Ambulance Paramedical team, and all, despite their frustrations and anxieties, endeavoured to do their best in very difficult circumstances to rescue and save Mrs Hume.
“I extend the sympathies of the Inquiry to Mrs Hume’s family who acted with great dignity and stoicism in the face of some very harrowing evidence”.
Read the full Determination.