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recurance

Rachel Burke

25 Feb 2014 · Coroner Andrew Harris · London (Inner South)

The coroner's concerns

  1. 1. excessive ascent rate

    “The Adventure Company (TAC) Everest Gokyo Lakes Trek had advertised the ascent from Namche Bazaar at 3440m to Dole at 3780m, when in fact it was 4050m. This was an ascent of 610m in one day, whilst its preferred code of practice identified Id be a maximum of 300m per day.”
  2. 2. lack of medical assistance

    “The HE trek leader was concerned about the costs of accessing services from the Health Centre and of making satellite phone calls, possibly mindful of the TAC manual for overseas group leaders, which states under”
  3. 3. inadequate guide training

    “The severity of her illness was not appreciated by the trek leader. The expert said that it was very well known in the trekking community that people were loathe to admit they were as ill as they were and that a good mountain guide was as capable of picking up the subtle signs of mountain sickness as most doctors. Nevertheless, this severely sick trekker with ataxia and cyanosis, signs of HACE and HAPE, was asked by the trek leader to descend under her own steam with a Himalayan Encounters guide”
  4. 4. misdiagnosis of cause of death

    “The cause of death was found to be High altitude cerebral oedema and high altitude pulmonary oedema. Coronary arteriosclerosis did not cause death in this 28 year old, despite that being found by the autopsy in Nepal.”

Responses

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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